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Psychiatry’s Manual of Disorders and the Issues Surrounding Its Design and Use American Psychiatric Association 1.

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1 Psychiatry’s Manual of Disorders and the Issues Surrounding Its Design and Use American Psychiatric Association 1

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. 2

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4 * 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) 4

5 * 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. 5

6 * 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, 62- 63) High praise for the man who guided the DSMs into a new direction New York Times APA 6

7 * 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: 7

8 * 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 American Psychiatric Assoc. What you’ve been teaching from all this time! Get ready to change what you knew! 8

9 * 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 o 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 9

10 * 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 2007 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 Kupfer Regier www.psychiatry.pitt.eduAmerican Psychiatric Assoc. 10

11 * 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 11

12 * 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) 12

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14 * The old structure is gone No more Five Axes  These were seen as incompatible with ICD-10 and other medical diagnostic systems o 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” Illus.: 14

15 * 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 15

16 * 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: tr--to-dsm-5%5B1%5D.pdf 16

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18 * 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 18

19 * 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) 19

20 * 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 o On a 0 to 1 scale, depression had a low 0.28; Mixed Anxiety-Depressive Disorder at -0.004 (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, 109-110) 20

21 * 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 21

22 * 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 22

23 * 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? 23

24 * 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 24

25 * 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 25

26 * 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 26

27 * The National Institute of Mental Health (NIMH) has an initiative known as Research Domain Criteria (RDoC) The system would assess  Negative Valence Systems o Threat, fear of loss, frustration  Positive Valence Systems o Motivation, learning, and habit  Cognitive Systems o Attention, perception, and Memory  Social Process Systems o facial expression identification, imitation, attachment/separation fear  Arousal/Regulatory Processes o Stress regulation These would be analyzed in terms of genes, molecules, and cells (Greenburg, 339-342) 27

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

30 * 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 30

31 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 31

32 * 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 32

33 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 33

34 * 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 34

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

36 * 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 36

37 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 37

38 * 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 38

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

40 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 40

41 * 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 41

42 * 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 42

43 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 43

44 * 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 44

45 * 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 45

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

47 * 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? 47

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

49 * 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 49

50 * 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 50

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

52 * 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 52

53 * 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 53

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

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

56 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 56

57 * “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 57

58 * 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 58

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

60 * 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 60

61 * Subtypes changed 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 61

62 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 62

63 * 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 63

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

65 Problems with controlling emotions in personal and social situations, marked by extreme anger, explosive behaviors, or lack of affect and sense of responsibility 65

66 * 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 66

67 * 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 67

68 * 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 68

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

70 * 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 70

71 * 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 71

72 * 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 72

73 * 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 73

74 * 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 74

75 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 75

76 * 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 76

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

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

79 * 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 79

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

81 * Greatest change: 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 o 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 81

82 * 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 82

83 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 83

84 * 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 Examples:  Medication-Induced Parkinsonism  Medication-Induced Acute Dystonia  Medication-Induced Acute Akathisia  Tardive Dyskinesia, Dystonia, or Akathisia  Medication-Induced Postural Tremor 84

85 * 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 85

86 * 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 o Borderline Personality Disorder o Obsessive-Compulsive Personality Disorder o Avoidant Personality Disorder o Schizotypal Personality Disorder o Antisocial Personality Disorder o Narcissistic Personality Disorder The model seeks to discover impairments in functioning and is included to prompt further research 86

87 * Conditions for Further Study Disorders judged to need further research before being included as full disorders  Attenuated Psychosis Syndrome o 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 87

88 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 3-08-15-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 88

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: 109-130. 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 89

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