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Presentation on theme: "DSM-5: NOT WITHOUT CONTROVERSY"— Presentation transcript:

American Psychiatric Association Psychiatry’s Manual of Disorders and the Issues Surrounding Its Design and Use

2 An Introduction to DSM-5,Its Development, Changes, and Controversies
Researched and Developed by Rhinehart Lintonen The presentation herein is the intellectual property of Rhinehart Lintonen and does not reflect the attitudes or positions of the American Psychiatric Association. This presentation was developed for the use of the membership of the Milwaukee Area Teachers of Psychology and their students. Any other use should request permission at The intent of this presentation is to delineate the development of the present DSM and to document changes from DSM-IV-TR. Critiques and controversies presented are those of the persons or groups cited.

3 A Short History of the DSM The Diagnostic and Statistical Manual of Mental Disorders

4 Development of the DSMs
DSM-5, issued on May 18, 2103, is the culmination of changes begun in 1999 and intended to replace DSM-IV-TR which was seen as needing revision due to scientific discoveries in brain biology and issues surrounding perceived needed changes in the diagnostic categories themselves. The prior editions stem back to post-World War II when the Army and Veteran’s Administration were looking for a way to diagnose what psychiatrically affected returning troops. Thus began DSM-I, published in 1952. Other revisions include DSM-II (1968), DSM-III (1980), DSM- IIIR (1987), DSM IV (1994) and DSM-IV-TR (2000)

5 Development of the DSMs
Along the way, revisions reflected current thinking and trends in psychiatry DSM-1 was largely psychodynamic in nature, reflecting Freud’s impact on psychiatry Disorders referred to as “reactions” under the influence of Adolf Meyer and also showed the psychoanalytic bent Two groups of disorders based on causality Those caused by or associated with brain tissue dysfunction Those of “psychogenic” origin not clearly related to structural changes in the brain DSM-II increases number of disorders to 182 Drops use of “reactions” while still using Freudian terms such as “neurosis” and “psychosis” Illustrations: American Psychiatric Assoc.

6 Development of the DSMs
DSM-III represented a major change in the construction of the manual with 265 categories of disorders Gone was the prior emphasis on psychodynamic views Now the emphasis was on empirically-obtained observations Coincided with move in US away from psychoanalysis and with publics’ skepticism of psychiatry in general DSM-IIIR influenced by Emil Kraepelin’s insistence on the roles of biology and genetics in disorders Task Force Chair Dr. Robert Spitzer suggested there was a hierarchy of mental illness (Greenberg, 54) Dr. Allen Frances accords him great respect, saying that “Without Robert Spitzer, psychiatry might have become increasingly irrelevant” and that “Spitzer had laid the foundations for the psychiatric research enterprise.” (Frances, ) High praise for the man who guided the DSMs into a new direction APA New York Times

7 Development of the DSMs
DSM-IV was not much of a sea-change from DSM-III The number of disorders were now over 300 Allen Frances, MD chaired the task force and insisted that the manual was not to be taken as a “Bible” of mental illnesses All changes had to be science-driven and evidence-based and needed to have checks and balances which would protect against bias and individual’s pet ideas (Frances, xiii) One of his regrets is that “Even though we had been boringly modest in our goals, obsessively meticulous in our methods, and rigidly conservative in our product, we failed to predict or prevent three new false epidemics of mental disorder in children – autism, attention-deficit, and childhood bipolar disorder.” (Frances, xiv) American Psychiatric Assoc. Photo:

8 Development of DSM-5 DSM-IV-TR (2000) was an update to DSM-IV, not in the categories of disorders but in two main areas: Prevalence Familial patterns These were updated to reflect new scientific knowledge regarding genetics and other neuroscientific advances What you’ve been teaching from all this time! Get ready to change what you knew! American Psychiatric Assoc.

9 Development of DSM-5 Beginning in 1999, there were specific calls for changes to DSM-IV-TR including: •In two decades, much new info on disorders had emerged •Biological psychiatry and neuroscience were being embraced with great enthusiasm Prominent neuroscientists like Eric Kandel were proclaiming that “all mental disorders involve disorders of brain function.” (Greenberg, 61) New drugs seemed to ease burden of psychological disorders Think serotonin imbalances being eased by SSRI antidepressants (which later proved to be a false hypothesis) • Genetics research had added new knowledge of the possible sources of disturbances • Need for a more defined nosology (classification system) • A hoped-for “paradigm shift” to recreate that nosology

