Presentation of DSM-5 Changes

June 26th, 2013

Intellectual Disability (Intellectual Developmental Disorder)

• Mental Retardation changed to Intellectual Disability

• (Intellectual Developmental Disorder) World Health Organization’s classification system

Communication Disorders

• Combines DSM-IV expressive and mixed receptive-expressive language disorders, speech sound disorder (new name for phonological disorder), and childhood-onset fluency disorder (new name for stuttering).

• Addition of social (pragmatic) communication disorder: persistent difficulties in the social use of verbal and nonverbal communication)

Autism Spectrum Disorder

• Includes Autism, Asperger’s, Childhood Disintegrative Disorder, and Pervasive Developmental Disorder NOS

– 1. Deficits in social communication/social interaction

– 2. Restricted repetitive behaviors, interests, and activities

– Both 1 and 2 must be present

Attention-Deficit/Hyperactivity Disorder

• Examples added to help apply dx throughout life span

• Onset criteria: severe inattentive or hyperactive-impulsive symptoms present prior to age 12 (used to be age 7).

• Comorbid diagnosis with ASD is now allowed • Only 5 symptoms required for adults compared

to 6 for children • Placement in Neurodevelopmental disorders

chapter

Specific Learning Disorder

• Combination of reading disorder, mathematics disorder, disorder of written expression, and learning disorder NOS

• Combined because learning deficits in reading, written expression, and mathematics commonly occur together.

Motor Disorders

• Developmental Coordination Disorder

• Stereotypic movement Disorder

• Tourette’s Disorder

• Persistent (Chronic) motor or vocal tic disorder

• Provisional Tic Disorder

• Other Specified Tic Disorder

• Unspecified Tic Disorder – Tic criteria standardized across all disorders

– Stereotypic movement disorder more clearly differentiated from body-focused repetitive behavior disorders

Schizophrenia

• Eliminated the special attribution of bizarre delusions and Schneiderian first-rank auditory hallucinations (e.g., two or more voices conversing). – Eliminated due to poor reliability in distinguishing

bizarre from nonbizarre delusions, and poor specificity of Schneiderian symptoms

Individual must have at least one of three symptoms: delusions, hallucinations, and disorganized speech

Schizophrenia Subtypes

• Subtypes have been eliminated (e.g., paranoid, disorganized, catatonic, undifferentiated, and residual) due to limited diagnostic stability, low reliability, and poor validity

• Instead, a dimensional approach to rating severity of symptoms is included in Section 3

Schizoaffective Disorder

• Now, it is required that a major mood episode be present for a majority of the disorder’s total duration after Criterion A has been met.

• This makes schizoaffective disorder longitudinal rather than cross-sectional

• More comparable to schizophrenia, bipolar disorder, and MDD

• Improves reliability, diagnostic stability and validity of this disorder

Delusional Disorder

• Criterion A no longer requires that the delusions are nonbizarre

• Now there is a nonbizarre specifier

• No longer separated from shared delusional disorder.

• If diagnosis cannot be made, but shared beliefs are present, then the diagnosis “other specified schizophrenia spectrum and other psychotic disorder” is used

Catatonia

• All contexts require three catatonic symptoms

• The same criteria are used to diagnose catatonia whether the context is a psychotic, bipolar, depressive, or other medical disorder

Bipolar Disorders

• Criterion A for manic and hypomanic episodes now includes an emphasis on changes in activity and energy as well as mood.

• This was done to enhance accuracy of diagnosis and facilitate earlier detection in clinical settings

• Mixed episode was replaced by a new specifier “with mixed features” which can be applied to episodes of mania or hypomania when depressive features are present, and to episodes of depression in the context of MDD or bipolar disorder when mania/hypomania are present

Other Specified Bipolar and Related Disorder

• Includes categories for individuals with a past history of MDD meeting criteria for hypomania except the duration criterion (i.e., at least 4 consecutive days)

• Too few symptoms of hypomania are present to meet criteria for the full bipolar II syndrome although duration is sufficient

Anxious Distress Specifier

• Specifier intended to identify patients with anxiety symptoms that are not part of the bipolar diagnostic criteria

Disruptive Mood Dysregulation Disorder

• Created to address concerns about potential overdiagnosis and overtreatment of bipolar disorder in children

• For children up to age 18 exhibiting persistent irritability and frequent episodes of extreme behavioral dyscontrol

Premenstrual Dysphoric Disorder

• Based on strong scientific evidence, PMDD has been moved from DSM-IV Appendix B “Criteria Sets and Axes Provided for Further Study,” to the main body of DSM-5

Dysthymia

• Now falls under the category of persistent depressive disorder, which includes both chronic MDD, and the previous dysthymic disorder.

