DSM-5 NOT WITHOUT CONTROVERSY

Report
NOT WITHOUT
CONTROVERSY
American Psychiatric Association
* DSM-5:
Psychiatry’s Manual of
Disorders and the Issues
Surrounding Its Design and Use
1
An Introduction to DSM-5,Its
Development, Changes, and
Controversies
Researched and Developed by Rhinehart Lintonen
The presentation herein is the intellectual property of Rhinehart Lintonen and does not
reflect the attitudes or positions of the American Psychiatric Association. This
presentation was developed for the use of the membership of the Milwaukee Area
Teachers of Psychology and their students. Any other use should request permission at
[email protected] The intent of this presentation is to delineate the development of
the present DSM and to document changes from DSM-IV-TR. Critiques and
controversies presented are those of the persons or groups cited.
2
* A Short History of the DSM
The Diagnostic and
Statistical Manual of
Mental Disorders
3
*Development of the DSMs
* DSM-5, issued on May 18, 2103, is the culmination of
changes begun in 1999 and intended to replace DSM-IV-TR
which was seen as needing revision due to scientific
discoveries in brain biology and issues surrounding
perceived needed changes in the diagnostic categories
themselves.
* The prior editions stem back to post-World War II when
the Army and Veteran’s Administration were looking for a
way to diagnose what psychiatrically affected returning
troops.
• Thus began DSM-I, published in 1952.
* Other revisions include DSM-II (1968), DSM-III (1980), DSMIIIR (1987), DSM IV (1994) and DSM-IV-TR (2000)
4
*Development of the DSMs
* Along the way, revisions reflected current thinking and
trends in psychiatry
* DSM-1 was largely psychodynamic in nature, reflecting
Freud’s impact on psychiatry
• Disorders referred to as “reactions” under the influence of
Adolf Meyer and also showed the psychoanalytic bent
• Two groups of disorders based on causality
Illustrations: American Psychiatric Assoc.
 Those caused by or associated with brain tissue dysfunction
 Those of “psychogenic” origin not clearly related to structural
changes in the brain
* DSM-II increases number of disorders to 182
• Drops use of “reactions” while still using Freudian
terms such as “neurosis” and “psychosis”
5
*Development of the DSMs
* DSM-III represented a major change in the construction of the
manual with 265 categories of disorders
• Gone was the prior emphasis on psychodynamic views
• Now the emphasis was on empirically-obtained observations
• Coincided with move in US away from psychoanalysis and with
•
•
publics’ skepticism of psychiatry in general
DSM-IIIR influenced by Emil Kraepelin’s insistence on the roles of
biology and genetics in disorders
Task Force Chair Dr. Robert Spitzer suggested there was
a hierarchy of mental illness (Greenberg, 54)
Dr. Allen Frances accords him great respect, saying that
“Without Robert Spitzer, psychiatry might have become
increasingly irrelevant” and that “Spitzer had laid the
foundations for the psychiatric research enterprise.” (Frances, 62-
New York Times
•
APA
63)
• High praise for the man who guided the DSMs into a new
direction
6
American Psychiatric Assoc.
*Development of the DSMs
* DSM-IV was not much of a sea-change from DSM-III
• The number of disorders were now over 300
• Allen Frances, MD chaired the task force and insisted
that the manual was not to be taken as a “Bible” of mental
illnesses
• All changes had to be science-driven and evidence-based and
needed to have checks and balances which would protect
against bias and individual’s pet ideas (Frances, xiii)
• One of his regrets is that “Even though we had been boringly
modest in our goals, obsessively meticulous in our methods,
and rigidly conservative in our product, we failed to predict
or prevent three new false epidemics of mental disorder in
children – autism, attention-deficit, and childhood bipolar
disorder.” (Frances, xiv)
Photo: healthcareblog.com
7
*Development of DSM-5
* DSM-IV-TR (2000) was an update to DSM-IV, not in the
categories of disorders but in two main areas:
• Prevalence
• Familial patterns
* These were updated to reflect new scientific knowledge
regarding genetics and other neuroscientific advances
What you’ve been
teaching from all this
time! Get ready to
change what you
knew!
American Psychiatric Assoc.
8
*Development of DSM-5
* Beginning in 1999, there were specific calls for changes to
DSM-IV-TR including:
•In two decades, much new info on disorders had emerged
•Biological psychiatry and neuroscience were being embraced
with great enthusiasm
 Prominent neuroscientists like Eric Kandel were proclaiming that
“all mental disorders involve disorders of brain function.”
(Greenberg, 61)
 New drugs seemed to ease burden of psychological disorders
o Think serotonin imbalances being eased by SSRI antidepressants
(which later proved to be a false hypothesis)
• Genetics research had added new knowledge of the possible
sources of disturbances
• Need for a more defined nosology (classification system)
• A hoped-for “paradigm shift” to recreate that nosology
9
*How Was DSM-5 Created?
* New edition preceded by 13 scientific conferences and a
number of white papers, monographs, and journal articles
researching and evaluating new nosologies
www.psychiatry.pitt.edu
under Chairman David Kupfer, MD and Vice-Chairman
Darrel Regier, MD
Kupfer
American Psychiatric Assoc.
* APA set up the DSM-5 Task Force of 27 members in 2007
Regier
* 160 researchers and clinicians formed the Work Groups
and Study Groups to develop the new manual, revising or
tweaking criteria from the DSM-IV-TR and deleting or
adding diagnostic classifications
10
*How Was DSM-5 Created?
