Diagnostic and statistical manual-5 PART 1

Diagnostic and Statistical Manual
Of Mental Disorders
Changing from
DSM-IV to DSM-5
Part 1
DR .ABID RIZVI
M.D(psychiatry).
Registrar
Aligarh muslim university
india

DSM – a brief history
• First official attempt - 1840 census,  single category,
"idiocy/insanity“.
• Whole black town named insane.
• The AMSAII formed in 1844, in 1892 name changed to the
AMPA.
• In 1921 named APA.

• Tenth Census (1880) used seven categories of mental
illness: dementia, dipsomania , epilepsy, mania, melancholia,
monomania and paresis.
• These categories were also adopted by the Association.
• In 1917, together with the National Commission on Mental
Hygiene, the APA developed a new guide for mental hospitals
-"Statistical Manual for the Use of Institutions for the Insane".
• This included 22 diagnoses and would be revised several
times by the APA

DSM-I (1952)
• "Categorized mental disorders in rubrics similar to those of the
armed forces nomenclature."
• A version specifically for use in the united states.
• 132 pages and 106 disorders.
• Definitions were simple, brief paragraphs with prototypical
descriptions .
• included several categories of "personality disturbance", generally
distinguished from "neurosis" .

DSM-II (1968)
• The antipsychiatry movement.
• Thomas szasz a myth used to disguise moral conflicts;
• Eerving goffman example of how society labels and controls
non-conformists.
• Behaviourists challenged psychiatry's reliance on unobservable
phenomena.
• Gay rights activists  criticised homosexuality as a mental
disorder.

• 134 pages ,“Reaction” terminology dropped
• Multiple psychiatric diagnoses (in order of importance) and
associated physical conditions
• Coincided with ICD-8 (1st time included mental disorders)
• Both DSM I and DSM II reflected psycho dynamic psychiatry
• Homosexuality dropped in 1974 after massive protest.
• Robert Spitzer and Joseph L. Fleiss demonstrated that the second
edition of the DSM (DSM-II) was an unreliable diagnostic tool.

DSM-III (1980)
• 494 pp , 265 diagnostic categories ,Coincided with ICD-9.
• The psychodynamic or physiologic view was abandoned,
in favor of a regulatory or legislative model.
• categorization on colloquial English descriptive language
(easier to use by federal administrative offices), rather than
assumptions of etiology, although its categorical approach
assumed each particular pattern of symptoms in a category
reflected a particular underlying pathology.
• Research Diagnostic Criteria (RDC) and Feighner Criteria
• Multiaxial classification system.
• Goal to introduce reliablilty.

DSM-IV (1994)
• 886 pp
• Inclusion of a clinical significance criterion
• New disorders introduced (e.g., Acute Stress Disorder, PTSD
Bipolar II Disorder, Asperger’s Disorder).
• Others deleted (e.g., Cluttering, Passive-Aggressive
Personality Disorder).

DSM-5 (2013)
947 pp
“5” instead of “V”

• Development started with 1999 meeting
• Task force recruited in 2006
• Work Groups to consider
 dimensional measures.
e.g.
 severity scales
 or cross-cutting across disorders
 culture/gender issues.

Field trials
• Organized to assess reliability
• 2246 patients interviewed (86% twice)
• Based on DSM-5 criteria.
• Interviews were conducted by 279 clinicians in various
disciplines
• Scientific reviews written.
• Over 1000 members/consultants involved.

• 3 Internet postings of changes for review
• A Scientific Review Committee reviewed evidence for
validating revisions.
• Peer Review process with hundreds of experts to consider
clinical/public health risks and benefits of proposed
changes.

Approved
APAAssembly (November 2012)
Board of Trustees (December 2012)

DSM-5
22 Chapters
DSM-IV
17 Chapters

Section I
DSM-5 BASICS
• Orientation
• Historical back ground
• Development of DSM-5
• How to use it
• Cautionary statement for forensic use – (assignment of a
particular diagnosis does not imply a specific level of
impairement or disability.)
• Manual should not be used by non medical non clinical.

Section II
Diagnostic Criteria and Code
• Diagnostic Criteria and codes
• “Medication-induced Movement Disorders”
• “Other Conditions That May be
a Focus of Clinical Attention.”

