hanipsych, dsm 5

Changes from DSM-IV-TR to DSM-5

Dr. Hani Hamed Dessoki, M.D.Psychiatry

Prof. Psychiatry

Chairman of Psychiatry Department

Beni Suef University

Supervisor of Psychiatry Department

El-Fayoum University

APA member

Schizophrenia Spectrum & Other Psychotic Disorders

22 Chapters:

1. Neurodevelopmental Disorders

2. Schizophrenia Spectrum & Other Psychotic Disorders

3. Bipolar & Related Disorders4. Depressive Disorders5. Anxiety Disorders6. Obs-Compulsive & Related 7. Trauma- & Stressor-Related 8. Dissociative Disorders9. Somatic Symptom Disorders10.Feeding & Eating Disorders11.Elimination Disorders12.Sleep/Wake Disorders

13. Sexual Dysfunctions14. Gender Dysphoria15. Disruptive, Impulse-Control

& Conduct Disorders16. Substance Related &

Addictive Disorders17. Neurocognitive Disorders18. Personality Disorders19. Paraphilic Disorders20. Other Mental Disorders21. Medication-induced

Movement…Med Effects22. Other Conditions (v codes)

Schizophrenia Spectrum & Other Psychotic Disorders

A. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these must be (1), (2), or (3):

1.Delusions.

2.Hallucinations.

3.Disorganized speech (e.g., frequent derailment or incoher-ence).

4.Grossly disorganized or catatonic behavior.

5.Negative symptoms (i.e., diminished emotional expression or avolition)

.B. For a significant portion of the time since the onset of the disturbance, level of functioning in one or more major areas, such as work, interpersonal relations, or self-care,

Schizophrenia

C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms(or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms.

During these prodromal or residual periods ,the signs of the disturbance may be manifested by only negative symptoms or by two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

Schizophrenia Spectrum and Other Psychotic Disorders:

Schizophrenia:

The elimination of bizarre delusions.

Rationale: Poor reliability in distinguishing bizarre vs. non-bizarre delusions.

Schizophrenia Spectrum and Other Psychotic DisordersCont…

Schizophrenia cont…

The DSM-IV subtypes of schizophrenia have been eliminated.

Instead a dimensional approach to rating severity for the core symptoms of schizophrenia is included in DSM-5 Section III.

Rationale: Limited diagnostic stability, low reliability, and poor validity.

Reliability (الموثوقيه) is the degree to which an assessment tool produces stable and consistent results.

Validity (صدق) refers to how well a test measures what it is purported to measure.

Schizophrenia

Specify if: With catatonia (refer to the criteria for catatonia associated with another mental disorder, pp. 60–61, for definition).

Coding note: Use additional code 293.89 (F06.1) catatonia associated with schizophrenia to indicate the presence of the comorbid catatonia.


Catatonia: Catatonia is now a separate psychotic disorder that can be associated with other mental or medical disorders.

The criteria for catatonia is now uniform for all contexts and requires 3 sx from a total of 12.

Delusional disorder

A. The presence of one (or more) delusions with a duration of 1 month or longer.

B. Criterion A for schizophrenia has never been met. Note: Hallucinations, if present, are not prominent and are related to the delusional theme (e.g., the sensation of being infested with insects associated with delusions of infestation).

- Bizzare is Ok.


Schizoaffective Disorder:

The primary change to schizoaffective disorder is that a major mood episode be present for the majority of the disorders total duration after criterion A has been met.

Rationale: To improve reliability, diagnostic stability, and validity of this disorder.

Other important aspects

Brief PD & schizoaffective no major change but emphasis on positive active symptoms

Other Specified Schizophrenia Spectrum and Other Psychotic Disorder

1.Persistent auditory hallucinations

.2.Delusions with significant overlapping mood episode

.3.Attenuated psychosis syndrome: This syndrome is characterized by psychotic-like symptoms that are below a threshold for full psychosis (e.g., the symptoms are less severe and more transient, and insight is relatively maintained)

.4.Delusional symptoms in partner of individual with delusional disorder:

Bipolar Disorder

22 Chapters:








Bipolar Disorders

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

bipolar I disorder, mixed episode, requiring that the individual simultaneously meet full criteria for both mania and major depressive episode, has been removed.

Instead, a new specifier, “with mixed features,” has been added that can be applied to the episodes when mixed features are present.

Bipolar II disorder, another specified bipolar and related disorder is that too few symptoms of hypomania are present to meet criteria for the full bipolar II syndrome, although the duration is sufficient at 4 or more days.

Depressive Disorder

DSM-5 contains several new depressive disorders, including disruptve mood dysregulaton disorder and premenstrual dysphoric disorder.

It is included for children up to age 18 years who exhibit persistent irritability and frequent episodes of extreme behavioral dyscontrol.