10 How Was DSM-5 Created? New edition preceded by 13 scientific conferences and a number of white papers, monographs, and journal articles researching and evaluating new nosologies APA set up the DSM-5 Task Force of 27 members in under Chairman David Kupfer, MD and Vice-Chairman Darrel Regier, MD 160 researchers and clinicians formed the Work Groups and Study Groups to develop the new manual, revising or tweaking criteria from the DSM-IV-TR and deleting or adding diagnostic classifications American Psychiatric Assoc. Kupfer Regier

11 How Was DSM-5 Created? The new task force stated in its goals that
“The previous version of DSM was completed nearly two decades ago; since that time, there has been a wealth of new research and knowledge about mental disorders.” (APA) Therefore, the APA set about to use this evidence to determine whether certain diagnoses (a very hotly debated term) should be removed or changed Additionally, the APA felt that they needed to better define the disorders by symptoms and behaviors than DSM-IV did This would allow for future revision processes to be more responsive through incremental updates (DSM-5.0, 5.1, etc.) as new scientific breakthroughs became available

12 How Was DSM-5 Created? Changes like this are costly
DSM-5 cost between $20-25 million to produce However, the DSM is a cash cow for the APA! It is the sole agency producing such a product except for the ICD-10 The greatest percentage of the income of the APA comes from its publishing arm Since it brings in so much income, the DSM is critically important to the APA There are calls for a more open, diversified medical organization to be created to write a new manual with more inputs and better designed to help the practice of psychiatry rather than simply refine the nosology (also important)

13 The New DSM-5 Change is Good (Maybe)

14 Basic Changes The old structure is gone
Illus.: The old structure is gone No more Five Axes These were seen as incompatible with ICD-10 and other medical diagnostic systems Replaced with a 0 to 4 point severity ratings scale for each diagnosis No more assessment of global relative functioning according to a scale (GARF) The term “general medical condition” has been replaced with “another medical condition” Asperger Syndrome is no longer a discrete classification Now merged into Autism Spectrum Disorder Subtypes for Schizophrenia are gone This was done because of low reliability, poor validity, and because of limited diagnostic stability (APA) NOS categories (not otherwise specified) are now “other specified disorder” and “unspecified disorder”

15 Basic Changes Structure of the Manual Preface
DSM-5 Classification and Coding Section I Use of the Manual Cautionary Statement for Forensic Use of DSM-5 Section II Disorders listed among 22 major categories

16 Basic Changes Gone is the category “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence” These are now found under other appropriate headings Other changes pertinent to each category will be discussed in the following section “The New DSM-5: Disorders” For a complete discussion of in-depth changes in each diagnostic category, go to:

17 The New DSM-5 The Controversies

18 DSM Under Fire The new DSM has been under fire almost from the beginning Initial complaints involved failure to supply minutes of committee meetings and questions about transparency As time progressed, the questions and criticisms grew Two camps essentially: The American Psychological Association with David Kupfer and Darrel Regier defending their work Former DSM-III and DSM-IV task force leaders Robert Spitzer and Allen Frances This brought about what became high drama never before seen at this level of medical/scientific process The availability of the Internet allowed the criticism to reach unheard of numbers of therapists and professionals able to comment on the proceedings

19 The Charges The Spitzer/Francis camp charged:
The manual was being drawn up in secrecy Transparency was not being allowed The Task Force members had to sign confidentiality agreements which limited their open discussion about the proceedings DSM not etiologically based and adding things which were not disorders Continued emphasis on Asperger’s, ADHD, and Childhood Bipolar Disorder (what Frances called “false epidemics”) would lead to diagnostic inflation (Francis, 77-86) DSM-5 was leading to the “medicalization of normalcy” (Frances and Widiger, 123) Too many psychiatrists on the development committees had ties to Big Pharma and were thus in danger of being influenced in their decisions (Frances, 75)

20 The Charges The Spitzer/Francis camp charged:
Field Trials were improperly vetted and hastily drawn up and weren’t adequately presented for review The trials failed spectacularly in some areas with very low kappa scores On a 0 to 1 scale, depression had a low 0.28; Mixed Anxiety-Depressive Disorder at (Freedman, The APA was in too much of a hurry to bring the manual to market APA’s financial vesting in the book meant that the organization needed to bring it to market quickly to continue the flow of sales Behind it all, Frances charged that there were a number of conceptual issues: “an elusive definition of mental disorder, the limits of neuroscience, the limits of descriptive psychiatry, an unclear epistemology, the absence of a unified theoretical model, pragmatism, and fads.” (Frances and Widiger, )

21 The Charges Frances admits that “Psychiatric classification is necessarily a sloppy business.” (Frances and Widiger, 114) and that “the only way to define a mental disorder is ‘that which clinicians treat; researchers research; educators teach; and insurance companies pay for.’” (Frances, 18) Frances warns that DSM-IV had some unintended consequences being heightened by DSM-5 (Frances and Widiger, 115) Four fads creating diagnostic inflation autism attention deficit childhood bipolar disorder paraphilia not otherwise specified

