DSM-5•No Roman numerals•Changes/Updates - 5.1, 5.2 …•Print and electronic versions•Severity scales - more specific•Suicide risk will be discussed with many

diagnoses•Cultural context emphasized-

• section 3 - chapter on cultural formulation; structured interview •Implementation date unclear- ICD 10

• DSM-5 websites:• www.dsm5.org and www.psychiatry.org/dsm5

NOS Eliminated

• Other specified disorder• Other unspecified disorder• Provisional diagnoses – time limited

Multiaxial System Eliminated• Axis I-V eliminated• GAF eliminatedPsychosocial and environmental problems

eliminatedContributing medical conditions eliminated• V Codes still available• Decision trees in an appendix eliminated• Lots of specifiers are available• Online assessment measures at www.psychiatry.org/dsm5)

Diagnostic Groupings1. Neurodevelopmental Disorders2. Schizophrenia Spectrum and Other

Psychotic Disorders3. Bipolar and Related Disorders4. Depressive Disorders5. Anxiety Disorders6. Obsessive-Compulsive and Related

Disorders7. Trauma and Stressor-Related

Disorders8. Disruptive, Impulse Control, and

Conduct Disorders9. Personality Disorders

Neurodevelopmental Disorders

Category includes:Intellectual Disability Communication DisordersAutism Spectrum DisorderADHDSpecific Learning DisorderMotor Disorders

Intellectual DisabilityIQ not the sole diagnostic criteria IQ typically below 70Severity is based upon adaptive functioning and

IQ scoreReplaces Mental retardation - DSM-IVBorderline Intellectual Functioning is a V codeAssess functional ability in 3 domains:

◦ Conceptual-language, reading, writing, math, reasoning,knowledge, memory

◦ Social-empathy, social judgment, interpersonalcommunication skills, friendships

◦ Practical-personal care, job responsibilities, moneymanagement, recreation, organizing school and workactivities

Communication Disorders

Language Disorder ◦ Difficulties in acquisition and use of language

Speech Sound Disorder (was Phonological Disorder)

Childhood-Onset Fluency Disorder (was Stuttering)

Social (Pragmatic) Communication Disorder (new) ◦ Persistent difficulties in the social use of

verbal and nonverbal communicationAutism

Autism Spectrum Disorders (ASD)

Asperger’s, Childhood Disintegrative Disorder, Rett’s Disorder, and Pervasive Developmental Disorder (PDD) NOS will be eliminated

Autism Spectrum Disorders

Three domains in DSM-IV - Two in DSM-5:DSM-IV:1. Qualitative impairment in social interaction2. Qualitative impairments in communication3. Restricted repetitive and stereotyped, patterns of behavior, interests, and activities (RRB’s)DSM-5:1. Social and communication deficits2. Restricted repetitive behaviors, interests, and activities (RRB’s)

ADHD

Age of onset of symptoms will be raised from age 7 to age 12

Must have several symptoms two or more settings

Can now have a comorbid diagnosis with autism

Fewer symptoms needed for adults (5 instead of 6 for both inattention and hyperactivity/impulsivity)

Greater emphasis on identifying adults (but onset must still be before age 12)

Symptom lists basically unchanged

Specific Learning Disorder

Specifiers:Reading (dyslexia)Mathematics (dyscalculia)Written Expression

Schizophrenia Spectrum andOther Psychotic Disorders

Schizotypal Personality Disorder (also listed under personality disorders)

Delusional DisorderBrief Psychotic DisorderSchizophreniform DisorderSchizophreniaSchizoaffective Disorder

Schizophrenia Spectrum andOther Psychotic Disorders

The 5 subtypes of schizophrenia have been dropped. ◦Paranoid◦Disorganized◦Catatonic◦Undifferentiated◦Residual

Bipolar and Related Disorders

Bipolar I Disorder◦ Presence or history of one or more

manic episodes, may also have episodes of depression or hypomania

Bipolar II Disorder◦Presence or history of one or more

major depressive episodes◦ Presence or history of at least one

hypomanic episode◦There has never been a manic

episode◦Cyclothymic Disorder

Depressive Disorders

• Category includes:• Disruptive Mood

Dysregulation Disorder (new)• Major Depressive Disorder• Persistent Depressive

Disorder (was Dysthymia)• Premenstrual Dysphoric

Disorder (new)

Depressive Disorders• Core criteria are little changed from DSM-IV

• Prevalence:• 12-month=7%• 18-29 year olds 3x risk of people over 60• Females 1.5-3x greater risk than males

