Presentation on theme: "Matt Dugan, LPC Steve Donaldson, MAC,CACII DAODAS: Charleston Center"— Presentation transcript:
1 Matt Dugan, LPC Steve Donaldson, MAC,CACII DAODAS: Charleston Center DSM-5: A First LookMatt Dugan, LPCSteve Donaldson, MAC,CACIIDAODAS: Charleston Center
2 Opening Considerations Brand NEW!Clinician’s PerspectiveAssumes familiarity with DSM-IV-TRRelax…we’ve got time.Good News: 947 vs pagesThis is not like driving your first new car off the lot. This instruction manual is far more complex!Not a physician: will attempt to incorporate my current clinical experience with the new materialCodes and Dx will be implemented over many months.Large number of slides meant for handouts for future reference.
3 Overview Rationale for revisions Specific Diagnostic Changes Controversies discussed throughoutMuch maligned book.Autism and ADHD changesMany fear over dx, but in fact, substance disorders dx will be more resticted
4 Goals of the DSM5Many resources, including handouts, field trial information, and video clips are available at psychiatry.org
5 Why Change?“DSM must evolve.…a too-rigid categorical system does not capture clinical experience or important scientific observations….[it] should accommodate ways to introduce dimensional approaches to mental disorders, including dimensions that cut across current categories.” (p5).Arbitrary categories: Disorders usually diagnosed in infancy, early childhood or adolescence and impulse control d/o not elsewhere classifiedWhile in the past DSM versions, disorders were diagnosed in categories when a certain number of symptoms were met, and if the number was not met, they were not diagnosed.However, the categorical syndromes do not always fit with the reality of the range of symptoms that individuals’ experience. For example, individuals with Schizophrenia often have other symptoms that do not match the criteria for diagnosing Schizophrenia – Insomnia, for example, or symptoms of depression and anxiety.Also, because the criteria for diagnosis are “yes/no” (i.e., does the individual have this disorder or not?), in most cases there is no method in DSM-IV to account for the severity of the disorder, and thus no specified way to determine if the patient is improving with treatment.
6 4 Revision Principles DSM5 is intended to be used by clinicians Revisions should be guided by research evidenceConsistency with previous versions, where possibleNo constraints should be placed on the degree of change between IV-TR and 5For clinicians, so must have clinical practice utility and ease.No Sacred CowsWorkgroups examined broader methodological concerns in the field, including contradictory evidence.Development of a refined definition of mental disorderConsistency: No Windows8 revision!Revision of the NOS disorders for greater specificityWeak and undervalidated diagnoses were considered for deletion.
7 Organizational Structure Many categories have been refined and diagnoses have been re-assignedICD and DSM collaboration to improve clarity and guide researchHarmony with ICD-11Far easier to use (much less page flipping)Each d/o has associated differentials and rationalesThough disorders have undergone field testing for interrater reliability, the classification of disorders into specific categories (Disorders of infancy, mood, psychotic, etc.) has not been considered scientifically significant.DSM III originally defined the diagnostic categories currently in use a half-century ago.Therefore, we currently see a high rate of comorbidity across categories , excessive use of NOS disorders, and inability to integrate DSM disorders with current genetic and scientific data.The existence of 2 classifications of mental disorders hinders the collection and use of national health statistics, clinical trials, treatments, etc.2 systems impair study across broad national boundariesEven when the intention was to identify identical patient populations, DSM-IV and ICD-10 did not always agree.It was imperative to collaborate to reduce confusion and improve utility across the global medical field.Currently DSM-IV utilizes ICD-9CMICD-10 implementation Oct 2014ICD-11 impending release: chosen code set for DSM5 (though both codes are present in the DSM5; already found some typos!)The goal is for insurance companies to be using DSM5 codes by Dec 31, 2013ALL of the criteria needed for specific mood disorders are located on consecutive pages, no need to specifically locate the criteria for hypomania and MDE
8 Dimensional Approach Removal of narrow categorical schema “…the once plausible goal of identifying homogeneous populations for treatment and research resulted in narrow diagnostic categories that did not capture clinical reality, symptom heterogeneity within disorders, and significant sharing of symptoms across multiple disorders.” (p12)DSM-IV in many ways focused on reducing false positive dx’s.Because its approach considered each dx as categorically separate from health and other disorders (Axis II and III) it didn’t capture the widespread sharing of sxs and risk factors across many disorders.Like most human ills, mental disorders are heterogeneous at many levels, ranging from genetic risk factors to symptoms.