Section III
Emerging Measures and Models
• Assessment measures
• Cultural formulation.(cultural formulation interview).
• Alternative DSM-5 model for personality disorders
• “Criteria Sets for Conditions
for Further Study”

Appendix
• Highlights of changes from DSM-IV to DSM-5.
• Glossary of technical terms.
• Glossary of cultural terms.
• Alpha & numeric listings of diagnoses and codes.
• List of advisors and contributors.

• Chapters reorganized to reflects developmental lifespan
between and within chapters (Neurocognitive disorder
towards the end.
• Multiaxial system discontinued.
 Axis I, II and III combined into one. Multiple diagnosis should
be listed in order of importance. Medical condition that are
important to management of individual mental disorder should
be listed.
Rationale :- the different axis implied that there are fudamental
differences in the conceptualization in disorder recorded on
different axis.
General medical conditions cannot be delinked from mental
disorder.

• Axis 4 replaced by Z codes of ICD 10.
• Axis 5 replaced by WHO disability assessment
schedule.(WHODAS).
• RATIONALE – to provide a global universal assessment of
disability. GAF lacked clarity).
• NOS replaced by "Other Specified” or “Unspecified”
• “Another Medical Condition" instead of “General Medical
Condition”

SECTION 2: CHAPTERS
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 stressor-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. Substance-related and addictive disorders
17. Neurocognitive disorders
18. Personality disorders
19. Paraphilic disorders
20. Other Mental Disorders
21. Medication-induced movement disorders and other
adverse effects of medication
22. Other conditions that may be a focus of clinical attention
(V/Z Codes)

The changes in chapter names
(outline)1. Disorders usually first diagnosed in infancy, childhood or
adolescence  neurodevelopmental disorders.
2. Mood disorder  bipolar and related disorders and
depressive disorder.
3. Separate category made – obsessive compulsive and related
disorder( OCD- anxiety disorder, body dysmorphic disorder
somatoform disorder, hoarding disorder *, trichotillomania-
impulse control disorder, excoriation (skin picking)
disorder*.

4. Separate category- trauma and stressor related disorder (PTSD
and acute stress disorder –anxiety disorder, Reactive
attachment disorder and Disinhibited social engagement
disorder*, Adjustment disorder – separate chapter deleted .
5. Somatoform disorder  Somatic symptom and related
disorders.(factitious disorder – separate chapter deleted).
6. Eating disorder  feeding and eating disorder (pica and
rumination disorder – ch1, binge eating disorder*,
avoidant/restrictive food intake disorder*.

7. Elimination disorder – (eneuresis and encopresis –(ch 1).
8. Sleep disorder- sleep wake disorder (restless leg syndrome).
9. Sexual and gender identity disorder split into 3 chapters.
• Sexual dysfunction
• Gender dysphoria
• Paraphillic disorders
10. Impulsive control disorder not elsewhere classified 
disruptive, impulse control and conduct disorder. (pathological
gambling changed to gambling disorder and moved to
substance related and addictive disorder).

11. Substance related disorder  substance related and addictive
disorder (substance use disorder, cannabis withdrawal*,
caffeine withdrawal).
12. Neurocognitive disorder
13. Medication induced movement disorder

• Social (Pragmatic) Communication Disorder
• Disruptive Mood Dysregulation Disorder
• Premenstrual Dysphoric Disorder
• Hoarding Disorder
• Excoriation (Skin‐Picking) Disorder
New Disorders

New Disorders
• Disinhibited Social Engagement Disorder (split from Reactive
Attachment Disorder).
• Binge Eating Disorder.
• Central Sleep Apnea.
• Sleep-Related Hypoventilation.
• Rapid Eye Movement Sleep Behavior Disorder .

New Disorders
• Restless Legs Syndrome.
• Caffeine Withdrawal.
• Cannabis Withdrawal.
• Major Neurocognitive Disorder with Lewy Body Disease
(Dementia Due to Other Medical Conditions).
• Mild Neurocognitive Disorder

ELIMINATED
• Sexual Aversion Disorder
• Polysubstance-Related Disorder

• Language Disorder
(Expressive Language Disorder
& Mixed Receptive Expressive Language Disorder)
• Autism Spectrum Disorder
(Autistic Disorder, Asperger’s Disorder, Childhood
Disintegrative Disorder, Rett’s disorder Pervasive
Developmental Disorder-NOS).
• Specific Learning Disorder
(Reading Disorder, Math Disorder, Disorder of Written
Expression)
• Delusional Disorder
(Shared Psychotic Disorder, Delusional Disorder)
COMBINED

