Changes in Specific Diagnoses from DSM IV to 5

Report
Diagnostic groupings in the DSM 5
Diagnostic groupings in IV-TR and 5
 In DSM-IV TR, the diagnostic groupings had a separate
category for children and adolescents.
 DSM 5 does not make a separate category for children and
adolescents
 In DSM-IV TR some of the categories had names that made
no sense-such as somatoform disorders
 DSM 5 attempts to simplify diagnostic category names
 DSM 5 organizes diagnostic categories into 20 chapters,
starting with diagnostic categories that are seen earlier in
life and progressing to those that are seen later in life
X
Changes throughout DSM
 Attention to severity assessment and specification of
severity for each diagnosis
 Inclusion of other specified disorder and unspecified
disorder as a diagnosis for each group (Replaces that
NOS)
 "Other specified disorder" permits clinician to
communicate sub threshold diagnoses and specific
reasons why client did not meet criteria for other
diagnoses within that group
DSM 5 changes in classification
 DSM 5 has 20 diagnostic groupings plus a group of
other conditions that might be a focus clinically (V
codes)
 DSM 5 organizes these categories beginning with
those that might be seen earlier in life and
progressing to those later in life
Neuro
develop
mental
Bipolar
Schizophrenia
Younger
Anxiety
Depr
essiv
e
Somatic
symptom
related
Trauma
related
Obsessiv
ecompuls
ive and
related
Dissocia
tive
Eliminatio
n
disorders
Feeding and
eating
disorders
Sexual
dysfuncti
ons
Sleep wake
disorders
Gender
dysphoria
Disruptive
, impulse
control
disorders
Neurocog
nitive
disorders
Substance
related and
addictive
disorders
Paraphilia
disorders
Personality
disorder
Others
Older
The progression from younger to older in the DSM is general and there are
specific disorders such as some early childhood feeding disorders that
clearly occur later
1. Neurodevelopmental disorders
2. schizophrenia spectrum and other
psychotic disorders
3. bipolar and related disorders
4. depressive disorders
5. anxiety disorders
6. obsessive-compulsive and related
disorders
7. Trauma and related disorders
8. dissociative disorders
9. Somatic symptom and related
disorders
10. feeding and eating disorders
11. elimination disorders
12. sleep wake disorders
13. sexual dysfunctions
14. gender dysphoria
15. disruptive, impulse control, and
conduct disorders
16. neurocognitive disorders
17. paraphilia disorders
Which are your top 7 or 8
Changes in the groupings:
1. Neurodevelopmental disorders
SUMMARY
 Neurodevelopmental disorders1.
mental retardation is removed intellectual disability is
put in.
2. Autism spectrum disorder is the new DSM 5 diagnosis
encompassing autistic disorder. Aspergers and
childhood disintegrative disorder as well as pervasive
developmental disorder.
3. Several changes have been made to ADHD- specifiers =
combined; inattententive type; hyperactive/impulsive
type
MENTAL RETARDATION = INTELLECTUAL DISABILITY
Severity level for intellectual disability
Severity
level
Conceptual domain
Social domain
Practical domain
Mild
Preschool = no obvious differences. School-aged
children and adults = academic skills involving
reading writing math time or money. In adults
abstract thinking planning cognitive flexibility are
somewhat impaired impaired. Tendency toward
concrete thinking
Immaturity and social interactions; some
difficulty picking up social cues
communication conversation in language
more concrete than peers. Possible
difficulties in emotional regulation and ageappropriate behavior. Perhaps impairment in
risk assessment
Personal care may be age-appropriate, but more
complex tasks might require support. For
example grocery shopping, transportation home
and childcare organization food prep banking
and money management
Moderate
Conceptual skills lag markedly language
development and pre-academic skills slow to
develop. School-age children = progress in reading
writing mass understanding of time and money
but slower than peers. Adults = academic skill
development is at an elementary level. Ongoing
assistance needed in conceptual decision-making
Marked differences in social and
communication from peers. Spoken language
is much less complex than peers. Capacity for
relationships evident in familial friendship
ties. Problems with perceiving social cues in
social situations accurately. Social judgment
and decision-making limited. Help is needed
with life decisions
Personal care is okay in adulthood. Adults
typically can participate in all household tasks
with teaching. Can work with considerable
support in the workplace
Severe
Limited attainment of conceptual skills. Little or no
understanding of written language math, time and
money. Extensive support for problem solving is
needed
Spoken language is limited in terms of
vocabulary and grammar. Communication is
focused on the here and now an everyday
event. Relationships and relational ability is
considerable.
Support needed for all activities of daily living.
Supervision required at all times. We will not
make responsible decisions regarding well-being
.skill acquisition is very limited
Profound
No concept of symbolic processes, perhaps some
functional use of objects, although this might be
Might understand simple instructions and
cues. Social expression is often nonverbal.
Can respond and enjoy relationships with
people who were well known to them. Can
initiate limited social interaction with such
people through gestures. Sensory and
physical impairments may prevent social
activities
Dependent on others for all aspects of daily
physical care. Participation in these activities is
limited.. Some simple concrete tasks such as
carrying dishes to the table might be
accomplished. Co-occurring physical and sensory
impairments are often barriers to participation
limited by disturbance and motor skills
.
SEVERITY DETERMINED BY ADAPTIVE FUNCTIONING NOT IQ
Includes deficits in language speech and communication
1.
2.
3.
4.
Expressive language disorder
Combined into "language disorder" (315.39) in
Receptive-expressive language disorder DSM 5
Phonological (articulation) disorder= speech sound disorder (315.39) In DSM 5
Stuttering AKA Childhood onset fluency disorder (315.35) In DSM 5
Social pragmatic communication
disorder 315.39
A.
Persistent difficulties in the social use of verbal and nonverbal communication as
manifested by all of the following;
deficits in using communication for searching purposes
A. impairments of the ability to change communications to match the context or needs of the listener
B. difficulties following rules for conversation and storytelling such as taking turns in conversation ,
rephrasing and knowing how to use verbal and nonverbal to regulate interaction
C. Difficulties in understanding what is not explicitly stated
B.
C.
Deficits result in functional limitations and effective communications. The onset
is in the early developmental. (But deficits aren't fully noticeable until later in
life)
Not attributable to another medical condition or neurological condition and not
better explained by other neurodevelopmental disorders
Differential diagnoses should always consider the possibility of autism spectrum
disorder, in particular those with mild severity.
Primary deficits of ADHD can cause some impairments in social communication
social anxiety disorder and social phobia can often appear with similar
symptoms and again mild intellectual developmental disorder might also mask
symptoms
LEARNING DISORDERS
 DEFINED INDEPENDENT FROM GENERAL INTELLIGENCE
 DIAGNOSED WHEN AN INDIVIDUAL’S ACHIEVEMENT ON
INDIVIDUALLY ADMINISTERED STANDARDIZED TESTS IN
READING, MATH OR WRITTEN EXPRESSION IS
SUBSTANTIALLY BELOW THAT FOR EXPECTED AGE AND
INTELLIGENCE
 DSM IV
 Dyslexia – reading disorder
 Dyscalculia – math disorder
 Dysgraphia – written expression disorder
DSM 5 criteria – no separation
A.
Difficulty learning and using academic skills indicated by the presence of at least
one of the following symptoms for at least 6 months despite interventions.
1.
2.
3.
4.
5.
6.
B.
C.
D.
Inaccurate or slow and effortful word reading
Difficulty understanding the meaning of what is read
Difficulties with spelling
Difficulties with written expression
Difficulties mastering number sense, number facts, or calculation
Difficulty with mathematical reasoning
Affected academic skills are substantially and quantifiably below those expected
for the individual's chronological age causing significant interference with
performance (quantifiable suggest testing)
The learning difficulties begin during school way cheers but might not become
apparent until those faculties require more regular use
Not better accounted for by intellectual disabilities visual or auditory deficits other
mental or neurological disorders etc.
X
ADHD
 In DSM-IV TR, ADHD was grouped in the diagnostic
domain of "disruptive behavior disorders seen in
childhood and adolescence"
 DSM 5 has moved it to neurodevelopmental
disorders
 DSM-IV TR separated ADHD into 2 subtypes:
 predominantly attention deficit
 predominantly hyperactivity impulsivity
 DSM 5 has moved these two sub-types to specifiers
X
Diagnostic Criteria for ADHD
(DSM-IV)
DSM Must
5 has
moved
onset
age limit to 12!
occur
before age
7 years
 Present for at least 6 months
 Causes impairment in at least 2 settings
Now requires “SEVERAL SYMPTOMS”
across settings
 Meets 6 of 9 symptoms of inattention
 AND/OR 6 of 9 symptoms of
hyperactivity/impulsivity
 – Must be developmentally inappropriate levels
DSM 5 criteria
X
A.
Persistent pattern of inattention and or hyperactivity-impulsivity that
interferes with functioning or development as characterized by
inattention and or hyperactivity/impulsivity
1.
Inattention: 6 or more of the following symptoms have persisted for
at least 6 months to a degree that is inconsistent with developmental
level and that negatively impacts directly on social and academic
activities
A.
B.
C.
D.
E.
F.
G.
H.
I.
Often fails to give close attention to details or makes careless mistakes in schoolwork
Has difficulty sustaining attention in tasks or play activitiesAnd remaining focused
Often does notseem to listen when spoken to directly
Does not follow through on instructions and fails to finish schoolwork chores or duties
Has difficulty organizing tasks and activities
Avoids dislikes or is reluctant to engage in tasks that require sustained mental effort
Loses things necessary for tasks or activities
Is easily distracted
Is forgetful in daily activities
Specifiers





314.01 – combined presentation
314.00-predominantly inattentive presentation
314.01 predominantly hyperactive impulsive
In partial remission
Severity level (mild moderate severe)
X Other important changes ADHD




ADHD can now be co-morbid with Autism spectrum
Symptom threshold has been specified for adults
Adults require a minimum of 5 symptoms – not 6
Developmentally appropriate example of symptoms
are offered
X
Autism Spectrum disorder
 Represents a new classification of several disorders
that were considered different forms of autism
 Previously, these were separate diagnoses.





