Psychiatry’s Manual of Disorders and the Issues Surrounding Its Design and Use - PowerPoint Presentation

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Psychiatry’s Manual of Disorders and the Issues Surrounding Its Design and Use

DSM-5:NOT WITHOUT CONTROVERSY

American Psychiatric Association

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An Introduction to DSM-5,Its Development, Changes, and Controversies

Researched and Developed by Rhinehart Lintonen

The presentation herein is the intellectual property of Rhinehart Lintonen and does not reflect the attitudes or positions of the American Psychiatric Association. This presentation was developed for the use of the membership of the Milwaukee Area Teachers of Psychology and their students. Any other use should request permission at lintonen@hotmail.com. The intent of this presentation is to delineate the development of the present DSM and to document changes from DSM-IV-TR. Critiques and controversies presented are those of the persons or groups cited.

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A Short History of the DSM

The Diagnostic and Statistical Manual ofMental Disorders

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Development of the DSMs

DSM-5, issued on May 18, 2103, is the culmination of changes begun in 1999 and intended to replace DSM-IV-TR which was seen as needing revision due to scientific discoveries in brain biology and issues surrounding perceived needed changes in the diagnostic categories themselves.The prior editions stem back to post-World War II when the Army and Veteran’s Administration were looking for a way to diagnose what psychiatrically affected returning troops.

Thus began DSM-I, published in 1952.Other revisions include DSM-II (1968), DSM-III (1980), DSM-IIIR (1987), DSM IV (1994) and DSM-IV-TR (2000)

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Development of the DSMs

Along the way, revisions reflected current thinking and trends in psychiatryDSM-1 was largely psychodynamic in nature, reflecting Freud’s impact on psychiatry

Disorders referred to as “reactions” under the influence of Adolf Meyer and also showed the psychoanalytic bentTwo groups of disorders based on causality

Those caused by or associated with brain tissue dysfunctionThose of “psychogenic” origin not clearly related to structural changes in the brainDSM-II increases number of disorders to 182

Drops use of “reactions” while still using Freudian terms such as “neurosis” and “psychosis”

Illustrations: American Psychiatric Assoc.

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Development of the DSMs

DSM-III represented a major change in the construction of the manual with 265 categories of disordersGone was the prior emphasis on psychodynamic views

Now the emphasis was on empirically-obtained observationsCoincided with move in US away from psychoanalysis and with publics’ skepticism of psychiatry in general

DSM-IIIR influenced by Emil Kraepelin’s insistence on the roles of biology and genetics in disordersTask Force Chair Dr.

Robert Spitzer suggested there was a hierarchy of mental illness (Greenberg, 54)

Dr. Allen Frances accords him great respect, saying that “Without Robert Spitzer, psychiatry might have become increasingly irrelevant” and that “Spitzer had laid the foundations for the psychiatric research enterprise.”

(Frances, 62-63)

High praise for the man who guided the DSMs into a new direction

New York Times

APA

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Development of the DSMs

DSM-IV was not much of a sea-change from DSM-IIIThe number of disorders were now over 300

Allen Frances, MD chaired the task force and insisted that the manual was not to be taken as a “Bible” of mental

illnesses All changes had to be science-driven and evidence-based and needed to have checks and balances which would protect against bias and individual’s pet ideas (Frances, xiii)

One of his regrets is that “Even though we had been boringly modest in our goals, obsessively meticulous in our methods, and rigidly conservative in our product, we failed to predict or prevent three new false epidemics of mental disorder in children – autism, attention-deficit, and childhood bipolar disorder.” (Frances, xiv)

American Psychiatric Assoc.

Photo: healthcareblog.com

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Development of DSM-5

DSM-IV-TR (2000) was an update to DSM-IV, not in the categories of disorders but in two main areas:Prevalence

Familial patternsThese were updated to reflect new scientific knowledge regarding genetics and other

neuroscientific advances

American Psychiatric Assoc.

What you’ve been teaching from all this time! Get ready to change what you knew!

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Development of DSM-5

Beginning in 1999, there were specific calls for changes to DSM-IV-TR including:•In two decades, much new info on disorders had emerged

•Biological psychiatry and neuroscience were being embraced with great enthusiasmProminent neuroscientists like

Eric Kandel were proclaiming that “all mental disorders involve disorders of brain function.” (Greenberg, 61)New drugs seemed to ease burden of psychological disorders

Think serotonin imbalances being eased by SSRI antidepressants (which later proved to be a false hypothesis

)

•

Genetics research had added new knowledge of the possible sources of disturbances

•

Need for a more defined nosology (classification system)

•

A hoped-for “paradigm shift” to recreate that nosology

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How Was DSM-5 Created?

New edition preceded by 13 scientific conferences and a number of white papers, monographs, and journal articles researching and evaluating new nosologiesAPA set up the DSM-5 Task Force of 27 members in 2007 under Chairman David Kupfer

, MD and Vice-Chairman Darrel Regier, MD160 researchers and clinicians formed the Work Groups and Study Groups to develop the new manual, revising or tweaking criteria from the DSM-IV-TR and deleting or adding diagnostic classifications

Kupfer

Regier

www.psychiatry.pitt.edu

American Psychiatric Assoc.