COMBINED
• Panic Disorder
(Panic Disorder Without Agoraphobia & Panic Disorder With
Agoraphobia)
• Dissociative Amnesia
(Dissociative Fugue &Dissociative Amnesia)
• Somatic Symptom Disorder
• (Somatization Disorder, undifferentiated Somatoform Disorder
Pain Disorder)
• Insomnia Disorder
(Primary Insomnia ,Insomnia Related to Another Mental Disorder)

COMBINED
• Hypersomnolence Disorder
(Primary Hypersomnia, Hypersomnia Related to Another
Mental Disorder).
• Non-Rapid Eye Movement Sleep Arousal Disorders
(Sleepwalking Disorder, Sleep Terror Disorder).
• Genito‐Pelvic Pain/Penetration Disorder
(Vaginismus, Dyspareunia)
• Substance Use Disorder
(Substance Abuse &Substance Dependence)

COMBINED
• Stimulant Intoxication & Withdrawal
(Amphetamine Intoxication &Withdrawal
Cocaine Intoxication &Withdrawal)

NEURODEVELOPMENTAL DISORDERS
Autistic Spectrum Disorder (ASD)
1) Deficits in social communication and social interaction and
2) Restricted repetitive behaviors, interests, and activities (RRBs).
• Because both components are required for diagnosis of ASD,
social communication disorder is diagnosed if no RRBs are
present.
Rationale:
4 previously separate disorders are actually a single condition
with different levels of symptom severity in two core DOMAIN.
Poor reliability in application of DSM-4 criteria of different
subtypes of PDD.

• 3 levels of severity
• Specifiers can describe variants
e.g., ASD
I. with or Without intellectual impairment
II. with or without language impairment.(Instead of
Asperger’s).
III. with catatonia.
IV. associated with another medical, genetic condition or
envoromental factor.

Intellectual Disability (Intellectual Developmental Disorder)
Following three criteria should be met.
1. Deficit in intellectual function .
2. Deficit in adaptive function in either conceptual, social and
practical domain.
3. Onset of above two deficits during developmental period.
RATIONALE: Rosa’s law  replaces mental retardation with
intellectual disability. Intellectual Developmental Disorder
to be used in ICD 10.

• Severity specifies same (mild, moderate, severe and profound)
but based on adaptive function deficit rather than IQ.
• Standardized measures( for adaptive and intellectual
functioning) must be interpreted with clinical judgment.
• IQ is only a rough estimate of intellectual functioning.

COMMUNICATION DISORDERS
• Language Disorder,
• Speech Sound disorder.(phonological disorder).
• Childhood-Onset Fluency Disorder (stuttering)
• Social (pragmatic) Communication Disorder-new
(Impaired Social Nonverbal communication
“not better explained by ASD, IDD, GDD” )

ADHD
Same set of criterias (18 divided in two groups)
1. “Symptoms that caused impairment were present before
age 7 years” “several inattentive or hyperactive-
impulsive symptoms present prior to age 12”.
2. Comorbid diagnosis with ASD is now allowed.
3. Cut off for ADHD of 5 symptoms, for younger persons.

SPECIFIC LEARNING DISORDER
• Umbrella of criteria
• Specifiers for math, reading, written
MOTOR DISORDERS
• Developmental Coordination Disorder
• Stereotypic Movement Disorder
•

• Developmental Coordination Disorder
• Stereotypic Movement Disorder
• Tic Disorders
1. Tourette’s,
2. Persistent (Chronic) Motor or Vocal TD
3. Provisional TD (previously“Transient”)
4. Other
5. Unspecified

Schizophrenia Spectrum and Other Psychotic Disorders:
Schizophrenia: 2 changes in the diagnosis criteria.
• The elimination of bizarre delusions and two or more voices
commenting type hallucination
Rationale: Poor reliability and nonspecificity of Schneiderian
symptoms
• At least 1 of 2 required sx to meet Criterion A must be
delusions, hallucinations, or disorganized speech.
Rationale: Improve reliability and prevent individuals w/ only
egative sx and catatonia from being dx w/ Schizophrenia.

Schizophrenia Spectrum and Other Psychotic Disorders
Cont…
Schizophrenia cont…
• The DSM-IV subtypes of schizophrenia have been eliminated.
• Instead a dimensional approach to rating severity for the core
symptoms of schizophrenia is included in DSM-5 Section III.
• Rationale: Limited diagnostic stability, low reliability, and
poor validity.

