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10/16/2014
DSM-5:
Implications for Social Work Practice
Latino Social Work Organization
October 16, 2014
Stanley G. McCracken, Ph.D., LCSW, RDDP
Lecturer
[email protected]
The University of Chicago School of Social Service Administration
Agenda
• Introduction. Process of revision.
General characteristics.
• Structural, Conceptual, and Crosscutting Changes
– Dimensional approach
– Developmental Perspectives in DSM-5
• Selected Disorders
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Citation for DSM-5
• American Psychiatric Association (2013).
Diagnostic and Statistical Manual of Mental
Disorders, 5th Ed. Arlington, VA: American
Psychiatric Association.
• DSM-5 general access website:
http://www.psychiatry.org/dsm5
Process of Revision
• DSM-5: the first major revision in 30 years.
• Revisions of both DSM (5) and ICD (11 [2017]).
Continuing effort to make DSM/ICD compatible
– NIMH: Research Domain Criteria (RDoC).
• Workgroups. Invitation only conferences.
Field trials. APA website for feedback.
• Both APA and WHO committed to making the
DSM-5 and ICD-11 a “living document.”
– If diagnosis and classification are to be evidencebased, changes can’t wait for publication of a new
edition. Both print and electronic versions plus a mobile
app of diagnostic criteria for iOS and Android.
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Criticism & Controversy
•
•
•
•
Further movement toward a “medical model”.
Pathology-based, not strength-based.
Insufficient support from clinical trials.
Diagnoses/criteria not based on genetics,
pathophysiology.
• Concerns about over-diagnosing, overprescribing, e.g. Bereavement exclusion, Mild
Neurocognitive Disorder.
• Advocacy groups, e.g., Autism Spectrum
Disorder.
DSM-5 Structure
• No more Axes I-V. Just list diagnostic codes.
• There are still V codes (Z codes in ICD-10CM).
• 3 Sections and Appendix.
– Section I, DSM-5 Basics: Introduction, Use of the
Manual, Cautionary Statement for Forensic Use of DSM-5
– Section II, Diagnostic Criteria and Codes.
– 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, etc.
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Characteristics of DSM-5
• Final draft approved Dec. 1, 2012 and
released May, 2013.
• No more Roman numerals; changes will
be: 5.1, 5.2
• Severity scales are more specific.
Assessment tools online:
http://www.psychiatry.org/dsm5
Characteristics of DSM-5, cont.
• Cultural formulation and structured interview
in Section III. Interview and additional
modules online.
• Coding:
– Now: continue to use ICD-9CM (numbers only).
– ICD-10CM initially scheduled for implementation
in US in October, 2014, moved back to October,
2015. Use letter and number, e.g., F43.0. The
specific code will depend on specifier.
– ICD-11 due for release, 2017.
Implementation???
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Characteristics of DSM-5, cont.
• No more NOS. Instead:
– Other specified _____ disorder
– Other unspecified _____ disorder
– Provisional diagnoses still allowed.
• Many specifiers.
Diagnostic Groupings
• Neurodevelopmental Disorders
• Schizophrenia Spectrum and Other Psychotic
Disorders
• Bipolar and Related Disorders
• Depressive Disorders
• Anxiety Disorders
• Obsessive-Compulsive and Related Disorders
• Trauma- and Stressor-Related Disorders
• Dissociative Disorders
• Somatic Symptom and Related Disorders
• Feeding and Eating Disorders
• Elimination Disorders
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Diagnostic Groupings, cont.
•
•
•
•
•
•
•
•
Sleep-Wake Disorders
Sexual Dysfunctions
Gender Dysphoria
Disruptive, Impulse-Control, and Conduct Disorders
Substance-Related and Addictive Disorders
Neurocognitive Disorders
Personality Disorders
Paraphilic Disorders
• Other Mental Disorders
• Medication-Induced Movement Disorders and Other Adverse
Effects of Medication
• Other Conditions that may be a Focus of Clinical Attention
Information Provided for Disorders
• The full DSM-5 manual has a good deal of information
in addition to the basic diagnostic criteria.
• Diagnostic criteria with coding and recording
procedures for both ICD 9CM and (ICD 10CM).
• Diagnostic features—description of symptoms.
• Associated features supporting diagnosis.
• Prevalence—US and may include world, age groups,
gender, other.
• Development and course—onset, development,
remission, recurrence.
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Information Provided for Disorders, cont
• Risk and prognostic factors—temperament,
environment, genetic and physiological, course
modifiers.
•
•
•
•
•
•
Culture-related diagnostic issues.
Gender-related diagnostic issues.
Suicide Risk.
Functional consequences of disorder.
Differential diagnosis.
Comorbidity.
Dimensional Approach
• Movement from more categorical to a
more dimensional approach.