* The new task force stated in its goals that
• “The previous version of DSM was completed nearly two
decades ago; since that time, there has been a wealth of new
research and knowledge about mental disorders.” (APA)
* Therefore, the APA set about to use this evidence to
determine whether certain diagnoses (a very hotly debated
term) should be removed or changed
* Additionally, the APA felt that they needed to better define
the disorders by symptoms and behaviors than DSM-IV did
* This would allow for future revision processes to be more
responsive through incremental updates (DSM-5.0, 5.1,
etc.) as new scientific breakthroughs became available
11
*How Was DSM-5 Created?
* Changes like this are costly
• DSM-5 cost between $20-25 million to produce
* However, the DSM is a cash cow for the APA!
• It is the sole agency producing such a product except for the
ICD-10
• The greatest percentage of the income of the APA comes from
its publishing arm
* Since it brings in so much income, the DSM is critically
important to the APA
* There are calls for a more open, diversified medical
organization to be created to write a new manual with
more inputs and better designed to help the practice of
psychiatry rather than simply refine the nosology (also
important)
12
* The
New DSM-5
Change is Good
(Maybe)
13
* The old structure is gone
Illus.: gracebooks.org
*Basic Changes
• No more Five Axes
 These were seen as incompatible with ICD-10 and other medical
diagnostic systems
o Replaced with a 0 to 4 point severity ratings scale for each diagnosis
• No more assessment of global relative functioning according to a
scale (GARF)
* The term “general medical condition” has been replaced with
“another medical condition”
* Asperger Syndrome is no longer a discrete classification
• Now merged into Autism Spectrum Disorder
* Subtypes for Schizophrenia are gone
• This was done because of low reliability, poor validity, and
because of limited diagnostic stability (APA)
* NOS categories (not otherwise specified) are now “other specified
disorder” and “unspecified disorder”
14
*Basic Changes
* Structure of the Manual
• Preface
• DSM-5 Classification and Coding
• Section I
 Use of the Manual
 Cautionary Statement for Forensic Use of DSM-5
• Section II
 Disorders listed among 22 major categories
15
*Basic Changes
* Gone is the category “Disorders Usually First Diagnosed in
Infancy, Childhood, or Adolescence”
• These are now found under other appropriate headings
* Other changes pertinent to each category will be discussed
in the following section “The New DSM-5: Disorders”
For a complete discussion of in-depth changes in each diagnostic
category, go to:
http://www.ldaofky.org/changes-from-dsm-ivtr--to-dsm-5%5B1%5D.pdf
16
* The
New DSM-5
The Controversies
17
news.bbc.co.uk
DSM Under Fire
* The new DSM has been under fire almost from the beginning
• Initial complaints involved failure to supply minutes of
committee meetings and questions about transparency
* As time progressed, the questions and criticisms grew
• Two camps essentially:
 The American Psychological Association with David Kupfer and
Darrel Regier defending their work
 Former DSM-III and DSM-IV task force leaders Robert Spitzer and
Allen Frances
* This brought about what became high drama never before
seen at this level of medical/scientific process
* The availability of the Internet allowed the criticism to
reach unheard of numbers of therapists and professionals
able to comment on the proceedings
18
The Charges
* The Spitzer/Francis camp charged:
• The manual was being drawn up in secrecy
• Transparency was not being allowed
• The Task Force members had to sign confidentiality agreements
which limited their open discussion about the proceedings
• DSM not etiologically based and adding things which were not
disorders
• Continued emphasis on Asperger’s, ADHD, and Childhood
Bipolar Disorder (what Frances called “false epidemics”) would
lead to diagnostic inflation (Francis, 77-86)
• DSM-5 was leading to the “medicalization of normalcy” (Frances
and Widiger, 123)
• Too many psychiatrists on the development committees had
ties to Big Pharma and were thus in danger of being influenced
in their decisions (Frances, 75)
19
The Charges
* The Spitzer/Francis camp charged:
• Field Trials were improperly vetted and hastily drawn up and
weren’t adequately presented for review
 The trials failed spectacularly in some areas with very low kappa scores
o On a 0 to 1 scale, depression had a low 0.28; Mixed Anxiety-Depressive
Disorder at -0.004 (Freedman, et.al.)
• The APA was in too much of a hurry to bring the manual to market
• APA’s financial vesting in the book meant that the organization
needed to bring it to market quickly to continue the flow of sales
• Behind it all, Frances charged that there were a number of
conceptual issues:
 “an elusive definition of mental disorder, the limits of neuroscience,
the limits of descriptive psychiatry, an unclear epistemology, the
absence of a unified theoretical model, pragmatism, and fads.”