9 Improvement Over Previous DSM The DSM-5 allows you to better capture the symptoms and severity of the illness.Assessments will be much more “dimensional”Clinicians will be able to rate both the presence and the severity of the symptoms, such as “Severe,” or “Moderate”This rating could also be done to track a patient’s progress in treatment, allowing a way to note improvements even if the symptoms don’t disappear entirely.The problem with the “Severe Vs Moderate, is they are the same dx code, so change is harder to see from an MIS view.
10 Dimensional Approach New Groupings were tied to scientific validators Shared neural substrates, family traits, environmental factors, biomarkers, temperamental antecedents, abnormalities of emotional or cognitive processing, symptoms similarity, course of illness, high comorbidity and shared treatment response.Internalizing and Externalizing FactorsFormed the empirical guidelines to inform decision making by the work groups about how to cluster disorders to maximize validity and clinical utility.Disorders will be broken out from their previous groupings based on new scientific understanding of their principal features.For example: because recent studies have shown that obsessive-compulsive disorder involves distinct neurocircuits, it and several related disorders will constitute their own chapter rather than be addressed in the chapter on anxiety disorders. Similarly, mood disorders are being divided into two chapters for bipolar and related disorders and for depressive disorders.Purpose: enable future research to enhance understanding of disease origin, pathophysiological commonalities between disorders, provide a base for validity through replication studies.Research demonstrated (via twin studies) links common genetic and environmental risk factors for Anxiety, Depressive and Somatic disorders (the internalizing group) These categories are adjacent in the DSM5.The Externalizing factors group (impulsive, disruptive conduct and substance use) shared similar risk factors and so were also placed next to each other.Perhaps analogous to the introversion-extroversion trait regarding stimulus or sensation seekingGoal: encourage advances in diagnosis, markers, and underlying mechanisms in future research.
11 Developmental/Lifespan Considerations Organized by developmental processesBoth within and between categoriesNeurodevelopmental disorders before Bipolar Disorders before Neurocognitive disordersSeparation Anxiety Disorder before Specific Phobia before Panic DisorderDSM-5 will be organized in sequence with the developmental lifespan. This organization will be evident in every chapter and within individual diagnostic categories, with disorders typically diagnosed in childhood detailed first, followed by those in adolescence, adulthood and later life. Disorders previously addressed in a single “infancy, childhood and adolescence” chapter will now be integrated throughout the manual.
12 DSM5 Categories Neurodevelopmental d/o Internalizing Group (Emotional and Somatic d/o)Bipolar and RelatedDepressiveAnxietyObsessive-Compulsive and RelatedTrauma- and Stressor-RelatedDissociativeSomatic symptom and RelatedWhile the actual number of disorders will not increase significantly, three additional disorder chapters will be added to DSM-5 to better classify the disorders based on known similarities to one another.The organization will be easier to follow..
13 DSM5 Categories Externalizing Group Neurocognitive Disorders Feeding and EatingEliminationSleep-WakeSexual DysfunctionGender DysphoriaDisruptive, Impulse-Control and ConductSubstance Related and AddictiveNeurocognitive DisordersPersonality DisordersParaphilic DisordersOther Mental Disorders/Conditions of Clinical Attention
14 DSM5 Categories Section III Assessment Measures Cultural Formulation Cross-Cutting Symptom Measures (Adult & child)Clinician rated dimensions of Psychosis Symptom SeverityWHO Disability Assessment Schedule 2.0Cultural FormulationAlternative DSM5 Model for Personality DisordersConditions for Further StudyCan replace GAF?Considerations for future study and possible dx: Caffeine Substance Related DO/ Intenet Gaming DO, etc, which may be addressed in the DSM5.1 or DSM5.2
15 Attention to Gender, Race, and Ethnicity The process for developing the proposed diagnostic criteria for DSM-5 has included careful consideration of how gender, race and ethnicity may affect the diagnosis of mental illness.Each chapter has considerations for gender, race, and ethnicity i.e, percentage of dx , etc.