– Disorders in several groups are structured
or discussed as spectrum disorders or
dimensions, e.g., Autism Spectrum, Mild
and Major Neurocognitive Disorders.
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Dimensional Assessment
• Assessment measures discussed in Section III.
Available: http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures
• Cross-cutting symptom measures (modeled on
general medicine’s review of systems).
– Level 1 (Screening) brief survey of 13 (adults) or 12
(child and adolescent) symptom domains.
• Adults: Depression, Anger, Mania, Anxiety, Somatic
symptoms, Suicidal ideation, Psychosis, Sleep problems,
Memory, Repetitive thoughts & behaviors, Dissociation,
Personality functioning, Substance use.
• Child/adolescent (6-17): Somatic symptoms, Sleep problem,
Inattention, Depression, Anger, Irritability, Mania, Anxiety,
Psychosis, Repetitive thoughts & behaviors, Substance use,
Suicidal ideation/suicide attempt.
•
Dimensional Assessment,
cont’d
Cross-cutting symptom measures, cont
– Level 1
• Items rated on 5-point scale: 0=none/not at all;
1=slight or rare; <a day or two; 2=mild or several
days; 3=moderate or >half the days; 4=severe or
nearly every day.
• Items rated >mild or >slight (Suicidal, Psychosis,
Substance use; Inattention) or Yes/Don’t Know
(Substance use and Suicidal ideation/suicide attemptschild/adol)  further assessment with relevant Level
2 measure.
http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures#Level1
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Dimensional Assessment, cont’d
• Cross-cutting symptom measures.
– Level 2. Detailed clinical inquiry. Currently available:
• Adult: Depression, Anger, Mania, Anxiety, Somatic Symptom,
Sleep Disturbance, Repetitive Thoughts and Behaviors,
Substance Use. None currently available for: Dissociation
or Psychosis (see Clinician-Rated Dimensions of Psychosis
Symptom Severity).
• Child (6-17) (Child Self-Report ages 11-17; Parent/Guardianrated ages 6-17): Somatic Symptoms, Sleep Disturbance,
Inattention, Depression, Anger, Irritability, Mania, Anxiety,
Substance Use. None currently available for: Psychosis,
Repetitive thoughts and behaviors, Suicidal ideation/suicide
attempts.
http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures#Level2
Assessment, cont’d
• Other Measures of Symptoms and Functioning
– Disorder-specific Severity Measures
• Adult: Depression, Separation Anxiety, Specific Phobia, Social
Anxiety Disorder, Panic Disorder, Agoraphobia, Generalized
Anxiety Disorder, Post-traumatic Stress Symptoms, Acute
Stress Symptoms, Dissociative Symptoms
• Children S-R (11-17): Depression, Separation Anxiety, Specific
Phobia, Social Anxiety Disorder, Panic Disorder, Agoraphobia,
Generalized Anxiety Disorder, Post-traumatic Stress
Symptoms, Acute Stress Symptoms, Dissociative Symptoms
• Clinician-rated: Severity of Autism Spectrum and Social
Communication Disorders, Dimensions of Psychosis Symptom
Severity, Severity of Somatic Symptom Disorder, Severity of
Conduct Disorder, Severity of Oppositional Defiant Disorder,
Severity of Nonsuicidal Self-Injury
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Assessment, cont’d
• Other Measures of Symptoms and Functioning
– Disability Measures
• World Health Organization Disability Schedule (WHODAS
2.0) 36 item self-administered.
• World Health Organization Disability Schedule (WHODAS
2.0) 36 item proxy-administered.
– Personality Inventories
• Adult: Personality Inventory for DSM-5—Brief form (PID-5BF)—Adult; Personality Inventory for DSM-5 (PID-5)—
Adult; Personality Inventory for DSM-5-Informant form
(PID-5-IRF)—Adult.
• Child S-R (11-17): Personality Inventory for DSM-5—Brief
form (PID-5-BF)—Child 11-17; Personality Inventory for
DSM-5 (PID-5)—Child 11-17.
Assessment, cont;d
• Other Measures of Symptoms and Functioning
– Early Development and Home Background
• For Parents of Children Ages 6–17: Early Development and
Home Background (EDHB) Form—Parent/Guardian.
• Clinician Rated: Early Development and Home Background
(EDHB) Form—Clinician.
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Assessment, cont’d
– Cultural Formulation Interviews
• Cultural Formulation Interview (CFI) also Informant version.
• 12 Supplementary Modules to the Core Cultural Formulation
Interview (CFI): Explanatory Model; Level of Functioning;
Social Network; Psychosocial Stressors; Spirituality,
Religion, and Moral Traditions; Cultural Identity; Coping
and Help Seeking; Patient-Clinician Relationship; SchoolAge Children and Adolescents; Older Adults; Immigrants
and Refugees; Caregivers.