(Frances and Widiger, 109-110)
20
The Charges
* Frances admits that “Psychiatric classification is necessarily
a sloppy business.” (Frances and Widiger, 114) and that “the only
way to define a mental disorder is ‘that which clinicians
treat; researchers research; educators teach; and insurance
companies pay for.’” (Frances, 18)
* Frances warns that DSM-IV had some unintended
consequences being heightened by DSM-5 (Frances and Widiger,
115)
• Four fads creating diagnostic inflation
 autism
 attention deficit
 childhood bipolar disorder
 paraphilia not otherwise specified
21
The Charges
* Additional critiques from Frances and others
• APA was trying to create a paradigm shift in psychiatric
diagnosis which is, at present, unrealizable
• New category of Mood Dysregulation Disorder will create a
mental disorder out of temper tantrums
• Normal grief is being medicalized
• Everyday characteristics of old age will be misdiagnosed as
cognitive disorders
• ADHD will lead to more adults being diagnosed in a fit of
diagnostic inflation
• Excessive eating is now a disorder, not just plain gluttony
• Problems in everyday living will be elevated to General Anxiety
Disorder
• Behavioral addictions can apply to anything one does often
enough
22
The Charges
* And the list goes on
• Just exactly what is a mental disorder, anyway?
 Are they simply problems in living as Thomas Szasz claimed?
• Will we stigmatize too many people?
• Will all of this encourage Big Pharma to find a drug for
everything?
 Many psychiatric drugs don’t work nearly as well as patient think
anyway
* At least a number of proposed “disorders” didn’t make it
• E,g., Hypersexual Disorder
 How much sex is too much?
 Is it possible to be mentally ill because of a desire for sex?
23
Anything Positive in DSM-5?
* Is it all for naught?
Does DSM-5 or any other manual have
any redeeming value?
* The APA said it “would work to overcome one of the
clearest limitations of our current diagnostic criteria…the
lack of quantitative measures.” (Greenberg, 175)
• Frances counters that we “still do not have a single laboratory
test in psychiatry.” (Frances, 10)
• However, the APA did adhere to attempting to validate all
disorders through empirical evidence from clinical practice and
an exhaustive search of the literature
* So, at the end of the day, even Spitzer and Frances admit
that, while it isn’t a “bible,” the DSM is still the best thing
we have to guide us until something better comes along
24
Anything Positive in DSM-5?
*DSM-5 has many supporters among clinicians and
therapists
*It is considered robust compared to the ICD-10 or any
other attempt to create a different manual
*Perhaps therapists are best reminded that it is just a
guide, it needs to be used judiciously, and the most
apt advice may be that of the British Psychological
Society which admonishes therapists to treat the
person first, not the disease
25
Other Methodologies
*Other methodologies are in the works
• Creating categories of disorders based on brain
biology and neuroscience
• Diagnosing disorders based on measuring the
psychological dimensions of personality
• Using a system of “stepped diagnosis” (Frances, 222)
 A form of watchful waiting emphasizing normalizing
problems and using minimal interventions until arriving at a
definitive diagnosis and treatment plan
26
Another Possible System
*The National Institute of Mental Health (NIMH) has
an initiative known as Research Domain Criteria
(RDoC)
• The system would assess
 Negative Valence Systems
o Threat, fear of loss, frustration
 Positive Valence Systems
o Motivation, learning, and habit
 Cognitive Systems
o Attention, perception, and Memory
 Social Process Systems
o facial expression identification, imitation, attachment/separation fear
 Arousal/Regulatory Processes
o Stress regulation
• These would be analyzed in terms of genes, molecules, and
cells (Greenburg, 339-342)
27
* The
New DSM-5
Diagnostic Criteria
Disorders
28
Neurodevelopmental
Disorders
Conditions which begin in early
development and which cause significant
functional impairment
29
*Neurodevelopmental
Disorders
* Mental Retardation now called “intellectual disability”
* Language disorders/stuttering now called “communication
disorders”
• Intellectual Disabilities
• Communication Disorders
• Autism Spectrum Disorder
• Attention-Deficit-Hyperactivity Disorder
• Specific Learning Disorder
• Motor Disorders
• Tic Disorders
www.dsrf.com
* Subcategories
30
Schizophrenia Spectrum and
Other Psychotic Disorders
A group of disorders which is
characterized by major disturbances in
such areas as thought, language,
perceptions, emotion, and behavior and
which make it difficult to separate
reality from fantasy
31
*Schizophrenia Spectrum and
Other Psychotic Disorders
* All subtypes deleted
•
Former subtypes are now diagnostic symptoms
•
•
•
•
•
•
•
•
•
•
•
Schizotypal (Personality) Disorder
Delusional Disorder
Brief Psychotic Disorder
Schizophreniform Disorder
Schizophrenia
Schizoaffective Disorder
Substance/Medication-Induced Psychotic Disorder
Psychotic Disorder Due to Another Medical Condition
Catatonia
Other Specified Schizophrenia Spectrum and Other Psychotic Disorder
Unspecified Schizophrenia Spectrum and Other Psychotic Disorder
 Paranoid, disorganized, etc.
* Subcategories
32
Bipolar and Related Disorders
Disorders which are marked by major
mood changes, alternating from manic to
depressive and which can exhibit
psychotic experiences – the reason they
are located between Schizophrenia and
Depressive Disorders in DSM-5
33
*Bipolar and Related Disorders
* Separated from Mood Disorders (category no longer exists)
* A new specifier (“with mixed features” has been added for
each subcategory
* Anxiety symptoms are a specifier, although not part of the
diagnostic criteria (in many of the categories such specifiers
may now exist without being a diagnostic necessity)
* Subcategories
• Bipolar I Disorder
• Bipolar II Disorder
• Cyclothymic Disorder
• Substance/Medication-Induced Bipolar and Related Disorder
• Other Specified Bipolar and Related Disorder
• Unspecified Bipolar and Related Disorder
34
Depressive Disorders
Conditions in which the person feels in an
extremely depressed mood for persistent
periods of time, often without any letup
or recurring in cycles
35
*Depressive Disorders
* Replaces Mood Disorders Category for depressions
* Specifiers have been added for mixed symptoms and also for anxiety
* Most controversial: bereavement exclusion
•
•
Was excluded in DSM-IV-TR, now included
At what point should we medicalize normal grieving?