16 What happened to NOS? We now have two options! Other Specified D/o Clinician communicates the specific reason that the presentation does not meet the criteria for any specific category within a diagnostic class.E.g., “Other Depressive D/o, depressive episode with insufficient symptoms”Unspecified D/oNo clinician specific reasonDecision between these is based on the clinician, providing maximum flexibility for diagnosis.Differentiating between these does not have to rely on some feature of the presentation, as with NOS in some cases.
17 Farewell Multiaxial System DSM-IV-TRDSM-5“The multiaxial distinction among Axis I, II, and III disorders does not imply that there are fundamental differences in their conceptualization….”Axis IV problems were specifically defined by DSM-IVAxis V: GAFIt’s gone.Psychosocial and Environmental problems are directly adopted from ICD-9-CM V codes and the new ICD-10 Z codes.WHODAS 2.0 (proposed for further study) Available at psychiatry.org/dsm5Even 20 years ago, there was concern about the validity of multiaxial taxonomy.In short, it is unnecessary for the purpose of making an effective diagnosis.GAF was dropped due to lack of conceptual clarity and questionable psychometrics in clinical practice.WHODAS (disability assessment schedule) internationally used, self-administered 5 pt likert rating 36Q, but clinician rated.6 domains: Understanding and Communicating, Getting Around, Self Care, Getting Along with People, Life Activities, household, Life Activities, school/work and Participation in Society.
18 Diagnostic exampleBrief Psychotic D/o ICD-9CM (F23) ICD-10 Stimulant Use disorder, severe, amphetamine type substance, (F15.20) Homelessness V60.0 (Z59.0) Extreme Poverty V60.2 (Z59.5) WHODAS: Average General Disability = 4 Severe
19 Highlights of Diagnostic Changes DSM5 (New disorders are underlined)
20 Neurodevelopmental Disorders MR has been replaced with Intellectual DisabilityCommunication D/O’sNow include Language and Speech Sound d/o (Replaced mixed receptive-expressive d/o and phonological d/o); added Social (Pragmatic) Comm d/o.Autism Spectrum d/osubsumes Asperger’s, Rett’s, Childhood Disintegrative d/o, and PDD NOS.ADHDMinimal changes to Learning and Motor d/o’s.ID: Criteria assess both adaptive functioning as well as cognitive capacitySocial Prag: new condition persistent difficulties in the social uses of verbal and nonverbal communicationAutism Spectrum: characterized by 2 Core domains: deficits in social communication and interaction and restricted pattern of behavior interests and activities.ADHD: subtle changes. Was: some impairing ADHD sxs before age 7 to Several impairing sx by age 12; comorbid dx with autism is now permitted; symptom threshold for adult ADHD has been revised (5 symptoms instead of 6).
21 Schizophrenia Spectrum Eliminated special attribution of bizarre delusions and Schneiderian first rank AHAdded the requirement that at least one of Criterion A symptoms must be delusions, hallucinations or disorganized speech.Eliminated all subtypesSchizoaffective d/oRequires that a major mood episode be present for a majority of the illness’s durationDelusional D/oNo longer requires that delusions be nonbizarreCatatonia is now uniform throughout the DSM and may be used with a specifierEliminated Shared Psychotic d/o1st rank: two or more voices conversingTherefore requiring 2 Criterion A symptoms for a dx of SCZ: delusions (Not bizare), Hallucinations, disorg speech, grossly disorg or catatonic beh and neg sxSubtypes were not validated, unstable across the lifespan and low reliabilitySAFD ex: “I’ve got schizophrenia bipolar d/o.”