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The new task force stated in its goals that “The previous version of DSM was completed nearly two decades ago; since that time, there has been a wealth of new research and knowledge about mental disorders.”

(APA)Therefore, the APA set about to use this evidence to determine whether certain diagnoses (a very hotly debated term) should be removed or changedAdditionally, the APA felt that they needed to better define the disorders by symptoms and behaviors than DSM-IV did

This would allow for future revision processes to be more responsive through incremental updates (DSM-5.0, 5.1, etc.) as new scientific breakthroughs became available

How Was DSM-5 Created?

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Changes like this are costlyDSM-5 cost between $20-25 million to produce

However, the DSM is a cash cow for the APA!It is the sole agency producing such a product except for the ICD-10The greatest percentage of the income of the APA comes from its publishing armSince it brings in so much income, the DSM is critically important to the APA

There are calls for a more open, diversified medical organization to be created to write a new manual with more inputs and better designed to help the practice of psychiatry rather than simply refine the nosology (also important)

How Was DSM-5 Created?

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The New DSM-5

Change is Good

(Maybe)

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The old structure is goneNo more Five Axes

These were seen as incompatible with ICD-10 and other medical diagnostic systemsReplaced with a 0 to 4 point severity ratings scale for each diagnosisNo more assessment of global relative functioning according to a scale (GARF)

The term “general medical condition” has been replaced with “another medical condition”Asperger Syndrome is no longer a discrete classificationNow merged into Autism Spectrum Disorder

Subtypes for Schizophrenia are goneThis was done because of low reliability, poor validity, and because of limited diagnostic stability (APA)NOS categories (not otherwise specified) are now “other specified disorder” and “unspecified disorder”

Basic Changes

Illus.: gracebooks.org

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Structure of the ManualPreface

DSM-5 Classification and CodingSection IUse of the Manual

Cautionary Statement for Forensic Use of DSM-5Section IIDisorders listed among 22 major categories

Basic Changes

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Gone is the category “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence”These are now found under other appropriate headings

Other changes pertinent to each category will be discussed in the following section “The New DSM-5: Disorders”Basic Changes

For a complete discussion of in-depth changes in each diagnostic category, go to:

http://www.ldaofky.org/changes-from-dsm-iv-tr--to-dsm-5%5B1%5D.pdf

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The New DSM-5

The Controversies

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The new DSM has been under fire almost from the beginningInitial complaints involved failure to supply minutes of committee meetings and questions about transparency

As time progressed, the questions and criticisms grewTwo camps essentially:The American Psychological Association with David

Kupfer and Darrel Regier defending their work

Former DSM-III and DSM-IV task force leaders Robert Spitzer and Allen FrancesThis brought about what became high drama never before seen at this level of medical/scientific processThe availability of the Internet allowed the criticism to reach unheard of numbers of therapists and professionals able to comment on the proceedings

DSM Under Fire

news.bbc.co.uk

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The Spitzer/Francis camp charged:The manual was being drawn up in secrecy

Transparency was not being allowedThe Task Force members had to sign confidentiality agreements which limited their open discussion about the proceedingsDSM not etiologically based and adding things which were not disorders

Continued emphasis on Asperger’s, ADHD, and Childhood Bipolar Disorder (what Frances called “false epidemics”) would lead to diagnostic inflation

(Francis, 77-86)DSM-5 was leading to the “medicalization of normalcy” (Frances and Widiger, 123)

Too many psychiatrists on the development committees had ties to Big Pharma and were thus in danger of being influenced in their decisions (Frances, 75)

The Charges

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The Spitzer/Francis camp charged:Field Trials were improperly vetted and hastily drawn up and weren’t adequately presented for review

The trials failed spectacularly in some areas with very low kappa scoresOn a 0 to 1 scale, depression had a low 0.28; Mixed Anxiety-Depressive Disorder at -0.004 (Freedman, et.al.)

The APA was in too much of a hurry to bring the manual to marketAPA’s financial vesting in the book meant that the organization needed to bring it to market quickly to continue the flow of sales

Behind it all, Frances charged that there were a number of conceptual issues:“an elusive definition of mental disorder, the limits of neuroscience, the limits of descriptive psychiatry, an unclear epistemology, the absence of a unified theoretical model, pragmatism, and fads.” (Frances and

Widiger, 109-110)

The Charges

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Frances admits that “Psychiatric classification is necessarily a sloppy business.” (Frances and Widiger

, 114) and that “the only way to define a mental disorder is ‘that which clinicians treat; researchers research; educators teach; and insurance companies pay for.’” (Frances, 18)Frances warns that DSM-IV had some unintended consequences being heightened by DSM-5 (Frances and Widiger, 115)

Four fads creating diagnostic inflationautism

attention deficitchildhood bipolar disorderparaphilia not otherwise specified

The Charges

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Additional critiques from Frances and othersAPA was trying to create a paradigm shift in psychiatric diagnosis which is, at present, unrealizable

New category of Mood Dysregulation Disorder will create a mental disorder out of temper tantrumsNormal grief is being

medicalizedEveryday characteristics of old age will be misdiagnosed as cognitive disorders

ADHD will lead to more adults being diagnosed in a fit of diagnostic inflationExcessive eating is now a disorder, not just plain gluttonyProblems in everyday living will be elevated to General Anxiety Disorder

Behavioral addictions can apply to anything one does often enough

The Charges

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And the list goes onJust exactly what is a mental disorder, anyway?

