An Introduction to the DSM-5

An Introduction to the DSM-5
Mark Schwarze, PhD, LPCS, NCC, LCAS, CCS Assistant Professor & Program Director Clinical Mental Health Counseling Program Appalachian State University

History Improving Research
DSM I (1952) & DSM II (1968) – very brief manuals, guided by psychoanalysis, gross categories (e.g., neurosis, psychosis), lack of reliability, no research base DSM III (1980), DSM IV (1994), DSM IV TR (2000) – field trials to improve reliability, better research base, multiaxial classification

History Each DSM has tried to resolve problems in previous versions.
Problems in DSM-IV-TR Not very user friendly. 9 categories for diagnostic uncertainty. NOS predominated. Insufficient on culture. DZ

Intent of the DSM-5 David Kupfer, MD DSM-5 Task Force Chair
1. “incorporation of a developmental approach to psychiatric disorders” 2. “a move toward the use of dimensional measures to rate severity and disaggregate symptoms that tend to occur across multiple disorders” 3. “harmonization of the text with ICD” 4. “integration of genetic and neurobiological findings by grouping clusters of disorders that share genetic or neurobiological substrates”

Principles for Revision
Four principles for revision insure DSM-5 has clinical utility evidence will inform DSM-5 maintain continuity with DSM-IV but revise where the evidence requires doing so Intended to address frequently co-occuring disorders such as depression and anxiety Reduce use of NOS Introduction of dimensional assessments

Big Changes Summarized
Representation of developmental issues related to diagnosis Integration of scientific findings from the latest research in genetics and neuroimaging Consolidation of autistic d/o, Asperger’s d/o, and pervasive development d/o in autism spectrum d/o Streamlined classification of bipolar and depressive d/o’s

Big Changes Summarized
Restructuring of substance use d/os for consistency and clarity Enhanced specificity for major and mild neurocognitive d/os Transition in conceptualizing personality d/os Section III added: New d/os and assessment features Online enhancements –

Criticisms of the DSM-5 Allen J. Frances, Huffington Post on 5/1/13 DSM-5 represents a wholesale, imperial medicalization of normality Sachdev, P. S. (2013). Is DSM-5 defensible? Australian and New Zealand Journal of Psychiatry, 47(1), doi: http: //dx. doi. org/ / DSM-5 is lowering the thresholds of various diagnoses, resulting in the medicalization of normal human experience and the creation of spurious epidemics of mental illness. DSM-5 work group members are compromised by their declared and undeclared conflicts of interest. DSM-5 continues to inappropriately impose categorical constructs on dimensional mental states or conditions. DSM-5 is creating new mental disorder diagnoses for the benefit of the profession and the pharmaceutical industry.

Of the DSM-5 task force members, 69% report having ties to the pharmaceutical industry Cosgrove, L. & Drimsky, L. (2012).

Sections and General Content
Section I: DSM-5 Basics Introduction Use of the Manual Cautionary Statement for Forensic Use of DSM-5 Section II: Diagnostic Criteria and Codes Present the categorical diagnoses according to a revised 20 chapter organization that eliminates the multiaxial system Section III: Emerging Measures and Models Assessment Measures Cultural Formulation Alternative DSM-5 Model for Personality Disorders Conditions for Further Study Appendix Highlights of Changes From DSM-IV to DSM-5 Glossary of Technical Terms Glossary of Cultural Concepts of Distress DSM-5 Diagnoses and Codes (ICD-9-CM and ICD-10-CM)

Diagnostic Categories

Major Diagnostic Classifications
1. Neurodevelopmental Disorders 2. Schizophrenia Spectrum and Other Psychotic Disorders 3. Bipolar and Related Disorders 4. Depressive Disorders 5. Anxiety Disorders 6. Obsessive-Compulsive and Related Disorders 7. Trauma and Stressor- Related Disorders 8. Dissociative Disorders 9. Somatic Symptom and Related Disorders 10. Feeding and Eating Disorders 11. Elimination Disorders 12. Sleep-Wake Disorders 13. Sexual Dysfunctions 14. Gender Dysphoria 15. Disruptive, Impulse- Control, and Conduct Disorders 16. Substance-Related and Addictive Disorders 17. Neurocognitive Disorders 18. Personality Disorders 19. Paraphilic Disorders 20. Other Disorders

