DSM-5 Update:Transitioning to the Fifth Edition

NASWILOctober 28, 2013

Susan McCracken, Ph.D.

Private Practice & Adjunct Faculty

susanm@uchicago.edu

Stanley G. McCracken, Ph.D., LCSW, RDDP

Senior Lecturer

s-mccracken@uchicago.edu

The University of Chicago School of Social Service Administration

Agenda• Introduction. Process of revision. General

characteristics.• Structural, Conceptual, and Cross-cutting Changes

– Dimensional approach• Severity Ratings and Assessment Tools• Spectra and clusters

– Developmental Perspectives in DSM-5• Changes to selected disorders and clusters• We will focus on DSM-5 changes to the DSM-IVTR.

We will not cover all disorders. This workshop is not recommended for people preparing to take a licensing exam this year.

Process of Revision• DSM-5 represents the first major revision in 30

years.

• Revisions of both DSM (5) and ICD (11 [2015]). Continuing effort to make DSM/ICD compatible – NIMH: Research Domain Criteria (RDoC).

• Workgroups. Conferences. Field trials. APA website w/ updates & opportunity for feedback.

• Both APA and WHO committed to making the DSM-5 and ICD-11 a “living document.” – Print and electronic versions plus a mobile app of diagnostic

criteria for iOS and Android.

DSM-5 Structure• No more Axes I-V. Just list diagnostic codes.

– There are still V codes ( Z codes in ICD-10CM).

• 3 Sections and Appendix.– Section I, DSM-5 Basics: Introduction, Use of the

Manual, Cautionary Statement for Forensic Use of DSM-5

– Section II, Diagnostic Criteria and Codes.– Section III, Emerging Measures and Models:

Assessment Measures, Cultural Formulation, Alternative DSM-5 Model for Personality Disorders, Conditions for Further Study.

– Appendix: Highlights of Changes from DSM-IV to DSM-5, Glossary of Technical Terms, Glossary of Cultural Concepts of Distress, etc.

Characteristics of DSM-5• Final draft approved Dec. 1, 2012 and released

May, 2013.

• APA recommended implementation early 2014. Illinois DMH has not yet decided on a date. [Rumor: October, 2014 being considered???]

• Coding:– Now: continue to use ICD-9CM (numbers only).– ICD-10CM scheduled for implementation in US in

October, 2014. Use letter and number, e.g., F43.0. The specific code will depend on specifier.

– ICD-11 due for release, 2015. Implementation???

Characteristics of DSM-5, cont.• DSM-5 website:

http://www.psychiatry.org/dsm5

http://www.dsm5.org/Pages/Default.aspx

• No more NOS. Instead:– Other specified _____ disorder– Other unspecified _____ disorder– Provisional diagnoses still allowed.

• Many specifiers.

Diagnostic Groupings• Neurodevelopmental Disorders• Schizophrenia Spectrum and Other Psychotic

Disorders• Bipolar and Related Disorders• Depressive Disorders• Anxiety Disorders• Obsessive-Compulsive and Related Disorders• Trauma- and Stressor-Related Disorders• Dissociative Disorders• Somatic Symptom and Related Disorders• Feeding and Eating Disorders• Elimination Disorders

Diagnostic Groupings, cont.• Sleep-Wake Disorders• Sexual Dysfunctions• Gender Dysphoria• Disruptive, Impulse-Control, and Conduct Disorders• Substance-Related and Addictive Disorders• Neurocognitive Disorders• Personality Disorders• Paraphilic Disorders• Other Mental Disorders• Medication-Induced Movement Disorders and Other Adverse

Effects of Medication• Other Conditions that may be a Focus of Clinical Attention

Developmental Perspectives in DSM-5 • The full diagnostic manual provides many of the same

informational features as did DSM IV but in expanded form – diagnostic criteria and recording codes with ICD 9 and 10, diagnostic features, description of symptoms, associated features supporting diagnosis, culture-related diagnostic issues, gender-related diagnostic issues, prevalence, and differential diagnoses.

• New sections have been added (suicide risks, comorbidity) and applied to many different disorders. The addition of a developmental section, however, is a major thread throughout the DSM-5.

Developmental Perspective• DSM-5 diagnoses are anchored in the perspective that

pathology in youth = deviation from developmental norms ( from delay in accomplishing developmental task to not accomplishing it at all). Diagnoses fall along a continuum or within a spectrum.