Autistic disorder
Retts disorder
Childhood disintegrative disorder
Aspergers
PDD NOS





PDDs in DSM IV TR
Autistic disorder
Retts disorder
Childhood disintegrative disorder
Aspergers
PDD NOS
All characterized by severe deficits and
pervasive impairment in multiple areas of development
•Reciprocal social interaction
•Communication impaired
•Stereotyped behavior, interests and activities
X
With the new DSM 5. Those separate disorders have now been
consolidated and ASD is evaluated in terms of severity rather than
separate diagnosis
RETTS Disorder removed because it has been established as a
physical disease
X
major changes for ASD
Three domains from the DSM IV-TR became two: 1Social
interaction; 2 communication deficits; 3 repetitive
behavior/fixated interest =
1) Social interaction/communication deficits
2) Fixated interests and repetitive behaviors
 Deficits in communication and social behaviors are inseparable and more
accurately considered as a single set of symptoms with contextual and
environmental specificities
 Delays in language are not unique nor universal in ASD and are more
accurately considered as a factor that influences the clinical symptoms of ASD,
rather than defining the ASD diagnosis
 Requiring both criteria to be completely fulfilled improves specificity of
diagnosis without impairing sensitivity
 Providing examples for subdomains for a range of chronological ages and
language levels increases sensitivity across severity levels from mild to more
severe, while maintaining specificity with just two domains
 Decision based on literature review, expert consultations, and workgroup
discussions; confirmed by the results of secondary analyses of data from CPEA
and STAART, University of Michigan, Simons Simplex Collection databases
X
DSM 5 criteria for all ASD
A. Persistent deficits in social communication and social interaction across contexts, not accounted for by general
developmental delays, and manifest by all 3 of the following:
1. Deficits in social-emotional reciprocity; ranging from abnormal social approach and failure of normal back
and forth conversation through reduced sharing of interests, emotions, and affect and response to total
lack of initiation of social interaction,
2. Deficits in nonverbal communicative behaviors used for social interaction; ranging from poorly integratedverbal and nonverbal communication, through abnormalities in eye contact and body-language, or deficits
in understanding and use of nonverbal communication, to total lack of facial expression or gestures.
3. Deficits in developing and maintaining relationships, appropriate to developmental level (beyond those
with caregivers); ranging from difficulties adjusting behavior to suit different social contexts through
difficulties in sharing imaginative play and in making friends to an apparent absence of interest in people
B. Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the
following:
1. Stereotyped or repetitive speech, motor movements, or use of objects; (such as simple motor stereotypies,
echolalia, repetitive use of objects, or idiosyncratic phrases).
2. Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive
resistance to change; (such as motoric rituals, insistence on same route or food, repetitive questioning or
extreme distress at small changes).
3. Highly restricted, fixated interests that are abnormal in intensity or focus; (such as strong attachment to or
preoccupation with unusual objects, excessively circumscribed or perseverative interests).
4. Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment; (such as
apparent indifference to pain/heat/cold, adverse response to specific sounds or textures, excessive smelling
or touching of objects, fascination with lights or spinning objects).
C. Symptoms must be present in early childhood (but may not become fully manifest until social demands
exceed limited capacities)
D.
Symptoms together limit and impair everyday functioning.
E. Symptoms are not better explained by intellectual developmental disorder or global developmental delay
X
Specifiers
 With or without accompanying intellectual
impairment
 With her without accompanying language impairment
 Associated with a known medical or genetic condition
or environmental factor
 With catatonia
 Specify severity level
X
severity
Severity level
ASD
Social communication and
interaction
Restricted interests and repetitive
behaviors
3.Requires very substantial
support
Severe deficits in verbal and
nonverbal social communication
skills cause severe impairments in
functioning; very limited initiation
of social interactions and minimal
response to social overtures from
others.
Preoccupations, fixated rituals
and/or repetitive behaviors
markedly interfere with functioning
in all spheres. Marked distress
when rituals or routines are
interrupted; very difficult to
redirect from fixated interest or
returns to it quickly
2 requires substantial support
Marked deficits in verbal and
nonverbal social communication
skills; social impairments apparent
even with supports in place;
limited initiation of social
interactions and reduced or
abnormal response to social
overtures from others
RRBs and/or preoccupations or
fixated interests appear frequently
enough to be obvious to the
casual observer and interfere with
functioning in a variety of
contexts. Distress or frustration is
apparent when RRB’s are
interrupted; difficult to redirect
from fixated interest
I requires support
Without supports in place, deficits
in social communication cause
noticeable impairments. Has
difficulty initiating social
interactions and demonstrates
clear examples of atypical or
unsuccessful responses to social
overtures of others. May appear to
have decreased interest in social
Rituals and repetitive behaviors
(RRB’s) cause significant
interference with functioning in
one or more contexts. Resists
attempts by others to interrupt
RRB’s or to be redirected from
fixated interest.
X
ASD CONCERNS
 STIGMA - aspergers made autism respectable! Will it
continue to de-stigmatize or re-stigmatize
 Will clinicians and insurance companies “control for”
the intellectual disability bias?
 Prior co-morbid estimates with previous classification =
25-75%
 Drops to negligible with PDD and Aspergers
2. Schizophrenia
spectrum
Schizophrenia spectrum and other
X
psychotic disorders
1.
2.
3.
4.
5.
6.
7.
The spectrum seems to emphasize degrees of psychosis
Change in criteria for schizophrenia now requires at least one
criteria to be either a. Delusions, b. Hallucinations or c.
Disorganized speech
Subtypes of schizophrenia were eliminated
Dimensional measures of symptom severity are now included
Schizoaffective disorder has been reconceptualized
Delusional disorder no longer requires the presence of “nonbizarre" in delusions. There is now specifier for bizarre
delusions.
Schizotypal personality disorder is now considered part of the
spectrum
2: schizophrenia and the DSM 5
X Overview of changes from DSM-IV
TR to the DSM five
 Schizophrenia and other disorders related to schizophrenia
are now grouped within a spectrum
 Overall definition of schizophrenia has not changed that
much
 Requirements that delusions must be bizarre and
hallucinations must be "first rank." (eg. Two or more
voices conversing together) have been eliminated.
 The four subtypes of schizophrenia (paranoid, catatonic,
disorganized and chronic undifferentiated) have been
eliminated.
 Rating of symptom severity is most important
Spectrums
 ‘Spectrum’ as it applies to mental disorder is a range of linked
conditions, sometimes also extending to include singular
symptoms and traits. The different elements of a spectrum
either have a similar appearance or are thought to be caused
by the same underlying mechanism. In either case, a spectrum
approach is taken because there appears to be "not a unitary
disorder but rather a syndrome composed of subgroups". The
spectrum may represent a range of severity, comprising
relatively "severe" mental disorders through to relatively
"mild and nonclinical deficits".[1]
 In some cases, a spectrum approach joins together conditions
that were previously considered separately.(wikipedia)
Spectrum suggests a progression from
Mild or brief
Debilitation
Severity
Attenuated
psychosis
Syndrome
in conditions
for further
study
Major or lengthy
Debilitation
severity
Schizotypal
personality
Disorder
(Found in PD
Section)
In
1.
2.
3.
4.
5.
delusional
disorder
Brief
psychotic
disorder
Schizophreniform
disorder
Schizophrenia
Schizoaffective
disorder
the following areas
Delusions
Hallucinations
Disorganized thinking/speech
Disorganized or abnormal motor behavior
Negative symptoms
Attenuated psychosis syndrome
CRITERIA
A.
At least one of the following symptoms is present in attenuated form and with relatively
intact reality testing. It is of sufficient severity or frequency to warrant clinical attention
1. Delusions
2. Hallucinations
3. Disorganized speech
B.
Symptoms must have been present at least once per week for the last month
C.
Symptoms have begun or worsened in the last year
D.
Symptom is sufficiently distressing or disabling to the individual
E.
Symptom is not better explained by another mental disorder including a depressive or
bipolar disorder with psychotic features and is not caused by a substance
F.
Criteria for any other psychotic disorder have never been met
Symptoms are psychosis like, but below the threshold for a full psychotic disorder. Typically the
symptoms are less severe and more transient than in another psychotic disorder. Insight is
relatively intact this condition might be stress related. Typically the individual realizes that these
changes are taking place and something is wrong. Usually occurs in late adolescence or early
adulthood
DIAGNOSTIC FEATURES
Schizotypal personality disorder
(Technically not in the spectrum)
Criteria
A.
A pervasive pattern of social and interpersonal deficits marked by acute discomfort with and reduce capacity
for close relationships as well as by cognitive or perceptual distortions and eccentric cities of behavior
beginning by early adulthood and present in a variety of contexts as Indicated by 5 or more of the following:
1.
2.
3.
4.
5.
6.
7.
8.
9.
B.
Ideas of reference (excluding delusions of reference)
Odd beliefs or magical thinking that influences behavior; i.e. belief in clairvoyance, astral projection telepathy etc.
Unusual perceptual experiences, including bodily illusions
Odd thinking and speech
Suspicious or paranoid ideation
Inadequate or constricted affect
Behavior or appearance that is odd eccentric or peculiar
Lack of close friends or confidants
Excessive social anxiety that does not diminish
does not occur exclusively within the course of schizophrenia a bipolar disorder or depressive
disorder with psychotic features or another psychotic disorder or autism spectrum disorder
Pervasive pattern of social and it interpersonal deficits as well as eccentricities of behavior and
cognitive distortions. Such people usually have few close relationships and are considered odd. They
may be fascinated or preoccupied with paranormal phenomena and/or superstitions they might believe
that they have magical powers. They typically do not fit in and have difficulty matching the norms of
consensual social interaction. Typically these people do not become psychotic and any psychotic
symptoms are often transient and mild
X
Schizophrenia
DSM-5 Criteria and DSM-IV criteria are same:
CRITERION A.
2 or more characteristic symptoms present
for 1-month period over a 6-month
period:
1.
2.
3.
4.
5.
Delusions
Hallucinations
Disorganized speech
disorganized behavior
Negative symptoms (personality
X
Except for
 Requirement of “bizarre delusions”and/or
schneidnerian 1st rank hallucinations is
changed to
 At least 1 of the two below need to be from core
positive symptoms (delusions, hallucinations,
disorganized speech)
1.
2.
3.
4.
5.
Delusions
Hallucinations
Disorganized speech
disorganized behavior
Negative symptoms (personality
 B. Level of functioning in one or more areasX work, interpersonal relations, self care, vocationis markedly below the level of functioning prior to
the onset; social/ occupational dysfunction – cant
work or relate
 C. Continuous signs of the disturbance for at
least 6 months (at east 1 month with symptoms
from category A. Duration is the main factor in
differentiating schizophrenia from similar
illnesses
 D. have successfully ruled out schizoaffective
disorder and mood disorder (with psychotic
symptoms) b/c no evidence of mania or
depression
 E. not due to substance abuse
 F. not due to Autism spectrum disorder
X
Specifiers








1st episode, currently in acute stage
1st episode currently in partial remission
1st episode in full remission
multiple episodes, currently in acute episode
multiple episodes currently in partial remission
multiple episodes currently in full remission
continuous
with catatonia
X
Schizophrenia
Diagnostic features
 Other symptoms outside the major diagnostic criteria include mood dysphoria, inappropriate affect
sleep disturbance depersonalization, derealization somatic concerns, vocational impairments