Cont…
Schizoaffective Disorder:
• The primary change to schizoaffective disorder is that a major
mood episode be present for the majority of the disorders total
duration after criterion A has been met.(substantial time in
DSM IV)
• Rationale: To improve reliability, diagnostic stability, and
validity of this disorder.

Cont…
Delusional Disorder:
• Criterion A no longer has the requirement that the delusions be
non-bizarre. A specifier is now included for bizarre type
delusions.
• Delusional disorder is no longer separated from shared
delusional disorder.
Catatonia: (catatonia due to another medical condition and
catatonia due to another psychaitric condition)
• The criteria for catatonia is now uniform for all contexts and
requires 3 sx from a total of 12. (in DSM IV 2 for psychiatric
disorder and one for medical disorder).

Bipolar and Related Disorders
Manic/hypomanic
• Add to criterion A:
“Abnormally and persistently increased goal-directed activity
or energy Along with mood”.
No more “Mixed Episode”
• Now a specifier:
• ( full Manic + MDD nearly every day

DEPRESSIVE DISORDERS
DISRUPTIVE MOOD DISREGULATION
• Severe, age inappropriate temper outbursts 3+x weekly
• Daily irritable, angry mood 12 months, not asymptomatic 3
months; 2/3 settings
• Dx between 6-18 years; onset <10 years
• Not meeting criteria for manic/hypomanic for more than
one day or ODD or IED
• (Purpose: Prevent Manic dx & subsequent antipsychotic
medication)

MAJOR DEPRESSIVE DISORDER
“Bereavement exclusion” removed
• Includes “note”: significant loss may result in some
Criterion A symptoms. MDD may also be considered in
context of clinical judgment, history, and cultural normo
distinguish grief from depression.
• Detailed foot note is given t
rationales. Duration lasts for 1 or 2 years .
• Bereavement may be a significant psychosocial stressor
that can ppt criteria A symptom of depression.

Persistent Depressive Disorder (Dysthymia)
• MDD may be present 2 years (previously excluded)
Premenstrual Dysphoric Disorder*
• 5 symptom present final week before the onset of menses and
improves after menses.
• 5 of4+7 symptoms appear in final week before onset of most
menses, then improve (lability, irritability, anxiety, depressive,
being keyed on the edge).

OTHER SPECIFIED DEPRESSIVE DISORDER
• Lists a few examples.
1. Recurrent brief discussion.
2. Short duration depressive episode.
3. Depressive episode with insufficient symptoms.
UNSPECIFIED DEPRESSIVE DISORDER
• e.g. insufficient information
SPECIFIERS
• With Anxious distress
• PostPartum onset now peripartum onset (includes during/following
pregnancy)

Anxiety Disorders
•“The anxiety must be out of proportion to the actual danger or
threat in the situation”
•This chapter no longer includes OCD and PTSD and acute stress
disorder.
•Sequential arrangement of chapters reflect the link.
•Now includes Separation Anxiety and Selective Mutism.
•Agoraphobia, Specific Phobia, and Social Anxiety Disorder
deletion of the requirement that individuals over age 18 years
recognize that their anxiety is excessive or unreasonable and
symptoms for atleast 6 month.

•Panic disorder and Agoraphobia are “unlinked” in DSM- 5
•DSM- IV terminology describing different types of Panic Attacks
replaced in DSM-5 with the terms “expected” or “unexpected” panic
attack.
•Social Anxiety Disorder :
“Generalized” specifier in DSM-IV has been deletedReplaced with
“performance only” specifier

• Panic and agoraphobia two separate diagnosis.
• Agoraphobia ( 2 or more)
1. Using public transportation.
2. Being in open spaces.
3. Being in enclosed spaces.
4. Standing in line or in crowd.
5. Being outside of the home alone.
In situation from where escape is difficult or embarrassing.( due
to fear of panic attack, fear of falling or incontinence (in
elderly).

• Includes selective mutism and separation anxiety disorder.

