DSM –IV TR DSM

Report
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HIGHLIGHTS of CHANGES:
DSM-IV-TR to DSM-5
Venkata Kolli
Creighton-Nebraska Psychiatry Residency Program
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DSM- A long road!
 Medical
 DSM
203 (1943)
I : 1952: 130 pages long
 DSM
II: 1968:1974 (7th printing) homosexuality
was removed as a disorder by voting!
 DSM
III: 1980: “multiaxial”
 DSM
IIIR: 1987.
 DSM
IV: 1994.
 DSM
IV-TR:2000.
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DSM I-DSM 5
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 Why
is the roman
numeral discarded?
DSM –IV to DSM-5
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 DSM-5, book
divided into 3 sections
1. Section I: Basics
2. Section II: Diagnostic Criteria and
Codes
3. Section III: Emerging Measures and
Models
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DSM –IV TR
DSM -5
Axis –I
Psychiatric disorders
Axis –II
Personality disorder & MR
Axis III
Medical problems
Diagnosis
Psychosocial & contextual
factors
Axis IV
Axis V (GAF)
World Health Organization
Disability Assessment
Schedule (WHODAS 2.0)
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Neurodevelopmental disorders
 Autism
Spectrum Disorder
 ADHD
 Intellectual
Disability
 Communication
 Specific
Disorders
Learning Disorders
 Motor
Disorders
 Other
Neurodevelopmental disorders
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Pervasive Developmental
Disorder
DSM -5
Autistic Disorder
Childhood Disintegrative
disorder
Autism Spectrum Disorder
Asperger's Disorder
Pervasive Developmental
Disorder NOS
Rett’s Disorder
Can still be diagnosed as ASD
but with specifier ‘with known
genetic or medical condition’
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Autism Spectrum Disorder
DSM –IV TR

DSM-5
Formerly (DSM-IV-TR):
DSM–V: Characterized by
Required Deficits in 3 Areas:
Deficits in

Social Interaction

Communication

Restricted, Repetitive and
Stereotyped Behavior
2 CORE Domains:

Social Communication and
Interaction

Restricted & Repetitive
Behavior, Interests, and
Activities
Deficits in communication are related to social interaction deficits.
DSM-5 fixes this double counting.
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Autism Spectrum Disorders
Social Communication and
Interaction

Social-Emotional
Reciprocity

Non-verbal Communication

Developing, Maintaining, &
Understanding relationships

Level 3 is most severe, Level
1 Mild
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Autism Spectrum Disorders
Restricted & Repetitive Behavior,
Interests, and Activities

Stereotyped Movements, Use of
Objects, or Speech

Insistence on Sameness,
Inflexibility, Ritual Behaviors

Highly Restricted/Fixated
Abnormal Interests

Hyper- or Hypo-Reactivity to
Sensory Input

Level 3 is most severe
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Autism Spectrum Disorders
 Present
in Early Development
 Symptoms
Cause Significant Impairment in
Social, Occupational Functioning
 Symptoms
Not Better Explained by
Intellectual Disability or Developmental
Delay
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Intellectual Disability
(Intellectual Developmental
Disorder)
 Formerly
Mental retardation
 Previously
part of Axis II of DSM- IV TR
 DSM-5
focus is on adaptive functioning along with
standardized testing
 In





DSM IV Levels of Retardation based on IQ Scores:
Mild (IQ = 50/55 to 70),
Moderate (IQ=35/40 to 50/55),
Severe (IQ= 20/25 to 35/40),
Profound (IQ= <20/25)
Severity Unspecified (Unmeasurable)
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Intellectual Disability (Intellectual
Developmental Disorder)
 Deficits
in: a) Intellectual and
b) Adaptive Functioning
c) Onset in Developmental Period
 Specifiers:
Severity - Based on Conceptual, Social,
Practical Functioning & Supports Needed:

Mild

Moderate

Severe

Profound
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Changes related to Attention
Deficit Hyperactivity Disorder
 Symptoms
present prior to age 12 (opposed to 7 in
DSM –IV TR)
 Can
now have a diagnosis of ADHD & Autism
Spectrum Disorder
 Adults
with ADHD: Symptom cutoffs for diagnosis
is 5 criteria (instead of 6 for those <16 years old)
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Schizophrenia Spectrum and Other
Psychotic Disorders
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Schizophrenia symptoms
Positive symptoms
Hallucinations
Eg. Second
person, Third
person
(Schneiderian
symptom)
Delusions
Bizzare
Eg. Aleins
controlling
thoughts
Nonbizzare
Eg. Someone
following
Negative symptoms
Disorganization
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No special attributes
 Elimination
of the special attribution of
bizarre delusions and Schneiderian firstrank auditory hallucinations (e.g., two or
more voices conversing).
 No
bizzare Vs non-bizzare significance
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Psychotic disorders time frames
Unchanged from DSM-IV
Brief psychotic
disorder
<1 month
Schizophreniform
disorder
1-6 months
Duration of disturbance
Schizophrenia
> 6 months
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Schizophrenia: Criteria A
symptoms
Hallucinations
Delusions
At least one of these
symptoms should be present
Disorganized speech
Grossly disorganized or
catatonic behavior
Negative symptoms
At least two symptoms
must be present for the
majority duration
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No more Schizophrenia subtypes
Schizophrenia
No more subtypes
paranoid
disorganized
catatonic
Specifier can be
used
three catatonic
symptoms (out
of 12)
undifferentiat
ed
Residual
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Other Psychotic disorders
 Schizoaffective
disorder:
 Psychosis + Mood symptoms
 Major mood episode should be present for
majority of the disorders total duration after
criteria A(psychotic symptoms) is met.
 Delusional
disorder no longer has the requirement
that the delusions must be nonbizarre
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Psychotic disorders
Part of
Section III
Attenuated Psychosis Syndrome
Schizophrenia
Early intervention improves prognosis in psychotic disorders.
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Bipolar disorder
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Bipolar Disorders
 Changes
in activity & energy as well as mood
needs to be present for a diagnosis of mania or
hypomania.
 NOS
changed to ‘other specified bipolar and
related disorder’
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Mixed features specifier
 Full
criteria for one
mood (depression,
mania or hypomania)
 Have
3 or more
symptoms of the
other mood pole.
 Distractibility,
irritability, insomnia
& indecisiveness are
not included.
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Depressive disorder
 Bereavement
specifier removed from
major depressive episode
 Previously
categorical exclusion 2 months
following bereavement
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Disruptive Mood Dysregulation
Disorder (DMDD)
 Exhibiting
persistent irritability and severe
behavioral outbursts 3 or more times per
week for more than 1 year.
 The
mood in between temper outbursts is
persistently negative (irritable, angry, or
sad), are present in at least 2 settings.
 Onset