Lack of insight or awareness or even denial about the existence of the illness is also a symptom that
commonly occurs.
 Aggression, sometimes associated with delusions is common in males, although not as a rule
 Although there are many brain and genetic abnormalities that have been identified, there are no
“absolute” biological markers
 Schizophrenia is often overdiagnosed in the poor
 There is a high rate of suicide among schizophrenics-6%. With a suicide attempt rate of close to 20%
 Still thought to be a lifelong illness although the occurrence of "positive symptoms" seem to
diminish with age
 Depression often shows up over time
Schizophreniform disorder
X
Diagnostic features
 * At least one third of people who receive this diagnosis recover.
However the other two thirds will eventually be diagnosed with
schizophrenia
 Meets all the diagnostic criteria for Schizophrenia, except duration
 Diagnosed when duration is less than six months (Absence of
criterion B) (this includes prodromal, active and residual phase)_
 Make this diagnosis when someone is having an episode longer
than one month, but it has not yet lasted 6 months (call it
‘provisional)
 The 'Tweener' disorder in terms of length. The period of active
psychotic symptoms (delusions, hallucinations, disorganized
thinking, disorganize motor behavior) is longer than a brief
psychotic episode, but not as long as schizophrenia
 Make this diagnosis when an individual Has already recovered
And the episode lasted between 1 and 6 months
Schizophreniform
XDiagnostic criteria – 295.40
A. 2 or more of the following present for a significant portion
of time. At least one of these must be one 2 or 3
1.
2.
3.
4.
5.
Delusions
Hallucinations
Disorganized speech
Disorganized motor behavior
Negative symptoms
B. Lasts at least one month but less than 6 months. When
diagnosis is made before recovery, specify "provisional“
C. Schizoaffective disorder, depressive disorder or bipolar
disorder with psychotic features have been ruled out
because either no major mood episodes have occurred with
the psychotic symptoms or if they have occurred, their
occurrence was infrequent
D. Not attributable to substances or another medical condition
X
Schizoaffective disorder
Diagnostic criteria295.70
A.
B.
C.
D.
An uninterrupted. period which there is a major mood episode con current
with criterion A of schizophrenia
1.
Delusions
2.
Hallucinations
3.
Disorganized thinking
4.
Grossly abnormal motor behavior
5.
Negative symptoms of schizophrenia
In addition, Delusions or hallucinations must occur for two or more weeks
with an absence of a major mood episode during the lifetime duration
of the illness
Symptoms that meet criteria for major mood episode be present for the
majority of the duration of the Active, and residual portions of the illness
Not attributable to the effects of a substance medication or other medical
condition
The requirement that a major mood disorder must be present for the majority
Of the duration of illness AFTER criterion A is met, makes this alongitudinal
Illness or bridge on spectrum
X
Subtypes
Specify whether:
295.70-bipolar type
295.70-depressive type
Specify if:
with catatonia
1st episode currently in acute episode
1st episode currently in partial remission
1st episode currently in full remission
multiple episodes currently in acute episode
multiple episodes currently in partial remission
multiple episodes currently in full remission
continuous
severity level-use. Clinician related dimensions of psychotic
symptoms
X
PSYCHOTICISM
HIGH
SCHIZOAFFECTIVE
SCHIZOPHRENIA
ACUTE
A
F
F
E
C
T
NONE
MOOD DISORDERWITH
PSYCHOTIC FEATURES
HIGH
SCHIZOPHRENIA
PARTIAL REMISSION
MOOD DISORDER
NONE
X 3. Bipolar and related disorders
summary
 Diagnosis must now include both changes in mood and




changes in activity/energy level
Some particular conditions can now be diagnosed under
"other specified bipolar and related disorders“
An "anxiety" specifier has now been included
Attempts made to clarify definition of 'hypomania". However
it was not successful
Bipolar I mixed episode –no longer requires full criteria for
depressed and mania or hypomania
 New specifier is “mixed features”.
X
Some particular conditions can now be diagnosed under
"other specified bipolar and related disorders”
These do not meet full criteria for bipolar diagnosis
1. No history of major depression with hypomanic
episode052. Short durations. Cyclothymic (less than 24 months).
3. Multiple episodes of hypomanic symptoms that do
not meet criteria and multiple episodes of depressive
symptoms that you might meet criteria
4. History of major depressive disorder
• Hypomanic symptoms present but not of
sufficient duration (less than 4 days)
• Insufficient number of hypomanic
symptoms
Problems
 Severity Criteria are unclear
 "Severity is based on the number of criterion symptoms,
Francis severity of those symptoms and the degree of
functional disability." (Page 154)
 Dimensional measures for both mania and depression exist
as level II crosscutting measures. These could be used to
measure severity.
Bipolar I Coding for severity
Bipolar I
disorder
Current or
most recent
episode-manic
Current or
most recent
episodehypomanic
Current or
most recent
episodedepressed
Current or
most recent
episodeunspecified
Mild
296.41
Not applicable
296.51
Not applicable
Moderate
296.42
Not applicable
296.52
Not applicable
Severe
296.43
Not applicable
296.53
Not applicable
Mild = few if any symptoms in excess of those required to meet the diagnostic criteria are
present. The intensity is distressing that manageable. Symptoms resulting minor
impairment of social and occupational functioning
Moderate = number of symptoms and intensity and/or functional impairment are between
those specified for mild and severe
Severe = number of symptoms is substantially in excess of those required to make DX.
Intensity of symptoms is seriously distressing and unmanageable. Symptoms interfere
The dimensional Alternative assessment
of mania and hypomania
 DSM 5 offer some assistance
 Suggests 1st using the level I crosscutting symptoms
scale-PP.734 – 735.
 That the answers to question 9 and 10-increased energy
anddecreased need for sleepare positive then
 Move to use of the Altman self rating mania scale
(ASRM) - See next slide
Level 2
Dimensional
Measure for
Mania
Level II
measures are
more in-depth
than level I
measures. The
level I measure
shown in week 1
measured a
number of
different
symptoms. Level
II focuses in on
only one
subgroup. In this
case mania
Instructions for the mania scale
Instructions to Clinicians
The DSM-5 Level 2—Mania—Adult measure is the Altman Self-Rating Mania Scale. The ASRM is a 5-item se rating mania scale
designed to assess the presence and/or severity of manic symptoms. The measure is completed by the individual prior to a
visit with the clinician. If the individual receiving care is of impaired capacity and unable to complete the form (e.g., an
individual with dementia), a knowledgeable informant complete the measure. Each item asks the individual (or informant) to
rate the severity of the individual’s manic symptoms during the past 7 days.
Scoring and Interpretation
Each item on the measure is rated on a 5-point scale (i.e., 1 to 5) with the response categories having differ anchors depending
on the item. The ASRM score range from 5 to 25 with higher scores indicating greater severity of manic symptoms. The
clinician is asked review the score on each item on the measure during th clinical interview and indicate the raw score for each
item in the section provided for “Clinician Use”. The r scores on the 5 items should be summed to obtain a total raw score and
should be interpreted using the Interpretation Table for the ASRM below:
Interpretation Table for the ASRM
- A score of 6 or higher indicates a high probability of a manic or hypomanic condition
- A score of 6 or higher may indicate a need for treatment and/or further diagnostic workup
- A score of 5 or lower is less likely to be associated with significant symptoms of mania
Instructions: for client
On the DSM-5 Level 1 cross-cutting questionnaire you just completed, you indicated that during the past 2 weeks you (the
individual receiving care) have been bothered by “sleeping less than usual, but still having a lot of energy” and/or “starting lots more projects than
usual or doing more risky things than usual” at a mild or greater level of severity. The five statement groups or questions below ask about these
feelings in more detail.
1. Please read each group of statements/question carefully.
2. Choose the one statement in each group that best describes the way you (the individual receiving care) have been feeling for the past week.
3. Check the box (P or x) next to the number/statement selected.
4. Please note: The word “occasionally” when used here means once or twice; “often” means several times o more and frequently” means most
of the time.

Coding and recording procedures for
bipolar one disorder
 Coding is complicated
 Must specify the following in the order presented below
1. Bipolar I disorder
2. Type of current episode (manic or depressive)
3. Severity level
4. Current state of most recent episode (active, in partial
remission, in full remission, unspecified)
5. Psychotic features present
6. Presence of other specifiers (uncoded)
Bipolar I Coding for Current state of episode
& psychosis
Bipolar I disorder Current or
most recent
episodemanic
Current or most Current or most Current or most
recent episode- recent episode- recent episodehypomanic*
depressed
unspecified**
W/ psychotic
features
296.44
Not applicable
296.54
Not applicable
In Partial
remission
296.45
296.45
296.55
Not applicable
In full remission
296.46
296.46
296.56
Not applicable
Unspecified
296.40
296.40
296.50
Not applicabl
*Do not code severity and psychotic features if current or most recent
episode is hypomanic. **Do not code severity and psychotic features if
current or most recent episode = unspecified.
X
4. Depressive disorders
SUMMARY
 New diagnosis included = "disruptive mood
dysregulation disorder-use for children up to age 18
 New diagnosis included = "premenstrual dysphoric
disorder“
 What used to be called dysthymic disorder is now
"persistent depressive disorder“
 Bereavement is no longer excluded
X
MDD: Specifiers
 Severity
 With anxious distress
 With mixed features
 Melancholic Features
 Atypical Features
 Catatonic
 Postpartum
 Seasonal
 With Psychotic Features(Mood congruent or
incongruent)
Depression is mainly coded by
severity and recurrence
Severity/course specifier
Single episode
Recurrent episode
Mild
296.21
296.31
Moderate
296.22
296.332
Severe
296.23
296.33
With psychotic features
296.24
296.34
In partial remission
296.25
296.35
In full remission
296.26
296.36
Unspecified
296.20
296.30
Mild = few if any symptoms in excess of those required to meet the diagnostic criteria are present.
The intensity is distressing that manageable. Symptoms resulting minor impairment of social and
occupational functioning
Moderate = number of symptoms and intensity and/or functional impairment are between those
specified for mild and severe
Severe = number of symptoms is substantially in excess of those required to make DX. Intensity of
symptoms is seriously distressing and unmanageable. Symptoms interfere markedly with social and
Problems with severity
 Severity Criteria are unclear
 "Severity is based on the number of criterion symptoms,
Francis severity of those symptoms and the degree of
functional disability." (Page 154)
 Dimensional measures for both mania and depression exist
as level II crosscutting measures. These could be used to
measure severity.
LEVEL ii CROSS-CUTTING MEASURE FOR DEPRESSION. The questions below ask about these
feelings in more detail and especially how often you (the individual receiving care) have been bothered
by a list of symptoms during the past 7 days. Please respond to each item by marking ( or x) one box
per row.
Instructions to Clinicians
The DSM-5 Level 2—Depression—Adult measure is the 8-item PROMIS
Depression Short Form that assesses the pure domain of depression in
individuals age 18 and older. The measure is completed by the individual prior
to a visit with the clinician. If the individual receiving care is of impaired
capacity and unable to complete the form (e.g., an individual with dementia),
a knowledgeable informant may complete the measure as done in the DSM-5
Field Trials. However, the PROMIS Depression Short Form has not been
validated as an informant report scale by the PROMIS group. Each item asks
the individual receiving care (or informant) to rate the severity of the
individual’s depression during the past 7 days.
Scoring and Interpretation
Each item on the measure is rated on a 5-point scale (1=never; 2=rarely;
3=sometimes; 4=often; and 5=always) with a range in score from 8 to 40 with
higher scores indicating greater severity of depression. The clinician is asked
to review the score on each item on the measure during the clinical interview
and indicate the raw score for each item in the section provided for “Clinician
Use.” The raw scores on the 8 items should be summed to obtain a total raw
score. Next, the T-score table should be used to identify the T-score
associated with the individual’s total raw score and the information entered in
the T-score row on the measure.
Note:
This look-up table works only if all items on the form are answered. If 75% or more of the
questions have been answered; you are asked to prorate the raw score and then look up the
conversion to T-Score. The formula to prorate the partial raw score to Total Raw Score is:
(Raw sum x number of items on the short form)
Number of items that were actually answered
If the result is a fraction, round to the nearest whole number. For example, if 6 of 8 items were
answered and the sum of those 6 responses was 20, the prorated raw score would be 20 X 8/
6 = 26.67. The T-score in this example would be the T-score associated with the rounded
whole number raw score (in this case 27, for a T-score of 64.4).
The T-scores are interpreted as follows:
Less than 55 = None to slight
55.0—59.9 = Mild
60.0—69.9 = Moderate
70 and over = Severe
Note: If more than 25% of the total items on the measure are