Obsessive Compulsive and Related Disorders
• OCD
• Body dysmorphic disorder
• Hoarding disorder *,
• Trichotillomania(
• Excoriation (skin picking) disorder*.
Rationale for this chapter grouping:
Increasing evidence that these disorders are related to each
other

OCD and Related Disorders
Specifiers listed for each OCD disorder
-Specifier “with poor insight” in DSM- IV has been expanded in
DSM- 5
-New Specifiers are
- “with good or fair insight”
- “with poor insight”
- “with absent insight/delusional beliefs”
Rationale: Intent of these specifiers is to improve
differential diagnoses

Hoarding Disorder added to DSM-5
•.Persistence difficulty discarding or parting with possession
regardless of their actual values and distress associated with
discarding them.
Rationale : Due to evidence that it is not a variant of OCD;Evidence
that it is a separate diagnosis
Excoriation Disorder added to DSM-5
Repeated skin picking resulting in skin lesionand repeated attempt
to decrease or stop skin picking.
Rationale: Based on strong evidence of diagnostic validity and
clinical utility

Other Specified and Unspecified Obsessive-
Compulsive and Related Disorders
DSM-5 includes conditions in this chapter such as
Body-focused repetitive behavior disorder
- other than excoriation and trichotillomania
i.e. nail biting, lip chewing
Obsessional jealousy

Trauma- and Stressor-Related Disorders
New chapter in DSM-5 brings together anxiety disorders that are
preceded by a distressing or traumatic event
1. Reactive Attachment Disorder
2. Dis-inhibited Social Engagement Disorder*
3. PTSD (includes PTSD for children 6 years and younger)
4. Acute Stress Disorder
5. Adjustment Disorders

•Both result of social neglect or other situations that limit a young
child’s opportunity to form selective attachments.
•DSM-IV reactive attachment disorder  two subtypes: emotionally
withdrawn/inhibited and indiscriminately social/disinhibited.
•reactive attachment disorder  a lack of or incompletely formed
preferred attachments to caregiving adults.
•disinhibited social engagement disorder there is a pattern of behavior that
involves culturally inappropriate, overly familiar behavior with relative
strangers. This behavior violates the social boundaries of the culture.”
DSM-5, p. 269
Reactive Attachment Disorder &Disinhibited
Social Engagement Disorder

•Acute Stress Disorder
•-Criterion a explicit whether qualifying traumatic events were
experienced directly, witnessed, or experienced indirectly.(not by
electronic media).
•-DSM-IV Criterion A2 regarding reaction to the event- “the
person’s response involved intense fear, helplessness, or horror” –
has been eliminated.
•Excessive reliance on dissociative symptoms removed.
•9 or move criteria from 14 arranged in 5 groups of intrusion,
negative mood, dissociation, avoidance, and arousal.

• Time 3 days to 1 month ( instead of 2 days to 4 weeks).

PTSD Criteria
•Like acute stress disorder explicit statement about mode of
exposure and deletion of criteria A2
Four symptom clusters, rather than three
•Re-experiencing.
•Avoidance.
•Persistent negative alterations in mood and
cognition*(avoidance/numbing)
•Arousal: describes behavioral symptoms.

DSM-5 more clearly defines what constitutes a traumatic event
•Sexual assault is specifically included
•Recurring exposure, that could apply to first responders.
•Dissociative symptoms as specifier.

Recognition of PTSD in Young children
• Criteria have been modified for children age 6 and younger
• Thresholds – number of symptoms in each cluster - have
been lowered

Adjustment Disorders -DSM-5
Adjustment Disorders are redefined as an array of stress-response
syndromes occurring after exposure to a distressing event.
Adjustment Disorder subtypes are unchanged
- with depressed mood
- with anxiety
- with disturbance of conduct

Dissociative Disorders
• Dissociative identity disorder.
• Dissociative amnesia
• Depersonalization/ derealization.
• Other specified
• Unspecified.

• Derealization has been added to the name and symptom structure of
depersonalization disorder.
Criteria A. The presence of persistent experiences of either
depersonalization or derealization or both.
Depersonalization: Experiences of unreality, detachment, or
being an outside observer with respect to one’s thoughts,
feelings, body
Derealization: Experiences of unreality or detachment with
respect to one’s surroundings
• Dissociative fugue is now a specifier of Dissociative Amnesia
and not a separate disorder.

Dissociative Identity Disorder
Changes in Criterion A
Expanded - includes certain possession-form phenomena and
neurological symptoms (disturbance of affect, memory, sensory/motor
phenomenon, cognition.)
specifically states that transitions in identity may be observable by
others or self-reported

Somatic Symptom and Related Disorders:
• Somatoform disorders are now referred to as somatic symptoms &
related disorders in the DSM-5 and are reduced in number and
subcategories to avoid problematic overlap.
• Somatization disorder, hypochondrias, pain disorder, and
undifferentiated somatoform disorder have been removed.
• Includes
1. Somatic Symptom Disorder
2. Illness Anxiety Disorder:
3. Conversion Disorder:
4. Psychological Factors Affecting Other Medical Conditions
5. Factitious disorder.