22 The Charges Additional critiques from Frances and others
APA was trying to create a paradigm shift in psychiatric diagnosis which is, at present, unrealizable New category of Mood Dysregulation Disorder will create a mental disorder out of temper tantrums Normal grief is being medicalized Everyday characteristics of old age will be misdiagnosed as cognitive disorders ADHD will lead to more adults being diagnosed in a fit of diagnostic inflation Excessive eating is now a disorder, not just plain gluttony Problems in everyday living will be elevated to General Anxiety Disorder Behavioral addictions can apply to anything one does often enough

23 The Charges And the list goes on
Just exactly what is a mental disorder, anyway? Are they simply problems in living as Thomas Szasz claimed? Will we stigmatize too many people? Will all of this encourage Big Pharma to find a drug for everything? Many psychiatric drugs don’t work nearly as well as patient think anyway At least a number of proposed “disorders” didn’t make it E,g., Hypersexual Disorder How much sex is too much? Is it possible to be mentally ill because of a desire for sex?

24 Anything Positive in DSM-5?
Is it all for naught? Does DSM-5 or any other manual have any redeeming value? The APA said it “would work to overcome one of the clearest limitations of our current diagnostic criteria…the lack of quantitative measures.” (Greenberg, 175) Frances counters that we “still do not have a single laboratory test in psychiatry.” (Frances, 10) However, the APA did adhere to attempting to validate all disorders through empirical evidence from clinical practice and an exhaustive search of the literature So, at the end of the day, even Spitzer and Frances admit that, while it isn’t a “bible,” the DSM is still the best thing we have to guide us until something better comes along

25 Anything Positive in DSM-5?
DSM-5 has many supporters among clinicians and therapists It is considered robust compared to the ICD-10 or any other attempt to create a different manual Perhaps therapists are best reminded that it is just a guide, it needs to be used judiciously, and the most apt advice may be that of the British Psychological Society which admonishes therapists to treat the person first, not the disease

26 Other Methodologies Other methodologies are in the works
Creating categories of disorders based on brain biology and neuroscience Diagnosing disorders based on measuring the psychological dimensions of personality Using a system of “stepped diagnosis” (Frances, 222) A form of watchful waiting emphasizing normalizing problems and using minimal interventions until arriving at a definitive diagnosis and treatment plan

27 Another Possible System
The National Institute of Mental Health (NIMH) has an initiative known as Research Domain Criteria (RDoC) The system would assess Negative Valence Systems Threat, fear of loss, frustration Positive Valence Systems Motivation, learning, and habit Cognitive Systems Attention, perception, and Memory Social Process Systems facial expression identification, imitation, attachment/separation fear Arousal/Regulatory Processes Stress regulation These would be analyzed in terms of genes, molecules, and cells (Greenburg, )

28 The New DSM-5 Diagnostic Criteria Disorders

29 Neurodevelopmental Disorders
Conditions which begin in early development and which cause significant functional impairment

30 Neurodevelopmental Disorders
Mental Retardation now called “intellectual disability” Language disorders/stuttering now called “communication disorders” Subcategories Intellectual Disabilities Communication Disorders Autism Spectrum Disorder Attention-Deficit-Hyperactivity Disorder Specific Learning Disorder Motor Disorders Tic Disorders

31 Schizophrenia Spectrum and Other Psychotic Disorders
A group of disorders which is characterized by major disturbances in such areas as thought, language, perceptions, emotion, and behavior and which make it difficult to separate reality from fantasy

32 Schizophrenia Spectrum and Other Psychotic Disorders
All subtypes deleted Former subtypes are now diagnostic symptoms Paranoid, disorganized, etc. Subcategories Schizotypal (Personality) Disorder Delusional Disorder Brief Psychotic Disorder Schizophreniform Disorder Schizophrenia Schizoaffective Disorder Substance/Medication-Induced Psychotic Disorder Psychotic Disorder Due to Another Medical Condition Catatonia Other Specified Schizophrenia Spectrum and Other Psychotic Disorder Unspecified Schizophrenia Spectrum and Other Psychotic Disorder

33 Bipolar and Related Disorders
Disorders which are marked by major mood changes, alternating from manic to depressive and which can exhibit psychotic experiences – the reason they are located between Schizophrenia and Depressive Disorders in DSM-5