22 Bipolar and Related Disorders Diagnosis requires both changes in mood and changes in activity or energyMixed episode is replaced with new specifier: “With mixed features.”Anxious Distress specifier was added; all other specifiers remainMore flexibility for ‘orphaned’ patients whose spectrum of sxs don’t fit perfectly.Orphaned: Other Specified Bipolar d/o example: hx of MDE and symptoms of hypomania but only for 3 days (4 days required for Bipolar II dx)
23 Depressive Disorders Disruptive Mood Dysregulation d/o Addresses overtreatment and over-dx of bipolar in children. Persistent irritability and episodes of extreme behavior dysregulationPMDD is now officially classifiedPersistent Depressive d/o subsumes dysthymia and chronic MDDMixed Features specifier replaced Mixed EpisodeBereavement symptom duration exclusion has been removed for MDDOther Specified Depressive d/ocan capture recurrent brief depression, short duration episodes, or episodes with insufficient sxsDMDD: up to 12 years. Most research demonstrates these children develop unipolar depression in adulthood not bipolar.Bereavement: MDE lasting less than 2 mos following death was excluded from DX of MDD in DSM –IV. Doesn’t match grief science Grief= 1-2 years and MDD symptoms can be precipitated by these events.Once again, the mixed features specifier assists the clinician. Gray areas of disorders. Dimensional not categorical.Proposed conditions for further study:Suicidal Beh d/oNonsuicidal self-injury
24 Anxiety Disorders OCD and PTSD removed Specific Phobia and Social Anxiety d/oRemoved criterion that adults recognize their anxiety is excessive/unreasonable; instead level of anxiety must be disproportional to the actual dangerGeneralized specifier for SAD has been replaced with ‘performance only’ specifierPanic Attacks specifierPanic attacks and Agoraphobia are unlinked in DSM5Separation Anxiety d/o and Selective Mutism now are classified hereGiven their own chaptersDisproportional after cultural factors have been accounted forPanic attacks can specify any DSM d/oNew Dx: Panic d/o and Agoraphobia, replace panic w/agor, panic w/o agor, and agor w/o panic (much simpler)Wording of Criteria for Separation Anxiety d/o better account for adult onset sx
25 Obsessive-Compulsive and Related D/O New to DSM5Hoarding d/oExcoriation (skin-picking) d/oSubstance-induced Obsessive-Compulsive d/oObsessive-Compulsive and related d/o due to another medical conditionTrichotillomania has been reclassified from DSM-IV Impulse-Control d/o categoryBody Dysmorphic d/oSpecifiersGood or Fair Insight, Poor Insight and Absent insight/delusionalOCD now includes ‘tic-related’ specifier“Muscle dysphoria’ added to BDDDelusional variant of BDD is coded with absent insight specifier instead of an additional delusional d/o, somatic typeTic specifier has important clinical implications
26 Trauma- and Stressor-Related Disorders Adjustment d/o are reclassified hereReactive Attachment d/o and Disinhibited Social Engagement d/oPTSD criteria differ significantlyAdj: have been reconceptualized as a heterogeneous array of stress-response syndromes that occur after a stressful event rather than a residual category for subsyndromal distress.RAD and DSE d/o more fully explain the DSM-IV subtypes of Reactive Attachment d/o and reflect the Internalizing and Externalizing Factors for conceptualizing DSM5 disorders discussed earlier.
27 PTSD What constitutes ‘traumatic’ is more explicit Criterion A2 (DSM-IV) referencing intense-negative subjective reaction has been removedDSM-IV had 3 symptoms clusters; DSM5 has 4Re-experiencingAvoidancePersistent negative alterations in cognitions and moodArousalAs with DSM-IV but now includes irritable beh or angry outbursts and reckless or self-destructive beh.Dx thresholds have been lowered for children and adolescents.Separate criteria have been added for children age 6 or younger.Specifier for dissociative symptoms has been addedAvoidance cluster was broken into avoidance and persistent negative cognitions/mood
28 Definition of Trauma DSM-IV Criterion A DSM-5 Criterion A “1) the person experienced, witnessed, or was confronted with an event or events that involved actual or threatened death or serious injury, or a threat to the physical integrity of self or others.2) the person’s response involved intense fear, helplessness, or horror.” p467“Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways:1) Directly experiencing the traumatic event(s)2)Witnessing, in person, the event(s) as it occurred to others.3) Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental4) Experiencing repeated or extreme exposure to aversive details of the traumatic event(s)….” p271DSM5 A4 does not include exposure through electronic media, etc.