Examples of Specific Disorders
Diagnostic Category Examples of Specific Disorders Neurodevelopmental Disorders Autism Spectrum Disorder Specific Learning Disorder Communication Disorders ADHD, Motor Disorders, etc. Schizophrenia Spectrum and Other Psychotic Disorders Schizophrenia Schizophreniform Disorder Schizoaffective Disorder Delusional Disorder Schizotypal Personality Disorder Bipolar and Related Disorders Bipolar I Disorder, Bipolar II Disorder Cyclothymic Disorder Depressive Disorders Disruptive Mood Dysregulation Disorder Major Depressive Disorder Persistent Depressive Disorder Premenstrual Dysphoric Disorder

Diagnostic Category Examples of Specific Disorders Anxiety Disorders Specific Phobia Social Anxiety Disorder (Social Phobia) Panic Disorder Agoraphobia Generalized Anxiety Disorder Separation Anxiety Disorder Selective Mutism Obsessive-Compulsive and Related Disorders Obsessive-Compulsive Disorder Body Dysmorphic Disorder Hoarding Disorder Hair-Pulling Disorder (Trichotillomania) Excoriation (Skin-Picking) Disorder Trauma and Stressor Related Disorders Adjustment Disorders Acute Stress Disorder Posttraumatic Stress Disorder Reactive Attachment Disorder Disinhibited Social Engagement Disorder

Diagnostic Category Examples of Specific Disorders Dissociative Disorders Dissociative Identity Disorder Dissociative Amnesia Depersonalization/Derealization Disorder Somatic Symptom and Related Disorders Somatic Symptom Disorder Illness Anxiety Disorder Conversion Disorder (Functional Neurological Symptom Disorder) Factitious Disorder Feeding and Eating Disorders Anorexia Nervosa Bulimia Nervosa Binge Eating Disorder Pica, Rumination Disorder Avoidant/Restrictive Food Intake Disorder Elimination Disorders Enuresis Encopresis

Diagnostic Category Examples of Specific Disorders Sleep-Wake Disorders Insomnia Disorder Hypersomnolence Disorder Narcolepsy Breathing-Related Sleep Disorders Circadian Rhythm Sleep-Wake Disorders Parasomnias: Sleepwalking, Sleep Terrors, Nightmare Disorder, Rapid Eye Movement Sleep Behavior Disorder Restless Legs Syndrome Sexual Dysfunctions 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

Examples of Specific Disorder
Diagnostic Category Examples of Specific Disorder Gender Dysphoria Disruptive, Impulse-Control, and Conduct Disorders Oppositional Defiant Disorder Intermittent Explosive Disorder Conduct Disorder Antisocial Personality Disorder Pyromania Kleptomania Substance-Related and Addictive Disorders Substance Use Disorders Substance-Induced Disorders Gambling Disorder Neurocognitive Disorders Delirium Major & Mild Neurocognitive Disorders

Diagnostic Category Examples of Specific Disorders Personality Disorders Paranoid Personality Disorder Schizoid Personality Disorder Schizotypal Personality Disorder Antisocial Personality Disorder Borderline Personality Disorder Histrionic Personality Disorder Narcissistic Personality Disorder Avoidant Personality Disorder Dependent Personality Disorder Obsessive-Compulsive Personality Disorder

Diagnostic Category Examples of Specific Disorders Paraphilic Disorders Voyeuristic Disorder Exhibitionistic Disorder Frotteuristic Disorder Sexual Masochism Disorder Sexual Sadism Disorder Pedophilic Disorder Fetishistic Disorder Transvestic Disorder Other Mental Disorders Other Specified Mental Disorder due to Another Medical Condition