• The question is whether, how, and when will any
of these be used, and who will require. (Too early to
tell.)
Developmental Perspectives in DSM-5
• DSM-5 diagnoses are anchored in the perspective that
pathology in youth = deviation from developmental
norms ( from delay in accomplishing developmental task
to not accomplishing it at all). Diagnoses fall on a
continuum/spectrum/dimension.
• The “Development and Course” section for each disorder
reflects a lifespan approach:
– age at which typical symptoms present
– detailed symptom presentation specific to each age group &
descriptions of how presentations change over the lifespan
– the trajectory over time of one disorder becoming another at a
later point in time (fluidity of diagnoses)
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Developmental Perspective (cont)
• Risks and Prognostic Factors includes
– Temperament, genetic or physiological factors
– Descriptions of situations associated w/each age group in which
the disorder would disrupt normal functioning
– Expected long term outcome, points of increased risk, and
course modifiers  improvement or stability
– Recognition that changes in environment can moderate level of
impairment in children (i.e. enabling parents as compared to
non-enabling parents)
• Associated Features section in DSM -5
– includes comprehensive information than DSM IV to support
the diagnosis (medical, other behavioral or emotional signs,
other common associations) as well as parent-child associations
Developmental Perspectives, cont.
• Functional Consequences Section
– Refers to consequences of having a disorder during different
ages/stages of development
• Comorbidity Section (greater number in DSM-5)
– For some comorbidities, associations at different ages are
highlighted
• Some disorders in DSM-5 include:
– Explicit descriptions of developmental manifestations as part
of the diagnostic criteria for each disorder
– Procedures for evaluating developmental subtypes of
disorders
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Neurodevelopmental Disorders
• Neurodevelopmental Disorders replaces “Disorders
First Seen in Infancy and Early Childhood” .
– All disorders in the group have deficits in development
which onset within first few years of life, have multiple
causes and multiple trajectories, and may produce
lifelong functional impairments.
– The neurodevelopmental disorders are often comorbid.
– Deficits range from narrow & specific learning problems, to
more global problems in language acquisition, intellectual
functioning, adaptive skills, and social functioning.
– Some DSM IV disorders have been renamed and/or reconceptualized, and some new disorders have been added.
Disorders Usually First Diagnosed in Childhood
Disorders: Where Do I Find Them in DSM-5 ?
DSM IV
DSM-5
• Disorders Usually First
• “Disorders Usually First” has been
Diagnosed in Childhood and
eliminated and several disorders
Early Adolescence….
moved to new a group category Neurodevelopmental Disorders
which includes:
– Mental Retardation
– 3 Learning Disorders
– Developmental Coordination
Disorder
– ADHD
– MR -Renamed Intellectual Disability,
changes in criteria
– One LD Renamed “Specific Learning
Disorder” (specifiers w/ impairment in
reading, in written expression, in math)
– Developmental Coordination Disorder
– ADHD
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Other Disorders Moved from “First Diagnosed..
in….” to “Neurodevelopmental Disorders”
DSM IV
• Communication Disorders
DSM-5
• Communication Disorders
– Expressive Language
Disorder (ELD)
– Mixed Receptive-Expressive
Language Disorder (MRELD)
– Stuttering Disorder
– Phonologic Disorder (PD)
• Motor Skills/Tic Disorders
– ELD and MRELD eliminated and
subsumed under new dx
“Language Disorder”
– Stuttering renamed “Childhood
Onset Fluency Disorder”
– PD renamed “Speech-Sound
Disorder”
• Motor Disorders subsection
– Tourettes, Dev. Coord Disord
– Chronic Vocal & Motor Tics
– Stereotypic Movement Disor.
– Specifiers added to Stereotypic
Movement Dis.-w/ SI, w/out SI,
assoc. w/ other known dis./med
More Disorders Moved from “Disorders First
Seen” to Other Groups in DSM-5
DSM IV
• PDD’s (Autistic Disorder,
Asperger’s, Childhood
Disintegrative Disorder ,
Rett’s, PDD NOS)
• Separation Anxiety D. and
Selective Mutism
• Pica, Rumination Disorder
& Feeding D. of Infancy
• Reactive Attachment Dis.
• Encopresis & Enuresis
• Conduct Disorder & ODD
& Intermittent Explosive D.
DSM-5
• Included in Neurodevelopmental
Disorders, all subsumed under
Autism Spectrum Disorder except
Rett’s which is a genetic disorder
• SAD & SM moved to Anxiety D.