34 Bipolar and Related Disorders
Separated from Mood Disorders (category no longer exists) A new specifier (“with mixed features” has been added for each subcategory Anxiety symptoms are a specifier, although not part of the diagnostic criteria (in many of the categories such specifiers may now exist without being a diagnostic necessity) Subcategories Bipolar I Disorder Bipolar II Disorder Cyclothymic Disorder Substance/Medication-Induced Bipolar and Related Disorder Other Specified Bipolar and Related Disorder Unspecified Bipolar and Related Disorder

35 Depressive Disorders Conditions in which the person feels in an extremely depressed mood for persistent periods of time, often without any letup or recurring in cycles

36 Depressive Disorders Replaces Mood Disorders Category for depressions
Specifiers have been added for mixed symptoms and also for anxiety Most controversial: bereavement exclusion Was excluded in DSM-IV-TR, now included At what point should we medicalize normal grieving? For children up to 18 a new category added DMDD: Disruptive Mood Dysregulation Disorder Also controversial Now medicalizing temper tantrums? Premenstrual Dysphoric Disorder now a subcategory Subcategories Disruptive Mood Dysregulation Disorder Major Depressive Disorder Persistent Depressive Disorder (Dysthymia) Premenstrual Dysphoric Disorder Substance/Medication-Induced Depressive Disorder Depressive Disorder Due to Another Medical Condition Other Specified Depressive Disorder Unspecified Depressive Disorder

37 Anxiety Disorders Disorders which are marked by extreme conditions of fear or uneasiness that impair one’s basic functioning and which may or may not appear to have a cause according to the sufferer

38 Anxiety Disorders Panic Attack has become a specifier for all DSM-5 disorders Panic Attack and Agoraphobia are no longer necessarily associated Specific types of Phobia have become specifiers No longer requires patient/client to recognize that their fear(s) are excessive or unreasonable Duration now must be 6 months Separation Anxiety Disorder and Selective Mutism have been moved here from Early Onset Disorders Subcategories Separation Anxiety Disorder Selective Mutism Disorder Specific Phobia Social Anxiety Disorder (formerly Social Phobia) Panic Disorder Agoraphobia Generalized Anxiety Disorder Substance/Medication-Induced Anxiety Disorder Anxiety Disorder Due to Another Medical Condition

39 Anxiety Disorders Subcategories (con’t.)
Other Specified Anxiety Disorder Unspecified Anxiety Disorder

40 Obsessive-Compulsive and Related Disorders
Conditions which arise in response to some sort of traumatic event or severe stress; characteristic of not only soldiers, but many public safety workers and anyone, including children, who experience major shock

41 Obsessive-Compulsive and Related Disorders
Four new disorders Excoriation Disorder (skin-picking) Hoarding Disorder (won’t the TV reality shows delight in this!) Substance/Medication-Induced Obsessive-Compulsive and Related Disorder Obsessive-Compulsive and Related Disorder Due to Another Medical Condition Body Dysmorphic Disorder (BDD) adds criteria dealing with repetitive behaviors and mental acts “which may arise with perceived defects or flaws in physical appearance” (APA) Specifiers have been added for “with good or fair insight,” “with poor insight,” or “with absent insight-delusional beliefs” These also appear for Obsessive-Compulsive Disorder and Hoarding Disorder Trichotillomania (hair-pulling) has moved here from Impulse- Control Disorders

42 Obsessive-Compulsive and Related Disorders
Subcategories Obsessive-Compulsive Disorder Body Dysmorphic Disorder Hoarding Disorder Trichotillomania Excoriation Disorder Substance/Medication-Induced Obsessive-Compulsive and Related Disorder Obsessive-Compulsive and Related Disorder Due to Another Medical Condition Other Specified Obsessive-Compulsive and Related Disorder Unspecified Obsessive-Compulsive and Related Disorder

43 Trauma- and Stressor-Related Disorders
Conditions in which the person experiences periods of obsessive thoughts often followed by compulsive behavior in response to that thinking; obsessions (thoughts) and compulsions (actions) can occur separately

44 Trauma -and Stressor-Related Disorders
Now includes PTSD which was an anxiety disorder in DSM-IV-TR Anxiety still an important symptom but not all sufferers will experience fear and anxiety Symptom clusters now include negative alterations in cognition and mood E.g., negative thoughts abut oneself, outbursts of anger, self- destructive behavior, etc. Separate criteria for children 6 and under Specifiers modified to some extent to reflect emotional reaction training of soldiers, police, emergency personnel Two new disorders Reactive Attachment Disorder Disinhibited Social Engagement Disorder Adjustment Disorders moved here as Stress-Response Syndromes