•
•
DMDD: Disruptive Mood Dysregulation Disorder
Also controversial


Now medicalizing temper tantrums?
Premenstrual Dysphoric Disorder now a subcategory
* Subcategories
•
•
•
•
•
•
•
•
Disruptive Mood Dysregulation Disorder
Major Depressive Disorder
Persistent Depressive Disorder (Dysthymia)
Premenstrual Dysphoric Disorder
Substance/Medication-Induced Depressive Disorder
Depressive Disorder Due to Another Medical Condition
Other Specified Depressive Disorder
Unspecified Depressive Disorder
www.healthclinicsource.com
* For children up to 18 a new category added
36
Anxiety Disorders
Disorders which are marked by extreme
conditions of fear or uneasiness that
impair one’s basic functioning and which
may or may not appear to have a cause
according to the sufferer
37
*Anxiety Disorders
* Panic Attack has become a specifier for all DSM-5 disorders
* Panic Attack and Agoraphobia are no longer necessarily associated
* Specific types of Phobia have become specifiers
* No longer requires patient/client to recognize that their fear(s) are
excessive or unreasonable
* Duration now must be 6 months
* Separation Anxiety Disorder and Selective Mutism have been moved
here from Early Onset Disorders
* Subcategories
•
•
•
•
•
•
•
•
•
Separation Anxiety Disorder
Selective Mutism Disorder
Specific Phobia
Social Anxiety Disorder (formerly Social Phobia)
Panic Disorder
Agoraphobia
Generalized Anxiety Disorder
Substance/Medication-Induced Anxiety Disorder
Anxiety Disorder Due to Another Medical Condition
38
*Anxiety Disorders
* Subcategories (con’t.)
www.suzannesutton.com
• Other Specified Anxiety Disorder
• Unspecified Anxiety Disorder
39
Obsessive-Compulsive and
Related Disorders
Conditions which arise in response to
some sort of traumatic event or severe
stress; characteristic of not only soldiers,
but many public safety workers and
anyone, including children, who
experience major shock
40
*Obsessive-Compulsive and
Related Disorders
* Four new disorders
• Excoriation Disorder (skin-picking)
• Hoarding Disorder (won’t the TV reality shows delight in this!)
• Substance/Medication-Induced Obsessive-Compulsive and Related
•
Disorder
Obsessive-Compulsive and Related Disorder Due to Another
Medical Condition
* Body Dysmorphic Disorder (BDD) adds criteria dealing with
repetitive behaviors and mental acts “which may arise with
perceived defects or flaws in physical appearance” (APA)
• Specifiers have been added for
•
“with good or fair insight,” “with
poor insight,” or “with absent insight-delusional beliefs”
These also appear for Obsessive-Compulsive Disorder and Hoarding
Disorder
* Trichotillomania (hair-pulling) has moved here from ImpulseControl Disorders
41
*Obsessive-Compulsive and
Related Disorders
• Obsessive-Compulsive Disorder
• Body Dysmorphic Disorder
• Hoarding Disorder
• Trichotillomania
• Excoriation Disorder
• Substance/Medication-Induced Obsessive-Compulsive
www.wedpages.scu.edu
* Subcategories
and
Related Disorder
• Obsessive-Compulsive and Related Disorder Due to Another
Medical Condition
• Other Specified Obsessive-Compulsive and Related Disorder
• Unspecified Obsessive-Compulsive and Related Disorder
42
Trauma- and Stressor-Related
Disorders
Conditions in which the person
experiences periods of obsessive thoughts
often followed by compulsive behavior in
response to that thinking; obsessions
(thoughts) and compulsions (actions) can
occur separately
43
*Trauma -and Stressor-Related
Disorders
* Now includes PTSD which was an anxiety disorder in DSM-IV-TR
• Anxiety still an important symptom but not all sufferers will
•
experience fear and anxiety
Symptom clusters now include negative alterations in cognition
and mood
 E.g., negative thoughts abut oneself, outbursts of anger, selfdestructive behavior, etc.
* Separate criteria for children 6 and under
* Specifiers modified to some extent to reflect emotional reaction
training of soldiers, police, emergency personnel
* Two new disorders
• Reactive Attachment Disorder
• Disinhibited Social Engagement Disorder
* Adjustment Disorders moved here as Stress-Response Syndromes
44
*Trauma -and Stressor-Related
* Subcategories
• Reactive Attachment Disorder
• Disinhibited Social Engagement Disorder
www.knottiesniche.com
Disorders
 Child approaching and interacting with strange adult
• Posttraumatic Stress Disorder
• Acute Stress Disorder
• Adjustment Disorders
• Other Specified Trauma –and Stressor-Related Disorder
• Unspecified Trauma –and Stressor-Related Disorder
45
Dissociative Disorders
Disruptions of cognitive functioning in
which identity, consciousness, and
memory can be impaired causing the
person to experience confusion and
discontinuity
46
*Dissociative Disorders
* Dissociative Fugue no longer a separate condition
• Now a specifier for Dissociative Amnesia
* Depersonalization Disorder renamed
Depersonalization/Derealization Disorder
* Diagnosis for Dissociative Identity Disorder may include culturallyspecific experiences of pathological possession
• Also, identity transitions may be observed by others as well as
•
self-reported
Now takes into account the nature and course of identity
disruptions
• Dissociative Identity Disorder
• Dissociative Amnesia
• Depersonalization/Derealization Disorder
• Other Specified Dissociative Disorder
• Unspecified Dissociative Disorder
en.wikipedia.org
* Subcategories
Really?