• The “Development and Course” section for each disorder reflects a lifespan approach:– age at which typical symptoms present

– detailed symptom presentation specific to each age group & descriptions of how presentations change over the lifespan

– the trajectory over time of one disorder becoming another at a later point in time (fluidity of diagnoses)

Developmental Perspective (cont)• Risks and Prognostic Factors includes

– Temperament, genetic or physiological factors

– Descriptions of situations associated w/each age group in which the disorder would disrupt normal functioning

– Expected long term outcome, points of increased risk, and course modifiers improvement or stability

– Recognition that changes in environment can moderate level of impairment in children (i.e. enabling parents as compared to non-enabling parents)

• Associated Features section in DSM -5 – includes comprehensive information than DSM IV to support

the diagnosis (medical, other behavioral or emotional signs, other common associations) as well as parent-child associations

Developmental Perspectives, cont.• Functional Consequences Section

– Refers to consequences of having a disorder during different ages/stages of development

• Comorbidity Section (greater number in DSM-5) – For some comorbidities, associations at different ages are

highlighted

• Some disorders in DSM-5 include:– Explicit descriptions of developmental manifestations as part

of the diagnostic criteria for each disorder

– Procedures for evaluating developmental subtypes of disorders

Dimensional Approach in DSM-5

• DSM-5 is shifting toward a more dimensional approach.

• Disorders in several groups are structured or discussed as spectrum disorders or dimensions, e.g., Autism Spectrum, Mild and Major Neurocognitive Disorders.

Dimensional Assessment• Assessment measures placed in Section III.Available:

http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures

• Cross-cutting symptom measures.– Level 1 (Screening) brief survey of 13 (adults) or 12

(child and adolescent) symptom domains.• Adults: Depression, Anger, Mania, Anxiety, Somatic

symptoms, Suicidal ideation, Psychosis, Sleep problems, Memory, Repetitive thoughts & behaviors, Dissociation, Personality functioning, Substance use.

• Child/adolescent (6-17): Somatic symptoms, Sleep problem, Inattention, Depression, Anger, Irritability, Mania, Anxiety, Psychosis, Repetitive thoughts & behaviors, Substance use, Suicidal ideation/suicide attempt.

Dimensional Assessment, cont• Cross-cutting symptom measures, cont

– Level 1• Items rated on 5-point scale: 0=none/not at all;

1=slight or rare; <a day or two; 2=mild or several days; 3=moderate or >half the days; 4=severe or nearly every day.

• Items rated >mild or >slight (Suicidal, Psychosis, Substance use; Inattention) or Yes/Don’t Know (Substance use and Suicidal ideation/suicide attempts-child/adol) further assessment with relevant Level 2 measure.

http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures#Level1

Dimensional Assessment, cont• Cross-cutting symptom measures.

– Level 2. Detailed clinical inquiry. Currently available:• Adult: Depression, Anger, Mania, Anxiety, Somatic Symptom,

Sleep Disturbance, Repetitive Thoughts and Behaviors, Substance Use. None currently available for: Dissociation or Psychosis (see Clinician-Rated Dimensions of Psychosis Symptom Severity).

• Child (6-17) (Child Self-Report ages 11-17; Parent/Guardian-rated ages 6-17): Somatic Symptoms, Sleep Disturbance, Inattention, Depression, Anger, Irritability, Mania, Anxiety, Substance Use. None currently available for: Psychosis, Repetitive thoughts and behaviors, Suicidal ideation/suicide attempts.

http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures#Level2

Assessment, cont• Other Measures of Symptoms and Functioning

– Disorder-specific Severity Measures• Adult: Depression, Separation Anxiety, Specific Phobia, Social

Anxiety Disorder, Panic Disorder, Agoraphobia, Generalized Anxiety Disorder, Post-traumatic Stress Symptoms, Acute Stress Symptoms, Dissociative Symptoms

• Children S-R (11-17): Depression, Separation Anxiety, Specific Phobia, Social Anxiety Disorder, Panic Disorder, Agoraphobia, Generalized Anxiety Disorder, Post-traumatic Stress Symptoms, Acute Stress Symptoms, Dissociative Symptoms

• Clinician-rated: Severity of Autism Spectrum and Social Communication Disorders, Dimensions of Psychosis Symptom Severity, Severity of Somatic Symptom Disorder, Severity of Conduct Disorder, Severity of Oppositional Defiant Disorder, Severity of Nonsuicidal Self-Injury

Assessment, cont• Other Measures of Symptoms and Functioning

– Disability Measures• World Health Organization Disability Schedule (WHODAS

2.0) 36 item self-administered.