• Pica & RD in “ Feeding & Eating
Disorders ” & FDI new name
“Restrictive Food Intake D”
• RAD in Trauma & Stress-Related D
• E & E in “Elimination Disorders”
• CD/ODD in “Disrupt, Impulse-C &
Conduct Disorders” w/ IED
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List of Neurodevelopmental Disorders
• Include the following disorders:
– Intellectual Disability (Intellectual Development
Disorder), Global Developmental Delay (children < 5)
– Communication Disorders –
• Language Disorder, Speech Sound Disorder, ChildhoodOnset Fluency Disorder, Social Communication Disorder
–
–
–
–
Attention Deficit Hyperactivity Disorder
Specific Learning Disorder
Autism Spectrum Disorder
Motor Disorders
• Developmental Coordination Disorder, Stereotypic
Movement Disorder, Tic Disorders/Tourette’s Disorder
Changes in MR: Intellectual Disability
• In DSM -5, IQ below 70 is no longer the only criteria
• Severity based on functional ability, not IQ, or adaptive
functioning in comparison with same age norms has been
added as a criteria and must be assessed in 3 domains.
(1) Conceptual deficits: language, reading, writing,
math, reasoning, knowledge and memory
(2) Social deficits: interpersonal communication skills,
friendships, social judgment, empathy
(3) Practical deficits: personal care, organizing school and
work activities, money management, job duties
Severity rating scale for each domain is based on the level
of support required. Mild, Moderate, Profound
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Attention Deficit Hyperactivity Disorder
Changes in Criteria for ADHD
• Required age on onset of sxs changed from 7 to 12
• Greater emphasis on identifying adults (& sx suited to age)
– Addition of sx descriptions more applicable to older teens and
adults (“forgetful in keeping appointments or returning calls”)
– Symptom threshold reduced to 5 for ages 17 and older, still 6 for
children and younger teens
• Symptom lists for hyperactive-inattentive and inattentive
basically unchanged (sx description more age appropriate)
• Cross-situational requirement increased to several
symptoms in > 2 settings
• Included in Neurodevelopmental Disorders to reflect brain
development corrrelates w/ ADHD
• Comorbid dx of ADHD & Autism Spectrum D. allowed
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ADHD (cont)
• Subtypes replaced with specifiers “presentations
within the past 6 months predominantly_______”
• Added duration of 6 months to the specifier “In partial
remission” when full criteria were previously met but have
not been met for past 6 mos., still evidence of impairment.
• Severity ratings
– Mild = no symptoms (or few) in excess of number required for
diagnosis with minor impairments,
– Moderate = functional impairment falls between mild and severe
– Severe = more symptoms than required or several symptoms
result in marked impairment in social, school or occupational
areas
Social (Pragmatic) Communication Disorder
• New diagnosis characterized by difficulty in social
uses of verbal and nonverbal communication in
naturalistic contexts
– Use of communication for greeting and sharing is not
appropriate to the context
– Impairment in ability to adjust communication to the
needs of the listener or the context
– Difficulties following the rules for conversation
• Difficulties impact development of social
relationships and can’t be explained by low abilities
in areas of word structure and grammar
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Social (Pragmatic) Communication Disorder
• There are no repetitive patterns or restricted interests (i.e.
criteria for ASD would not be met).
• Language impairment is a common associated feature as
is ADHD, behavior problems and specific learning
disorders. Family history of ASD, LD or communication
disorder increases the risk for social comm’cn. disorder.
– Symptoms present in early childhood yet may not be fully
manifested until social demands exceed capabilities; milder
forms may not be identified until early adolescence.
– Trajectory is variable with some experiencing substantial
improvement over time while others continue with problems
through adult years.
• Replaces the PDD, NOS
Autism Spectrum Disorder
• The 3 defining areas of impairment (social
deficits; communication deficits; and restricted,
repetitive behaviors and interest) were reduced to
2 domains by combining social and
communication to “social/communication deficits”
and retaining the behavioral impairment domain.
– Asperger’s Disorder eliminated.
• The single diagnosis should include specifiers
(severity, verbal abilities) and associated features
(known genetic disorders, epilepsy, intellectual
disability, etc.).
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Schizophrenia Spectrum and
Other Psychotic Disorders
• Disorders in this group:
– Schizotypal Personality Disorder criteria
– Delusional Disorder
– Brief Psychotic Disorder
– Schizophreniform Disorder
– Schizophrenia
– Schizoaffective Disorder
in Personality Disorders
– Substance/Medication-Induced Psychotic Disorder
– Psychotic Disorder Due to Another Medical Condition
– Catatonia Associated with Another Mental Disorder (Catatonia Specifier)
– Other Specified… and Unspecified…
– [Attenuated Psychosis Syndrome in Section III.]
Schizophrenia Spectrum/Other Psychotic
Disorder, cont.
• Major changes.
– Elimination of special attribution of certain symptoms
(e.g., bizarre delusions, voices talking to each other) in
Criterion A of Schizophrenia (only one of these needed
in DSM-IV).
– Criterion A now requires 2 sx, at least 1 of 3 psychotic sx
(Delusions, Hallucinations, or Disorganized Speech).