Are they simply problems in living as Thomas Szasz claimed?Will we stigmatize too many people?

Will all of this encourage Big Pharma to find a drug for everything?Many psychiatric drugs don’t work nearly as well as patient think anyway

At least a number of proposed “disorders” didn’t make itE,g., Hypersexual DisorderHow much sex is too much?

Is it possible to be mentally ill because of a desire for sex?

The Charges

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Is it all for naught? Does DSM-5 or any other manual have any redeeming value?The APA said it “would work to overcome one of the clearest limitations of our current diagnostic criteria…the lack of quantitative measures.”

(Greenberg, 175)Frances counters that we “still do not have a single laboratory test in psychiatry.” (Frances, 10)However, the APA did adhere to attempting to validate all disorders through empirical evidence from clinical practice and an exhaustive search of the literature

So, at the end of the day, even Spitzer and Frances admit that, while it isn’t a “bible,” the DSM is still the best thing we have to guide us until something better comes along

Anything Positive in DSM-5?

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DSM-5 has many supporters among clinicians and therapistsIt is considered robust compared to the ICD-10 or any other attempt to create a different manual

Perhaps therapists are best reminded that it is just a guide, it needs to be used judiciously, and the most apt advice may be that of the British Psychological Society which admonishes therapists to treat the person first, not the disease

Anything Positive in DSM-5?

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Other methodologies are in the worksCreating categories of disorders based on brain biology and neuroscience

Diagnosing disorders based on measuring the psychological dimensions of personalityUsing a system of “stepped diagnosis” (Frances, 222)

A form of watchful waiting emphasizing normalizing problems and using minimal interventions until arriving at a definitive diagnosis and treatment plan

Other Methodologies

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The National Institute of Mental Health (NIMH) has an initiative known as Research Domain Criteria (RDoC

)The system would assessNegative Valence SystemsThreat, fear of loss, frustration

Positive Valence SystemsMotivation, learning, and habit

Cognitive SystemsAttention, perception, and MemorySocial Process Systems

facial expression identification, imitation, attachment/separation fearArousal/Regulatory Processes

Stress regulation

These would be analyzed in terms of genes, molecules, and cells

(Greenburg, 339-342)

Another Possible System

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The New DSM-5

Diagnostic Criteria

Disorders

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Conditions which begin in early development and which cause significant functional impairment

Neurodevelopmental Disorders

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Mental Retardation now called “intellectual disability”Language disorders/stuttering now called “communication disorders”

SubcategoriesIntellectual DisabilitiesCommunication Disorders

Autism Spectrum DisorderAttention-Deficit-Hyperactivity Disorder

Specific Learning DisorderMotor Disorders

Tic Disorders

Neurodevelopmental Disorders

www.dsrf.com

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A group of disorders which is characterized by major disturbances in such areas as thought, language, perceptions, emotion, and behavior and which make it difficult to separate reality from fantasy

Schizophrenia Spectrum and Other Psychotic Disorders

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All subtypes deleted

Former subtypes are now diagnostic symptomsParanoid, disorganized, etc.Subcategories

Schizotypal (Personality) DisorderDelusional Disorder

Brief Psychotic DisorderSchizophreniform Disorder

SchizophreniaSchizoaffective Disorder

Substance/Medication-Induced Psychotic Disorder

Psychotic Disorder Due to Another Medical Condition

Catatonia

Other Specified Schizophrenia Spectrum and Other Psychotic Disorder

Unspecified

Schizophrenia Spectrum and Other Psychotic Disorder

Schizophrenia Spectrum and Other Psychotic Disorders

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Bipolar and Related Disorders

Disorders which are marked by major mood changes, alternating from manic to depressive and which can exhibit psychotic experiences – the reason they are located between Schizophrenia and Depressive Disorders in DSM-5

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Separated from Mood Disorders (category no longer exists)A new

specifier (“with mixed features” has been added for each subcategoryAnxiety symptoms are a specifier, although not part of the diagnostic criteria (in many of the categories such

specifiers may now exist without being a diagnostic necessity)Subcategories

Bipolar I DisorderBipolar II Disorder

Cyclothymic DisorderSubstance/Medication-Induced Bipolar and Related Disorder

Other Specified Bipolar and Related Disorder

Unspecified Bipolar and Related Disorder

Bipolar and Related Disorders

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Depressive Disorders

Conditions in which the person feels in an extremely depressed mood for persistent periods of time, often without any letup or recurring in cycles

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Replaces Mood Disorders Category for d

epressionsSpecifiers have been added for mixed symptoms and also for anxietyMost controversial: bereavement exclusion

Was excluded in DSM-IV-TR, now includedAt what point should we medicalize

normal grieving?For children up to 18 a new category addedDMDD: Disruptive Mood Dysregulation

DisorderAlso controversial

Now

medicalizing

temper tantrums?