The frequency of diagnosis of bipolar disorder has risen dramatically in children and adolescents.

The DSM-V has suggested a new diagnosis termed disruptive mood dysregulation disorder (DMDD) (formerly temper dysregulation disorder with dysphoria) to reduce the rate of false diagnosis of bipolar disorder in young people.

(Margulies et al,Bipolar Disord, Aug 2012; 14(5): 488-96. )

DSM-5 conceptualizes chronic forms of depression in a somewhat modified way.

What was referred to as dysthymia in DSM-IV now falls under the category of persistent depressive disorder, which includes both chronic major depressive disorder and the previous dysthymic disorder.

Neither the core criterion symptoms applied to the diagnosis of major depressive episode nor the requisite duration of at least 2 weeks has changed from DSM-IV.

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 is omitted in DSM-5 for several reasons.

Specifers for Depressive Disorders

With suicide: suicidal thinking, plans, and the presence of other risk factors

“with anxious distress”

Discriminating primary clinical states in bipolar disorder with a comprehensive symptom scale.

Small subset of symptoms, several of which are absent in DSM-IV-TR criteria and traditional rating scales for bipolar studies, aid in distinguishing mixed episodes from depressive or manic/hypomanic episodes.

Most anxiety items were more severe in mixed subjects.

(Singh et al,Acta Psychiatr Scand, Jul 2012)

DEPRESSIVE DISORDERS

SUBSTANCE/MEDICATION-INDUCED DEPRESSIVE DISORDER

Removed Criterion A2:elevated, expansive or irritable mood

OTHER SPECIFIED DEPRESSIVE DISORDERLists a few examples

UNSPECIFIED DEPRESSIVE DISORDERe.g. insufficient information

SPECIFIERSWith Anxious distressPostPartum onset now peripartum onset (includes during/following pregnancy)

Somatoform disorders

Somatic symptom and related disorders

http://en.wikipedia.org/wiki/Somatoform_disorder

22 Chapters:








Somatic Symptom Disorders

Joel E. Dimsdale, M.D. ChairJames L. Levenson, M.D., Text Coordinator Michael R. Irwin, M.D.Francis J. Keefe, Ph.D. (2007-2011)Arthur J. Barsky III, M.D. Sing Lee, M.D.Francis Creed, M.D. Michael Sharpe, M.D.Nancy Frasure-Smith, Ph.D. (2007-2011) Lawson R. Wulsin, M.D.


Somatoform disorders are now called somatic symptom and related disorders.

In DSM-IV, there was significant overlap across the somatoform disorders and a lack of clarity about their boundaries.

These disorders are primarily seen in medical settings, and nonpsychiatric physicians found the DSM-IV somatoform diagnoses problematic to use.

http://en.wikipedia.org/wiki/Somatoform_disorder


The DSM-5 classification reduces the number of these

disorders and subcategories to avoid problematic overlap.

Diagnoses of somatization disorder, hypochondriasis, pain disorder, and undifferentiated somatoform disorder have been removed.

Somatic Symptom Disorder

In DSM-IV, the diagnosis undifferentiated somatoform disorder did not prove to be a useful clinical diagnosis.

The distinction between somatization disorder and undifferentiated somatoform disorder was arbitrary.

Somatic Symptom Disorder

The diagnosis of somatization disorder was essentially based on a long and complex symptom count of medically unexplained symptoms.

DSM-5 criteria for somatic symptom disorder includes the maladaptive thoughts, feelings, and behaviors that define the disorder, in addition to their somatic symptoms.

Somatic Symptom and Related Disorders (161)

300.82 (F45.1)Somatic Symptom Disorder (161)

Specify if: With predominant pain

Specify if: Persistent

Specify current severity: Mild, Moderate,

Severe

Medically Unexplained Symptoms

The DSM-5 classification defines disorders on the basis of positive symptoms (i.e., distressing somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to these symptoms).

Medically unexplained symptoms do remain a key feature in conversion disorder and pseudocyesis.


In DSM-5, people with chronic pain can be diagnosed with

somatic symptom disorder with predominant

pain;

or psychological factors that affect other medical

conditions;

or with an adjustment disorder.

Hypochondriasis and Illness Anxiety Disorder J02

In DSM-5, individuals with high health anxiety without somatic symptoms would receive a diagnosis of illness anxiety disorder (unless their health anxiety was better explained by a primary anxiety disorder, such as generalized anxiety disorder).

Specify whether: Care seeking type,

Care avoidant type

Conversion Disorder (Functional Neurological Symptom Disorder) J03

Criteria for conversion disorder (functional neurological symptom disorder) are modified to emphasize the essential importance of the neurological examination, and in recognition that relevant psychological factors may not be demonstrable at the time of diagnosis.