45 Trauma -and Stressor-Related Disorders
Subcategories Reactive Attachment Disorder Disinhibited Social Engagement Disorder Child approaching and interacting with strange adult Posttraumatic Stress Disorder Acute Stress Disorder Adjustment Disorders Other Specified Trauma –and Stressor-Related Disorder Unspecified Trauma –and Stressor-Related Disorder

46 Dissociative Disorders
Disruptions of cognitive functioning in which identity, consciousness, and memory can be impaired causing the person to experience confusion and discontinuity

47 Dissociative Disorders
Dissociative Fugue no longer a separate condition Now a specifier for Dissociative Amnesia Depersonalization Disorder renamed Depersonalization/Derealization Disorder Diagnosis for Dissociative Identity Disorder may include culturally- specific experiences of pathological possession Also, identity transitions may be observed by others as well as self-reported Now takes into account the nature and course of identity disruptions Subcategories Dissociative Identity Disorder Dissociative Amnesia Depersonalization/Derealization Disorder Other Specified Dissociative Disorder Unspecified Dissociative Disorder Really?

48 Somatic Symptom and Related Disorders
Bodily symptoms (such as loss of function or pain) experienced as a result of extreme stress; formerly called “psychosomatic” symptoms

49 Somatic Symptom and Related Disorders
Previously called Somatoform Disorders Due to overlap and lack of clarity, these diagnoses have been eliminated Somatization Disorder Hypochondriasis Considered a pejorative term Pain Disorder Some pain can be medical and there is a lack of validity and reliability in the distinctions Undifferentiated Somatoform Disorder Somatic Symptom Disorder is defined by positive symptoms Psychological Factors Affecting Other Medical Conditions is a new disorder Subcategories Somatic Symptom Disorder Illness Anxiety Disorder

50 Somatic Symptom and Related Disorders
Subcategories (con’t.) Conversion Disorder Also known as Functional Neurological Symptom Disorder Psychological Factors Affecting Other Medical Conditions Factitious Disorder Other Specified Somatic Symptom and Related Disorder Unspecified Somatic Symptom and Related Disorder

51 Feeding and Eating Disorders
Difficulties with eating that often reflect psychological stressors and interpersonal reactions; cause difficulties with personal imagery and health

52 Feeding And Eating Disorders
Eating disorders from infancy and early childhood moved here Pica and Rumination Disorder can occur at any age Feeding Disorder of Infancy or Early Childhood now known as Avoidant/Restrictive Food Intake Disorder Anorexia Nervosa no longer requires diagnosis of amenorrhea Bulimia Nervosa changed required minimum frequency from twice to once weekly Binge Eating Disorder moved up from DSM-IV-TR’s “Further Study” to full disorder Subcategories Pica Rumination Disorder

53 Feeding And Eating Disorders
Subcategories (con’t.) Avoidant/Restrictive Food Intake Disorder Anorexia Nervosa Bulimia Nervosa Binge Eating Disorder Other Specified Feeding or Eating Disorder Unspecified Feeding or Eating disorder

54 Elimination Disorders
Conditions which involve improper elimination of bodily substances (urine or feces) most often associated with problems in growth phases and occurring during sleep

55 Elimination Disorders
No significant changes from DSM-IV-TR Previously classified as “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence” Subcategories Enuresis

56 Sleep-Wake Disorders Disruptions of the normal circadian rhythm of sleep or of wakefulness which lead to inability to fall asleep or stay asleep or to remain awake

57 Sleep-Wake Disorders “Sleep Disorders Related to Another Mental Disorder” and “Sleep Disorders Related to a General Medical Condition” have been removed Acknowledges bidirectional and interactive effects between existing medical and mental disorders Primary and Secondary Insomnia have become Insomnia Disorder Narcolepsy separated from Hypersomnolence No known to be caused by hypocretin deficiency Breathing-Related Sleep Disorders know separated into 3 distinct categories Circadian-Rhythm Sleep-Wake Disorders now include 3 distinct subtypes Jet Lag subtype has been removed Rapid Eye Movement Sleep Behavior Disorder and Restless Legs Syndrome moved from “NOS” to independent status

58 Sleep-Wake Disorders Subcategories Insomnia Disorder
Hypersomnolence Disorder Narcolepsy Breathing-Related Sleep Disorder Obstructive Sleep Apnea Hypopnea Central Sleep Apnea Sleep-Related Hypoventilation Circadian Rhythm Sleep-Wake Disorders Parasomnias Non-Rapid Eye Movement Sleep Arousal Disorders Nightmare Disorder Rapid Eye Movement Sleep Behavior Disorder Restless Legs Syndrome Substance/Medication-Induced Sleep Disorder Other Specified and Unspecified