Premenstrual Dysphoric Disorder now a subcategory

Subcategories

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

Depressive Disorders

www.healthclinicsource.com

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Anxiety Disorders

Disorders which are marked by extreme conditions of fear or uneasiness that impair one’s basic functioning and which may or may not appear to have a cause according to the sufferer

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Panic Attack has become a specifier

for all DSM-5 disorders Panic Attack and Agoraphobia are no longer necessarily associatedSpecific types of Phobia have become specifiers

No longer requires patient/client to recognize that their fear(s) are excessive or unreasonableDuration now must be 6 monthsSeparation Anxiety Disorder and Selective Mutism have been moved here from Early Onset Disorders

SubcategoriesSeparation Anxiety DisorderSelective Mutism Disorder

Specific PhobiaSocial Anxiety Disorder (formerly Social Phobia)

Panic Disorder

Agoraphobia

Generalized Anxiety Disorder

Substance/Medication-Induced Anxiety Disorder

Anxiety Disorder Due to Another Medical Condition

Anxiety Disorders

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Subcategories

(con’t.)Other Specified Anxiety Disorder

Unspecified Anxiety Disorder

Anxiety Disorders

www.suzannesutton.com

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Obsessive-Compulsive and Related Disorders

Conditions which arise in response to some sort of traumatic event or severe stress; characteristic of not only soldiers, but many public safety workers and anyone, including children, who experience major shock

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Four new disorders

Excoriation Disorder (skin-picking)Hoarding Disorder (won’t the TV reality shows delight in this!)Substance/Medication-Induced Obsessive-Compulsive and Related Disorder

Obsessive-Compulsive and Related Disorder Due to Another Medical ConditionBody Dysmorphic Disorder (BDD) adds criteria dealing with repetitive behaviors and mental acts “which may arise with perceived defects or flaws in physical appearance”

(APA)Specifiers have been added for “with good or fair insight,” “with poor insight,” or “with absent insight-delusional beliefs”

These also appear for Obsessive-Compulsive Disorder and Hoarding DisorderTrichotillomania (hair-pulling) has moved here from Impulse-Control Disorders

Obsessive-Compulsive and Related Disorders

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Subcategories

Obsessive-Compulsive DisorderBody Dysmorphic DisorderHoarding Disorder

TrichotillomaniaExcoriation Disorder

Substance/Medication-Induced Obsessive-Compulsive and Related DisorderObsessive-Compulsive and

Related Disorder Due to Another Medical ConditionOther Specified

Obsessive-Compulsive

and

Related

Disorder

Unspecified

Obsessive-Compulsive and Related Disorder

Obsessive-Compulsive and Related Disorders

www.wedpages.scu.edu

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Trauma- and Stressor-Related Disorders

Conditions in which the person experiences periods of obsessive thoughts often followed by compulsive behavior in response to that thinking; obsessions (thoughts) and compulsions (actions) can occur separately

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Now includes PTSD which was an anxiety disorder in DSM-IV-TR

Anxiety still an important symptom but not all sufferers will experience fear and anxietySymptom clusters now include negative alterations in cognition and moodE.g., negative thoughts abut oneself, outbursts of anger, self-destructive behavior, etc.

Separate criteria for children 6 and underSpecifiers modified to some extent to reflect emotional reaction training of soldiers, police, emergency personnel

Two new disordersReactive Attachment Disorder

Disinhibited Social Engagement DisorderAdjustment Disorders moved here as Stress-Response Syndromes

Trauma -and Stressor-Related Disorders

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Subcategories

Reactive Attachment DisorderDisinhibited Social Engagement DisorderChild approaching and interacting with strange adult

Posttraumatic Stress DisorderAcute Stress Disorder

Adjustment DisordersOther Specified Trauma –and Stressor-Related Disorder

Unspecified Trauma –and Stressor-Related Disorder

Trauma -and Stressor-Related Disorders

www.knottiesniche.com

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Dissociative Disorders

Disruptions of cognitive functioning in which identity, consciousness, and memory can be impaired causing the person to experience confusion and discontinuity

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Dissociative Fugue no longer a separate condition

Now a specifier for Dissociative AmnesiaDepersonalization Disorder renamed Depersonalization/Derealization

DisorderDiagnosis for Dissociative Identity Disorder may include culturally-specific experiences of pathological possession

Also, identity transitions may be observed by others as well as self-reportedNow takes into account the nature and course of identity disruptionsSubcategories