• This change was made due to a lack of scientifically meaningful differences between these two conditions

Major Depressive Disorder (MDD)

• The coexistence within a major depressive dpisode of at least three manic symptoms (insufficient to satisfy criteria for a manic episode) is now acknowledged by the specifier “with mixed features”

Bereavement Exclusion

• In DSM-IV, there was an exclusion criterion for major depressive episode that was applied to depressive sxs lasting less than 2 months following the death of a loved one. This exclusion is omitted in DSM-5 for several reasons: – To remove implication that bereavement typically

lasts only 2 months

– The depressive symptoms associated with bereavement related depression respond to the same psychosocial and medication treatments as non-bereavement-related major depressive episodes

Specifiers for Depressive Disorders

• Guidance for assessment of suicidality (e.g., suicidal thinking, plans, and presence of other risk factors)

• Research points to the importance of anxiety as relevant to prognosis and treatment decision making.

• The “anxious distress” allows the clinician to rate the severity of anxious distress in all individuals with bipolar and depressive disorders

Agoraphobia, Specific Phobia, Social Phobia

• Deletion of the requirement that individuals over age 18 recognize that their anxiety is excessive or unreasonable

• Instead, anxiety must be out of proportion to the actual danger or threat in the situation after taking cultural contextual factors into account

• 6-month duration used to be limited to individuals under age 18, but is now extended to all ages

Panic Attack

• Now can be listed as a specifier that is applicable to all DSM-5 disorders

Panic Disorder and Agoraphobia

• These two diagnoses are no longer linked in DSM-5

• The co-occurrence of these two disorders is now coded with two diagnoses

• This change was made because there is a substantial number of individuals with agoraphobia who do not experience panic symptoms.

Specific Phobia

• No longer required that individuals over age 18 recognize their fear and anxiety as excessive or unreasonable

• Duration requirement (6 months or more) now applies to all ages

Social Anxiety Disorder (Social Phobia)

• Formerly called Social Phobia, but now called Social Anxiety Disorder

• Deleted requirement of recognizing anxiety as excessive

• Duration of 6 months or more now required for all ages

• Generalized specifier has been deleted and replaced with a “performance only” specifier

• Individuals who fear only performance (i.e., speaking or performing in front of others) seems to represent a distinct subset of individuals regarding etiology, age at onset, physiological response, and treatment response

Separation Anxiety Disorder

• Formerly in the section “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence.”

• Now, classified as an anxiety disorder • Includes symptoms in adulthood as well as

childhood • No longer specifies that age at onset is before 18 • To minimize overdiagnosis, for adults, a duration

criterion was added “typically lasting for 6 months or more.”

Selective Mutism

• Was formerly classified in the section “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence.”

• Now classified as an anxiety disorder, given that a majority of children with selective mutism are anxious.

Hoarding Disorder

• New Diagnosis

• Previously listed in DSM-IV as a possible symptom of OCD and OCPD

• Research has found evidence for the diagnostic validity and clinical utility of a separate diagnosis of hoarding disorder

• Reflects persistent difficulty discarding or parting with possessions due to a perceived need to save the items, and distress associated with discarding them.

Excoriation (skin-picking) disorder

• Added due to strong evidence for its diagnostic validity and clinical utility

Substance-/Medication-Induced Obsessive-Compulsive and Related

Disorder • In DSM-IV, anxiety disorders due to a general

medical condition, and substance-induced anxiety disorders included a specifier “with obsessive-compulsive symptoms.”