• Anxious Distress specifier (negatively impacts prognosis)

• Keyed up/tense• Unusually restless• Decreased concentration• Fear of something awful happening• Fear of losing control

Persistent Depressive Disorder(Dysthymia)Symptoms are a consolidation of

chronic major depression and dysthymia

Early or late onset (age 21 is dividing line)

Prevalence 1%

SuicidePrimary cause of psychiatric malpractice

suits but discussed rarely in DSM-IVU.S. Preventive Services Task Force has

determined that risk scales are not predictive of who will commit suicide

Active suicidal ideation (SI) is no more predictive than passive SI

When assessing risk look at:• Long-term factors• Recent factors (past 3 months)• Current factors (past week)

Disruptive Mood DysregulationDisorderNew diagnosisSimilar to Bipolar Disorder with

extreme temper and rage, also similar to Oppositional Defiant Disorder, but more severe

Prevalence 2-5%

Disruptive Mood DysregulationDisorderSevere recurrent temper outbursts• Verbal or behavioral• Inconsistent with developmental level

Mood between outbursts is persistently irritable or angry

Present in at least 2 settings, severe in at least one

Don’t diagnose before age 6 or after age18Frequency of at least 3 times weeklyDuration 12 months, no more than 3

months symptom-free

Premenstrual Dysphoric DisorderSymptoms usually begin during

the week before the menstrual cycle starts and terminate with the onset of menses

About 1.8-5.8% prevalenceMust happen in at least two

cycles

Anxiety DisordersPTSD and OCD no longer in this categoryCategory includes:• Separation Anxiety Disorder (can diagnose

with adult onset)• Selective Mutism• Specific Phobia• Social Anxiety Disorder (Social Phobia)• Panic Disorder• Panic Attack (now just a specifier)• Agoraphobia (now a stand-alone diagnosis,

doesn’t need to be linked with Panic Disorder)• Generalized Anxiety Disorder

Trauma and Stressor-Related DisordersCategory includes:• Reactive Attachment Disorder• Disinhibited Social Engagement

Disorder• PTSD• Acute Stress Disorder• Adjustment Disorders

Reactive Attachment DisordersDisorders develop out of insufficient care,

comfort, and affection or neglect and deprivation,

Reactive Attachment Disorder• The child rarely seeks comfort when

distressed and shows emotional distress when others attempt to provide comfort• Minimal social and emotional responsiveness• Limited positive affect• Unexplained irritability, sadness, or fearfulness• This is rare, affecting about 10% of severely

neglected children

Disinhibited Social EngagementDisorderDisinhibited Social Engagement

Disorder• The child is overly familiar with

strangers and does not hesitate to leave familiar caregivers• The child has loose boundaries with

people, little reticence with strangers• Doesn’t check back with caregiver

after venturing away• This is rare, about 20% of severely

neglected children

PTSDDSM-IV3 symptom clusters

– Re-experiencing– Avoidance and numbing– Arousal

DSM-54 symptom clusters

– Re-experiencing and intrusive symptoms– Avoidance– Arousal and reactivity– Negative alterations in cognitions and

mood

Trauma and Stressor-RelatedAdjustment Disorders• Begins within 3 months, lasts no longer than

6 months after the stressor has ceased• Most symptoms are similar to DSM-IV• Prevalence in outpatient mental health is 5-

20%

Acute Stress Disorder• With Acute Stress Disorder early

intervention can help prevent PTSD• Only half of people with ASD develop PTSD.

It’s not predictive.

Disruptive, Impulse-Control, andConduct DisordersTrichotillomania and Gambling movedCategory includes:• Oppositional Defiant Disorder• Intermittent Explosive Disorder (must be

at least 18)• Conduct Disorder• Pyromania• Kleptomania• Antisocial Personality Disorder (dually

listed here and in personality disorders section)

Limited Prosocial Emotions SpecifierSpecifier for use with Conduct

Disorder• Lack of remorse or guilt• Unconcerned about performance• Shallow or deficient affect• Callous, lack of empathy• Less sensitive to punishment cues• Thrill-seeking, less inhibited• More proactive and reactive aggression• Traits can diminish when quality of

parenting improves

Personality DisordersCluster A (odd and eccentric):• Paranoid• Schizoid• Schizotypal

Cluster B (dramatic, emotional, erratic):• Antisocial• Borderline• Histrionic• Narcissistic

Cluster C (anxious and fearful):• Avoidant• Dependent• Obsessive-Compulsive (personality disorder, not OCD)