59 Sexual Dysfunctions Problems of sexuality which may involve difficulties initiating or maintaining intercourse and often related to stress and psychological difficulties

60 Sexual Dysfunctions Gender-specific sexual dysfunctions added
Female sexual desire and arousal disorders combined into one category: Female Sexual Interest/Arousal Disorder All sexual dysfunctions now require minimum duration of approximately 6 months and more precise severity criteria Sexual Aversion Disorder deleted New disorder Genito-Pelvic Pain/Penetration Disorder Combines Vaginismus and Dyspareunia from DSM-IV-TR Eliminated disorders Sexual Dysfunction Due to a General Medical Condition Sexual Dysfunction Due to Psychological Versus Combined Factors

61 Sexual Dysfunctions Subtypes changed Subcategories
Lifelong versus Acquired and Generalized versus Situational remain Due to Psychological Factors versus Due to Combined Factors deleted Subcategories Delayed Ejaculation Erectile Disorder Female Orgasmic Disorder Female Sexual Interest/Arousal Disorder Genito-Pelvic Pain/Penetration Disorder Male Hypoactive Sexual Desire Disorder Premature (Early) Ejaculation Substance/Medication-Induced Sexual Dysfunction Other Specified Sexual Dysfunction Unspecified Sexual Dysfunction

62 Gender Dysphoria Difficulties with determining and maintaining a sexual identity where the individual feels an incongruence between what they are and what they feel they were meant to be

63 Gender Dysphoria New diagnostic class
Emphasizes incongruity rather than cross-gender identification as such Separate criteria for children, adolescent, and adults Separates Sexual Dysfunctions from Gender Identity Recognizes that gender dysphoria is a condition mostly identified and treated by mental health care providers except for endocrine and surgical procedures In children, “strong desire to be of the other gender” replaces repeatedly stated desire” Subtype based on sexual orientation removed Not considered useful clinically Name was changed to “Dysphoria” because term “disorder” was pejorative

64 Gender Dysphoria Subcategories Gender Dysphoria
Other Specified Gender Dysphoria Unspecified Gender Dysphoria

65 Disruptive, Impulse-Control, and Conduct Disorders
Problems with controlling emotions in personal and social situations, marked by extreme anger, explosive behaviors, or lack of affect and sense of responsibility

66 Disruptive, Impulse-Control, and Conduct Disorders
New diagnostic class Combines disorders from “Disorders Usually First Diagnosed in Infancy, Childhood, and Adolescence” Intermittent Explosive Disorder, Pyromania, and Kleptomania also moved into this category Antisocial Personality Disorder also included in Personality Disorders category Symptom types for Oppositional Defiant Disorder Angry/Irritable Mood Argumentative/Defiant Behavior Vindictiveness Exclusion criterion for Conduct Disorder removed

67 Disruptive, Impulse-Control, and Conduct Disorders
Oppositional Defiant Disorder (con’t.) Since behavior is “normal” process of growing up, severity rating scales and guidance on frequency typically needed to be considered symptomatic have been added Conduct Disorder adds “limited prosocial emotion” specifier Intermittent Explosive Disorder adds verbal aggression and non-destructive/noninjurious physical aggression to DSM- IV’s physical aggression Also, specifiers were added for Impulsive and/or anger based in nature Must cause marked distress Causes impairment in occupational or interpersonal functioning Associated with legal or financial consequences

68 Disruptive, Impulse-Control, and Conduct Disorders
Subcategories Oppositional Defiant Disorder Intermittent Explosive Disorder Conduct Disorder Antisocial Personality Disorder Pyromania Kleptomania Other Specified Disruptive, Impulse-Control, and Conduct Disorder Unspecified Disruptive, Impulse-Control, and Conduct Disorder

69 Substance-Related and Addictive Disorders
Problems with controlling emotions in personal and social situations, marked by extreme anger, explosive behaviors, or lack of affect and sense of responsibility

70 Substance-Related and Addictive Disorders
New categories Gambling Disorder Added because of evidence that some behaviors activate the brain’s reward system with similar effects as those obtained from drugs Tobacco Use Disorder Diagnoses of substance abuse and dependence are not separated as in DSM-IV-TR Criteria were changed to reflect relevance of Intoxication Withdrawal Substance/Medication-Induced Disorders Unspecified Substance-Induced Disorders Craving or strong desire or urge to use a substance Caffeine and cannabis withdrawal are new criteria

71 Substance-Related and Addictive Disorders
Subcategories Substance-Related Disorders Substance Use Disorders Substance-Induced Disorders Alcohol-Related Disorders Alcohol Use Disorder Alcohol Intoxication Alcohol Withdrawal Unspecified Alcohol-Related Disorder Caffeine Intoxication Caffeine Withdrawal Unspecified Caffeine-Related Disorder Cannabis-Related Disorder Cannabis Use Disorder Cannabis Intoxication