Substance-Related and Addictive Disorders

Substance Use Disorders No more Substance Abuse and Substance Dependence Criteria Nearly identical to the DSM-IV substance abuse and dependence criteria combined into a single list Nearly all substances are diagnosed based on the same overarching criteria Criteria for intoxication, withdrawal, substance/medication-induced disorders, and unspecified substance-induced disorders Threshold = 2 of 11 symptoms Impaired control (criteria 1-4) Social impairment (criteria 5-7) Risky use (criteria 8-9) Pharmacological criteria (criteria 10-11) Removed: recurrent legal problems criterion Added: craving or a strong desire or urge to use a substance

SUD Criteria Impaired control (criteria 1-4) Social impairment (criteria 5-7) Risky use (criteria 8-9) Pharmacological criteria (criteria 10-11) ______ is often taken in larger amounts or over a longer period than was intended. There is a persistent desire or unsuccessful efforts to cut down or control _____ use. A great deal of time is spent in activities necessary to obtain ______, use _____, or recover from its effects. Craving, or a strong desire or urge to use ____. Recurrent _____ use resulting in a failure to fulfill major role obligations at work, school, or home. Continued _____ use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of _____. Important social, occupational, or recreational activities are given up or reduced because of _____use. Recurrent _____ use in situations in which it is physically hazardous. ____ 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 _____. Tolerance, as defined by either of the following: A need for markedly increased amounts of _____ to achieve intoxication or desired effect. A markedly diminished effect with continued use of the same amount of ____. Withdrawal, as manifested by either of the following: The characteristic withdrawal syndrome for ____ ____ is taken to relieve or avoid withdrawal symptoms.

Remission specifiers No more partial and full Early remission = at least 3 but less than 12 months without substance use disorder criteria (except craving) Sustained remission = at least 12 months without criteria (except craving) Severity ratings 2–3 criteria indicate = a mild disorder 4–5 criteria = moderate disorder 6 or more = a severe disorder Removed Polysubstance Abuse/Dependence Amphetamine Cocaine Specifier for a physiological subtype On agonist therapy Added: Cannabis & Caffeine Withdrawal Tobacco Use Disorder In a controlled environment specifier On Maintenance therapy specifier

Gambling Disorder “This change reflects the increasing and consistent evidence that some behaviors, such as gambling, activate the brain reward system with effects similar to those of drugs of abuse and that gambling disorder symptoms resemble substance use disorders to a certain extent” Lowering of the pathological gambling threshold to 4 symptoms Removal of the ‘‘illegal acts’’ criterion for the disorder

Depressive Disorders

Depressive Disorders Bereavement Exclusion
In DSM-IV, there was an exclusion criterion for a major depressive episode that was applied to depressive symptoms lasting less than 2 months following the death of a loved one (i.e., the bereavement exclusion). This exclusion has been omitted in DSM-5. - bereavement can be long lasting and persistent - it is a severe psychosocial stressor that can initiate depressive episodes - genetic connection - bereavement-related depression and non-bereavement depression respond to same treatments

Grief vs MDE in DSM-5 Grief
Dominant affect is feelings of emptiness and loss Dysphoria occurs in waves, vacillates with exposure to reminders and decreases with time Capacity for positive emotional experiences Self-esteem preserved Fleeting thoughts of joining deceased Major Depression Dominant affect is depressed mood Persistent dysphoria that is accompanied by self-critical preoccupation and negative thoughts about the future Limited capacity to experience happiness or pleasure Worthlessness clouds esteem Suicidal ideas about escaping life versus joining a loved one

Specifiers for MDD With anxious distress With mixed features
With melancholic features With atypical features With mood-congruent psychotic features or with mood-incongruent psychotic features With catatonia (code separately) With peripartum onset With seasonal pattern

Disruptive Mood Dysregulation Disorder (DMDD)
Essential feature: Severe temper outbursts with underlying persistent angry or irritable mood – Temper outburst frequency: Three or more time a week – Duration: Temper outbursts and the persistently irritable mood between outbursts lasts at least 12 months – Severity: Present in two settings and severe in at least one – Onset: Before age 10 but do not diagnose before age 6. Can not diagnose for the first time after age 18. – Common rule-outs: Bipolar disorder, intermittent explosive disorder, depressive disorder, ADHD, ASD, separation anxiety disorder If ODD present, do not dx