Cont…
Somatic Symptom Disorder:
• Patient have one or more somatic symptom AND maladaptive
thoughts, feelings, and behaviors related to them which are
disproportionate to the seriousness, with high level of anxiety or
in which excessive time and energy is devoted.
• Individuals previously dx w/ somatization disorder will usually
have sx that meet DSM-5 criteria for somatic sx disorder but
only if they have in addition to their somatic sx.
• With persistent pain as specifier.

Rationale:
• Recognizes the complexity of the interface between psychiatry
and medicine. Individuals with somatic symptoms plus
abnormal thoughts, feelings, and behaviors may or may not
have a diagnosed medical condition.
• Somatic symptom disorders can also accompany diagnosed
medical disorders.

Cont…
Illness Anxiety Disorder:
• Individuals previously dx w/ hypchondriasis who have high
health anxiety but no somatic sx would receive this DSM-5
dx.
• Hypochondriasis with somatic symptom somatic symptom
disorder.
Conversion Disorder:
• Modified to emphasize the importance of the neurological
exam and recognizes that relevant psychological factors may
not be present at the time of dx.

1. Altered voluntary motor or sensory function.
2. Evidence of incompatibility between symptoms and
recognizable neurological or medical condition.
Specifiers (symptom type).
With weakness
With abnormal movement
With swallowing
With speech symtoms
With seizure
With anaesthesia

Specify if
Acute episode. (symptom persist less than 6 month).
Persistent (symptom occuring for 6 month or more).
specify if
With/ without psychological stressior

Cont…
Psychological Factors Affecting Other Medical Conditions
• New mental disorder in DSM-5 (formerly in DSM-IV “other
conditions that may be a focus of clinical attention”).

Diagnostic and Statistical Manual
Of Mental Disorders
Changing from
DSM-IV to DSM-5
Part 11

recap
• 22 Chapters v/s 17 Chapters
• Chapters reorganized to reflects developmental
lifespan.
• Multiaxial system discontinued.

Feeding and Eating Disorders:
• DSM IV-TR chapter “Disorder Usually First Diagnosed in
Infancy Childhood, or Adolescence” has been eliminated.
• Therefore this chapter includes several disorders from DSM-IV
“Feeding and Eating Disorders of Infancy or Early Childhood”.

• Pica
• Rumination disorder
• Avoidant/ restrictive food intake disorder.

Cont…
Pica and Rumination Disorder:
• Criteria has been revised to allow diagnosis for individuals of
all ages.
Avoidant/Restrictive Food Intake Disorder:
• Previously feeding disorders of infancy or early childhood.
• Criteria is significantly expanded making it a broader category
to capture a wider range of clinical presentations.

Cont…
Anorexia Nervosa:
• The requirement for amenorrhea has been eliminated.
• Clarity and guidance re: how to judge if an individual is at
“significantly low weight” has been added.
• Criterion B has been expanded to include not only “overtly
expressed fear of weight gain” but also “persistent behavior
that interferes w/ weight gain”.

Cont…
Bulimia Nervosa :
• The only change is the reduction in the required minimum
average frequency of binge eating & inappropriate
compensatory behavior frequency from twice to once weekly
for 3 months.

Cont…
Binge Eating Disorder:
• Elevated to main body of manual from appendix B in DSM-IV.
• The only change is the minimum average frequency of binge
eating required for diagnosis is once weekly over the last 3
months (identical to frequency criterion for bulimia nervosa).

Elimination Disorders:
• No significant changes have been made to elimination
disorders.
• The disorders in this chapter (enuresis & encopresis) were
previously under “Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence” in DSM-IV and are now
independent classifications in DSM-5.

Sleep-Wake Disorders:
• Sleep disorder related to another mental disorder and sleep
disorder related to a general medical condition have been
removed.
Insomnia Disorder:
• Previously named primary insomnia.
• Rationale: to avoid the differentiation between primary &
secondary insomnia.