Dissociative Identity DisorderDissociative Amnesia

Depersonalization/

Derealization

Disorder

Other Specified Dissociative Disorder

Unspecified Dissociative Disorder

Dissociative Disorders

Really?

en.wikipedia.org

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Somatic Symptom and Related Disorders

Bodily symptoms (such as loss of function or pain

)

experienced as a result of extreme stress; formerly called “psychosomatic” symptoms

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Previously called Somatoform Disorders

Due to overlap and lack of clarity, these diagnoses have

been eliminated

Somatization DisorderHypochondriasis

Considered a pejorative termPain Disorder

Some pain can be medical and there is a lack of validity and reliability in the

distinctions

Undifferentiated Somatoform Disorder

Somatic Symptom Disorder is defined by positive symptoms

Psychological Factors Affecting Other Medical Conditions is a new disorder

Subcategories

Somatic Symptom Disorder

Illness Anxiety Disorder

Somatic Symptom and Related Disorders

www.addictiontreatmenttherapy.com

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Subcategories (

con’t.)Conversion Disorder

Also known as Functional Neurological Symptom Disorder

Psychological Factors Affecting Other Medical Conditions

Factitious DisorderOther Specified Somatic Symptom and Related Disorder

Unspecified Somatic Symptom and Related Disorder

Somatic Symptom and Related Disorders

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Feeding and Eating Disorders

Difficulties with eating that often reflect psychological stressors and interpersonal reactions; cause difficulties with personal imagery and health

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Eating disorders from infancy and early childhood moved here

Pica and Rumination Disorder can occur at any ageFeeding Disorder of Infancy or Early Childhood now known as Avoidant/Restrictive Food Intake DisorderAnorexia Nervosa no longer requires diagnosis of amenorrhea

Bulimia Nervosa changed required minimum frequency from twice to once weeklyBinge Eating Disorder moved up from DSM-IV-TR’s “Further Study” to full disorder

SubcategoriesPica

Rumination Disorder

Feeding And Eating Disorders

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Subcategories (

con’t.)Avoidant/Restrictive Food Intake Disorder

Anorexia Nervosa

Bulimia NervosaBinge Eating Disorder

Other Specified Feeding or Eating DisorderUnspecified Feeding or Eating disorder

Feeding And Eating Disorders

blog.lib.umn.edu

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Elimination Disorders

Conditions which involve improper elimination of bodily substances (urine or feces) most often associated with problems in growth phases and occurring during sleep

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No significant changes from DSM-IV-TR

Previously classified as “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence”SubcategoriesEnuresis

Elimination Disorders

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Sleep-Wake Disorders

Disruptions of the normal circadian rhythm of sleep or of wakefulness which lead to inability to fall asleep or stay asleep or to remain awake

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“Sleep Disorders Related to Another Mental Disorder” and “Sleep Disorders Related to a General Medical Condition” have been removed

Acknowledges bidirectional and interactive effects between existing medical and mental disordersPrimary and Secondary Insomnia have become Insomnia Disorder

Narcolepsy separated from Hypersomnolence

No known to be caused by hypocretin

deficiencyBreathing-Related Sleep Disorders know separated into 3 distinct categories

Circadian-Rhythm Sleep-Wake Disorders now include 3 distinct subtypes

Jet Lag subtype has been removed

Rapid Eye Movement Sleep Behavior Disorder and Restless Legs Syndrome moved from “NOS” to independent status

Sleep-Wake Disorders

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Subcategories

Insomnia Disorder

Hypersomnolence Disorder

NarcolepsyBreathing-Related Sleep Disorder

Obstructive Sleep Apnea HypopneaCentral Sleep Apnea

Sleep-Related Hypoventilation

Circadian Rhythm Sleep-Wake Disorders

Parasomnias

Non-Rapid Eye Movement Sleep Arousal Disorders

Nightmare Disorder

Rapid Eye Movement Sleep Behavior Disorder

Restless Legs Syndrome

Substance/Medication-Induced Sleep Disorder

Other Specified and Unspecified

Sleep-Wake Disorders

www.worldnewshut.com

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Sexual Dysfunctions

Problems of sexuality which may involve difficulties initiating or maintaining intercourse and often related to stress and psychological difficulties

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Gender-specific sexual dysfunctions added

Female sexual desire and arousal disorders combined into one category: Female Sexual Interest/Arousal DisorderAll sexual dysfunctions now require minimum duration of approximately 6 months and more precise severity criteriaSexual Aversion Disorder deleted

New disorder

Genito-Pelvic Pain/Penetration DisorderCombines

Vaginismus and Dyspareunia from DSM-IV-TR

Eliminated disorders

Sexual Dysfunction Due to a General Medical Condition

Sexual Dysfunction Due to Psychological Versus Combined Factors

Sexual Dysfunctions

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Subtypes changed

Lifelong versus Acquired and Generalized versus Situational remainDue to Psychological Factors versus Due to Combined Factors deleted