• World Health Organization Disability Schedule (WHODAS 2.0) 36 item proxy-administered.

– Personality Inventories• Adult: Personality Inventory for DSM-5—Brief form (PID-5-

BF)—Adult; Personality Inventory for DSM-5 (PID-5)—Adult; Personality Inventory for DSM-5-Informant form (PID-5-IRF)—Adult.

• Child S-R (11-17): Personality Inventory for DSM-5—Brief form (PID-5-BF)—Child 11-17; Personality Inventory for DSM-5 (PID-5)—Child 11-17.

Assessment, cont• Other Measures of Symptoms and Functioning

– Early Development and Home Background• For Parents of Children Ages 6–17: Early Development and

Home Background (EDHB) Form—Parent/Guardian.

• Clinician Rated: Early Development and Home Background (EDHB) Form—Clinician.

– Cultural Formulation Interviews• Cultural Formulation Interview.

• Cultural Formulation Interview—Informant version.

• Supplementary Modules to the Core Cultural Formulation Interview (CFI).

• The question is whether, how, and when will any of these be used, and who will require. (Too early to tell.)

Disorders Usually First Diagnosed in Childhood Disorders: Where are they ? What Changed?

DSM IV

• Disorders Usually First Diagnosed in Childhood and Early Adolescence….

– Mental Retardation

– 3 Learning Disorders

– Developmental Coordination Disorder

– ADHD

DSM-5

• “Disorders Usually First” has been eliminated and several disorders moved to new a group category - Neurodevelopmental Disorders which includes: – MR -Renamed Intellectual Disability,

changes in criteria

– One LD Renamed “Specific Learning Disorder” (specifiers w/ impairment in reading, in written expression, in math)

– Developmental Coordination Disorder

– ADHD

Other Disorders Moved from “First Diagnosed.. in….” to “Neurodevelopmental Disorders”

DSM IV

• Communication Disorders– Expressive Language

Disorder (ELD)

– Mixed Receptive-Expressive Language Disorder (MRELD)

– Stuttering Disorder

– Phonologic Disorder (PD)

• Motor Skills/Tic Disorders– Tourettes, Dev. Coord Disord

– Chronic Vocal & Motor Tics

– Stereotypic Movement Disor.

DSM-5

• Communication Disorders– ELD and MRELD eliminated and

subsumed under new dx “Language Disorder”

– Stuttering renamed “Childhood Onset Fluency Disorder”

– PD renamed “Speech-Sound Disorder”

• Motor Disorders subsection– Specifiers added to Stereotypic

Movement Dis.-w/ SI, w/out SI, assoc. w/ other known dis./med

More Disorders Moved from “Disorders First Seen” to Other Groups in DSM-5

DSM IV

• PDD’s (Autistic Disorder, Asperger’s, Childhood Disintegrative Disorder , Rett’s, PDD NOS)

• Separation Anxiety D. and Selective Mutism

• Pica, Rumination Disorder & Feeding D. of Infancy

• Reactive Attachment Dis.

• Encopresis & Enuresis

• Conduct Disorder & ODD

& Intermittent Explosive D.

DSM-5

• Included in Neurodevelopmental Disorders, all subsumed under Autism Spectrum Disorder except Rett’s which is a genetic disorder

• SAD & SM moved to Anxiety D.

• Pica & RD in “ Feeding & Eating Disorders ” & FDI new name “Restrictive Food Intake D”

• RAD in Trauma & Stress-Related D

• E & E in “Elimination Disorders”

• CD/ODD in “Disrupt, Impulse-C & Conduct Disorders” w/ IED

List of Neurodevelopmental Disorders• Include the following disorders:

– Intellectual Disability (Intellectual Development Disorder), Global Developmental Delay (children < 5)

– Communication Disorders –• Language Disorder, Speech Sound Disorder, Childhood-

Onset Fluency Disorder, Social Communication Disorder

– Attention Deficit Hyperactivity Disorder– Specific Learning Disorder– Autism Spectrum Disorder– Motor Disorders

• Developmental Coordination Disorder, Stereotypic Movement Disorder, Tic Disorders/Tourette’s Disorder

Changes in MR: Intellectual Disability• In DSM -5, IQ below 70 is no longer the only criteria

• Severity based on functional ability, not IQ, or adaptive functioning in comparison with same age norms has been added as a criteria and must be assessed in 3 domains.