Cont…
Narcolepsy:
• Is now distinguished from other forms of hypersomnolence.
Breathing-Related Sleep Disorders:
• Now divided into 3 distinct disorders: obstructive sleep apnea
hypopnea; central sleep apnea; and sleep related
hypoventilation.
• Rationale: reflects the growing understanding of
pathophysiology in these disorders.

Cont…
Circadian Rhythm Sleep-Wake Disorders:
• Subtypes expanded to include: advanced sleep phase
syndrome; irregular sleep-wake type; and non-24 hr sleep
wake type.
* Jet lag has been removed.
Rapid Eye Movement Sleep Behavior Disorder
Restless Legs Syndrome
• Both are now independent disorders.

Sexual Dysfunctions
“a group of disorders that are characterized by clinically
significant disturbance in a person’s ability to respond
sexually”
In DSM -5 gender-specific sexual dysfunctions
have been added
For purpose of diagnostic precision
-Criteria require a minimum duration
of six months
-Criteria for severity are more precisely defined
as mild, moderate, or severe.

Gender Dysphoria
New diagnostic class in DSM-5
Reflects change in definition, emphasizes “gender
incongruence” rather than cross-gender
identification.
In DSM-IV, three disparate diagnostic classes
grouped in one chapter, “Sexual and Gender
Identity Disorders”
Gender Identity Disorder is neither a sexual
dysfunction nor a paraphilia.

Gender Dysphoria
Is considered a multi-category concept, not a
dichotomy
Separate criteria sets are provided for gender
dysphoria in children, and in adolescents and
adults
Terminology changes include:
-“the other sex” is replaced by “some
alternative gender”
-“gender” is used instead of “sex”

Disruptive, Impulse-Control, and Conduct Disorders
More detailed

Oppositional Defiant Disorder
• Criteria exhibited “with at least one
individual who is not a sibling”
• “Spiteful or vindictive twice in 6
months”
• Severity: Mild, moderate, severe
• <5years most days for 6 months;
>5 years, weekly

Conduct Disorder
• Adds specifier “With limited prosocial emotions”
• Persistently in 12 months (2 of 4)
• Lack of Remorse/ guilt
• Callous—lack of empathy
• Unconcerned about performance
• Shallow or deficient affect

Intermittent Explosive Disorder
• Verbal aggression 2x weekly for 3 months
• Destruction or assault: 3x in 12 months
• 6 years +
• Not premeditated

• AntiSocial Personality Disorder
(criteria in PD chapter) “Dual coded”
• Pyromania
• Kleptomania
• Other DICCD
• Unspecified DICCD

Substance-Related and Addictive Disorders:
• DSM-5 consolidates substance abuse and dependence into one disorder:
substance use disorder accompanied by criteria for: intoxication,
withdrawal, substance-induced disorders, and unspecified related
disorders.
• Criteria are nearly identical to DSM-IV w/ exception of:
-Recurrent substance-related legal problems criterion has been deleted
from DSM-5.
-And new criterion: craving, or a strong desire or urge to use a substance
added.
• The threshold is set at 2 or more criteria vs. 1 or more for abuse and 3 or
more for dependence in the DSM-IV.

Cont…
New disorders in substance-related & addictive disorders
chapter of DSM-5:
• Gambling Disorder (non-substance related disorder)
• Cannabis Withdrawal
• Caffeine Withdrawal
* The dx of polysubstance dependence has been eliminated.

Cont…
Specifiers:
• In DSM-5 severity for substance use disorders is based on the
number of criteria endorsed:
-mild= 2-3 criteria
-moderate = 4-5 criteria
-Severe= 6 or more criteria
• The DSM-IV specifier for psychological subtype has been
eliminated.

Cont…
• In DSM-5 early remission is defined as at least 3 but less then
12 months without substance use disorder criteria (except
craving).
• Sustained remission is defined as at least 12 months without
criteria (except craving).
• New specifiers include:
-in a controlled environment
-on maintenance therapy

Neurocognitive Disorders:
• Dementia and amnestic disorder are now included under
neurocognitive disorder (NCD).
• Rationale: dementia has been associated w/ the older
population whereas NCD will capture etiologies occurring in
younger adults as well.
• The term dementia is not excluded from use in etiological
subtypes.

Cont…
• DSM-5 now recognizes a less severe level of cognitive
impairment, mild NCD, allowing a dx of a less disabling
syndrome that may be a focus of concern and treatment.
• Diagnostic criteria are provided for both mild NCD and major
NCD, followed by diagnostic criteria for the different
etiological subtypes.