• Reflects the recognition that substances, medications, and medical conditions can present with symptoms similar to primary obsessive-compulsive and related disorders

Obsessive-Compulsive and Related Disorder Due to Another Medical

Condition • OCD and related disorder includes body-focused

repetitive behavior disorder and obsessional jealousy

• Body-focused repetitive behavior disorder is characterized by recurrent behaviors other than hair pulling and skin picking (e.g., nail biting, lip biting, cheek chewing) and repeated attempts to decrease or stop the behaviors

• Obsessional jealousy is characterized by nondelusional preoccupation with a partner’s perceived infidelity

Trichotillomania (hair-pulling disorder)

• Moved from DSM-IV classification of impulse-control disorders not elsewhere classified to obsessive-compulsive and related disorders in DSM-5

• “Hair-pulling disorder” has been added in parentheses. No reason given.

Body Dysmorphic Disorder

• Added a diagnostic criterion describing repetitive behaviors or mental acts in response to preoccupations with perceived defects or flaws in physical appearance

• Muscle dysmorphia specifier

• Delusional variant for those who are completely convinced that the perceived defects/flaws are abnormal appearing

Specifiers for Obsessive-Compulsive and Related Disorders

• “with poor insight” specifier has been refined to allow a distinction between those with good or fair insight, poor insight, and “absent insight/delusional” obsessive-compulsive disorder beliefs (i.e., complete conviction that OCD beliefs are true)

Acute Stress Disorder

• Requires being explicit as to whether qualifying traumatic events were experienced directly, witnessed, or experienced indirectly

• Criterion A2 regarding subjective reaction has been eliminated (e.g., “the person’s response involved intense fear, helplessness, or horror”)

• Based on evidence that acute posttraumatic reactions are very heterogeneous and that DSM-IV’s emphasis on dissociative symptoms is overly restrictive, individuals may meet dx criteria in DSM-5 for acute stress disorder if they exhibit any 9 or 14 listed sxs in the following categories: intrusion, negative mood, dissociation, avoidance, and arousal

Adjustment Disorders

• Reconceptualized as a heterogeneous array of stress-response syndromes that occur after exposure to a distressing (traumatic or nontraumatic) event

• Residual category for those exhibiting clinically significant distress without meeting criteria for a more discrete disorder

PTSD

• Significant Differences • More explicit regarding how the individual experienced the

“traumatic” event(s) • Subjective reaction was eliminated (A2) • Now 4 sx clusters: reexperiencing, avoidance/numbing, and

arousal (previous clusters) • Now, avoidance/numbing cluster is divided into two distinct

clusters: avoidance and persistent negative alterations in cognitions and mood

• Developmentally sensitive with lowered dx threshold for children and adolescents

• More criteria added for children age 6 or younger

Reactive Attachment Disorder

• In DSM-IV: 2 subtypes (emotionally withdrawn/inhibited, and indiscriminately social/disinhibited)

• In DSM-5, the subtypes are defined as distinct disorders: Reactive attachment disorder & Disinhibited social engagement disorder

• Both disorders are result of social neglect or limitations to a child’s attachments

Reactive Attachment Disorder

• Due to dampened positive affect, RAD resembles internalizing disorders

• Lack of or incompletely formed preferred attachments to caregiving adults

Disinhibited Social Engagement Disorder

• More closely resembles ADHD

• Occurs in children who may have established secure attachments

Depersonalization Disorder

• Now called “depersonalization/derealization disorder”

Dissociative Fugue

• Now a specifier of dissociative amnesia rather than a separate dx

Dissociative Identity Disorder

• Criterion A has been expanded to include certain possession-form phenomena, and functional neurological symptoms to account for more diverse sxs presentation

• Criterion A now specifically states that transitions in identity may be observable by others or self-reported

• Criterion B now states that individuals with DID may have recurrent gaps in recall for everyday events, not just for traumatic experiences

• Experiences of pathological possession in some cultures are included in the description of identity disruption

Somatic Symptom Disorder Overview

• Somatoform disorders are now referred to as somatic symptom and related disorders

• Somatization disorder removed

• Hypochondriasis removed

• Pain disorder removed

• Undifferentiated somatoform disorder removed

Somatic Symptom Disorder

• Recognition that individuals with somatic sxs plus abnormal thoughts, feelings, and behaviors may or may not have a diagnosed medical condition

• Symptom count required to meet criteria for somatization disorder (DSM-IV) was very high