Persistent Depressive Disorder (formerly Dysthymia)
Essential feature: Depressed mood plus at least two other depressive symptoms • Duration: The symptoms persist for at least two years (one year for children and adolescents) • May include periods of major depressive episodes (double depression) • Rule outs: Be sure it is not due to another psychotic disorder, substance, medication or medical condition

Premenstrual Dysphoric Disorder (PMDD)
Essential feature: Significant affective symptoms that emerge in the week prior to menses and quickly disappear with the onset of menses Symptom threshold: At least five symptoms which include marked affective lability, depressed mood, irritability, or tension Duration: Present in all menstrual cycles in the past year and documented prospectively for two menstrual cycles Impairment: Clinically significant distress or impairment Rule outs: An existing mental disorder (e.g., MDD), another medical condition (e.g., migraines that worsen during the premenstrual phase) or substance or medication use

Bipolar and Related Disorders

Bipolar Disorders the primary criteria for manic and hypomanic episodes (Criterion A) now includes an emphasis on changes in activity and energy — not just mood. a new specifier, “with mixed features,” has been added, that can be applied to episodes of mania or hypomania when depressive features are present. A specifier for anxious distress is now defined. This specifier is intended to identify patients with anxiety symptoms that are not part of the bipolar diagnostic criteria

Anxiety Disorders

Changes from IV-TR to 5 1. Including Selective Mutism and Separation Anxiety Disorder into Anxiety Disorders 2. Changing the name of Social Phobia to Social Anxiety Disorder. 3. Removing Panic Attack as a specifier for Agoraphobia. 4. Assigning Panic Attack as a specifier that may be applied to a wide array of DSM-5 diagnoses. 5. Removing OCD, PTSD, ASD from this category

Separation Anxiety Disorder
Separation Anxiety Disorder was moved from Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence (DSM-IV-TR) to the Anxiety Disorders chapter. The age-of-onset requirement (‘‘before age 18 years’’) was been dropped; thus allowing for diagnosis of Separation Anxiety Disorder in adults (Mohr & Schneider, 2013).

Social Anxiety Disorder (SAD)
Social phobia was originally classified as a mental disorder in the DSM-III and has been renamed Social Anxiety Disorder (SAD) in the DSM-5. The main feature of SAD is ongoing fear and worry surrounding myriad social situations (Kerns, Corner, Pincus, & Hofmann, 2013). It is one of the most common mental disorders with a lifetime prevalence rate of slightly greater than 10%. The majority of diagnoses are made during childhood or early adolescence (Kerns et al., 2013; Marques et al., 2011). SAD is often seen in conjunction with Major Depressive Disorders, other Anxiety Disorders, and Substance Use Disorders (APA, 2013).

SAD Individuals with SAD often fear negative evaluation (e.g., being humiliated, embarrassed, or rejected) by others (either unfamiliar or familiar) in performance, interaction, or observation situations. A Performance only specifier has been added for SAD in the DSM-5 and includes a minimum duration of 6 months. Children, adolescents, and adults now share the same criteria for duration, and the criterion for adult insight has been dropped (Mohr & Schneider, 2013).

Trauma & Stress-Related Disorders

PTSD Instead of three major symptom clusters for PTSD, the DSM-5 now lists four clusters: Re-experiencing the event — For example, spontaneous memories of the traumatic event, recurrent dreams related to it, flashbacks or other intense or prolonged psychological distress. Heightened arousal — For example, aggressive, reckless or self-destructive behavior, sleep disturbances, hyper-vigilance or related problems. Avoidance — For example, distressing memories, thoughts, feelings or external reminders of the event. Negative thoughts and mood or feelings — For example, feelings may vary from a persistent and distorted sense of blame of self or others, to estrangement from others or markedly diminished interest in activities, to an inability to remember key aspects of the event.

PTSD Subtypes Children 6 and Younger Subtype, which is used to diagnose PTSD in children younger than 6 years. Post-traumatic stress disorder is also now developmentally sensitive, meaning that diagnostic thresholds have been lowered for children and adolescents. PTSD Dissociative Subtype. It is chosen when PTSD is seen with prominent dissociative symptoms. These dissociative symptoms can be either experiences of feeling detached from one’s own mind or body, or experiences in which the world seems unreal, dreamlike or distorted.