Cont…
• The DSM-5 also provides an updated listing of neurocognitive
domains to establish presence of NCD, level of impairment
(mild or major), and etiological subtypes.
• Delirium: Criteria for delirium has been updated and clarified
to reflect currently available evidence.

Personality Disorders
Initially proposed
• Retain 6 personality disorder
diagnoses of 10
• Move from a categorical to a
trait-based, dimensional
classification system.
• measuring a variety of
traits on a continuum.

• Voted down: Not adequately validated
• Included in a separate chapter in Section 3
of DSM-5 to stimulate further research
• In the field trials, only borderline personality
disorder had good interrater reliability
• obsessive-compulsive personality disorder
and antisocial personality disorder
were in the questionable reliability range

10 PD’s retained; Add
Personality Change Due to Another Medical Condition
Other Specified Personality Disorder
Unspecified Personality Disorder

Paraphilic Disorders
• Distinguishes between paraphilic behaviors
(paraphilias), and paraphilic disorders.
• A Paraphilic Disorder :
"paraphilia that is currently causing distress
or impairment to the individual or a paraphilia
whose satisfaction has entailed personal
harm, or risk of harm, to others."
• Demedicalizes and destigmatizes
unusual sexual preferences and behaviors

Voyeuristic Disorder
• nonconsenting person, or distress/ impairment
• >18
• Specifier: controlled environment or in remission
Exhibitionistic Disorder
• nonconsenting person, or distress/ impairment
• Specifiers: children, adults, or both;
controlled environment or in remission

Frotteuristic disorder
• Nonconsenting person, or distress/impairment
• Specifier: controlled environment or in remission
Sexual Masochism disorder
• Specifier: with asphyxiophilia;
Sexual Sadism disorder
• Nonconsenting person, or distress/impairment
• Specifier: with asphyxiophilia;

Pedophilic Disorder
• Acted on urges, or distress/impairment, or
interpersonal difficulty
Fetishistic Disorder
• (Add to “nonliving objects”):
“highly specific focus on nongenital body parts”
• Specifiers:
Body part(s),nonliving object(s)
Other

Transvestic Disorder
• No longer specifies “In a heterosexual male”
• Specifiers:
(Gender Dysphoria now separate section)
With fetishism
With autogynephilia

Other Mental Disorders
Four disorders in this chapter
“This residual category applies to presentation
of symptoms characteristic of mental disorders, which
cause clinically significant distress or impairment, but do
not meet the full criteria for any other mental disorder”
Other Specified Mental Disorder Due to Another
Medical Condition
-Unspecified Mental Disorder Due to Another
Medical Condition
-Other Specified Mental Disorder
-Unspecified Mental Disorder

Medication-Induced Movement Disorders
and the Adverse Effects of Medication
These disorders are included in Section II of
DSM-5 “because of the importance of
1.The management by medication of mental
disorders or other medical conditions
2.The differential diagnosis of mental disorders”

Other Conditions that may be a
Focus of Clinical Attention
“The conditions and problems listed in this chapter are
not mental disorders.”
“They may be included in the medical record as useful
information that may affect client’s care. “
Inclusion in the DSM-5 draws attention to the scope of
issues encountered in clinical practice

OtherConditionsthatmaybea
Focusof ClinicalAttention
Commonly referred to as “the V codes”
Child Maltreatment and Neglect
Adult Maltreatment and Neglect
Relational Problems
Educational Problems
Occupational Problems
Housing Problems
Economic Problems

Director of the National Institute of Mental Health (NIMH)
Thomas Insel
• NIMH Research Domain Criteria (RDoC),
a possible future replacement diagnostic tool
incorporates genetics, imaging, and other data
into a new classification system and as "a
first step towards precision medicine."
• "what may be realistically feasible today for
practitioners is no longer sufficient for
researchers."

Director of the National Institute of Mental Health (NIMH)
Thomas Insel
BUT
[DSM & ICD (International Classification of Diseases)]
“remain the contemporary consensus standard
to how mental disorders are diagnosed and
treated," …
"DSM-5 and RDoC represent complementary,
not competing, frameworks for this goal."

Diagnostic and statistical manual-5 PART 1

More Related Content

What's hot (20)

Viewers also liked (20)

Similar to Diagnostic and statistical manual-5 PART 1 (20)

Recently uploaded (20)

Diagnostic and statistical manual-5 PART 1