Conversion Disorder (Functional Neurological Symptom Disorder) (163)

Specify symptom type:

(F44.4)With weakness or paralysis

(F44.4)With abnormal movement

(F44.4)With swallowing symptoms

(F44.4)With speech symptom

(F44.5)With attacks or seizures

(F44.6)With anesthesia or sensory loss

(F44.6)With special sensory symptom

(F44.7)With mixed symptoms

Specify if: Acute episode, Persistent

Specify if: With psychological stressor (specifystressor), Without psychological stressor

Psychological Factors Affecting Other Medical Conditions and Factitious Disorder

Psychological factors affecting other medical conditions is a new mental disorder in DSM-5, having formerly been included in the DSM-IV chapter “Other Conditions That May Be a Focus of Clinical Attention.”

Specify current severity: Mild, Moderate, Severe, Extreme

Specific Changes Per Diagnostic Category in DSM-5

Obsessive-Compulsive and Related DisordersOCD is now a stand alone categoryBody Dysmorphic Disorder listed under OCD as

F01Added Hoarding under category of OCD as F02Trichotillomania now called Hair-Pulling Disorder is

listed under OCD as F03Skin Picking Disorder moved under OCD as F04

Factitious Disorder 300.19

Factitious Disorder (includes Factitious Disorder Imposed on Self,

Factitious Disorder Imposed on Another) (165)

Specify Single episode,

Recurrent episodes

Somatic Symptom and Related Disorders

Somatic Symptom Disorder Illness Anxiety DisorderConversion Disorder (Functional Neurological Symptom

Disorder)Psychological Factors Affecting Other Medical

ConditionsFactitious DisorderOther Specified Somatic Symptom and Related

DisorderUnspecified Somatic Symptom and Related Disorder

Personality Disorders

22 Chapters:








Personality and Personality Disorders^

Andrew E. Skodol, M.D.ChairJohn M. Oldham, M.D.Co-ChairRobert F. Krueger, Ph.D., Text CoordinatorRenato D. Alarcon, M.D., Carl C. Bell, M.D.Donna S. Bender, Ph.D.Lee Anna Clark, Ph.D.W. John Livesley, M.D., Ph.D. (2007-2012)Leslie C. Morey, Ph.D.Larry J. Siever, M.D.Roel Verheul, Ph.D. (2008-2012)

Borderline personality disorder controversy

In 2003, the Treatment and Research Advancements National Association for Personality Disorders (TARA-APD) campaigned to change the name and designation of borderline personality disorder in DSM-5.

“The name BPD is confusing, imparts no relevant or

descriptive information, and reinforces existing stigma...". Instead, it proposed the name "emotional regulation disorder" or "emotional dysregulation disorder".

There was also discussion about changing borderline personality disorder, an Axis II diagnosis (personality disorders and mental retardation), to an Axis I diagnosis (clinical disorders).

http://en.wikipedia.org/wiki/Borderline_personality_disorder

http://en.wikipedia.org/wiki/Social_stigma

Diagnosing Personality Disorders

How can it be “disordered”? An enduring pattern of inner experience and behavior that

deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.

DSM-IV-TR Clusters

• Cluster A : Odd or eccentric – Schizoid, Paranoid, Schizotypal

• Cluster B : Dramatic, emotional or erratic– Antisocial, Borderline, Narcissistic, Histrionic

• Cluster C : Anxious, fearful– Avoidant, Dependent, Obsessive-Compulsive

Could Redefine “Personality”

DSM-IV: A pervasive pattern of thinking/ behaving/emotionality.

Perhaps? A personality disorder reflects "adaptive failure" involving:

"Impaired sense of self-identity" or "Failure to develop effective interpersonal functioning."

DSM -5 and multiaxial system

DSM-5 moves from the multiaxial system to a new assessment that removes the arbitrary boundaries between personality disorders and other mental disorders.

Obvious Changes in DSM-5

The DSM-5 will discontinue the Multiaxial Diagnosis, No more Axis I,II, III, IV & V-which means that Personality Disorders will now appear as diagnostic categories and there will be no more GAF score or listing of psychosocial stressor or contributing medical conditions.

The Multi-axial model will be replaced by Dimensional component to diagnostic categories.