29 Dissociative Disorders Depersonalization d/o is now Depersonalization/Derealization d/oDissociative Fugue is now a specifier of Dissociative AmnesiaDissociative Identity d/oDisruptions of identify may be reported as well as observedGaps in recall for events may occur for everyday, not just traumatic events.Cultural note: DID criterion A includes: “Disruption of identity characterized by two or more distinct personality states, which may be described in some cultures as an experience of possession…”DSM5 incorporates these cultural references throughout.
30 Somatic Symptom and Related Disorders New name for Somatoform d/oVery likely to be identified/treated by the PCP and NOT by psychiatryReduces number of d/o to avoid problematic overlapSomatization, hypochondriasis, pain, and undiff. somatoform d/o have been removedSomatic Symptom d/o = somatization d/oIllness Anxiety d/o = hypochondriasisPsychological factors affecting other medical conditionsConversion d/o (Functional Neurological Symptom d/o)In psychology, a somatic sx d/o are mental disorders characterized by physical symptoms that suggest physical illness or injury – symptoms that cannot be explained fully by a general medical condition, direct effect of a substance, or attributable to another mental disorder (e.g. panic disorder).The symptoms that result from a somatoform disorder are due to mental factors.In people who have a somatoform disorder, medical test results are either normal or do not explain the person's symptoms. It is not malingering or a factious disorder.DSM5 stresses the importance of neurological testing when attempting to diagnose a Somatic Symptom or related d/osomatization d/o only if maladaptive thoughts, feelings and beh are present.Illness Anxiety d/o = hypochondriasis: high health anxiety but no somatic symptoms, unless better explained by another condition; specifier care-seeking type, care avoidant typeSome individuals with chronic pain would be appropriately diagnosed as having somatic sx d/o with predominant painConversion specifiers: weakness/paralysis, abnormal movement, swallowing sx, speech sx, attacks or sz, anesthesia or sensory loss, special sensory sx, mixed sxs.
31 Feeding and Eating Disorders Avoidant/restrictive food intake d/o for infantsAnorexia nervosarequirement for amenorrhea was eliminated.Bulimia nervosaAverage frequency of binge/compensatory beh reduced to once weeklyBinge Eating d/oCriteria as proposed in DSM-IV appendix is unchanged substantiallyDSM-IV eating disorders of childhood will be reclassified and placed in the “Eating Disorders” category (Pica, Rumination).It is proposed that the wording of "non-food substances" be added alongside the current DSM-IV-TR wording of "non-nutritive substances to clarify that items consumed are not just merely lacking nutrients (diet soda, according to the DSM-V committee, is an example of a non-nutritive substance), but are actual non-foodstuffs.Mayor Bloomberg joke
32 Sleep-Wake DisordersNarcolepsy (associated with hypocretin deficiency) is now distinguished from hypersomnolence d/oBreathing-related sleep d/oObstructive sleep apneaHypopneaCentral sleep apneaSleep-related hypoventilationExpanded circadian rhythm sleep disordersREM sleep Behavior d/oRestless Legs syndrome
33 Sexual DysfunctionsFemale arousal and desire d/o have been combined: Female sexual interest/arousal d/oGenito-pelvis pain/penetration d/oSexual Aversion d/o removed2 subtypes:Lifelong vs. acquiredGeneralized vs. situationalGenito- :combined vaginismus and dyspareunia, which were highly comorbidAversion: rare use or supporting research
34 Gender DysphoriaEmphasizes the phenomenon of gender incongruence rather than cross-gender identification, as in DSM-IV Gender Identity d/oCriteria for Child diagnosis has been made more restrictive and conservativeSubtyping on the basis of sexual orientation was removedPosttransition specifierDSM5 focuses on the clinical problem, the dysphoria, not the identity of the individualAlong with these changes comes the creation of a separate Gender Dysphoria in Children as well as one for Adults and Adolescents. The grouping will be moved out of the Sexual Disorders category and into its own. The name change was made in part due to stigmatization of the term "disorder" and the relatively common use of "gender dysphoria" in the GID literature and among specialists in the area. The creation of a specific disorder for children reflects the lesser ability of children to have insight into what they are experiencing and ability to express it in the event that they have insight
35 Disruptive, Impulse-Control, and Conduct Disorders ODD criteria grouped in 3 types:Angry/irritable moodArgumentative/defiant behaviorVindictivenessConduct d/o now requires limited prosocial emotionsIntermittent Explosive d/o criteria is not limited to physical aggressionConduct: b/c ASPD is frequently associated with these d/o it is listed in this category as well as PD’s.