SubcategoriesDelayed Ejaculation

Erectile DisorderFemale Orgasmic Disorder

Female Sexual Interest/Arousal Disorder

Genito

-Pelvic Pain/Penetration Disorder

Male Hypoactive Sexual Desire Disorder

Premature (Early) Ejaculation

Substance/Medication-Induced Sexual Dysfunction

Other Specified Sexual Dysfunction

Unspecified Sexual Dysfunction

Sexual Dysfunctions

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Gender Dysphoria

Difficulties with determining and maintaining a sexual identity where the individual feels an incongruence between what they are and what they feel they were meant to be

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New diagnostic class

Emphasizes incongruity rather than cross-gender identification as suchSeparate criteria for children, adolescent, and adultsSeparates Sexual Dysfunctions from Gender Identity

Recognizes that gender dysphoria is a condition mostly identified and treated by mental health care providers except for endocrine

and surgical proceduresIn children, “strong desire to be of the other gender” replaces repeatedly stated desire”

Subtype based on sexual orientation removedNot considered useful clinically

Name was changed to “Dysphoria” because term “disorder” was pejorative

Gender Dysphoria

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Subcategories

Gender DysphoriaOther Specified Gender Dysphoria

Unspecified Gender Dysphoria

Gender Dysphoria

wassupdoc.wordpress.com

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Disruptive, Impulse-Control, and Conduct Disorders

Problems with controlling emotions in personal and social situations, marked by extreme anger, explosive behaviors, or lack of affect and sense of responsibility

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New diagnostic class

Combines disorders from “Disorders Usually First Diagnosed in Infancy, Childhood, and Adolescence”Intermittent Explosive Disorder, Pyromania, and Kleptomania also moved into this category

Antisocial Personality Disorder also included in Personality Disorders categorySymptom types for Oppositional Defiant Disorder

Angry/Irritable Mood

Argumentative/Defiant BehaviorVindictiveness

Exclusion criterion for Conduct Disorder removed

Disruptive, Impulse-Control, and Conduct Disorders

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Oppositional

Defiant Disorder (con’t

.)

Since behavior is “normal” process of growing up, severity rating scales and guidance on frequency typically needed to be considered symptomatic have been addedConduct Disorder

adds “limited prosocial emotion”

specifier

Intermittent Explosive Disorder adds verbal aggression and non-destructive/

noninjurious

physical aggression to DSM-IV’s physical aggression

Also,

specifiers

were added for

I

mpulsive and/or anger based in nature

Must cause marked distress

Causes impairment in occupational or interpersonal functioning

Associated with legal or financial consequences

Disruptive, Impulse-Control, and Conduct Disorders

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Subcategories

Oppositional Defiant DisorderIntermittent Explosive Disorder

Conduct Disorder

Antisocial Personality DisorderPyromania

KleptomaniaOther Specified Disruptive, Impulse-Control, and Conduct Disorder

Unspecified

Disruptive,

Impulse-Control

, and Conduct Disorder

Disruptive, Impulse-Control, and Conduct Disorders

www.parentingteens.about.com

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Substance-Related and Addictive Disorders

Problems with controlling emotions in personal and social situations, marked by extreme anger, explosive behaviors, or lack of affect and sense of responsibility

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New categories

Gambling DisorderAdded because of evidence that some behaviors activate the brain’s

reward system with similar effects as those obtained from

drugsTobacco Use Disorder

Diagnoses of substance abuse and dependence are not separated as in DSM-IV-TRCriteria were changed to reflect relevance of

Intoxication

Withdrawal

Substance/Medication-Induced Disorders

Unspecified Substance-Induced Disorders

Craving or strong desire or urge to use a substance

Caffeine and cannabis withdrawal are new criteria

Substance-Related and Addictive Disorders

www.omicsgroup.co.in

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Subcategories

Substance-Related DisordersSubstance Use Disorders

Substance-Induced Disorders

Alcohol-Related DisordersAlcohol Use Disorder

Alcohol IntoxicationAlcohol Withdrawal

Unspecified Alcohol-Related Disorder

Caffeine Intoxication

Caffeine Withdrawal

Unspecified Caffeine-Related Disorder

Cannabis-Related Disorder

Cannabis Use Disorder

Cannabis Intoxication

Substance-Related and Addictive Disorders

blogs.tekegraph.co.uk

71Slide72

Subcategories

(con’t.)

Cannabis Withdrawal

Other Cannabis-Induced DisordersHallucinogen-Related

DisordersPhencyclidine

Use Disorder

Other Hallucinogen Use Disorder

Phencyclidine Intoxication

Other Hallucinogen Intoxication

Hallucinogen Persisting Perception Disorder

Other Phencyclidine-Induced Disorders

Other Hallucinogen-Induced Disorders

Unspecified

Phencyclidine-Induced

Disorders

Unspecified Hallucinogen-Induced Disorders

Substance-Related and Addictive Disorders

www.aloveaffair.sorayadarwish.com

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Subcategories

(con’t.)