• Individuals previously diagnosed with somatization disorder will usually meet DSM-5 criteria for somatic sxs disorder only if they have the maladaptive thoughts, feelings, and behaviors

Hypochondriasis and Illness Anxiety Disorder

• Hypochondriasis eliminated (negative connotation)

• Changed to Illness Anxiety Disorder

Pain Disorder

• DSM-IV: Assumed that some pain was associated solely with psychological factors

• This assumption has not been supported by research

Avoidant/Restrictive Food Intake Disorder

• New name for DSM-IV feeding disorder of infancy or early childhood

• Children and adolescents who substantially restrict their food intake and experience significant associated physiological or psychosocial problems, but do not meet criteria for any DSM-IV eating disorder

• This new category is more broad and is intended to be a better fit for such individuals

Anorexia Nervosa

• Requirement for amenorrhea has been eliminated

• Males

• Females taking contraceptives

• Those meeting all criteria except amenorrhea show similar profiles to those who meet all DSM-IV criteria (same population)

Bulimia Nervosa

• Reduction in required minimum average frequency of binge eating and inappropriate compensatory behavior frequency from twice to once weekly

• Clinical characteristics and outcome of those meeting the slightly lower threshold are similar to those meeting the DSM-IV criterion.

Binge Eating Disorder

• Moved from Appendix B of DSM-IV, to Eating Disorders section of DSM-5

• Minimum average frequency of binge eating changed from at least twice weekly for 6 months, to at least once weekly over the last 3 months

Sleep-Wake Disorders Overview

• Sleep disorders related to another mental disorder removed

• Sleep disorder related to a general medical condition removed

• Moves away from making causal attributions between coexisting disorders

• Primary insomnia renamed “insomnia diaorder”

• Narcolepsy differentiated from other forms of hypersomnolence

Genito-Pelvic Pain/Penetration Disorder

• New diagnosis that represents a merging of the DSM-IV categories of vaginismus and dyspareunia

• Sexual aversion disorder removed due to rare use and lack of supporting research

Gender Dysphoria

• New diagnostic class

• New conceptualization of defining features by emphasizing the phenomenon of “gender incongruence” rather than cross-gender identification

• Removed from “Sexual and Gender Identity Disorders” section to separate this diagnosis from sexual dysfunctions and paraphilias

Oppositional Defiant Disorder

• Sxs now grouped into 3 categories: Angry/irritable mood, argumentative/defiant behavior, and vindictiveness

Conduct Disorder

• Specifier added for individuals meeting full criteria for the disorder, but also present with limited prosocial emotions

• This specifier applies to those with conduct disorder who show a callous and unemotional interpersonal style across multiple settings and relationships

Intermittent Explosive Disorder

• Changed the type of aggressive outbursts

• In DSM-IV, physical aggression was required

• Now, verbal aggression and non-destructive/noninjurious physical aggression also meet criteria

• Must be at least 6 years of age to be diagnosed

Major and Mild Neurocognitive Disorder

• Dementia and Amnestic disorder are now subsumed under the new name of “Major Neurocognitive disorder.”

• The term “Dementia” is not precluded from use

• DSM-5 recognizes a less severe level of cognitive impairment called mild NCD

• Major or mild vascular NCD and major or mild NCD due to Alzheimer’s disease have been retained

NCD continued..

• New separate criteria presented for major or mild NCD due to – Frontotemporal NCD – Lewy Bodies – Traumatic Brain Injury – Parkinson’s Disease – HIV infection – Huntington’s Disease – Prion Disease – Another medical condition – Multiple etiologies – Substance/medication-induced NCD – Unspecified NCD

Personality Disorders

• Alternative approach to diagnosis developed for further study and can be found in section 3

• Moderate level of impairment in personality functioning required now

• Diagnostic thresholds for both Criterion A and Criterion B have been set empirically to minimize change in prevalence and overlap with other personality disorders

• Personality disorder, trait specified replaces NOS

Paraphilic Disorders Specifiers

• Addition of course specifiers: – “in a controlled environment”

– “in remission”

• Differences between paraphilias and paraphilic disorders: – Disorder is a paraphilia that is currently causing

distress or impairment to the individual

– Paraphilia alone does not automatically justify or require clinical intervention

• Thank You