Explanation of other specifiers
With anxious distress = 1. Tense, 2. Restless 3. Excessive worry 4. Fear of catastrophe 5. Fear of losing control
 If present, Code severity of anxiety
 Mild = 2 symptoms
 moderate = 3 symptoms
 moderate- severe = 4 or 5 symptoms
With mixed features = prominent dysphoria or depressed mood, diminished interest or pleasure, psychomotor retardation and/or other symptoms
found in depressive episodes

With melancholic features = loss of pleasures and all activities, lack of reactivity to pleasurable experiences. 3 or more of the following; depressed
mood that is worse in the morning, early-morning awakening mark psychomotor agitation or retardation, significant weight loss, excessive guilt

With atypical features = mood improves in response to positive events (mood reactivity) 2 or more of the following; weight gain or increase in
appetite, hypersomnia, heavy feeling in arms or legs heightened sensitivity to interpersonal rejection

Mood congruent psychotic features = with depression, delusions and hallucinations are often punitive, self punishing and rejecting. Perhaps
delusions of persecution or annihilation.

Mood incongruent psychotic features = delusions and hallucinations are not consistent with mood being displayed

With postpartum onset = onset of mood symptoms occurs during pregnancy or in the 4 weeks following delivery. Depressive episodes are far more
common than manic episodes

Seasonal pattern = regular temporal correlation between the onset of manic, hypomanic or depressive episodes and a particular time of year,
usually without the presence of psychosocial stressors
With anxiety
 Anxiety is very common with depression

anxious distress =
 1. Tense
 2. RelentlessRestlessness
 3. Excessive worryOr concern that is unwarranted
 4. Excessive concern regarding the occurrence of
a major negative event 5. Fear of losing control
 If present, Code severity of anxiety
 Mild = 2 symptoms
 moderate = 3 symptoms
 moderate- severe = 4 or 5 symptoms
XPersistent depressive disorder 300.4
Formerly known as dysthymic disorder
•
In The DSM-IV TR, dysthymia was considered a depressive
disorder that that was
A. long-lasting (chronic) and
B. did not meet the full criteria for a major depressive episode- a
milder form of depression
XPersistent depressive disorder in the DSM 5
Combines dysthymia and a chronic form of
major depressive disorder (without certain
symptoms
Persistent
depressive disorder
Dysthymia-2 or
more years
Chronic major
depressive
disorder- Must last
for 2 or more years
with little or no
abatement – no
suicidal ideation, or
anhedonia
X
Dysthymia vs MDD
 Chronic sense of inadequacy
 Depression is not as intense as with MDD
 Symptoms are typically not as “acute” as with
MDD
 MDD = depressed mood, most of day, nearly every day
for two weeks
 Dys = depressed mood more days than not over a period
of 2 years
 Seems more like a personality disorder
“dissatisified personality”
N
XDysthymic Disorder and Chronic
major depressive disorder
 2 or more of the following associated Symptoms
Along with depressed mood
1.
2.
3.
4.
5.
6.
.
Change in appetite
Change in sleep
Decreased energy
Decreased self worth
Poor concentration
Hopelessness
X
 Please note that there are 3 major symptoms missing from
this list that are included in major depressive disorder;
 1. Absence of pleasure (anhedonia)
 2. Recurrent thoughts of suicide
 3. Psychomotor retardation or agitation
This suggests that only a particular type of major depressive
disorder-1 without suicidal ideation, anhedonia and lethargy
qualify for this diagnosis
X











PDD: Specifiers
Severity
With anxious distress
With mixed features
Melancholic Features
Atypical Features
Psychosis-mild (mood congruent or incongruent)
Postpartum
Partial remission
Full remission
Late onset-21 or older
Early onset
 With pure dysthymic syndrome-criteria for major depression is not been met
 With persistent major depressive episode-full criteria have been met, excluding
anhedonia, psychomotor retardation and suicidal ideation
 Intermittent major depressive episodes with or without current episode
X
The bereavement exclusion is gone
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. The first is to remove the
implication that bereavement typically lasts only 2 months when both
physicians and grief counselors recognize that the duration is more
commonly 1–2 years. Second, bereavement is recognized as a severe
psychosocial stressor that can precipitate a major depressive episode in a
vulnerable individual, generally beginning soon after the loss. When major
depressive disorder occurs in the context of bereavement, it adds an
additional risk for suffering, feelings of worthlessness, suicidal ideation,
poorer somatic health, worse interpersonal and work functioning, and an
increased risk for persistent complex bereavement disorder, which is now
described with explicit criteria in Conditions for Further Study in DSM-5
Section III. Third, bereavement-related major depression is most likely to
occur in individuals with past personal and family histories of major
depressive episodes. It is genetically influenced and is associated with similar
personality characteristics, patterns of comorbidity, and risks of chronicity
and/or recurrence as non–bereavement-related major depressive episodes.
Finally, the depressive symptoms associated with bereavement-related
depression respond to the same psychosocial and medication treatments as
non–bereavement-related depression.
X
Disruptive mood dysregulation disorder
296.99
 The purpose of this diagnosis was to provide a category for
children that created an alternative to the diagnosis of bipolar
disorder
 Evidence for such a diagnosis has long been available. Earlier
proposals were "severe mood dysregulation“
 Evidence suggests that children with this type of mood
dysregulation will not go on to be bipolar, but more likely
suffer from major depression
Diagnostic criteria
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
Severe recurrent temper outburst manifested verbally or behaviorally;
grossly out of proportion to the situation to the situation
Outbursts are inconsistent with developmental level
Outbursts occur 3 or more times a week
Mood between temper outburst is persistently irritable or angry most of
the day, nearly every day.
Criterion a through D have been present for 12 or more months
Criteria a through D are present in at least 2 or more settings
Initial Diagnosis can be made between the ages of 6 to 18
Age of onset-established her history or observation-must be before the age
of 10
No presence of manic or hypomanic episode
These behaviors do not occur during an episode of major depression and are
not better explained by another mental disorder
Symptoms are not attributable to the effects of a substance, another medical
or neurological condition
X
Diagnostic features
 Chronic, severe persistent irritability with the
following:
 Frequent temper outbursts in response to frustration
over a sustained period of time and are developmentally
inappropriate
 Anger and irritability remains constant even after
temper outbursts of stopped
X
 Prevalence estimates range between 2% and 5%
 Affects males more than females
 such children seem to be extremely temperamental in
prodromal manifestation
 sometimes diagnosed as oppositional defiant
disorder
5. Anxiety disorders, 6. obsessivecompulsive disorder and 7. traumarelated disorders
SUMMARY
Stress and trauma related disorders
Anxiety disorders
Disinhibited social engagement dis.
Reactive attachment disorder
Adjustment disorders
Panic disorder
PTSD
Agoraphobia
Generalized anxiety disorder Acute stress disorder
Social phobia
Specific phobia
PTSD
Obsessive-compulsive related disorders
Specified
anxiety disorder
Acute Stressanxiety
disorder
Unspecified
disorder
Obsessive compulsive disorder Obsessive compulsive disorder
Separation anxiety disorder
ocd w/ poor insight
selectivemutism
Hoarding disorder
Hair-pulling disorder
Skin-picking disorder
Body dysmorphic disorder
Medication-induced ocd
Other specified/unspecified ocd
5. Anxiety disorders
 Obsessive-compulsive disorder has been moved
out of this category
 PTSD has been moved out of this category
 Acute stress disorder has been moved out of this
category
 Panic attacks can now be used as a specifier within
any other disorder in the DSM
 Separation anxiety disorder has been moved to this
group
 Selective mutism has been moved to this group
Other changes and anxiety
disorders
 Criteria for specific phobia, and social anxiety disorder that
requires that individuals over 18 recognize that their anxiety is
excessive or unreasonable has been deleted
 I don't know I don't see it in here. I don't know. I had a lot of
awareness requirement is now that anxiety must be out of
proportion to the actual danger or threat in a situation after a
cultural context is considerED
 Panic disorder and agoraphobia are unlinked in the DSM 5
 THE “generalized” specifier for social anxiety disorder has been
deleted and replaced with her “performance only” specifier
X
6. Obsessive-compulsive and related
disorders






A completely new diagnostic grouping category
Hoarding disorder-new diagnosis
Excoriation (skin picking) disorder-new diagnosis
Substance induced obsessive-compulsive disorder-new diagnosis
Tic specifier has been added
Muscle dysphoria is now a specifier within body dysmorphic
disorder
 Obsessive-compulsive disorder-refined to allow distinction between
individuals with good to fair poor or “absent/delusional”
OCD Specifiers
 In DSM-IV TR a requirement for the diagnosis was that the
person suffering realized that the worries and behaviors
were excessive
 Now insight is a specifier
 With good or fair insight-individual recognizes that beliefs
and behaviors are not true and will not work
 With poor insight-individual believes that behaviors and
beliefs will help
 With absent insight/delusional beliefs-individual is zealous in
thinking that thoughts and behaviors must happen
X
Hoarding disorder 300.3
A. Persistent difficulty discarding her, parting with possessions,
regardless of their actual value
B. Difficulty is due to perceived need to save the items and due to
distress associated with discarding them
C. To difficulty discarding results in the accumulation of possessions
that congest and clutter active living areas and compromise their
intended use
D. Causes clinically significant distress or impairment in social,
occupational or other Areas of functioning
E. Not attributable to another medical condition
F. Not better accounted for by….
Specifiers
 With excessive acquisition-in addition to keeping things, this type
actively seeks out more(80 to 90% of all hoarders)
 With good or fair insight
 With poor insight
 With absent insight and delusional beliefs – this would trump
delusional disorder
Excoriation (skin picking)
disorder 698.4
A. Recurrent skin picking resulting in lesions
B. Repeated attempts to stop or decrease behavior
C. Causes clinically significant distress or impairment in
social, occupational…
D. Not attributable to the effects of a substance or
medication
E. Not better explained by…
X Substance/medication induced
obsessive-compulsive and related
disorder
A. Obsessions, compulsions, skin picking, hair pulling or
other body focused repetitive behaviors occur
B. Evidence that symptoms began during or soon after
substance use, withdrawal or medication exposure.
Substance or medication is capable of producing
obsessive-compulsive symptoms
C. Not better accounted for by OCD that is not
substance/medication induced
D. Does not occur exclusively during delirium
E. Causes clinically significant distress
OCD due to another medical
condition 294.8
A. Obsessions, compulsions, skin picking, hair pulling
or other body focused repetitive behaviors occur
B. Evidence that symptoms began during or soon
after Another medical condition that could cause
the symptomsNot better accounted for by OCD
that is not substance/medication induced
C. Does not occur exclusively during delirium
D. Causes clinically significant distress
Specify if
• With the possessive compulsive disorder like symptoms
• With appearance. Preoccupation
• With hoarding symptoms
• With hair pulling symptoms
• With skin picking symptoms
Other specified obsessive-compulsive
and related disorder 300.3
 Use when OCD symptoms are there and cause
clinically significant distress, but do not meet full
criteria for an OCD related diagnoses
 Specify