– Schizophrenia subtypes eliminated.
– Schizoaffective Disorder now requires that a major mood
episode be present for a majority of the disorder’s total
duration (not just current episode) after Criterion A met.
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Schizophrenia Spectrum & Psychotic, cont.
• Major changes.
– Delusional disorder. Elimination of
requirement that delusions be non-bizarre.
• Differential diagnosis: if an individual with OCD
or Body Dysmorphic Disorder is completely
convinced that his/her OCD/BDD beliefs are true,
then Delusional Disorder is not diagnosed in
addition to OCD or BDD (more on this later).
Schizophrenia Spectrum & Psychotic, cont.
• Major changes.
• Rate symptoms on Clinician-Rated Dimensions of
Psychosis Symptom Severity (Section III).
• Symptoms (clusters)
– Psychotic symptoms: Hallucinations, Delusions,
Disorganization
– Psychomotor symptoms: Abnormal Psychomotor
Behavior
– Negative symptoms: Restricted Emotional Expression,
Avolition
– Cognition: Impaired Cognition
– Mood: Depression, Mania
– You may still make a diagnosis in this group even without
this rating.
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Bipolar and Related Disorders
• Mood Disorders split into two categories: Bipolar
and Related Disorders and Depressive Disorders,
• Disorders in this group
– Bipolar I Disorder
– Bipolar II Disorder
– Cyclothymic Disorder
–
–
–
–
Substance/Medication-Induced Bipolar and Related Disorder
Bipolar and Related Disorder Due to Another Medical Condition
Other Specified…
Unspecified...
Bipolar and Related Disorders, cont.
• Major changes.
– Criterion A for manic and hypomanic episodes now
includes emphasis on changes in activity and energy as
well as mood. (“A distinct period of abnormally and
persistently elevated, expansive, or irritable mood and
abnormally and persistently increased goal-directed
activity or energy, lasting at least….”
– Removal of Mixed Episode and addition of mixed
features specifier that can be added to mania and
hypomania if depressive features are present or to
episodes of depression when features of mania or
hypomania are present (> 3 symptoms from other pole).
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Bipolar and Related Disorders, cont.
• Major changes, cont
– Specifiers
•
•
•
•
•
•
•
•
•
•
With anxious distress
With mixed features
With rapid cycling
With melancholic features
With atypical features
With mood-congruent psychotic features
With mood-incongruent psychotic features
With catatonia.
With peripartum onset
With seasonal pattern
Depressive Disorders
• Disorders in this group.
– 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
– Specifiers for Depressive Disorders
– [Persistent Complex Bereavement Disorder in Section III.]
– [Suicidal Behavior Disorder and Nonsuicidal Self-Injury in
Section III.]
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Depressive Disorders, cont.
• Major changes
– New disorders.
• Disruptive Mood Dysregulation Disorder—new.
• Persistent Depressive Disorder—replaces Dysthymic Disorder
and Chronic Major Depressive Disorder.
• Premenstrual Dysphoric Disorder—moved to this group from
DSM-IV Appendix B (Criteria Sets…for Further Study).
– Mixed features specifier may be added to major
depression episode if features (at least three symptoms)
of mania or hypomania are present. (Increases probability
that the illness is in a bipolar spectrum, though if the person has
never had an illness that met criteria for a manic or hypomanic
episode the diagnosis of Major Depressive Disorder is retained.)
Depressive Disorders, cont.
• Major changes, cont.
– Bereavement exclusion eliminated.
• DSM-IV stated that symptoms that begin within 2 months of
loss of a loved one and do not persist beyond these 2 months
are “generally considered to result from Bereavement” unless
associated with functional impairment, preoccupation with
worthlessness, suicidal ideation, psychotic symptoms, or
psychomotor retardation. (Note: it did not say major depression
could not be diagnosed.)
– Implied that bereavement only lasts 2 months, when duration is more
commonly 1-2 years (depending on culture and other factors).
– Bereavement is severe psychosocial stressor that can precipitate major
depression in a vulnerable person, e.g., past history of depression.
– Major depression in context of bereavement adds: increased suffering,
worthlessness, suicidal ideation; worse somatic health and functioning,
increased risk complex bereavement.
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Comparison of Grief and Depression
Symptom
Grief
Depression
Affect
Emptiness and loss
Depressed mood, inability to
anticipate happiness or pleasure
Pattern
Dysphoria decreases in
intensity over days-weeks,
comes in waves associated
with thoughts/reminders of
deceased. Pain of grief
associated with positive
emotions and humor.
More persistent, not tied to specific
thoughts or preoccupations.
Pervasive unhappiness and misery.
Thought
Content
Preoccupation with thoughts Self-critical or pessimistic
and memories of the
ruminations
deceased
Self-esteem
Generally preserved
Thoughts of If present, focused on
death &
deceased and joining
dying
deceased.