Inhalant-Related Disorders

Inhalant Use DisordersInhalant Intoxication

Other Inhalant-Induced Disorders

Opioid-Related Disorders

Opioid Use Disorder

Opioid Intoxication

Opioid Withdrawal

Other Opioid-Induced Disorders

Sedative-, Hypnotic-, or Anxiolytic-Related Disorders

Sedative, Hypnotic, or Anxiolytic Use Disorder

Sedative, Hypnotic, or Anxiolytic

Intoxication

Other

Sedative-, Hypnotic-, or

Anxiolytic-Use Disorders

Stimulant-Related Disorders

Stimulant Use Disorder

Substance-Related and Addictive Disorders

www.freud-sigmund.com

www.drugaware.weebly.com

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Subcategories

(con’t.)

Stimulant Intoxication

Stimulant WithdrawalOther Stimulant Use Disorders

Tobacco-Related DisordersTobacco Use Disorder

Tobacco Withdrawal

Other Tobacco-Induced Disorders

Other (or Unknown) Substance-Related Disorders

Other (or Unknown)

Substance-Induced

Non-Substance Related

Gambling Disorder

Substance-Related and Addictive Disorders

www.healtham.com

en.wikipedia.org

74Slide75

Neurocognitive Disorders

Disorders of thought caused by organic conditions (e.g.,

Alzhemier’s

) or inorganic conditions (e.g., traumatic brain injury)

which can impair memory, judgment, decision-making, and identification of people and objects

75Slide76

Criteria for Delirium have been updated based on current neuroscience

Dementia and Amnestic Disorder have been changed to Major Neurocognitive DisorderThe term “dementia” may still be used in etiological subtypes

Mild Neurocognitive Disorder (Mild NCD) is a new subcategoryAllows for diagnosis of less-disabling syndromes which still are of concern

Major or Minor Vascular NCD and Major or Mild NCD Due to Alzheimer’s is retained

Separate criteria for Major or Mild NCD due to:

Frontotemporal

NCD

Lewy Bodies

Traumatic Brain Injury (TBI)

Parkinson’s Disease

HIV Infection

Huntington’s Disease

Prior Disease

Other medical Conditions or Multiple Etiologies

Neurocognitive Disorders

76Slide77

Subcategories

DeliriumOther Specified Delirium

Unspecified DeliriumMajor and Mild Neurocognitive Disorders

Major Neurocognitive Disorder

See subtypes of previous slideMild Neurocognitive Disorder

Major or Minor Neurocognitive Disorder Due to Alzheimer’s Disease

Major or Mild

Frontotemporal

Neurocognitive Disorder

With Lewy Bodies

Vascular

Due to Traumatic Brian Injury

Substance/Medication-Induced Major or Mild Neurocognitive Disorder

Due to HIV Infection

Due to Prion Disease

Due to Parkinson’s Disease

Due to Huntington’s Disease

Due to Another Medical Condition

Due to Multiple Etiologies

Unspecified Neurocognitive Disorder

Neurocognitive Disorders

www.silverliving.com

77Slide78

Personality Disorders

Enduring traits and patterns of behavior which cause impairment in interpersonal relations and societal functioning leading to significant life challenges

78Slide79

Criteria have not changed from DSM-IV-TR

A possible alternative approach for diagnosing personality disorders is in Section IIISubcategoriesGeneral Personality Disorder

Cluster A Personality Disorders

Paranoid Personality Disorder

Schizoid Personality

Disorder

Schizotypal

Personality

Disorder

Cluster B Personality

Disorders

Antisocial Personality Disorder

Borderline Personality Disorder

Histrionic Personality Disorder

Narcissistic Personality Disorder

Cluster C Personality Disorders

Avoidant Personality Disorder

Dependent Personality Disorder

Obsessive-Compulsive Personality Disorder

Other Personality Disorders

Personality Change Due to Another Medical Condition

Other Specified Personality Disorder

Unspecified Personality Disorder

Personality Disorders

wellingtongoose.tumblr.com

79Slide80

Paraphilic

Disorders

Disorders of sexual

appropriatness

which cause one to deviate from the norms regarding sexual activity

80Slide81

Greatest change:

Added specifiers for “in a controlled environment” and “in remission” to indicate changes in an individual’s status

No consensus whether a long-standing paraphilia can remit

Change in diagnostic names:Distinguishes between a “paraphilic

behavior” and “paraphilic

disorder”

Paraphilia is a necessary but insufficient condition for having a

paraphilic

disorder

Paraphilia by itself is not considered automatically justifying or requiring there be a clinical; intervention

Paraphilic

Disorder is a paraphilia that is causing impairment or distress to the individual or which causes personal harm to others if acted upon

Otherwise same structure is maintained from DSM-III-R

Person must meet both Criterion A and Criterion B symptoms for each disorder otherwise no paraphilia exists