47
Somatic Symptom and Related
Disorders
Bodily symptoms (such as loss of function
or pain) experienced as a result of
extreme stress; formerly called
“psychosomatic” symptoms
48
*Somatic Symptom and
Related Disorders
* Previously called Somatoform Disorders
* Due to overlap and lack of clarity, these diagnoses
have been eliminated
•
•
Somatization Disorder
Hypochondriasis
•
Pain Disorder
•
 Considered a pejorative term
 Some pain can be medical and there is a lack of validity and reliability in the
distinctions
Undifferentiated Somatoform Disorder
* Somatic Symptom Disorder is defined by positive symptoms
* Psychological Factors Affecting Other Medical Conditions is a new
disorder
* Subcategories
•
•
Somatic Symptom Disorder
Illness Anxiety Disorder
49
*Somatic Symptom and
Related Disorders
* Subcategories (con’t.)
• Conversion Disorder
 Also known as Functional Neurological Symptom Disorder
• Psychological Factors Affecting Other Medical Conditions
• Factitious Disorder
• Other Specified Somatic Symptom and Related Disorder
• Unspecified Somatic Symptom and Related Disorder
50
Feeding and Eating Disorders
Difficulties with eating that often reflect
psychological stressors and interpersonal
reactions; cause difficulties with personal
imagery and health
51
*Feeding And Eating Disorders
* Eating disorders from infancy and early childhood moved
here
* Pica and Rumination Disorder can occur at any age
* Feeding Disorder of Infancy or Early Childhood now known
as Avoidant/Restrictive Food Intake Disorder
* Anorexia Nervosa no longer requires diagnosis of
amenorrhea
* Bulimia Nervosa changed required minimum frequency from
twice to once weekly
* Binge Eating Disorder moved up from DSM-IV-TR’s “Further
Study” to full disorder
* Subcategories
• Pica
• Rumination Disorder
52
*Feeding And Eating Disorders
* Subcategories (con’t.)
53
blog.lib.umn.edu
• Avoidant/Restrictive Food Intake Disorder
• Anorexia Nervosa
• Bulimia Nervosa
• Binge Eating Disorder
• Other Specified Feeding or Eating Disorder
• Unspecified Feeding or Eating disorder
Elimination Disorders
Conditions which involve improper
elimination of bodily substances (urine or
feces) most often associated with
problems in growth phases and occurring
during sleep
54
*Elimination Disorders
* No significant changes from DSM-IV-TR
* Previously classified as “Disorders Usually First Diagnosed in
Infancy, Childhood, or Adolescence”
* Subcategories
• Enuresis
55
Sleep-Wake Disorders
Disruptions of the normal circadian
rhythm of sleep or of wakefulness which
lead to inability to fall asleep or stay
asleep or to remain awake
56
*Sleep-Wake Disorders
* “Sleep Disorders Related to Another Mental Disorder” and “Sleep
Disorders Related to a General Medical Condition” have been
removed
• Acknowledges bidirectional and interactive effects between
existing medical and mental disorders
* Primary and Secondary Insomnia have become Insomnia Disorder
* Narcolepsy separated from Hypersomnolence
• No known to be caused by hypocretin deficiency
* Breathing-Related Sleep Disorders know separated into 3 distinct
categories
* Circadian-Rhythm Sleep-Wake Disorders now include 3 distinct
subtypes
* Jet Lag subtype has been removed
* Rapid Eye Movement Sleep Behavior Disorder and Restless Legs
Syndrome moved from “NOS” to independent status
57
*Sleep-Wake Disorders
• Insomnia Disorder
• Hypersomnolence Disorder
• Narcolepsy
• Breathing-Related Sleep Disorder
 Obstructive Sleep Apnea Hypopnea
 Central Sleep Apnea
 Sleep-Related Hypoventilation
www.worldnewshut.com
* Subcategories
• Circadian Rhythm Sleep-Wake Disorders
• Parasomnias
 Non-Rapid Eye Movement Sleep Arousal Disorders
 Nightmare Disorder
 Rapid Eye Movement Sleep Behavior Disorder
 Restless Legs Syndrome
 Substance/Medication-Induced Sleep Disorder
• Other Specified and Unspecified
58
Sexual Dysfunctions
Problems of sexuality which may involve
difficulties initiating or maintaining
intercourse and often related to stress
and psychological difficulties
59
*Sexual Dysfunctions
* Gender-specific sexual dysfunctions added
* Female sexual desire and arousal disorders combined into
one category: Female Sexual Interest/Arousal Disorder
* All sexual dysfunctions now require minimum duration of
approximately 6 months and more precise severity criteria
* Sexual Aversion Disorder deleted
* New disorder
• Genito-Pelvic Pain/Penetration Disorder
 Combines Vaginismus and Dyspareunia from DSM-IV-TR
* Eliminated disorders
• Sexual Dysfunction Due to a General Medical Condition
• Sexual Dysfunction Due to Psychological Versus Combined
Factors
60
*Sexual Dysfunctions