72 Substance-Related and Addictive Disorders
Subcategories (con’t.) Cannabis Withdrawal Other Cannabis-Induced Disorders Hallucinogen-Related Disorders Phencyclidine Use Disorder Other Hallucinogen Use Disorder Phencyclidine Intoxication Other Hallucinogen Intoxication Hallucinogen Persisting Perception Disorder Other Phencyclidine-Induced Disorders Other Hallucinogen-Induced Disorders Unspecified Phencyclidine-Induced Disorders Unspecified Hallucinogen-Induced Disorders

73 Substance-Related and Addictive Disorders
Subcategories (con’t.) Inhalant-Related Disorders Inhalant Use Disorders Inhalant Intoxication Other Inhalant-Induced Disorders Opioid-Related Disorders Opioid Use Disorder Opioid Intoxication Opioid Withdrawal Other Opioid-Induced Disorders Sedative-, Hypnotic-, or Anxiolytic-Related Disorders Sedative, Hypnotic, or Anxiolytic Use Disorder Sedative, Hypnotic, or Anxiolytic Intoxication Other Sedative-, Hypnotic-, or Anxiolytic-Use Disorders Stimulant-Related Disorders Stimulant Use Disorder

74 Substance-Related and Addictive Disorders
Subcategories (con’t.) Stimulant Intoxication Stimulant Withdrawal Other Stimulant Use Disorders Tobacco-Related Disorders Tobacco Use Disorder Tobacco Withdrawal Other Tobacco-Induced Disorders Other (or Unknown) Substance-Related Disorders Other (or Unknown) Substance-Induced Non-Substance Related Gambling Disorder

75 Neurocognitive Disorders
Disorders of thought caused by organic conditions (e.g., Alzhemier’s) or inorganic conditions (e.g., traumatic brain injury) which can impair memory, judgment, decision-making, and identification of people and objects

76 Neurocognitive Disorders
Criteria for Delirium have been updated based on current neuroscience Dementia and Amnestic Disorder have been changed to Major Neurocognitive Disorder The term “dementia” may still be used in etiological subtypes Mild Neurocognitive Disorder (Mild NCD) is a new subcategory Allows for diagnosis of less-disabling syndromes which still are of concern Major or Minor Vascular NCD and Major or Mild NCD Due to Alzheimer’s is retained Separate criteria for Major or Mild NCD due to: Frontotemporal NCD Lewy Bodies Traumatic Brain Injury (TBI) Parkinson’s Disease HIV Infection Huntington’s Disease Prior Disease Other medical Conditions or Multiple Etiologies

77 Neurocognitive Disorders
Subcategories Delirium Other Specified Delirium Unspecified Delirium Major and Mild Neurocognitive Disorders Major Neurocognitive Disorder See subtypes of previous slide Mild Neurocognitive Disorder Major or Minor Neurocognitive Disorder Due to Alzheimer’s Disease Major or Mild Frontotemporal Neurocognitive Disorder With Lewy Bodies Vascular Due to Traumatic Brian Injury Substance/Medication-Induced Major or Mild Neurocognitive Disorder Due to HIV Infection Due to Prion Disease Due to Parkinson’s Disease Due to Huntington’s Disease Due to Another Medical Condition Due to Multiple Etiologies Unspecified Neurocognitive Disorder

78 Personality Disorders
Enduring traits and patterns of behavior which cause impairment in interpersonal relations and societal functioning leading to significant life challenges

79 Personality Disorders
Criteria have not changed from DSM-IV-TR A possible alternative approach for diagnosing personality disorders is in Section III Subcategories General Personality Disorder Cluster A Personality Disorders Paranoid Personality Disorder Schizoid Personality Disorder Schizotypal Personality Disorder Cluster B Personality Disorders Antisocial Personality Disorder Borderline Personality Disorder Histrionic Personality Disorder Narcissistic Personality Disorder Cluster C Personality Disorders Avoidant Personality Disorder Dependent Personality Disorder Obsessive-Compulsive Personality Disorder Other Personality Disorders Personality Change Due to Another Medical Condition Other Specified Personality Disorder Unspecified Personality Disorder

80 Paraphilic Disorders Disorders of sexual appropriatness which cause one to deviate from the norms regarding sexual activity