Paraphilic

Disorders

81Slide82

Subtypes

Voyeuristic DisorderExhibitionistic Disorder

Frotteuristic Disorder

Sexual Masochism DisorderSexual Sadism Disorder

Pedophilic DisorderFetishistic Disorder

Transvestic Disorder

Other Specified

Paraphilic

Disorder

Unspecified

Paraphilic

Disorder

Paraphilic

Disorders

82Slide83

Other Disorders

A category for disorders which do not conveniently fit into any of the main categories but which, nonetheless, cause significant distress or impairment to the individual

83Slide84

This category refers to symptoms which present due to another medical condition but do not meet the full criteria necessary to be considered a full disorder

Other Mental Disorders

Medication-Induced Movement Disorders and Other Adverse Effects of Medication

Examples:

Medication-Induced Parkinsonism

Medication-Induced Acute Dystonia

Medication-Induced Acute

Akathisia

Tardive Dyskinesia, Dystonia, or

Akathisia

Medication-Induced Postural Tremor

84Slide85

Examples:

Problems Related to Family UpbringingOther Problems Related to Primary Support Group

Child Maltreatment and Neglect Problems

Adult Maltreatment and Neglect ProblemsEducational or Occupational Problems

Housing and Economic ProblemsOther 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 Psychosocial, Personal, and Environmental Circumstances

Other Circumstances of Personal History

Other Conditions That May Be the Focus of Clinical Attention

85Slide86

Section III has several divisions which address emerging scientific evidence and data from clinical experiences that could be of use to the therapist

These divisions include:

Valuable Clinical ToolsAssessment tools of use in the diagnostic process

Accounting for CultureCultural formulation interview guide

Another Model for Personality Disorders

A ‘hybrid dimensional-categorical model”

(APA)

which emerged during debates on the Personality Disorders category

Suggests using five broad areas of pathological personality traits, coming up with six personality disorder types

Borderline Personality Disorder

Obsessive-Compulsive Personality Disorder

Avoidant Personality Disorder

Schizotypal Personality Disorder

Antisocial Personality Disorder

Narcissistic Personality Disorder

The model seeks to discover impairments in functioning and is included to prompt further research

Section III

86Slide87

Conditions for Further Study

Disorders judged to need further research before being included as full disordersAttenuated Psychosis Syndrome

Person has minor versions of symptoms of psychotic disorder

Depressive Episodes With Short-Duration HypomaniaPersistent Complex Bereavement Disorder

Caffeine Use Disorder

Internet Gaming Disorder

Neurobehavior

Disorder Due to Prenatal Alcohol Exposure

Suicidal Behavior Disorder

Nonsuicidal

Self-Injury

Section III

87Slide88

Sources

A history of the DSM-V controversy. Retrieved from http://www.psychologytoday.com/blog/dsm5-in-distress/201006/history- the-dsm5-controversy

A moment of crisis in the history of American psychiatry. Retrieved from

http://historypsychiatry.com/2010/04/27/a-moment-of-crisis-in-the-history- of-american-psychiatry/

American Psychiatric Association. (2013). Highlights of changes from DSM-IV to DSM-5

. Retrieved from

http

://

www.dsm5.org/Documents/changes%20from%20dsm-iv- tr%20to%20dsm-5.pdf

Controversy over DSM-5: New mental health guide

. Retrieved from

http

://

www.ncbi.nlm.nih.gov/pubmedhealth/behindtheheadlines/news/201 3-08-15-controversy-over-dsm-5-new-mental-health-guide

/

Desk reference to the diagnostic criteria from DSM-5.

(2013). Washington, DC: The American Psychiatric Association.

DSM-5: A ruse by another other name

. Retrieved from

http

://

blogs.discovermagazine.com/neuroskeptic/2013/01/13/dsm-5-a-ruse- by-any-other-name

/#.USyiSDcSHTo

DSM-5 is guide not Bible – Ignore its ten worst changes

. Retrieved from

http

://

www.psychologytoday.com/blog/dsm5-in-distress/201212/dsm-5-is- guide-not-bible-ignore-its-ten-worst-changes

88Slide89

Frances, A. (2013). Saving normal

. New York: William Morrow.Francis, A. and Widiger, T. (2012, September 4).

Psychiatric diagnosis: Lessons from the DSM-IV past and cautions from the DSM-5 future

. Annual Review of Of Clinical Psychology, 8: 109-130. Retrieved from http://psych.colorado.edu/~willcutt/pdfs/Frances_2012.pdf

Freedman, R. et. al. (2013) The initial field trials of DSM-5: New blooms and

old

thorns.

American Journal of Psychiatry. 170:1-5

Greenberg

, G. (2013).

The book of woe

. New York: Blue Rider Press

.

How the DSM developed: What you might not know.

Retrieved from

http

://

psychcentral.com/blog/archives/2011/07/02/how-the-dsm- developed-what-you-might-not-know

/

Kapline

, A.

DSM-5 controversies.

(2009, January 1). Retrieved from

http

://

www.psychiatrictimes.com/articles/dsm-v-controversies

Normal

or not? New psychiatric manual stirs controversy

. Retrieved from

http

://

www.livescience.com/34496-psychiatric-manual-stirs- controversy.html

89