Worthlessness, self-loathing
Thoughts of ending one’s life
because of worthlessness,
undeserving, unable to cope with
pain of depression
Depressive Disorders, cont.
• Disruptive Mood Dysregulation Disorder
• A new diagnosis intended to address concerns of over
diagnosis of bipolar disorder in children and unnecessary
and potentially harmful treatment
• These are children who are described by parents as
having “mood swings,” who have explosive outbursts of
extreme intensity and duration. Parents have to “walk on
eggshells.”
• These children present with persistent irritability and
outbursts of temper and the sxs overlap sxs of ADHD,
may be comorbid w/ ADHD but not w/ Bipolar or ODD
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ADHD
DMDD
More aggressive
BIPOLAR
More continuous
More
labile
Disruptive
Behavior
Disorders
Anxiety Disorders
• Disorders in this group. (Disorders listed developmentally.)
– Separation Anxiety Disorder
– Selective Mutism
– Specific Phobia
– Social Anxiety Disorder (Social Phobia)
– Panic Disorder
– Panic Attack Specifier
– Agoraphobia
– Generalized Anxiety Disorder
– Substance/Medication-Induced…, … Due to Another Medical
Condition
– Other Specified…; Unspecified…
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Anxiety Disorders, cont.
• Major changes.
– DSM-IV Anxiety Disorders separated into three
groups:
• Anxiety Disorders (excessive fear and anxiety and
related behavioral disturbances);
• Obsessive Compulsive and Related Disorders
(preoccupations and repetitive behaviors or mental
acts in response to preoccupations);
• Trauma- and Stressor-Related Disorders (exposure
to traumatic or stressful event leading to
psychological distress of varying kinds). Sequential
ordering reflects close relationship among these disorders.
Anxiety Disorders, cont.
• Anxiety disorders differ from developmentally normative
fear/anxiety by being excessive or persisting beyond
developmentally appropriate period.
• Anxiety disorders differ from transient fear/anxiety, often
stress induced, by being persistent, though the > 6 month
duration is a guide with some flexibility (shorter in children)
• Since people with anxiety disorders typically overestimate
the danger in situations they fear/avoid, determination of
excessive is made by clinician, considering cultural factors.
• Many disorders develop in childhood and persist if not
treated.
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Anxiety Disorders, cont.
• Major changes, cont.
– Separation Anxiety Disorder and Selective Mutism
moved from DSM-IV childhood disorders group and
placed into Anxiety Disorders group.
– Panic Disorder and Agoraphobia are diagnosed
separately (unlinked) with separate criteria (i.e., no more
Panic Disorder, Panic Disorder with Agoraphobia, Agoraphobia
without History of Panic Attacks).
– Panic Disorder requires 1 month of either persistent
worry about additional panic attack OR a significant
maladaptive change in behavior related to the attacks
(e.g., designed to avoid having a panic attack, such as avoiding
exercise, unfamiliar situations).
Anxiety Disorders, cont.
• Major changes, cont.
– Panic attack.
• Essential features unchanged, but types (cued/situationally
bound, situationally predisposed, unexpected) replaced with
unexpected or expected.
• Panic attacks can occur in the context of any mental disorder
and some medical conditions.
• Panic attacks act as a marker/prognostic factor for severity of
diagnosis, course, comorbidity across an array of disorders.
• Thus, panic attacks may be added as a specifier to other
DSM-5 disorders (e.g., anxiety disorders, depressive
disorders, bipolar disorders, eating disorders, OCD,
psychotic disorders).
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Anxiety Disorders, cont.
• Major changes, cont.
– Agoraphobia, Specific Phobia, and Social Anxiety
Disorder (Social Phobia) no longer require recognition
that anxiety is excessive or unreasonable.
• Anxiety must be out of proportion to actual danger or threat
and to sociocultural context. Situations are avoided, endured
with intense fear/anxiety, or (for Agoraphobia) require
presence of another person.
• All ages note typical duration of 6 months (not just <18).
• Agoraphobia requires fears of > 2 situations—open spaces,
public transportation, enclosed spaces, standing in a line or
being in a crowd, or being outside of home.
• Social anxiety: Delete generalized type, add performance only.
Obsessive Compulsive and Related
Disorders
• Disorders in this group.
–
–
–
–
–
Obsessive-Compulsive Disorder
Body Dysmorphic Disorder
Hoarding Disorder
Trichotillomania (Hair-Pulling Disorder)
Excoriation (Skin-Picking) Disorder
–
–
–
–
Substance/Medication-Induced…
…Due to Another Medical Condition
Other Specified…
Unspecified…
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Obsessive Compulsive and Related
Disorders, cont.
• Major changes.
– Separated from DSM-IV Anxiety Disorders.