* Subtypes changed
• Lifelong versus Acquired and Generalized versus Situational
•
remain
Due to Psychological Factors versus Due to Combined Factors
deleted
* Subcategories
• Delayed Ejaculation
• Erectile Disorder
• Female Orgasmic Disorder
• Female Sexual Interest/Arousal Disorder
• Genito-Pelvic Pain/Penetration Disorder
• Male Hypoactive Sexual Desire Disorder
• Premature (Early) Ejaculation
• Substance/Medication-Induced Sexual Dysfunction
• Other Specified Sexual Dysfunction
• Unspecified Sexual Dysfunction
61
Gender Dysphoria
Difficulties with determining and
maintaining a sexual identity where the
individual feels an incongruence between
what they are and what they feel they
were meant to be
62
*Gender Dysphoria
* New diagnostic class
• Emphasizes incongruity
rather than cross-gender identification
as such
* Separate criteria for children, adolescent, and adults
* Separates Sexual Dysfunctions from Gender Identity
* Recognizes that gender dysphoria is a condition mostly
identified and treated by mental health care providers
except for endocrine and surgical procedures
* In children, “strong desire to be of the other gender”
replaces repeatedly stated desire”
* Subtype based on sexual orientation removed
• Not considered useful clinically
* Name was changed to “Dysphoria” because term “disorder”
was pejorative
63
*Gender Dysphoria
* Subcategories
• Gender Dysphoria
• Other Specified Gender Dysphoria
• Unspecified Gender Dysphoria
64
Disruptive, Impulse-Control,
and Conduct Disorders
Problems with controlling emotions in
personal and social situations, marked by
extreme anger, explosive behaviors, or
lack of affect and sense of responsibility
65
*Disruptive, Impulse-Control,
and Conduct Disorders
* New diagnostic class
• Combines disorders from “Disorders Usually First Diagnosed in
Infancy, Childhood, and Adolescence”
* Intermittent Explosive Disorder, Pyromania, and
Kleptomania also moved into this category
* Antisocial Personality Disorder also included in Personality
Disorders category
* Symptom types for Oppositional Defiant Disorder
• Angry/Irritable Mood
• Argumentative/Defiant Behavior
• Vindictiveness
• Exclusion criterion for Conduct Disorder removed
66
*Disruptive, Impulse-Control,
and Conduct Disorders
* Oppositional Defiant Disorder (con’t.)
• Since behavior is “normal” process of growing up, severity
rating scales and guidance on frequency typically needed to be
considered symptomatic have been added
* Conduct Disorder adds “limited prosocial emotion” specifier
* Intermittent Explosive Disorder adds verbal aggression and
non-destructive/noninjurious physical aggression to DSMIV’s physical aggression
• Also, specifiers were added for
 Impulsive and/or anger based in nature
 Must cause marked distress
 Causes impairment in occupational or interpersonal functioning
 Associated with legal or financial consequences
67
*Disruptive, Impulse-Control,
and Conduct Disorders
• Oppositional Defiant Disorder
• Intermittent Explosive Disorder
• Conduct Disorder
• Antisocial Personality Disorder
• Pyromania
• Kleptomania
• Other Specified Disruptive, Impulse-Control, and Conduct
www.parentingteens.about.com
* Subcategories
Disorder
• Unspecified Disruptive, Impulse-Control, and Conduct Disorder
68
Substance-Related and
Addictive Disorders
Problems with controlling emotions in
personal and social situations, marked by
extreme anger, explosive behaviors, or
lack of affect and sense of responsibility
69
*Substance-Related and
* New categories
• Gambling Disorder
www.omicsgroup.co.in
Addictive Disorders
 Added because of evidence that some behaviors activate the brain’s
reward system with similar effects as those obtained from drugs
• Tobacco Use Disorder
* Diagnoses of substance abuse and dependence are not separated
as in DSM-IV-TR
* Criteria were changed to reflect relevance of
• Intoxication
• Withdrawal
• Substance/Medication-Induced Disorders
• Unspecified Substance-Induced Disorders
• Craving or strong desire or urge to use a substance
* Caffeine and cannabis withdrawal are new criteria
70
*Substance-Related and
Addictive Disorders
* Subcategories
 Substance Use Disorders
 Substance-Induced Disorders
• Alcohol-Related Disorders
 Alcohol Use Disorder
 Alcohol Intoxication
 Alcohol Withdrawal
blogs.tekegraph.co.uk
• Substance-Related Disorders
• Unspecified Alcohol-Related Disorder
• Caffeine Intoxication
• Caffeine Withdrawal
• Unspecified Caffeine-Related Disorder
• Cannabis-Related Disorder
 Cannabis Use Disorder
 Cannabis Intoxication
71
*Substance-Related and
Addictive Disorders
* Subcategories (con’t.)