Other TSRDs Adjustment disorders are reconceptualized in the DSM-5 as a stress-response syndrome. This takes them out of their residual, catch-all category and places them into a conceptual framework that these disorders represent a simple response to some type of life stress (whether traumatic or not).

Obsessive-Compulsive and Related Disorders

Hoarding Disorder Hoarding graduates from being listed as just one symptom of obsessive-compulsive personality disorder in the DSM-IV, to a full-blown diagnostic category in the DSM-5. Hoarding disorder is characterized by the persistent difficulty discarding or parting with possessions, regardless of the value others may attribute to these possessions

Autistic Spectrum Disorder

Pervasive Developmental Disorders (DSM-IV-TR)
Autistic Disorder Childhood Disintegrative Disorder Asperger’s Disorder Pervasive Developmental Disorder, NOS

Autism Spectrum Disorder
A. Persistent deficits in social communication and social interaction across multiple contexts, as manifested by the following, currently or by history Deficits in social-emotional reciprocity Deficits in nonverbal communicative behaviors uses for social interactions Deficits in developing, maintaining, and understanding relationships

Autism Spectrum Disorder
B. Restricted, repetitive patterns of behavior, interests, or activities, as manifested by at least two of the following, currently or by history ∗ Stereotyped or repetitive motor movements, use of objects, or speech ∗ Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior ∗ Highly restricted, fixated interests that are abnormal in intensity or focus ∗ Hyper- or hyporeactivity to sensory input or unusual interest in sensory aspects of the environment

Specifiers/Modifiers
With or without accompanying intellectual impairment ∗ With or without accompanying language impairment ∗ Associated with a known medical or genetic condition or environmental factor ∗ Associated with another neurodevelopmental, mental, or behavioral disorder ∗ With catatonia

Level of Severity Level 1: Requiring Support
Level 2: Requiring Substantial Support Level 3: Requiring Very Substantial Support

Example Diagnoses Autism Spectrum Disorder, Level 2, with mild intellectual disability and language impairment onset age 20 months loss of previously acquired language ∗ Autism Spectrum Disorder, Level 1, associated with ADHD without intellectual disability and without language impairment ∗ Autism Spectrum Disorder, Level 2, associated with Cerebral Palsy, mild intellectual impairment and stuttering

Personality Disorders

New Hybrid Personality Model
In the new proposed model, clinicians would assess personality and diagnose a personality disorder based on an individual’s particular difficulties in personality functioning and on specific patterns of those pathological traits. The hybrid methodology retains six personality disorder types: Borderline Personality Disorder Obsessive-Compulsive Personality Disorder Avoidant Personality Disorder Schizotypal Personality Disorder Antisocial Personality Disorder Narcissistic Personality Disorder

New Hybrid Personality Model
Criterion A includes assessment of personality functioning towards self (identity, self-direction), and interpersonally (empathy, intimacy). Criterion B includes Pathological Personality Traits Five broad traits- Negative Affectivity, Detachment, Antagonism, Disinhibition, and Psychotisim. (and 25 trait facets)

Assessment & Diagnosis

Purpose of a DSM-5 Diagnosis
“If the disorder does not usefully inform that person’s diagnosis, treatment, or prognosis, then the diagnosis is considered inappropriate” (Nussbaum, 2013, p. 10) The diagnosis should have clinical utility: Prognosis, Plan and Outcome

Approach to Clinical Case Formulation
Diagnostic content Diagnostic Features Associated Features Prevalence Development and Course Risk and Prognostic Factors (Environment, Genetic and physiological, Temperamental, Course modifiers) Culture-Related Diagnostic Issues Gender-Related Diagnostic Issue Suicide Risk Functional Consequences Differential Diagnosis Comorbidity Subtypes Specifiers – course, severity, descriptive, In Full/Partial Remission Mild/Moderate/Severe/Extreme/Profound, Single/Recurrent/Episodic/ Persistent Acute/Subacute Generalized/Situational Lifelong/Acquired