81 Paraphilic Disorders Greatest change: Change in diagnostic names:
Added specifiers for “in a controlled environment” and “in remission” to indicate changes in an individual’s status No consensus whether a long-standing paraphilia can remit Change in diagnostic names: Distinguishes between a “paraphilic behavior” and “paraphilic disorder” Paraphilia is a necessary but insufficient condition for having a paraphilic disorder Paraphilia by itself is not considered automatically justifying or requiring there be a clinical; intervention Paraphilic Disorder is a paraphilia that is causing impairment or distress to the individual or which causes personal harm to others if acted upon Otherwise same structure is maintained from DSM-III-R Person must meet both Criterion A and Criterion B symptoms for each disorder otherwise no paraphilia exists

82 Paraphilic Disorders Subtypes Voyeuristic Disorder
Exhibitionistic Disorder Frotteuristic Disorder Sexual Masochism Disorder Sexual Sadism Disorder Pedophilic Disorder Fetishistic Disorder Transvestic Disorder Other Specified Paraphilic Disorder Unspecified Paraphilic Disorder

83 Other Disorders A category for disorders which do not conveniently fit into any of the main categories but which, nonetheless, cause significant distress or impairment to the individual

84 Other Mental Disorders
This category refers to symptoms which present due to another medical condition but do not meet the full criteria necessary to be considered a full disorder Medication-Induced Movement Disorders and Other Adverse Effects of Medication Examples: Medication-Induced Parkinsonism Medication-Induced Acute Dystonia Medication-Induced Acute Akathisia Tardive Dyskinesia, Dystonia, or Akathisia Medication-Induced Postural Tremor

85 Other Conditions That May Be the Focus of Clinical Attention
Examples: Problems Related to Family Upbringing Other Problems Related to Primary Support Group Child Maltreatment and Neglect Problems Adult Maltreatment and Neglect Problems Educational or Occupational Problems Housing and Economic Problems Other Problems Related to the Social Environment Problems Related to Crime or Interaction with the Legal System Other Health Service Encounters for Counseling and Medical Advice Problems Related to Other Psychosocial, Personal, and Environmental Circumstances Other Circumstances of Personal History

86 Section III Section III has several divisions which address emerging scientific evidence and data from clinical experiences that could be of use to the therapist These divisions include: Valuable Clinical Tools Assessment tools of use in the diagnostic process Accounting for Culture Cultural formulation interview guide Another Model for Personality Disorders A ‘hybrid dimensional-categorical model” (APA) which emerged during debates on the Personality Disorders category Suggests using five broad areas of pathological personality traits, coming up with six personality disorder types Borderline Personality Disorder Obsessive-Compulsive Personality Disorder Avoidant Personality Disorder Schizotypal Personality Disorder Antisocial Personality Disorder Narcissistic Personality Disorder The model seeks to discover impairments in functioning and is included to prompt further research

87 Section III Conditions for Further Study
Disorders judged to need further research before being included as full disorders Attenuated Psychosis Syndrome Person has minor versions of symptoms of psychotic disorder Depressive Episodes With Short-Duration Hypomania Persistent Complex Bereavement Disorder Caffeine Use Disorder Internet Gaming Disorder Neurobehavior Disorder Due to Prenatal Alcohol Exposure Suicidal Behavior Disorder Nonsuicidal Self-Injury

88 Sources A history of the DSM-V controversy. Retrieved from the-dsm5-controversy A moment of crisis in the history of American psychiatry. Retrieved from of-american-psychiatry/ American Psychiatric Association. (2013). Highlights of changes from DSM-IV to DSM-5. Retrieved from tr%20to%20dsm-5.pdf Controversy over DSM-5: New mental health guide. Retrieved from controversy-over-dsm-5-new-mental-health-guide/ Desk reference to the diagnostic criteria from DSM-5. (2013). Washington, DC: The American Psychiatric Association. DSM-5: A ruse by another other name. Retrieved from by-any-other-name/#.USyiSDcSHTo DSM-5 is guide not Bible – Ignore its ten worst changes. Retrieved from guide-not-bible-ignore-its-ten-worst-changes

89 Frances, A. (2013). Saving normal. New York: William Morrow. Francis, A. and Widiger, T. (2012, September 4).Psychiatric diagnosis: Lessons from the DSM-IV past and cautions from the DSM-5 future. Annual Review of Of Clinical Psychology, 8: Retrieved from Freedman, R. et. al. (2013) The initial field trials of DSM-5: New blooms and old thorns. American Journal of Psychiatry. 170:1-5 Greenberg, G. (2013). The book of woe. New York: Blue Rider Press. How the DSM developed: What you might not know. Retrieved from developed-what-you-might-not-know/ Kapline, A. DSM-5 controversies. (2009, January 1). Retrieved from Normal or not? New psychiatric manual stirs controversy. Retrieved from controversy.html


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