 Cannabis Withdrawal
 Other Cannabis-Induced Disorders
• Hallucinogen-Related Disorders
 Phencyclidine Use Disorder
 Other Hallucinogen Use Disorder
 Phencyclidine Intoxication
 Other Hallucinogen Intoxication
 Hallucinogen Persisting Perception Disorder
 Other Phencyclidine-Induced Disorders
 Other Hallucinogen-Induced Disorders
 Unspecified Phencyclidine-Induced Disorders
 Unspecified Hallucinogen-Induced Disorders
72
*Substance-Related and
•
Inhalant-Related Disorders
 Inhalant Use Disorders
 Inhalant Intoxication
 Other Inhalant-Induced Disorders
•
Opioid-Related Disorders
 Opioid Use Disorder
 Opioid Intoxication
 Opioid Withdrawal
 Other Opioid-Induced Disorders
•
www.freud-sigmund.com
* Subcategories (con’t.)
www.drugaware.weebly.com
Addictive Disorders
Sedative-, Hypnotic-, or Anxiolytic-Related Disorders
 Sedative, Hypnotic, or Anxiolytic Use Disorder
 Sedative, Hypnotic, or Anxiolytic Intoxication
 Other Sedative-, Hypnotic-, or Anxiolytic-Use Disorders
•
Stimulant-Related Disorders
 Stimulant Use Disorder
73
*Substance-Related and
Addictive Disorders
• Tobacco-Related Disorders
 Tobacco Use Disorder
 Tobacco Withdrawal
 Other Tobacco-Induced Disorders
• Other (or Unknown) Substance-Related Disorders
• Other (or Unknown) Substance-Induced
• Non-Substance Related
 Gambling Disorder
en.wikipedia.org
 Stimulant Intoxication
 Stimulant Withdrawal
 Other Stimulant Use Disorders
www.healtham.com
* Subcategories (con’t.)
74
Neurocognitive Disorders
Disorders of thought caused by organic
conditions (e.g., Alzhemier’s) or inorganic
conditions (e.g., traumatic brain injury)
which can impair memory, judgment,
decision-making, and identification of
people and objects
75
*Neurocognitive Disorders
* Criteria for Delirium have been updated based on current
neuroscience
* Dementia and Amnestic Disorder have been changed to Major
Neurocognitive Disorder
•
The term “dementia” may still be used in etiological subtypes
•
Allows for diagnosis of less-disabling syndromes which still are of concern
* Mild Neurocognitive Disorder (Mild NCD) is a new subcategory
* Major or Minor Vascular NCD and Major or Mild NCD Due to
Alzheimer’s is retained
* Separate criteria for Major or Mild NCD due to:
•
•
•
•
•
•
•
•
Frontotemporal NCD
Lewy Bodies
Traumatic Brain Injury (TBI)
Parkinson’s Disease
HIV Infection
Huntington’s Disease
Prior Disease
Other medical Conditions or Multiple Etiologies
76
*Neurocognitive Disorders
•
Delirium
•
Major and Mild Neurocognitive Disorders
 Other Specified Delirium
 Unspecified Delirium
 Major Neurocognitive Disorder
o See subtypes of previous slide
www.silverliving.com
* Subcategories
 Mild Neurocognitive Disorder
 Major or Minor Neurocognitive Disorder Due to Alzheimer’s Disease
 Major or Mild Frontotemporal Neurocognitive Disorder
o With Lewy Bodies
o Vascular
o Due to Traumatic Brian Injury
o Substance/Medication-Induced Major or Mild Neurocognitive Disorder
o Due to HIV Infection
o Due to Prion Disease
o Due to Parkinson’s Disease
o Due to Huntington’s Disease
o Due to Another Medical Condition
o Due to Multiple Etiologies
 Unspecified Neurocognitive Disorder
77
Personality Disorders
Enduring traits and patterns of behavior
which cause impairment in interpersonal
relations and societal functioning leading
to significant life challenges
78
*Personality Disorders
* Criteria have not changed from DSM-IV-TR
* A possible alternative approach for diagnosing personality disorders is in Section III
* Subcategories
•
•
•
General Personality Disorder
Cluster A Personality Disorders



Paranoid Personality Disorder
Schizoid Personality Disorder
Schizotypal Personality Disorder
Cluster B Personality Disorders




Antisocial Personality Disorder
Borderline Personality Disorder
Histrionic Personality Disorder
Narcissistic Personality Disorder
Cluster C Personality Disorders



wellingtongoose.tumblr.com
•
•
Avoidant Personality Disorder
Dependent Personality Disorder
Obsessive-Compulsive Personality Disorder
Other Personality Disorders



Personality Change Due to Another Medical Condition
Other Specified Personality Disorder
Unspecified Personality Disorder
79
Paraphilic Disorders
Disorders of sexual appropriatness which
cause one to deviate from the norms
regarding sexual activity
80
*Paraphilic Disorders
* Greatest change:
• Added specifiers for “in a controlled environment” and “in
remission” to indicate changes in an individual’s status
 No consensus whether a long-standing paraphilia can remit
* Change in diagnostic names:
• Distinguishes between a “paraphilic behavior” and “paraphilic
disorder”
 Paraphilia is a necessary but insufficient condition for having a
paraphilic disorder
o Paraphilia by itself is not considered automatically justifying or requiring
there be a clinical; intervention
 Paraphilic Disorder is a paraphilia that is causing impairment or distress
to the individual or which causes personal harm to others if acted upon
* Otherwise same structure is maintained from DSM-III-R
* Person must meet both Criterion A and Criterion B symptoms for
each disorder otherwise no paraphilia exists
81