No More 5 Axes Diagnosis. Axis I Axis II Axis III Axis IV Axis V
Collapsing Axis I/II/III examining codes in the ICD-10 that might be comparable to the concepts in DSM-IV - allows DSM to more closely parallel the ICD goals is to operationalize disability to be more consistent with the WHO’s approach in the International Classification of Functioning, Disability and Health (ICF)

DSM 5 Diagnosis Primary Diagnosis:
The most acute condition that requires the most intensive skilled services

More Psychosocial Stressor Options (pp.715-727)
Relational Problems Problems related to family upbringing Other problems related to primary support group Abuse and Neglect Child maltreatment and neglect problems child physical abuse child sexual abuse child neglect child psychological abuse Adult maltreatment and neglect problems spouse or partner violence, physical spouse or partner violence, sexual spouse or partner neglect spouse of partner abuse, psychological Adult abuse by nonspouse or nonpartner

More Psychosocial Stressor Options (pp.715-727)
Educational and Occupational Problems Educational Problems Occupational Problems Housing and Economic Problems Housing Problems 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 Psychological, Personal, and Environmental Circumstances Other Circumstances of Personal history Problems Related to Access to Medical and Other Health Care Nonadherence to Medical Treatment

Assessment Measures Cross-Cutting Symptom
Level 1 Cross-Cutting Symptom Measure Treatment, prognosis, and track changes For substance use, suicidal ideation, and psychosis, a rating of slight or greater on any item within the domain may serve as a guide for additional inquiry and follow-up to determine if a more detailed assessment is needed Adult version 13 psychiatric domains Parent/guardian-rated version For children ages psychiatric domains Level 2 Cross-Cutting Symptom Measure More in-depth information on potentially significant symptoms to inform diagnosis, treatment planning, and follow-up Depression Anger Mania Anxiety Somatic symptoms Suicidal ideation Psychosis Sleep problems Memory Repetitive thoughts and behaviors Dissociation Personality functioning Substance use Clinician-Rated Dimensions of Psychosis Symptom Severity- Help with treatment planning and prognostic decision-making

Assessment Measures WHODAS 2.0
World Health Organization Disability Assessment Schedule (WHODAS 2.0) Provided in Section III (pp ) as the best current alternative for measuring disability: various disorder- specific severity scales Scoring for 36 item full version: 0 = no disability; 100 = full disability Adults age 18 years and older Areas of functioning past 30 days Self administered or interview administered Covers six domains Average domain score Average general disability score Cognition – understanding & communication Mobility – moving & getting around Self-care – hygiene, dressing, eating & staying alone Getting along – interacting with other people Life activities – domestic responsibilities, leisure, work & school Participation – joining in community activities

Cultural Formulation Outline for Cultural Formulation
Identity, conceptualization, psychosocial stressors, therapy relationship, and overall assessment Cultural Formulation Interview (CFI) In the CFI, culture refers primarily to the values, orientations, and assumptions that individuals derive from membership in diverse social groups (e.g., ethnic groups, the military, faith communities), which may conform or differ from medical explanations Set of 14 questions that clinicians may use to obtain information during a mental health assessment about the impact of culture on key aspects of care Cultural Definition of the Problem - Cultural Perceptions of Cause, Context, and Support - Cultural Factors Affecting Self Coping & Past Help Seeking Current Help Seeking Cultural Concepts of Distress To avoid misdiagnosis, obtain useful clinical information, improve clinical rapport and engagement, improve therapeutic efficacy, guide clinical research, and clarify cultural epidemiology

Web Resources

Sample Diagnosis Sample DSM-5 Diagnosis
F34.1 Persistent Depressive Disorder, mild severity, early onset F60.7 Dependent Personality Disorder G47.35 Comorbid Sleep-Related Hypoventilation E66.9 Overweight or Obesity WHODAS 2.0 Score of 53 with Severe deficiencies in getting around domain (standing up from sitting down, moving around house) and in getting along with people domain (dealing with people he does not know); moderate deficiencies in life activities domain (getting work done); mild deficiencies in participation in society domain (family problems because of health problems)

References ACA DSM-5 Webinar Series
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

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