– Body Dysmorphic Disorder moved to this group from
DSM-IV Somatoform Disorders.
– Trichotillomania moved from DSM-IV Impulse Control
Disorders.
– Hoarding Disorder added.
– Skin-Picking Disorder added.
Obsessive Compulsive and Related
Disorders, cont.
• Major Changes.
– Specifiers
• Insight specifiers reflect full range of insight from
good/ fair insight to poor insight to absent
insight/delusional beliefs. No longer necessary to add
diagnosis of delusional disorder. (applies to OCD, Hoarding,
Body Dysmorphic Disorders.)
• With muscle dysmorphia (for Body Dysmorphic Disorder)
preoccupation with the idea that body build is too small or
insufficiently muscular.
• Tic-related (for OCD).
• With excessive acquisition (for Hoarding Disorder).
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Trauma- and Stressor-Related
Disorders
• Disorders in this group.
–
–
–
–
–
–
Reactive Attachment Disorder
Disinhibited Social Engagement Disorder
Posttraumatic Stress Disorder
Acute Stress Disorder
Adjustment Disorders
Other Specified Trauma- and Stressor-Related
Disorder
– Unspecified Trauma- and Stressor-Related Disorder
– [DESNOS not in DSM-5]
Trauma- and Stressor-Related Disorders
• Major changes.
– Wide range of reactions to trauma and stress. Sometimes
responses can be understood in the context of anxiety and
fear. For other people the most prominent symptoms are
anhedonic and dysphoric, externalizing angry and
aggressive, dissociative, or some combination (with or
without anxiety and fear). Because of this range of
reactions, these disorders were placed in their own group
based on precipitants rather than symptoms.
– Placement of group between Anxiety Disorders and Obsessive
Compulsive and Related Disorders, and Dissociative Disorders
reflects close relationship between this group and the other
conditions.
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Trauma- and Stressor-Related Disorders
• Major Changes.
– Reactive Attachment Disorder moved to this group and
Disinhibited Social Engagement added.
– Adjustment Disorders moved to this group.
– Different set of PTSD criteria for children < 6.
– Sexual violence specifically included as a trauma
exemplar. Definition of trauma for PTSD and ASD are
more explicit and no longer require reaction of
intense fear, helplessness, or horror .
– Four symptom clusters for PTSD (3 clusters in DSMIV). Negative alterations in cognitions and mood
added.
Trauma- and Stressor-Related Disorders
• PTSD & ASD—Traumatic event:
– Exposure to actual or threatened death, serious injury,
or sexual violence in > 1 of the following ways:
• Directly experiencing the traumatic event(s).
• Witnessing, in person, the event(s) as it occurred to others.
• 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 accidental.
• Experiencing repeated or extreme exposure to aversive
details of the traumatic event(s).
– Note: Criterion A4 does not apply to exposure through electronic
media, television, movies, or pictures, unless this exposure is work
related.
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Trauma- and Stressor-Related Disorders
• PTSD symptom clusters:
– Re-experiencing and intrusive symptoms, e.g.
memories, dreams, dissociative reactions
(flashbacks), physiological or psychological
reactions to reminders.
– Avoidance, e.g., memories, thoughts, feelings,
and/or external reminders of event.
– Arousal and reactivity, e.g., irritable/angry behavior,
reckless/self-destructive behavior, hypervigilance,
exaggerated startle, problems with concentration,
sleep disturbance.
Trauma- and Stressor-Related Disorders
• PTSD symptom clusters, cont.
– Negative alterations in cognitions and mood, e.g.,
inability to remember important aspect of event
(typically due to dissociative amnesia, not drug effects);
negative beliefs/expectations about self, others, world;
distorted cognitions about cause or consequences of
event that lead individual to blame self or others;
markedly diminished interest or participation in
significant events; detachment or estrangement from
others; inability to experience positive emotions.
– Specify if with:
• dissociative symptoms (e.g., depersonalization, derealization).
• delayed expression [not onset]: full criteria not met > 6 mos.
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Trauma- and Stressor-Related Disorders
• Reactive Attachment Disorder and Disinhibited
Social Engagement Disorder
– The two RAD subtypes in DSM IV – inhibited and
disinhibited -- have been conceptualized as traumarelated and transformed into 2 separate disorders- one
internalizing & one externalizing.
• In DSM-5 the dx of RAD is essentially the inhibited type and
the new dx of Disinhibited Social Engagement Disorder (
(formerly the disinhibited type) but conceptualization changed
to violations in boundaries
– Cause of disorders unchanged. Both disorders are
presumably caused by insufficient care, comfort and
affection or from neglect and deprivation.
Trauma- and Stressor-Related Disorders
• Adjustment Disorders.