Body dysmorphia with actual flaws
Body dysmorphia without repetitive behaviors
Body dysmorphia with repetitive behaviors
obsessional jealousy
X
Substance-Related Disorders
:
 Substance Use Disorders
 Substance Dependence
 Substance Abuse
The distinction between
Dependence and abuse disorders
has been eliminated in the DSM 5
 Substance-Induced Disorders
 Substance Intoxication
 Substance Withdrawal
 Substance induced mental disorder
X
Substance use disorders maladaptive pattern
leading to clinically significant impairment or
distress for at least 12 months
Must have at least 2 of the following11:
1. Substance taken in larger amount (need more for
increased effect)
2. Persistent desire or efforts to quit
3. Time spent to obtain, use, recover from effects
4. Cravings Or urges to use
5. Failure to fulfill significant roles
6. Continued use despite persistent and recurrent
problems
7. Important social/occupational activities are reduced
8. Recurrent use in physically hazardous situations
9. Use continues despite knowledge of impact of the
problem
10. Tolerance, as defined by a. Increased amounts needed
to achieve intoxication or b. Diminished effect
11. Withdrawal
X
Substance-related disorders
Substance induced dis.
Substance use dis.
Pathological pattern of
behaviors related to use
of the substance
1. Impaired control
2. Social impairment
3. Risky use
=
= does occur also
4. Pharmacological effects
Increased tolerance
Substance
Intoxication
Recent
ingestion.
Reversible
symptoms
related to
ingestion
Substance
Withdrawal
Physiological and
psychological
symptoms due to
decreased use or
cessation
Substance
Induced
Mental
disorder.
Recent
ingestion
followed by
symptoms
of another
M.D.
Delirium; persisting dementia; persisting amnesia;
Psychotic disorder; mood dis; anxiety dis; sexual dys; sleep dis.
X
11 criteria four areas – USE Dx
1.
Impaired 2.
Control 3.
4.
5.
social
Impairment6.
7.
Risky 8.
use 9.
10.
Pharmacological
11.
effects
Substance taken in larger amount (need more for increased effect)
Persistent desire or efforts to quit
Time spent to obtain, use, recover from effects
Cravings Or urge to use
Failure to fulfill significant roles
Continued use despite persistent and recurrent problems
Important social/occupational activities are reduced
Recurrent use in physically hazardous situations
Use continues despite knowledge of impact of the problem
Tolerance, as defined by a. Increased amounts needed to achieve
intoxication or b. Diminished effect
Withdrawal
X 1. Criteria for Substance Use disorder
A. A maladaptive pattern of substance use leading to
impairment or distress, as seen in 2 of the following in
the same 12-mo. period:
1. Substance taken in larger amount (need more for increased
effect)
2. Persistent desire or efforts to quit
3. Time spent to obtain, use, recover from effects
4. Cravings Or urges to use
5. Failure to fulfill significant roles
6. Continued use despite persistent and recurrent problems
7. Important social/occupational activities are reduced
8. Recurrent use in physically hazardous situations
9. Use continues despite knowledge of impact of the problem
10. Tolerance, as defined by a. Increased amounts needed to
achieve intoxication or b. Diminished effect
11. Withdrawal
DSM 5 use = 2 or more crit. DSM IV
Abuse = 1 or more
1Failure to fulfill major role obligations at work, school,
home such as repeated absences or poor work performance
related to substance use;
#5 DSM 5
2. Frequent use of substances in situation which iis
physically hazardous
#8 dsm 5
3Frequent legal problems (e.g. arrests, disorderly conduct)
for substance abuse removed
4. Continued use despite having persistent or recurrent
social or interpersonal problems #6 dsm 5
Dependence = 3 or more
5. Tolerance or markedly increased amounts of the
substance to achieve intoxication or desired effect or
markedly diminished effect with continued use of the same
amount of substance #10 DSM 5
6 Withdrawal symptoms or the use of certain substances to
avoid withdrawal symptoms #11 DSM 5
7. Use of a substance in larger amounts or over a longer
period than was intended #1 DSM 5
8.persistent desire or unsuccessful efforts to cut down or
control substance use #2 DSM 5
9. Involvement in chronic behavior to obtain the
substance, use the substance, or recover from its effects
#3 DSM 5
10. .Reduction or abandonment of social, occupational or
X
Specifiers for use disorders
Severity
Mild = presence of 2-3 symptoms
moderate = presence of four – five symptoms
severe = presence of six or more symptoms
Course specifiers
In early remission = after full criteria were
previously met
none of the criteria have been met for at least three months but less
than 12 (with the
exception of craving)
In sustained remission = after full criteria were
previously met none exists except craving during
the
period of 12 months or more
X
Can also diagnose intoxication, withdrawal and induced mental disor
Simple substance dx
Mental disorders that can be induced by substances
I/W
I/W
I
X
7. Trauma and stress related
disorders
 For diagnosis of acute stress disorder, it must be
specified whether the traumatic events were
experienced directly or indirectly
 Adjustment disorders (a separate class in the DSM-IV)
are included here as various types of responses to
stress
 Major changes in the criteria for the diagnosis of
PTSD
XDiagnostic criteria has gotten more
detailed and specific = more
complicated diagnosis
The basics
Traumatic
events
Subsequent
reactions
A. Exposure to trauma-direct or indirect
B. Presence of intrusive thoughts, memories, flashbacks,
dreams, triggers that cause distress, or other external
cues that remind one of the trauma
C. Avoidance of stimuli associated with the traumatic
event
D. Changes (usually increased sensitivity) in thought
processes and emotions associated
E. Increased arousal or reactivity associated with the
traumatic event with the traumatic event
X
PTSD changes
 Criterion A - the stressor criterion is more explicit with regard to how
an individual experienced “traumatic” events.
 Criterion A2 (subjective reaction) has been eliminated.
 Three major symptom clusters in DSM-IV—reexperiencing,
avoidance/numbing, and arousal—
 Now four symptom clusters in DSM-5, because the
avoidance/numbing cluster is divided into two distinct clusters:
avoidance and persistent negative alterations in cognitions and
mood. This latter category, which retains most of the DSM-IV
numbing symptoms, also includes new or reconceptualized
symptoms, such as persistent negative emotional states. The final
cluster—alterations in arousal and reactivity—retains most of the
X
PTSD 309.81
A . Exposure to actual or threatened death, serious injury or sexual violence in one of the following ways
1. Directly experiencing the traumatic events
2. Witnessing in person. The event is it occurred to others
3. Learning that the traumatic events occurred to a close family member or close friend
4. Experiencing repeated or extreme exposure to aversive details of the traumatic events; a form of
Vicarious exposure experienced by police officers or 1st responders
B. Presence ofone or more of the following intrusion symptoms associated with the traumatic events beginning after
the event occurred
1. Recurrent, involuntary and intrusive distressing memories of the event
2. Recurrent distressing dreams in which the content is related to the event
3. Dissociative reactions (flashbacks) where individual feels or acts as if the event were recurring
4 intense-prolonged psychological distress when exposed to internal or external cues
5. Marked physiological reactions to internal or external cues
C. Persistence avoidance of stimuli associated with the traumatic events beginning after the event occurred
1. Avoidance or efforts to avoid distressing memories, thoughts or feelings associated with the event
2. Avoidance or efforts to avoid external reminders-people, places, conversations that might arouse
distressing memory starts her feelings associated with the event
D. Negative alterations in cognitions and mood associated with the events beginning or worsening after
the events
1. Inability to remember an important aspect of the traumatic event. This is not caused by a head injury
help call or drugs, but dissociative amnesia related to the event
2. Persistent exaggerated negative beliefs or expectations about oneself, Others and the world-I am bad,
No one can be trusted, the world sucks
3. Distorted cognitions that lead to self blame where the blame of others.
4. Persistent negative emotional state
5. Diminished interest or participation in significant activities
6. Feelings of detachment or estrangement from others
7. Persistent inability to experience positive emotions
X
PTSD 309.81-Continued
E. Significant alterations in arousal and reactivity associated with the traumatic event
1. Irritable behavior in angry outbursts with little or no provocation-started after the event, usually directed
toward people or objects
2. Reckless or self-destructive behavior
3. Hypervigilance
4. Exaggerated startle response
5. Problems with concentration
6. Sleep disturbance
F. Duration of the disturbance is longer than one month
G. Causes clinically significant distress or impairment
H. The disturbance is not attributable to the physiological effects of a substance or another medical condition
Specifiers
Specify whether:
Dissociative symptoms are present
Depersonalization = experience of feeling detached from, and disconnected from one self. Often described as
feeling as if one were outside observing oneself or as though in a dream.A sense or feeling of unreality
regarding oneself-with the knowledge that this is not true
Derealization= Experience of unreality of surroundings-the world feels unreal, dreamlike, distant her
distorted. However, one realizes this is not true
Specify if
Expression of symptoms is delayed = the full drive gnostic criteria are not met until at least 6 months or more
after the event
Please note the presence of anxiety, fear and avoidance. 3 conditions that we find in generalized anxiety disorder
X
PTSD In children-6 or younger
Avoidance and alterations in cognition collapsed into one criterion group
-
A . Exposure to actual or threatened death, serious injury or sexual violence in one of the following ways
1. Directly experiencing the traumatic events
2. Witnessing in person. The event is it occurred to others
3. Learning that the traumatic events occurred to a close family member or close friend
B. Presence ofone or more of the following intrusion symptoms associated with the traumatic events beginning after
the event occurred
1. Recurrent, involuntary and intrusive distressing memories of the event
2. Recurrent distressing dreams in which the content is related to the event
3. Dissociative reactions (flashbacks) where individual feels or acts as if the event were recurring
4 intense-prolonged psychological distress when exposed to internal or external cues
5. Marked physiological reactions to internal or external cues
C. One or more of the following symptoms involving either avoidance or negative alterations in cognition are made
must be Present
1. Avoidance or efforts to avoid distressing memories, thoughts or feelings associated with the event
2. Avoidance or efforts to avoid external reminders-people, places, conversations that might arouse
distressing memory starts her feelings associated with the event
3. Increase of negative emotional states
4. Diminished interest or participation in significant activities
5. Socially withdrawn Behavior
6. Reduction in expression of positive emotions
D. alterations in arousal and reactivity associated with the traumatic event
1. Irritable behavior in angry outbursts with little or no provocation2. Hypervigilance
3. Exaggerated startle response
4. Problems with concentration
5. Sleep disturbance
E.. Duration of the disturbance is longer than one month
F. Causes clinically significant distress or impairment
X
PTSD 309.81-Children
Specifiers are the same
Specifiers
Specify whether:
Dissociative symptoms are present
Depersonalization = experience of feeling detached from, and disconnected from one self. Often described as
feeling as if one were outside observing oneself or as though in a dream.A sense or feeling of unreality
regarding oneself-with the knowledge that this is not true
Derealization= Experience of unreality of surroundings-the world feels unreal, dreamlike, distant her
distorted. However, one realizes this is not true
Specify if
Expression of symptoms is delayed = the full drive gnostic criteria are not met until at least 6 months or more
after the event
In DSM-IV RAD was divided into
subtypes
 Subtypes = inhibited type and disinhibited type (criterion A),
 Inhibited = Persistent failure to initiate or respond in a developmentally
appropriate fashion to most social interactions, as manifest by
excessively inhibited, hypervigilant, or highly ambivalent and
contradictory responses (e.g. the child may respond to caregivers with a
mixture of approach, avoidance, and resistance to comforting, or may
exhibit "frozen watchfulness", hypervigilance while keeping an
impassive and still demeanor). Such infants do not seek and accept
comfort at times of threat, alarm or distress, thus failing to maintain
"proximity", an essential element of attachment behavior
 Disinhibited = Diffuse attachments as manifest by indiscriminate
sociability with marked inability to exhibit appropriate selective
attachments (e.g., excessive familiarity with relative strangers or lack of
selectivity in choice of attachment figures). There is therefore a lack of
"specificity" of attachment figure
Disinhibited = 313.89 disinhibited
social engagement disorder
A.
B.
C.
D.
E.
A pattern of behavior in which a child actively approaches and interacts with unfamiliar
adults and exhibits at least 2 of the following
1.
Reduced or absent reticence in approaching and interacting with unfamiliar adults
2.
Overly familiar verbal or physical behavior that is not consistent with age-appropriate
social boundaries
3.
Diminished or absent "checking back" behaviors
4.
Willingness to go with an unfamiliar adult with minimal or no hesitation
Behaviors in criterion a are not limited to impulsivity such as that seen in ADHD
The child has experienced a pattern of extremes of insufficient care, as evidenced by at
least one of the following
1.
Social neglect or deprivation in the form of persistent lack of having basic emotional
needs for comfort stimulation and affectation met by caregivers
2.
Repeated changes of primary caregivers that limit opportunities for stable attachment
3.
Rearing in unusual settings
The criterion C is presumed to be responsible for the disturbed behavior in criterion A
The child has a developmental age of at least 9 months
A.
B.
C.
D.
E.
F.
G.
313.89 RAD
A consistent pattern of inhibited, emotionally withdrawn behavior toward adult
caregivers manifested by both of the following
1.
The child rarely or minimally seeks comfort when distressed
2.
The child rarely or minimally responds to comfort. When distressed
A persistent social and emotional disturbance characterized by at least 2 of the
following
1.
Minimal social and emotional responsiveness to others
2.
Limited positive affect
3.
Episodes of unexplained irritability, sadness or fearfulness that are evident even
during nonthreatening interactions with caregivers
The child has experienced the pattern of extremes or insufficient care, as evidenced by
at least one of the following
1.
Social neglect or deprivation in the form of persistent lack of having basic
emotional needs for comfort stimulation and affection met by caregiving adults
2.
Repeated changes a primary caregivers that limit opportunities to form stable
attachment
3.
Rearing in unusual settings that severely limit opportunities to form attachments
To carry in criterion C is presumed to be responsible for the disturbed behavior in
criterion a
Criterion are not met for autism spectrum disorder
Disturbance is evident before age 5
Child has a developmental age of at least 9 months
Adjustment Disorders
In DSM-5, adjustment disorders are reconceptualized as a
heterogeneous array of stress-response syndromes that occur
after exposure to a distressing (traumatic or nontraumatic) event,
rather than as a residual category for individuals who exhibit
clinically significant distress without meeting criteria for a more
discrete disorder (as in DSM-IV ). DSM-IV subtypes marked by
depressed mood, anxious symptoms, or disturbances in conduct
have been retained, unchanged.
• Stressor can be of any severity or type (unlike PTSD Criterion A)
• Much more flexible diagnosis then PTSD or acute stress disorder
• Diagnose adjustment disorder when:
• PTSD criteria are not met
• Criterion A for PTSD stressors not met
• Subthreshold for acute stress disorder & PTSD
• Symptoms do not last longer than 6 months after stressor.A transitional state that is longer than acute stress disorder,
but typically not as intense
8. Dissociative disorders
SUMMARY
 Depersonalization disorder has been relabeled
“Depersonalization/Derealization disorder“
 Dissociative fugue is no longer a separate diagnosis
but is now specifier within the diagnosis of
"dissociative amnesia“
 Changes in criteria for the diagnosis of "dissociative
identity disorder"
DID
 Criterion A has been expanded to include certain
possession-form phenomena and functional
neurological symptoms to account for more diverse
presentations of the disorder.
 Criterion A now specifically states that transitions in
identity may be observable by others or selfreported.
 Criterion B, individuals with dissociative identity
disorder may have recurrent gaps in recall for
everyday events, not just for traumatic experiences.
Other text modifications clarify the nature and course
of identity disruptions.
Diagnostic criteria – DSM 5 300.14
A.
Presence of two or more distinct Personality states, which
may be described in some cultures as an experience of
possession. This disruption and identity involves marked
discontinuity in sense of self and personal agency. This is
accompanied by alterations (often sudden) in affect, behavior,
consciousness, memory, perception and/or sensorimotor
functioning. These signs and symptoms may be observed by
others or reported by the individual
B.
Inability to recall important personal information Or gaps in
recall of everyday events. Important personal information or
traumatic events. AKA dissociative amnesia
C.
D.
E.
Cause clinically significant distress , And/or impairment
Not a part of broadly accepted cultural or religious practice
Not due to a substance or general medical condition
Note the difference in the
Diagnostic criteria –IV TR
A. Presence of two or more distinct identities,
each with its own relatively stable pattern of
personality traits
B. At least two of these ‘alters’ take control of
the person’s behavior
C. Inability to recall important personal
information that is too extensive to be
explained by ordinary forgetfulness
D. Not due to a substance or general medical
condition
X
9. Somatic symptom and related
disorders
 This is a new name for what was previously called
"somatoform disorders“
 The number of diagnoses in this category has been
reduced. The diagnoses of somatization disorder,
hypochondriasis, pain disorder and undifferentiated
somatoform disorder have all been removed
 "Illness anxiety disorder" has been an added
diagnosis and replaces hypochondriasis
 Factitious disorder is now included in this group
X
Some definitions
 Factitious disorder: conscious and intentional feigning or production of
symptoms, because of a psychological need to assume the sick role to
obtain emotional gain
 Malingering: conscious and intentional production or exaggeration of
symptoms for material gain, such as money, lodging, food, drugs, avoidance
of military service, or escape from punishment
 Somatization: recurrent and multiple symptoms (eg, pain, GI, sexual,
pseudoneurological) with no organic basis, believed to be due to
unconscious expressions of suppressed emotional conflict or stress; unlike
factitious disorders, the symptoms are not created by voluntary, conscious
behavior
 Hypochondriasis: obsession with fears that one has a serious, undiagnosed
disease, presumably based on misinterpretation of bodily sensations - See
more at: http://www.psychiatrictimes.com/articles/factitious-disorderdetection-diagnosis-and-forensic-implications#sthash.trRTuLQM.dpuf
X Somatic Symptom Disorder
 Individuals with somatic symptoms plus abnormal thoughts, feelings, and behaviors may
or may not have a diagnosed medical condition.
 The relationship between somatic symptoms and psychopathology exists along a
spectrum.
 high symptom count required for DSM-IV somatization disorder did not accommodate this
spectrum.
 The diagnosis of somatization disorder was essentially based on a long and complex symptom
count of medically unexplained symptoms.
 Individuals previously diagnosed with somatization disorder will usually meet DSM-5
criteria for somatic symptom disorder, but only if they have the maladaptive thoughts,
feelings, and behaviors that define the disorder, in addition to their somatic symptoms.
 In DSM-IV, the distinction between “undifferentiated somatoform disorder” had been
created in recognition that “somatization disorder” would only describe a small minority
of “somatizing” individuals, but this disorder did not prove to be a useful clinical
diagnosis.
 They are merged in DSM-5 under somatic symptom disorder, and no specific number of
somatic symptoms is required.
X Somatic Symptom Disorder300.82
Diagnostic Criteria:
A. One or more somatic symptoms that are distressing and result in
significant disruption of daily life
B. Excessive thoughts, feelings or behaviors related to the
symptoms or associated health concerns, as manifested by at
least one of the following:
1.
2.
3.
Disproportionate and persistent thoughts about the seriousness of
symptoms
Persistently high level of anxiety about health or symptoms
Excessive time and energy devoted to the symptoms or health concerns
C. The state of being symptomatic is persistent (typically more than
6 months)
Specifiers
 Specify if:
 with predominant pain (previously classified as pain disorder and DSM-IV)
 Specify if:
 persistent: severe symptoms lasting longer than 6 months