*Paraphilic Disorders
* Subtypes
• Voyeuristic Disorder
• Exhibitionistic Disorder
• Frotteuristic Disorder
• Sexual Masochism Disorder
• Sexual Sadism Disorder
• Pedophilic Disorder
• Fetishistic Disorder
• Transvestic Disorder
• Other Specified Paraphilic Disorder
• Unspecified Paraphilic Disorder
82
Other Disorders
A category for disorders which do not
conveniently fit into any of the main
categories but which, nonetheless, cause
significant distress or impairment to the
individual
83
* Other Mental Disorders
* This category refers to symptoms which present due to another
medical condition but do not meet the full criteria necessary to
be considered a full disorder
* Medication-Induced Movement Disorders
and Other Adverse Effects of Medication
• Examples:
 Medication-Induced Parkinsonism
 Medication-Induced Acute Dystonia
 Medication-Induced Acute Akathisia
 Tardive Dyskinesia, Dystonia, or Akathisia
 Medication-Induced Postural Tremor
84
* Other Conditions That May Be the Focus of
Clinical Attention
*Examples:
• Problems Related to Family Upbringing
• Other Problems Related to Primary Support Group
• Child Maltreatment and Neglect Problems
• Adult Maltreatment and Neglect Problems
• Educational or Occupational Problems
• Housing and Economic Problems
• Other Problems Related to the Social Environment
• Problems Related to Crime or Interaction with the Legal System
• Other Health Service Encounters for Counseling and Medical
Advice
• Problems Related to Other Psychosocial, Personal, and
Environmental Circumstances
• Other Circumstances of Personal History
85
* Section III
* Section III has several divisions which address emerging scientific
evidence and data from clinical experiences that could be of use
to the therapist
* These divisions include:
•
Valuable Clinical Tools
•
Accounting for Culture
•
Another Model for Personality Disorders
 Assessment tools of use in the diagnostic process
 Cultural formulation interview guide
•
•
•
A ‘hybrid dimensional-categorical model” (APA) which emerged during debates on
the Personality Disorders category
Suggests using five broad areas of pathological personality traits, coming up with
six personality disorder types
o Borderline Personality Disorder
o Obsessive-Compulsive Personality Disorder
o Avoidant Personality Disorder
o Schizotypal Personality Disorder
o Antisocial Personality Disorder
o Narcissistic Personality Disorder
The model seeks to discover impairments in functioning and is included to
prompt further research
86
* Section III
*Conditions for Further Study
• Disorders judged to need further research before being
included as full disorders
 Attenuated Psychosis Syndrome
oPerson has minor versions of symptoms of psychotic
disorder
 Depressive Episodes With Short-Duration Hypomania
 Persistent Complex Bereavement Disorder
 Caffeine Use Disorder
 Internet Gaming Disorder
 Neurobehavior Disorder Due to Prenatal Alcohol Exposure
 Suicidal Behavior Disorder
 Nonsuicidal Self-Injury
87
*
A history of the DSM-V controversy. Retrieved from
http://www.psychologytoday.com/blog/dsm5-in-distress/201006/historythe-dsm5-controversy
A moment of crisis in the history of American psychiatry. Retrieved from
http://historypsychiatry.com/2010/04/27/a-moment-of-crisis-in-the-historyof-american-psychiatry/
American Psychiatric Association. (2013). Highlights of changes from DSM-IV to
DSM-5. Retrieved from
http://www.dsm5.org/Documents/changes%20from%20dsm-ivtr%20to%20dsm-5.pdf
Controversy over DSM-5: New mental health guide. Retrieved from
http://www.ncbi.nlm.nih.gov/pubmedhealth/behindtheheadlines/news/201
3-08-15-controversy-over-dsm-5-new-mental-health-guide/
Desk reference to the diagnostic criteria from DSM-5. (2013). Washington, DC:
The American Psychiatric Association.
DSM-5: A ruse by another other name. Retrieved from
http://blogs.discovermagazine.com/neuroskeptic/2013/01/13/dsm-5-a-ruseby-any-other-name/#.USyiSDcSHTo
DSM-5 is guide not Bible – Ignore its ten worst changes. Retrieved from
http://www.psychologytoday.com/blog/dsm5-in-distress/201212/dsm-5-isguide-not-bible-ignore-its-ten-worst-changes
88
Frances, A. (2013). Saving normal. New York: William Morrow.
Francis, A. and Widiger, T. (2012, September 4).Psychiatric diagnosis: Lessons
from the DSM-IV past and cautions from the DSM-5 future. Annual Review of
Of Clinical Psychology, 8: 109-130. Retrieved from
http://psych.colorado.edu/~willcutt/pdfs/Frances_2012.pdf
Freedman, R. et. al. (2013) The initial field trials of DSM-5: New blooms and
old thorns. American Journal of Psychiatry. 170:1-5
Greenberg, G. (2013). The book of woe. New York: Blue Rider Press.
How the DSM developed: What you might not know. Retrieved from
http://psychcentral.com/blog/archives/2011/07/02/how-the-dsmdeveloped-what-you-might-not-know/
Kapline, A. DSM-5 controversies. (2009, January 1). Retrieved from
http://www.psychiatrictimes.com/articles/dsm-v-controversies
Normal or not? New psychiatric manual stirs controversy. Retrieved from
http://www.livescience.com/34496-psychiatric-manual-stirscontroversy.html
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