36 Substance-Related and Addictive Disorders Gambling d/oAbuse and Dependence replaced with Substance Use d/oCriteria included for Intoxication, Withdrawal, Substance-Induced and Unspecified Substance-Related d/oNew criterion: CravingThreshold for Dx set at 2 criteriaCannabis and Caffeine Withdrawals
37 Substance-Related and Addictive Disorders Severity of SUD is based on number of endorsed criteriaMild 2-3Moderate 4-5Severe 6+SpecifiersEarly remissionSustained remissionIn a controlled environmentOn maintenance therapyEliminated from DSM-5With/Without Physiological dependencePartial/Full remissions specifiersPolysubstance DependenceControlled environment specifier can be added to early or sustained specifer: alcohol use disorder in early remission in a controlled environment.
38 SUD CriteriaA. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12-month period:1. recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)2. recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)3. continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)4. tolerance, as defined by either of the following:a. a need for markedly increased amounts of the substance to achieve intoxication or desired effectb. markedly diminished effect with continued use of the same amount of the substance(Note: Tolerance is not counted for those taking medications under medical supervision such as analgesics, antidepressants, ant-anxiety medications or beta- blockers.)(Next Page)>>>>>>
39 SUD Criteria Continued 5. withdrawal, as manifested by either of the following:a. the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)b. the same or a closely related substance is taken to relieve or avoid withdrawal symptoms6. the substance is often taken in larger amounts or over a longer period than was intended7. there is a persistent desire or unsuccessful efforts to cut down or control substance use8. a great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects9. important social, occupational, or recreational activities are given up or reduced because of substance use10. the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.11. Craving or a strong desire or urge to use a specific substance.Proposed for further study:Caffeine Use d/oInternet Gaming d/oNeurobehavioral d/o Associated with Prenatal Alcohol Exposure
40 Neurocognitive Disorders Dementia and Amnestic d/o are subsumed under Major or mild Neurocognitive d/o.Specific criteria for various etiologies are incorporatedFrontotemporal NCD, Lewy Bodies, Vascular, TBI, substance/medication induced, HIV, Prion, Parkinson’s, Huntington's, etc.
41 Personality Disorders The criteria for the 10 DSM-5 PD’s have not changed.Alternative approach was field tested3 Clusters remain (though empirically remain unvalidated)Field Test: results not robust enough yet. Included in Section III for further exploration. Strong connotation in the text for a reconceptualizing of PDs at large.Therefore, I’ve included an introduction to the Trait specified PD concept.
42 Personality Disorder (Proposed) Criteria similar to current understandingi.e., pervasive and relatively stable pattern of behavior, cognitions, affect and social interaction that are maladaptiveConceptualizes functioning based on dimensions of healthy vs. pathological personality domains & traitsAdopted from over a century of Personality Research
43 PD Proposed Impairment in functioning areas (2 or more): IdentitySelf-DirectionEmpathyIntimacyPresence of Pathological Personality Trait domains (or facets) (1 or more):Negative Affectivity (vs.. Emotional Stability)Detachment (vs.. Extraversion)Antagonism (vs.. Agreeableness)Disinhibition (vs.. Conscientiousness)Psychoticism (vs.. Lucidity)Identity and Self-direction represent general functioning of the selfEmpathy and Intimacy refer to interpersonal functioning.Both rated on 0-4 Likert scale from little or no impairment to Extreme impairment
45 ConclusionsDSM-5 has been a work in progress for 12 years and represents the most current understanding of psychiatric, psychological, and neurologic literature.Discrete classification has been tempered by dimensional conceptualization regarding symptoms and severity of presentationDevelopmental and Cultural implications are woven throughout for clarity, parsimony and to incorporate the broadest global understanding of mental disordersDesigned with the clinician in mind for ease of use