Specify current severity:
mild = only one of the symptoms specified in criterion B is the filled
moderate = 2 or more of the symptoms in criterion beer for filled
Severe = 2 or more of the symptoms are fulfilled. Plus, there are multiple other
somatic complaints
X
300. 7 Illness anxiety disorder criteria
Previously hypochondriasis
A. Preoccupation with having or acquiring a serious illness
B. No evidence of somatic symptoms or extremely mild
symptoms present
C. High anxiety about health and health status
D. Excessive health related behaviors or avoidant health
related behaviors
E. Illness preoccupation present for at least 6 months
F. not better explained by another disorder
Specify whether:
care seeking type: medical care, including physician visits frequently used
X Pain Disorder removed from
DSM 5
 DSM-IVpain disorder diagnoses assume that some pains are
associated solely with psychological factors, some with medical
diseases or injuries, and some with both.
 lack of evidence that such distinctions can be made with reliability
and validity, and a large body of research has demonstrated that
psychological factors influence all forms of pain.
 individuals with chronic pain attribute pain to a combination
of factors, including somatic, psychological, and environmental
influences-not either/or
 DSM-5 some individuals with chronic pain could be DXd
 having somatic symptom disorder, with predominant pain
 316.0psychological factors affecting other medical conditions
 adjustment disorder
Psychological Factors Affecting
Other Medical Conditions
 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.” This disorder
and factitious disorder are placed among the somatic
symptom and related disorders because somatic
symptoms are predominant in both disorders, and both
are most often encountered in medical settings. The
variants of psychological factors affecting other medical
conditions are removed in favor of the stem diagnosis.
Psychological Factors Affecting
Other Medical Conditions
 A. Medical symptom or condition is present
 B. psychological or behavioral factors adversely affect the
medical condition in one of the following ways
 The factors that influence the course of the medical condition as
shown by a close temporal association between a psychological
factors and the development or exacerbation of medical condition
 The factors interfere with the treatment of the medical condition
 The factors constitute additional well-established health risk for the
individual
The factors influence the underlying psychopathology precipitating
or exacerbating symptoms or necessitating medical attention
 C. psychological and behavioral factors in criterion B are not
better explained by another mental disorder
X300.19 Factitious disorder criteria
Self-imposed
A.
Falsification of physical or psychological signs or symptoms or induction of
injury or disease. In order to deceive
B.
Individual present self to others, as if impaired or injured
C.
D.
No apparent or obvious external rewards
, Not better accounted for by…
Imposed on others
A. Falsification of physical or psychological signs or symptoms or induction of injury
or disease. In order to deceive
B. Individual presents another individual to others as you know, impaired or injured
C. No apparent external rewards
D. Not better accounted for by…
E. When imposed on others. Diagnosis is given to the perp
Specify if
single episode
recurrent episodes
X
 Somatic symptoms – major focus on symptoms experienced as
well as anxiety- symptoms can have a physical cause, but the pt.
experiences no relief
 Illness anxiety – major focus on anxiety and what “might”
happen. Symptoms might or might not be present- but are mild
if there.
 Conversion disorder – symptoms present. Of a neuro-perceptual
type; blindness paralysis
 Factitious – symptoms intentionally produced – no apparent
gain-assess motivation
 Malingering (v code)– intentional gain can be documentedassess motivation
X
Somatic symptoms
Inauthentic –authentic illnesses
 Psychogenic illness – the mind causes symptoms that are
experienced by the patient but have no “real” presence
 Unconscious
 Somatic symptom
 Illness anxiety
 conversion
Diagnosed in part by LACK of evidence
 Conscious
 Factitious
 malingering
Diagnosed by evidence
X
When to suspect factitious
disorder
 The person's medical history doesn't make sense
 No believable reason exists for the presence of an
illness or injury
 The illness does not follow the usual course
 There is a lack of healing for no apparent reason,
despite appropriate treatment
 There are contradictory or inconsistent symptoms or
lab test results
 The person is caught in the act of lying or causing his
or her injury
X
http://www.psychiatrictimes.com)
The Case of Factitious Disorder Versus Malingering
(2009] Courtney B. Worley,
MPH ; Marc D. Feldman, MD and James C. Hamilton, PhD
X
Without detailing the full DSM diagnostic criteria sets for these
disorders and their relations, the
following is a summary of how DSM instructs psychiatrists to
diagnose cases of inauthentic illness
behavior:
1. In the absence of overwhelming affirmative evidence of
intentional medical deception (eg, caught
on video, evidence from a room search), diagnose a somatoform
disorder.
2. If there is traditional forensic evidence of overt medical
deception, diagnose malingering or
factitious disorder.
3. If there is any significant material or instrumental benefit from
the intentional medical deception
(eg, financial settlement, disability determination, access to
narcotic medicine), diagnose malingering.
http://www.psychiatrictimes.com)
The Case of Factitious Disorder Versus Malingering
(2009] Courtney B. Worley,
MPH ; Marc D. Feldman, MD and James C. Hamilton, PhD
10. Feeding and eating disorders
 "Binge eating disorder' is now included as a separate
diagnosis
 also includes a number of diagnosis that were
previously included in a DSM-IV TR in the chapter
"disorders usually 1st diagnosed during infancy
childhood and adolescence“.
 Pica and rumination disorder are 2 examples
11. Elimination disorders
 Originally classified in chapters on childhood and infancy.
Now have separate classification
12. Sleep wake disorders
 Primary insomnia renamed "insomnia disorder«
 Narcolepsy now distinguished from other forms of
hypersomnia
 Breathing related sleep disorders have been broken into 3
separate diagnoses
 Rapid eye movement disorder and restless leg syndrome are
now independent diagnoses within this category
13. Sexual dysfunctions
 Some gender related sexual dysfunctions have been outed
 Now only 2 subtypes-acquired versus lifelong and
generalized versus situational
 New diagnostic class and the DSM 5
 Include separate classifications for children adolescents and
adults
 The construct of gender has replaced the construct of sex
14. GENDER DYSPHORIA DSM 5
 Attempted to eliminate the stigma involved in the
previous diagnosis of gender identity disorder
 Likely that more research is needed. Prevalence is
remarkably low
Gender Dysphoria in Adolescents
and adults
A. Mark incongruence between one's
experienced/expressed gender and assigned gender. At
least 6 months duration, as manifested by at least 2 of
the following
1.
2.
3.
4.
5.
6.
Marked incongruence between one's experienced/expressed gender and primary and/orsecondary sex
characteristics
Strong desire to be rid of one's primary and/or secondary sex characteristics because of marked
incongruence with one's experienced/expressed gender
Strong desire for the primary and/or secondary sex characteristics of the other gender
Strong desire to be of the other gender
Strong desire to be treated as the other gender
Strong conviction that one has the typical feelings and reactions of the other gender
B. Condition is associated with clinically significant distress
or impairment
Specify if "post-transition“ = the individual has transition to full-time living in the desired gender
(with or without legalization of gender change), and has undergone or is preparing to have at least
one cross-section medical procedure or treatment regimen
X
Disruptive, impulse control and
conduct disorders
 New diagnostic grouping and DSM 5
 Combines a group of disorders previously included in disorders of
infancy and childhood such as conduct disorder oppositional
defiant disorder with a group previously known as impulse control
disorders not otherwise classified
 Oppositional defiant disorder now has 3 subtypes
 Intermittent explosive disorder no longer requires physical
violence but can include verbal aggression
X 15. Disruptive, impulse control,
and conduct disorders
Disruptive ones
oppositional defiant disorder
conduct disorder
Intermittent explosive disorder
Impulsive ones
Intermittent explosive disorder
pyromania
kleptomania
Gambling disorder
Major dynamic in all ICDs
Impulsive
act
Spike (steep rise)
In tension immediately
Before the act
Tension and stress
Begins to build
Immediate release in tension,
Experience of pleasure
or gratification
X
A.
ODD 313.81
Pattern of angry/irritable mood, argumentative/defiant behavior, Vindictiveness, lasting at least
6 months; evidenced by at least 4 symptoms for many of the following categories and exhibited
during interaction with at least one individual, not a sibling.
Angry, irritable mood
1. Often loses temper
2. Is often touchy or easily annoyed.
3. Often angry and resentful
Argumentative, defiant behavior
4. Often argues with authority figures.
5. Actively defies or refuses to comply with requests from authority figures.
6. Deliberately annoys others.
7. Blames others for his or her mistakes
Vindictive behavior
8. Has been spiteful or vindictive at least twice within the past 6 months
B.
C.
Causes distress in person, and others
Does not occur during the course of another disorder
Changes from DSM IV
ODD & conduct disorder are not mutually exclusive
3 symptom type groupings
guidance re: how to distinguish from developmental norms
severity measure included
X
Specifiers
 Mild
 Moderate
 Severe
Severity can be measured through intensity, frequency,
or pervasiveness. For example, if the behavior occurs in
more than one setting, it is more pervasive and thus
more severe. Usually occurs in the home and not
across settings
X
Dimensional severity assessment for
ODD
Instructions to clinicians for ODD
The Clinician-Rated Severity of Oppositional Defiant Disorder assesses the severity of the OPPOSITIONAL DEFIANT
symptoms for the individual based on their pervasiveness across settings. The measure is intended to capture meaningful
variation in the severity of symptoms, which may help with treatment planning and prognostic decision-making. The
measure is completed by the clinician at the time of the clinical assessment. The clinician is asked to rate the severity of
oppositional defiant problems as experienced by the individual in the past seven days.
Scoring and interpretation for ODD scale
The Clinician-Rated Severity of Oppositional Defiant Disorder is rated on a 4-point scale (Level 0=None; 1=Mild;
2=Moderate; and 3=Severe). The clinician is asked to review all available information for the individual and, based
on his or her clinical judgment, select ( ) the level that most accurately describes the severity of the individual’s
condition.
Frequency of use for ODD scale
To track changes in the individual’s symptom severity over time, the measure may be completed at regular intervals as
clinically indicated, depending on the stability of the individual’s symptoms and treatment status. Consistently high scores
on a particular domain may indicate significant and problematic areas for the individual that might warrant further
assessment, treatment, and follow-up. Your clinical judgment should guide your decision.
X
ODD dimensional assessment
X
Problems with diagnosis
 Differentiating this from developmental and/or
environmental stress related behavior
 Differentiating from other diagnoses such as bipolar 2
 Biased reporting or reporting based on reputation
 Expectation induced disruptive behaviors
 Behavior is often confined to one way one setting (for
example, the home)
 Little or no insight is present on the part of the suffer.
See self is victim
X Conduct disorder unchanged
Diagnostic criteria
A.
Repetitive and persistent pattern of behavior in which the basic rights of others or
major age-appropriate societal norms and rules are violated, as manifested by the
presence of at least 3 of the following 15 criteria in the past 12 months. For many of the
categories below, with at least one criteria present in the last 6 months
Aggression to people or animals
1 bullies, threatens or intimidates
2 often initiates physical fights
3 used weapons that can cause serious physical harm
4. been physically cruel to people
5. Been physically cruel to animals
6. Has stolen while confronting a victim
7. Forced someone into sexual activity
destruction of property
8. Has deliberately engaged in fire setting with intent of causing damage
9. Deliberately destroyed others property
deceitfulness or theft
10. Broken into someone else's home building car
11. lies or deceives to obtain goods or favors
12. Has stolen nontrivial items without confronting victim – shoplifting etc.
serious violation of rules
13. Stays out at night. Despite parental prohibitions. Begins before 13
14. Has run away from home at least twice
15. Often truant, beginning before age 13
B.
C.
Causes clinically significant impairment
If age 18 or over, not attributable to antisocial personality disorder
X
16. Neuro-cognitive disorders
 New diagnostic group
 Dementia and amnestic disorder are included in this
new group
 Mild NCD is a new diagnosis
X
 Term "dementia" has been deemphasized
 done to lessen stigma
 Deemphasize irreversibility
 Broadens category in a more neutral way (see The following
points below)
 Mild neurocognitive disorder has been added
 Distinguished from Major (severe) neurocognitive disorder
X Diagnostic criteria for delirium
unchanged
 A. disturbance Inattention (reduced ability to direct, focused,