New DSM 5 Classifications

DSM IV TR DSM 5Avoidant Avoidant

Borderline Borderline

Narcissistic Narcissistic

Obsessive –Compulsive Obsessive Compulsive

Schizotypal Schizotypal

Antisocial Antisocial

Paranoid Personality Disorder Trait Specified

Schizoid

Histrionic

Dependent

Personality Disorder NOS

Avoidant Personality Disorders

Pervasive pattern of social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation, and avoidance of social interaction

Borderline Personality

Condition in which people have long- term patterns of unstable or turbulent emotions, such as feelings about themselves and others. These inner experiences often cause them to take impulsive actions and have chaotic relationships uncertain about their identity. Interests and values may change rapidly

Narcissistic Personality Disorder

Pervasive pattern of social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation, and avoidance of social interaction

Obsessive Compulsive Disorder

People have unwanted and repeated thoughts, feelings, ideas, sensations (obsessions), or behaviors that make them feel driven to do something (compulsions). Often the person carries out the behaviors to get rid of the obsessive thoughts, but this only provides temporary relief. Not performing the obsessive rituals can cause great anxiety.

http://qwikstep.eu/search/what-is-obsessive-compulsive-personality-disorder.html

Schizotypal

Schizotypals believe

they have magical powers

Antisocial

When I left, I

joined the army, and when I took the service exam my psych profile fit a certain... moral flexibility would be the only

way to describe it... and I was loaned out to a

CIA-sponsored program, and we sort of found each other. That's how it works.

I know what I do isn't... moral, per se...

http://www.google.com/imgres?q=grosse+pointe+blank&hl=en&biw=1024&bih=587&gbv=2&tbm=isch&tbnid=NGwylEKDCLpNwM:&imgrefurl=http://www.ugo.com/movies/dialogue-coach-girl-of-your-dreams&docid=FafoS1KuxIJqwM&w=288&h=288&ei=NUNaTr6eCsWutweM_cSaDA&zoom=1

Personality Disorders in the DSM-5

The good news is that none of the criteria for personality disorders have changed in the DSM-5.

Based on feedback from a multilevel review of proposed revisions, the American Psychiatric Association Board of Trustees ultimately decided to retain the DSM-IV categorical approach with the same 10 personality disorders.

Specific Changes Per Diagnostic Category in DSM-5

Schizotypal Personality Disorder T03 also under Schizophrenia and Other Psychotic Disorders B02

Antisocial Personality Disorder T04 also under Disruptive Impulse Control and Conduct Disorders as Dyssocial Personality Disorder Q07.

The Big Six

Six specific personality disorder types

(antisocial, avoidant, borderline, narcissistic, obsessive-compulsive and schizotypal) are defined by criteria based on typical impairments in personality functioning and pathological personality traits in one or more trait domains.


A new hybrid personality model was introduced in the DSM-5′s Section III (disorders requiring further study) that included evaluation of impairments in personality functioning.

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 DisorderObsessive-Compulsive Personality DisorderAvoidant Personality DisorderSchizotypal Personality DisorderAntisocial Personality DisorderNarcissistic Personality Disorder


According to the APA, each type is defined by a specific pattern of impairments and traits.

This approach also includes a diagnosis of Personality Disorder—Trait Specified (PD-TS) that could be made when a Personality Disorder is considered present, but the criteria for a specific personality disorder are not fully met (PD-TS) replaces personality disorder not otherwise.

Personality Disorders

The criteria for personality disorders in Section II (clinical) of DSM-5 have not changed from those in DSM-IV.

Section III (research) includes the proposed research model for personality disorder diagnosis and conceptualization developed by the DSM-5 Personality and Personality Disorders Work Group.


APA hopes that inclusion of the new methodology in Section III of DSM-5 will encourage research that might support this model in the diagnosis and care of patients, as well as contribute to greater understanding of the causes and treatments of personality disorders.

Personality Disorders – The way it almost was

• Personality types defined by personality domains and facets:

– Negative affect (facets: lability,anxiety/ insecurity, hostility)

– Detachment (facets: withdrawal/depression, suspicion)

– Antagonism (facets: difficult to get along with: manipulative, deceitful, hostile)

– Disinhibition (facets: impulsive/irresponsible)– Psychoticism (facets: unusual/bizarre experiences,

eccentric)

PDTS Levels of Personality Functioning Scale

The diagnosis of Personality Disorder Trait Specified (PDTS) is defined by significant impairment in personality functioning, as measured by the Levels of Personality Functioning Scale, and one or more pathological personality trait domains or trait facets

Guide to Implementation

1. Is impairment in personality functioning (self and interpersonal) present or not?

2. If so, rate the level of impairment in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning on the Levels of Personality Functioning Scale.

3. Is one of the 6 defined types present?

4. If so, record the type and the severity of impairment.

5. If not, is PD-Trait Specified present?

6. If so, record PDTS, identify and list the trait domain(s) that are applicable, and record the severity of impairment.

7. If a PD is present and a detailed personality profile is desired and would be helpful in the case conceptualization, evaluate the trait facets.

8. If neither a specific PD type nor PDTS is present, evaluate the trait domains and/or the trait facets if these are relevant and helpful in the case conceptualization.

hanipsych, dsm 5

Health & Medicine