(1) Conceptual deficits: language, reading, writing, math, reasoning, knowledge and memory

(2) Social deficits: interpersonal communication skills, friendships, social judgment, empathy

(3) Practical deficits: personal care, organizing school and work activities, money management, job duties

Severity rating scale for each domain is based on the level of support required. Mild, Moderate, Profound

Changes in Criteria for ADHD• Required age on onset of sxs changed from 7 to 12• Greater emphasis on identifying adults ( & sx suited to age)

– Addition of sx descriptions more applicable to older teens and adults (“forgetful in keeping appointments or returning calls”)

– Symptom threshold reduced to 5 for ages 17 and older, still 6 for children and younger teens

• Symptom lists for hyperactive-inattentive and inattentive basically unchanged (sx description more age appropriate)

• Cross-situational requirement increased to several symptoms in > 2 settings

• Included in Neurodevelopmental Disorders to reflect brain development corrrelates w/ ADHD

• Comorbid dx of ADHD & Autism Spectrum D. allowed

ADHD (cont)• Subtypes replaced with specifiers “presentations

within the past 6 months predominantly_______”• Added duration of 6 months to the specifier “In partial

remission” when full criteria were previously met but have not been met for past 6 mos., still evidence of impairment.

• Severity ratings– Mild = no symptoms (or few) in excess of number required for

diagnosis with minor impairments,

– Moderate = functional impairment falls between mild and severe

– Severe = more symptoms than required or several symptoms result in marked impairment in social, school or occupational areas

Communication Disorders• Language Disorder (new dx =ELD & RELD combined)

– Difficulties in language acquisition and use of language across modalities including written, spoken and sign language

– Difficulties are not better accounted for by intellectual disability, hearing or sensory impairment

• Speech Sound Disorder (phonological disorder renamed) – difficulties with sounds articulation and voice quality

impact behavior, ideas and attitudes of others• Childhood Onset Fluency Disorder (stuttering renamed)

• Social (Pragmatic) Communication Disorder

Social (Pragmatic) Communication Disorder

• New diagnosis characterized by difficulty in social uses of verbal and nonverbal communication in naturalistic contexts– Use of communication for greeting and sharing is not

appropriate to the context– Impairment in ability to adjust communication to the

needs of the listener or the context– Difficulties following the rules for conversation

• Difficulties impact development of social relationships and can’t be explained by low abilities in areas of word structure and grammar

Social (Pragmatic) Communication Disorder

• There are no repetitive patterns or restricted interests (i.e. criteria for ASD would not be met).

• Language impairment is a common associated feature as is ADHD, behavior problems and specific learning disorders

• Symptoms present in early childhood yet may not be fully manifested until social demands exceed capabilities

• Replaces the PDD, NOS

Autism Spectrum Disorder (ASD)• The change from Pervasive Developmental

Disorders (PDD) to Autism Spectrum Disorder and to that one diagnosis, ASD, was justified by the following research:

– differentiation between Autism and the other DSM IV PDD’s (including Asperger’s ) as well as among the other PDD’s has been inconsistent, & often associated with severity, language level or IQ instead of features of the disorder.

– PDD,NOS – too many, >50% of diagnosed PDD

Rationale for ASD: Research on Asperger’s• A key difference in DSM IV to discriminate

between Autism and Asperger’s is that an individual with Asperger’s has no general delay in language and there is no significant delay in cognitive development or adaptive skills.

• However, individuals with Asperger’s technically do meet the criterion for Autistic Disorder… “in individuals with no language delay, have marked impairment in the ability to initiate or sustain a conversation with others”.