sustain and shift attention and awareness); reduced orientation
to environment
B. . develops over a short period of time and fluctuates during the
day
C. Add a disturbance in cognition (usually marked) – such as
memory deficit, disorientation, agitation, language or perceptual
disturbance
D. The criteria from A&C are Not better explained by a
preestablished neurocognitive disorder or evolving
neurocognitive disorder
E. evidence from the history, physical examination or lab findings
thate disturbances are direct consequence of another medical
condition, substance, intox or w/drawal
Specifiers
 Substance intoxication delirium = when criteria in A and C
predominate during a period of intoxication
 Substance withdrawal delirium = should be made it instead of
substance withdrawal when the symptoms in criterion a and C
predominate in the clinical picture
 Medication induced delirium = should be made when the symptoms
in criteria a and C arises a side effect of the medication taken as
prescribed
 Delirium due to another medical condition = evidence that the
disturbance is attributable to the physiological consequences of
another medical condition
 Delirium due to multiple etiologies = evidence that the delirium has
more than one cause or causal condition
Course =
acute: lasting a few hours or days
persistent: lasting weeks or months
X Diagnostic criteria for Major NCD
AKA DEMENTIA
 A. Evidence of significant decline from her previous
level of performance in one or more cognitive
domains.: (Cognitive attention, Memory impairment, Learning, attention,
recognition (Aphasia, agnosia), apraxia , Language, perceptual/motor problems , Social
cognition and/or other disturbance of executive functions)
 B. cause significant impairment in social, vocational
functioning; is a marked decline from previous
functioning And require assistance, and activities. If
daily living, because they interfere with
independence in every day activities
 C. Are not caused or related to by delirium
 D. Not better explained by…
X
Mild neurocognitive disorder
A.
Evidence of modest cognitive decline for previous data
performance in one or more cognitive domains-cognitive
attention, executive function, learning and memory, language,
perceptual motor or social cognition. Evidence based on
1.
2.
B.
C.
D.
Concern of individual, a knowledgeable informant or the clinician that there is
been a mild decline in cognitive function and
Modest impairment in cognitive performance preferably documented by
standardized neuropsychological testing or another quantified clinical
assessment
The cognitive deficits do not interfere for capacity with
independence in every day activities, but greater effort
compensatory strategies or accommodations may be required
The cognitive deficits do not occur exclusively in the context
of a delirium
Not better accounted for by another mental disorder (major
depression, schizophrenia
XSpecifiers whether (Sub-types) of Mild NCD
(dementia) are classified by etiology in DSM