of illness has to be before age 10 years
Chronological or developmental age of at least
6 years
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Premenstrual dysphoric disorder
again a mood diagnosis!
• Symptoms are
present in the final
week before onset
of menses
• Improves with
menses
• Minimal in the
week following
menses
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Anxiety disorders DSM changes
 Anxiety
disorders: Agoraphobia, Specific
Phobia, and Social Anxiety Disorder (Social
Phobia)
 Obsessive-Compulsive
and Related
Disorders
 Trauma-
and Stressor-Related Disorders
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Other changes
 Previous
versions: requirement that
individuals over age 18 years recognize
that their anxiety is excessive or
unreasonable
 Anxiety
must be out of proportion to the
actual danger or threat in the situation,
after taking cultural contextual factors into
account
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Panic disorder & Agoraphobia
 Panic
disorder and
agoraphobia are
unlinked in DSM-5.
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New OCD disorders
Trichotillomania
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New disorders -OCD’s
 Hoarding
disorder
 Excoriation
(skin-picking) disorder
 Substance-/medication-induced
obsessive-
compulsive and related disorder
 Obsessive-compulsive
and related disorder
due to another medical condition
 Trichotillomania
(Hair-Pulling
Disorder): From impulse control disorder
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Trauma- and Stressor-Related
Disorders
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Post Traumatic Stress DisorderDSM –IV TR
Trauma
‘reaction with horror, helplessness or fear’
intrusive
recollection
avoidant/numbi
ng
>3 months
chronic
hyper-arousal
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Post Traumatic Stress DisorderDSM –5
Trauma
Is better defined e.g. sexual assault, recurrent
exposure in police officers
‘reaction with horror, helplessness or fear’
Removed
>3 months
chronic
4 symptom clusters
Intrusive
recollection
Avoidance
Numbing
Hyper-arousal
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Trauma- and Stressor-Related
Disorders
 PTSD
will have 2 new sub types
1. PTSD in children less than 6 years
2. PTSD with Prominent dissociative
symptoms
PTSD Debate in the military: Should PTSD be
called Post Traumatic Stress injury?
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Somatic Symptom and Related
Disorders
 Somatic
symptom disorder covers previous
somatization disorder DSM-IV disorder
 DSM-IV
disorder diagnosis required large collection
of symptoms (4 pain, 2 GI, 1 sexual symptoms, 1
pseudo-neurological symptoms)
 DSM-V
diagnosis: Maladaptive thoughts, feelings,
and behaviors are required.
 Illness
Anxiety disorder (Hypochondriasis):high
health anxiety without somatic symptoms
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Feeding & Eating disorders
 Binge
eating disorder: Binging but no
compensatory purging
1.Eat more food in a short period
2. Once a week for 3 months
3. Guilt, embarrassment, or disgust
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Eating disorders
 Anorexia
Nervosa:
 Reduction in energy
intake leading to
significantly low weight
 Fear of gaining weight
 Body Image distortions
 Amenorrhea for 3 months
removed as a criteria
 Bulimia nervosa:
Binge/Purge
behavior once a
week, was twice a
week in DSM-IV
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Substance-Related and Addictive
Disorders
 Gambling
Disorder:
Gambling, activates the
same brain reward
system as other
substance use
disorders.
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Substance Use Disorders
 Not
separate the diagnoses of substance
abuse and dependence
 Cannabis
withdrawal, Caffeine withdrawal
are new
 2-3
criteria: mild, 4-5 :moderate, 6 or more:
severe
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Substance Use Disorder
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Personality disorders
 No
6
major changes
categories were proposed
 Finally
10 categories were retained
 Borderline
personality disorder had the
highest reliability
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Conditions of Further Study
Relevant for younger populations
1.
Attenuated psychosis syndrome
2.
Internet gaming disorder
3.
Neurobehavioral disorder with prenatal
alcohol exposure
4.
Suicidal behavior Disorder
5.
Non suicidal self injury
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References

American Psychiatric Association. Diagnostic and statistical
manual of mental disorders (5th ed.). Arlington, VA: American
Psychiatric Publishing;2013.

American Psychiatric Association. Diagnostic and statistical
manual of mental disorders (4th ed., text rev.). Arlington, VA:
American Psychiatric Publishing; 2000.

http://www.dsm5.org/Documents/PTSD%20Fact%20Sheet.p
df

Stetka BS, Correll, CU. A Guide to DSM-5. Medscape
Psychiatry. May 21, 2013. Retrived: 27th
Marchhttp://www.medscape.com/viewarticle/803884_15
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Images
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Dailymail.co.uk
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www.dutyfreeaddict.com
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www.brightsideofnews.com
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
ww.trekdek.com
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http://www.lastlashblog.com/2010/1
1/friday-eye-day.html
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www.dermatillomaniatreatment.com
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www.trekdek.com
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www.pjvoice.com
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www.uccs.edu -
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http://6foot4.net/articles/2013/03/0
5/utilizing-change/
www.glogster.com
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kidshealth.org
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ssgtleslie.wordpress.com
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ssgtleslie.wordpress.com
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school.discoveryeducation.com
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http://www.koemba.com/forum/stressed-out-with-an-adhd-child-whathelps/#sthash.981eD4Ns.dpuf
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http://emilysrosenlcsw.com/wp-content/uploads/2014/01/Distracted-Studentin-the-Classroom.jpg
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Communication disorders

DSM-5 communication disorders include language disorder
(which combines DSM-IV expressive and mixed receptiveexpressive language disorders):

Speech sound disorder (a new name for phonological
disorder)
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Childhood-onset fluency disorder (a new name for
stuttering)
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Social (pragmatic) communication disorder, a new condition
for persistent difficulties in the social uses of verbal and
nonverbal communication.
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Reactive attachment disorder
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emotionally withdrawn/inhibited and indiscriminately
social/disinhibited.
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In DSM-5, these subtypes are defined as distinct disorders:
reactive attachment disorder & disinhibited social
engagement disorder.

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