DSM 5 Conclusions for ASD• The 3 defining areas of impairment (social

deficits; communication deficits; and restricted, repetitive behaviors and interest) were reduced to 2 domains by combining social and communication to “social/communication deficits” and retaining the behavioral impairment domain (RRB’s). – Too difficult to separate social deficits from

communication deficits combine into one unit– Delays in language should be considered factors that

influence symptoms rather than define the disorder

Reconciling the Changes

• Individuals previously diagnosed with CDD, Asperger’s or PDD,NOS will meet criteria for ASD. If they do not meet criteria for ASD, they should be evaluated for Social (Pragmatic) Communication Disorder

• Individual’s currently receiving accommodations in Illinois public schools will continue to receive accommodations

Schizophrenia Spectrum and Other Psychotic Disorders

• Disorders in this group:– Schizotypal Personality Disorder criteria in Personality Disorders

– Delusional Disorder– Brief Psychotic Disorder– Schizophreniform Disorder– Schizophrenia– Schizoaffective Disorder– Substance/Medication-Induced Psychotic Disorder

– Psychotic Disorder Due to Another Medical Condition

– Catatonia Associated with Another Mental Disorder (Catatonia Specifier)

– Other Specified… and Unspecified…

Schizophrenia Spectrum/Other Psychotic Disorder, cont.

• Major changes.– Elimination of special attribution of certain symptoms

(e.g., bizarre delusions, voices talking to each other) in Criterion A of Schizophrenia (only one of these needed in DSM-IV).

– Criterion A now requires 2 sx, at least 1 of 3 psychotic sx (Delusions, Hallucinations, or Disorganized Speech).

– Schizophrenia subtypes eliminated.– Schizoaffective Disorder now requires that a major mood

episode be present for a majority of the disorder’s total duration (not just current episode) after Criterion A met.

Schizophrenia Spectrum & Psychotic, cont.

• Major changes.– Delusional disorder. Elimination of requirement that

delusions be non-bizarre.• Differential diagnosis: if an individual with OCD or Body

Dysmorphic Disorder is completely convinced that his/her OCD/BDD beliefs are true, then Delusional Disorder is not diagnosed in addition to OCD or BDD (more on this later).

– Criteria for catatonia are same regardless of the context in which it is used as a specifier (Schizophrenia, Bipolar Disorders, Depressive Disorders, or Other Medical Condition).

Schizophrenia Spectrum & Psychotic, cont.• Major changes.

• Rate symptoms on Clinician-Rated Dimensions of Psychosis Symptom Severity (Section III).

• Symptoms (clusters)

– Psychotic symptoms: Hallucinations, Delusions, Disorganization

– Psychomotor symptoms: Abnormal Psychomotor Behavior

– Negative symptoms: Restricted Emotional Expression, Avolition

– Cognition: Impaired Cognition

– Mood: Depression, Mania

– You may still make a diagnosis in this group even without this rating.

Bipolar and Related Disorders

• Disorders in this group– Bipolar I Disorder– Bipolar II Disorder– Cyclothymic Disorder– Substance/Medication-Induced Bipolar and Related

Disorder

– Bipolar and Related Disorder Due to Another Medical Condition

– Other Specified…

– Unspecified...

Bipolar and Related Disorders, cont.

• Bipolar and Related Disorders are separated from Depressive Disorders and placed between Depressive Disorders and Schizophrenia Spectrum and Other Psychotic Disorders to recognize their place as a bridge in terms of symptoms, family history, and genetics.

Bipolar and Related Disorders, cont.• Major changes.

– Criterion A for manic and hypomanic episodes now includes emphasis on changes in activity and energy as well as mood. (“A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least….”

– Removal of Mixed Episode and addition of mixed features specifier that can be added to mania and hypomania if depressive features are present or to episodes of depression when features of mania or hypomania are present (> 3 symptoms from other pole).

Bipolar and Related Disorders, cont.• Major changes, cont

– Specifiers• With anxious distress (see next slide)

• With mixed features

• With rapid cycling

• With melancholic features

• With atypical features

• With mood-congruent psychotic features

• With mood-incongruent psychotic features

• With catatonia.

• With peripartum onset (see next slide)

• With seasonal pattern (see next slide)

Bipolar and Related Disorders, cont.

• Major changes: specifiers– Anxious distress: at least two anxiety symptoms

during the majority of days of the current/most recent episode of mania, hypomania or depression.

• Symptoms: Feeling keyed up or tense, feeling unusually restless, difficulty concentrating because of worry, fear that something awful may happen, feeling that the individual might lose control of himself or herself.