Alzheimer’s type
Frontotemporal deterioration
Lewy body disease
Vascular (multi-infarct) dementia
Related to HIV
Head trauma Or TBI
Substance medication induced
Huntington’s disease
Parkinson’s diseases
Pick’s disease
Prions disease
Multiple etiologies
Unspecified
17. Difference between
paraphilia's and paraphilia
 Paraphilia describes disorders
the experience of intense Sexual
arousal to atypical objects, situations, or individuals.
 Paraphilic behavior (such as Pedophilia, zoophilia,
voyeurism and exhibitionism and may be illegal in
some jurisdictions, but may also be tolerated.
 A paraphilia is NOT a paraphilic disorder
 Paraphilia disorder requires the generation of
clinically significant distress, impairment or acting
them out with the nonconsenting person. (Criterion
B)
X
Personality disorders
Nothing changes
X
DSM 5 promised major changes in
criteria
 Promised dimensional focus
 Promised reduction in number of personaliity
disorders to five
 Changes did not occur
 Dimensional focus for personality disorders was
moved to section 3
X
Primary Criteria in DSM 5
(Unchanged from DSM-IV TR)
A.
Enduring pattern of inner experience & behavior
that deviates markedly from expectations of the
culture. This pattern is manifested in 2 or more of
the following areas
A.
B.
C.
D.
B.
C.
D.
Cognition;
Affect;
Interpersonal;
Impulse control
Inflexible & pervasive across situation
Distress or impairment in social, occupational
interpersonal..…
Long-standing (back to adolescence or early
X
DSM IV & 5 and personality
clusters
Cluster A
Odd/eccentric
Paranoid
Schizoid
schizotypal
Cluster B
Dramatic, erratic
Self-involved
Anti-social
Histrionic
Narcissistic
Borderline
Cluster C
Anxious/fearful
Dependent
Avoidant
Obsessive-compulsive
X
Dimensional classification of
personality disorders
 Authors of DSM 5 had planned to use dimensional
measures to diagnose personality disorders
 They plan to reduce personality disorders from 10 to 5
 This changed in a closed-door meeting
 Dimensional measures are now in section 3
X
ANTI_SOCIAL
 A) There is a pervasive pattern of disregard for and violation of the rights of
others occurring since age 15 years, as indicated by three or more of the
following:
1. failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly
performing acts that are grounds for arrest;
2. deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit
or pleasure;
3. impulsiveness or failure to plan ahead;
4. irritability and aggressiveness, as indicated by repeated physical fights or assaults;
5. reckless disregard for safety of self or others;
6. consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior
or honor financial obligations;
7. lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or
stolen from another;
 B) The individual is at least age 18 years.
 C) There is evidence of conduct disorder with onset before age 15 years.
 D) The occurrence of antisocial behavior is not exclusively during the course
of schizophrenia or a manic episode.
X
OR Mnemonic: “CALLOUS MAN”
Diagnostic Criteria for Antisocial PD







Conduct disorder before age 15; current age at least 18
Antisocial activities; commits acts that are grounds for arrest
Lies frequently
Lacunae—lacks a superego
Obligations not honored (financial, occupational etc.)
Unstable—can’t plan ahead
Safety of self and others is ignored
 Money– recklessness with money; spouse and children are not
supported because he bought a motorcycle
 Aggressive, Assaultive
 Not occurring during schizophrenia or mania
X
Antisocial signs






Glibness, shallow emotion
Requires constant stimulation
Criminal versatility
Promiscuity
Poor impulse control
Avoids responsibility for actions
X
 Millon identified five subtypes of Anti-Social
Personality Disorder
 covetous antisocial – variant of the pure pattern
where individuals feel that life has not given them
their due – including paranoid features.
 reputation-defending antisocial – including
narcissistic features
 risk-taking antisocial – including histrionic features
 nomadic antisocial – including schizoid, avoidant
features
 malevolent antisocial – including sadistic, paranoid
features.
X
BORDERLINE PD
A. A pervasive pattern of instability of interpersonal relationships, self-image and
affects, as well as marked impulsivity, beginning by early adulthood and
present in a variety of contexts, as indicated by five (or more) of the
following:
1. Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or selfinjuring behavior covered in Criterion 5
2. A pattern of unstable and intense interpersonal relationships characterized by alternating
between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g., promiscuous sex,
excessive spending, eating disorders, binge eating, substance abuse, reckless driving). Note:
Do not include suicidal or self-injuring behavior covered in Criterion 5
5. Recurrent suicidal behavior, gestures, threats or self-injuring behavior such as cutting,
interfering with the healing of scars or picking at oneself (excoriation) .
6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria,
irritability or anxiety usually lasting a few hours and only rarely more than a few days).
7. Chronic feelings of emptiness
8. Inappropriate anger or difficulty controlling anger (e.g., frequent displays of temper, constant
anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation, delusions or severe dissociative symptoms
X
OR Mnemonic for Diagnostic Criteria:
“I RAISED A PAIN”
 Identity disturbance




Relationships are unstable
Abandonment is frantically avoided
Impulsive
Self-mutilation, suicidal threats/attempts; splitting - as a predominant defense
mechanism is used
 Emptiness is a description of their inner selves
 Dissociative symptoms
 Affective instability
 Paranoid instability
 Anger is poorly controlled
 Idealization of others, followed by devaluation (splitting – person is either all
good or all bad)
 Negativistic—undermine their own efforts and those of others
X
 First called “as if” personality because or
changes in direction or interest
 Term “borderline” is unfortunate. Originally
referred to being on the ‘border’ between
psychotic and neurotic
 Label is often used pejoratively among mental
health professionals
 Misunderstood and mis-labeled as
“manipulative”
X
Borderline Themes







Parental neglect and abuse
Impulsivity
Fears of abandonment
Frequent suicide ideation or gestures
Substance abuse or dependence
Legal difficulties
Disrupted education relationships, vocations,
vacations
X
Propose general criteria for
personality disorder
A. Moderate or greater impairment in personality (self interpersonal
functioning)
B. One or more pathological personality traits
C. The impairments in personality functioning are inflexible and
pervasive across a broad range of personal and social situations
D. The impairments in personality functioning are relatively stable
across time
E. The impairments in personality function are not better explained
by another medical condition or substance
F. Impairments in personality functioning are not better understood
as normal for individuals developmental stage, or sociocultural
environment
X
Dimensional classification of
personality disorders
 Authors of DSM 5 had planned to use dimensional
measures to diagnose personality disorders
 They plan to reduce personality disorders from 10 to 5
 This changed in a closed-door meeting
 Dimensional measures are now in section 3
X
Proposed changes in assessment
broad
dimensions
Overall
personality
functioning
self
Identity
Interpersonal
Self
direction
Empathy
Two
5 Broad
Pathological
Trait Domains
Negative
affectivity
Intimacy
Detachment
Antagonism
Disinhibition
Psychoticism
How to deal with uncertainty
2 dimensions required for all DSM
diagnosis
1. Clarity of symptoms
2. Specified length of time for symptoms
4 basic levels of diagnostic warrant
High
Symptom
clarity
Diagnostic plausibility
symptom
Uncleartime
unstable
pattern
Diagnostic uncertainty or
Diagnostic confusion
low
Diagnostic certainty
over
Clear
stable
Diagnostic possibility
Diagnostic certainty
 The likelihood that a “plausible” diagnosis is
“probable”
 Clinicians often diagnoses based on “clinical hunches”,
which are a form of bias
 They select one or 2 salient characteristics –rather than
the complete 7 to 9- and make assumptions (Paris, 2013)
 This is a form of “fast thinking” or quick judgment that
leads to “framing effects” (Kahneman, 2011) sometimes
called the “clinicians illusion”.
Easy for clinicians to conflate
probability with plausibility
 Plausibility = the likelihood that an event or
events are representative of
something more; clinicians tend
to focus on this
 Probability = the statistical likelihood of an
event; researchers focus on this
Kahneman, 2011
2 conditions necessary for Diagnostic
certainty
 When symptoms are clear and stable over time
 When the relationship between plausibility and
probability has been considered
Plausibility- these symptoms represent X
Probability – the likelihood of X occurring
High
Symptom
clarity
Diagnostic plausibility
probability
Unclear
unstable
symptom
Diagnostic certainty
pattern
Diagnostic uncertainty or
Diagnostic confusion
low
over time
Clear
stable
Diagnostic possibility
Progression of domains of diagnostic certainty
over time
Diagnostic
uncertainty
Diagnostic
possibilities
Diagnostic
plausibility
Diagnostic
probabilities
Ethical issues arise here when:
Diagnostic
certainty
•Clinician unknowingly or unwittingly is in the
wrong domain (incompetence)
•Clinician knowingly chooses the wrong domain
Progression of diagnostic certainty over time
Documentation can help
Diagnostic
uncertainty
What leads
me to be
unsure?
Do I know
What don’t
I
Know?
Diagnostic
possibilities
Why are
these
The
possibilities
?
How do I
know that
other DXs
Diagnostic
plausibility
What am I
seeing that
is so
compelling?
What am I
missing?
Why am I
missing?
Diagnostic
probabilities
What
makes this
a
probability
and others
not?
Where is
my
Diagnostic
certainty
Why am I
certain?
How do I
know that I
know?
Progression of diagnostic certainty over time
Diagnostic
uncertainty
Diagnostic
possibilities
Diagnostic
plausibility
Diagnostic Diagnostic
probabilitiescertainty
The more uncommon or
unusual a diagnosis is, the
more time
and care one must take in
differentiating or excluding
other – more common (statistically) diagnoses

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