– While criteria essentially unchanged, adjustment
disorders are now conceptualized as a diverse array of
stress-response syndromes that occur after exposure to a
distressing (either traumatic or non-traumatic) event,
rather than as a residual category for individuals who
exhibit clinically significant distress but whose
symptoms do not meet criteria for a more discrete
disorder (as in DSM-IV).
• Stressors may be a single event or multiple; recurrent or
continuous; may affect a single individual, a family, or a larger
group/community; may accompany developmental events, e.g.,
going to school, leaving home, retirement, becoming a parent.
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Feeding and Eating Disorders
• Category includes the following disorders and
presentations across the lifespan
– Pica
– Rumination Disorder
– Avoidant/Restrictive Food Intake Disorder (this was
Feeding Disorder of Infancy yet with changes in
conceptualization - lifespan, restricted intake w/out body
image distortions, orthorexia …)
– Anorexia
– Bulimia
– Binge Eating Disorder ( has been in the Appendix of
DSM IV), in DSM-5 included as a coded diagnosis
Feeding and Eating Disorders in DSM-5
• Anorexia Nervosa –
– amenorrhea criteria has been removed,
– wording changed to “restriction of energy intake relative to need”
– Significantly low weight is defined as “weight that is less than
minimally normal” (for adults) or “less than minimally expected”
(for children and adolescents)
– Severity is based on Body Mass Index (BMI)
• Bulimia Nervosa
– The required minimum frequency of binge eating and purging is
reduced from 2 times a week to 1 time a week
– Severity based on number of episodes of compensatory behaviors
in a week; criteria given for remissions
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10/16/2014
Changes in Subtype Descriptions
Accommodate Crossovers in Anorexia
• Restricting Type: During the last 3 mos, the individual
has not engaged in recurrent episodes of binge eating or
purging
• Binge-eating/purging type: During the last 3 mos. the
individual has engaged in recurrent episodes of binge
eating or purging
• Specifiers:
– Severity criteria based on BMI percentiles but can increase to
reflect other symptoms ( need for supervision, degree of
impairment)
– In Partial Remission: Low weight criteria not met but presence
of other symptoms
Feeding and Eating Disorders, cont.
• Binge Eating Disorder (new diagnosis)
– Recurrent episodes of binge eating once a week or
more for 3 months
– Three of the following symptoms must be present
•
•
•
•
Eating much more rapidly than normal (for the individual)
Eating until uncomfortable
Eating large amounts of food when not hungry
Eating alone because of embarrassment by how much one is
eating
• Feeling disgusted, depressed, guilty after overeating
– No compensatory behavior
– Severity based on # of binge-eating episodes per week
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Substance Use and Addictive Disorders
• Disorders in this group:
– Substance Use Disorders.
– Substance Induced Disorders
• Intoxication.
• Withdrawal.
• Other Substance Induced Disorders (psychotic disorders,
bipolar and related disorders, depressive disorders, anxiety
disorders, obsessive-compulsive and related disorders,
sleep disorders, sexual dysfunctions, delirium, and
neurocognitive disorders). Described in group with
disorders with which they share phenomenology.
– Gambling Disorder
Substance Use and Related Disorders, cont.
• Major changes.
– Collapses abuse and dependence into a single diagnosis
“use disorder”, e.g., Alcohol Use Disorder, Cocaine Use
Disorder.
• Criteria: Adds craving. Deletes Legal problems.
– Abuse & dependence seen as a single disorder with a
continuum of severity. Severity specifier: Mild = 2-3,
Moderate = 4-5, Severe > 6 symptoms.
– Adds criteria for Cannabis Withdrawal.
– Gambling (moved from impulse control disorder).
– [Caffeine Use Disorder, Internet Gaming Disorder and
Neurobehavioral Disorder Associated with Prenatal Alcohol
Exposure (~fetal alcohol syndrome) in Section III.]
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Neurocognitive Disorders
• Disorders in this group
– Neurocognitive 6 Domains: complex attention,
executive function, learning and memory, language,
perceptual motor, social cognition.
– Delirium
– Other Specified Delirium
– Unspecified Delirium
– Major and Mild Neurocognitive Disorders
• Specify underlying pathology, where known, e.g., Major or
Mild Neurocognitive Disorder due to Alzheimer’s Disease.
– Criteria for Delirium are quite similar to DSM-IV.
Changes clarify some criteria.
Neurocognitive Disorders, cont.
• Major changes.
– Group renamed. Replaces DSM-IV, Dementia,
Delirium, Amnestic, and Other Cognitive Disorders.
– Disorders in this group attributable to changes in brain
structure, function, or chemistry. Etiologies will be
coded as subtypes, e.g., Alzheimer’s.
– “Dementia is subsumed under the newly named entity
major neurocognitive disorder, although the term
dementia is not precluded from use in the etiological
subtypes in which that term is standard.”
– Mild neurocognitive disorder added—similar to Mild
Cognitive Impairment (MCI).
37