• High levels of anxiety have been associated with higher risk of suicide, longer duration of illness, higher risk of poor treatment response.

• Specify severity based on number of anxiety symptoms: mild to severe.

Bipolar and Related Disorders, cont.

• Major changes: Specifiers– Peripartum onset. Can be applied to current/most

recent episode of mania, hypomania, or depression in Bipolar I or II if onset of mood symptoms was during pregnancy or in the 4 weeks following delivery.

– Seasonal pattern. Regular temporal relationship between onset (and remission) of manic, hypomanic, or depressive episodes and a particular time of year. Does not include cases where there is an obvious psychosocial stressor related to the season.

Depressive Disorders• Disorders in this group.

– 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

– Specifiers for Depressive Disorders– [Persistent Complex Bereavement Disorder in Section III.]

– [Suicidal Behavior Disorder and Nonsuicidal Self-Injury in Section III.]

Depressive Disorders, cont.• Major changes

– New disorders.• Disruptive Mood Dysregulation Disorder—new.

• Persistent Depressive Disorder—replaces Dysthymic Disorder and Chronic Major Depressive Disorder.

• Premenstrual Dysphoric Disorder—moved to this group from DSM-IV Appendix B (Criteria Sets…for Further Study).

– Mixed features specifier may be added to major depression episode if features (at least three symptoms) of mania or hypomania are present. (Increases probability that the illness is in a bipolar spectrum, though if the person has never had an illness that met criteria for a manic or hypomanic episode the diagnosis of Major Depressive Disorder is retained.)

Depressive Disorders, cont.• Major changes, cont.

– Bereavement exclusion eliminated.• DSM-IV stated that symptoms that begin within 2 months of

loss of a loved one and do not persist beyond these 2 months are “generally considered to result from Bereavement” unless associated with functional impairment, preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation. (Note: it did not say major depression could not be diagnosed.)

– Implied that bereavement only lasts 2 months, when duration is more commonly 1-2 years (depending on culture and other factors).

– Bereavement is severe psychosocial stressor that can precipitate major depression in a vulnerable person, e.g., past history of depression.

– Major depression in context of bereavement adds: increased suffering, suicidal ideation; increased risk complex bereavement; and responds to same treatment (meds & verbal) as non-bereavement depression.

Symptom Grief Depression

Affect Emptiness and loss Depressed mood, inability to anticipate happiness or pleasure

Pattern Dysphoria decreases in intensity over days-weeks, comes in waves associated with thoughts/reminders of deceased. Pain of grief associated with positive emotions and humor.

More persistent, not tied to specific thoughts or preoccupations. Pervasive unhappiness and misery.

Thought Content

Preoccupation with thoughts and memories of the deceased

Self-critical or pessimistic ruminations

Self-esteem Generally preserved Worthlessness, self-loathing

Thoughts of death & dying

If present, focused on deceased and joining deceased.

Thoughts of ending one’s life because of worthlessness, undeserving, unable to cope with pain of depression

Comparison of Grief and Depression

Depressive Disorders, cont.• Disruptive Mood Dysregulation Disorder

• A new diagnosis intended to address concerns of over diagnosis of bipolar disorder in children and unnecessary and potentially harmful treatment

• These are children who are described by parents as having “mood swings,” who have explosive outbursts of extreme intensity and duration. Parents have to “walk on eggshells.”

• These children present with persistent irritability and outbursts of temper and the sxs overlap sxs of ADHD, may be comorbid w/ ADHD but not w/ Bipolar or ODD

ADHDADHD

Disruptive Behavior Disorders

Disruptive Behavior Disorders

BIPOLARBIPOLAR

More aggressiveMore aggressive More continuousMore continuous

More labileMore labile

DMDD

• Recurrent severe temper outbursts, – verbal and/or behavioral and inappropriate developmentally

– frequency of outbursts 3 or more times/week

• Symptom duration at least 12 months, no more than 3 months symptom-free

• The outbursts are present in at least two settings, severe in at least one setting

• Child is at least 6, but no older than 18, & onset before 10• Criteria never been met for manic or hypomanic episode• Mood between outbursts is persistently irritable or angry

most of the day and mood is observable by others• Trajectory is anxiety and/or unipolar mood disorders

DMDD

Non-Suicidal Self Injury (NSSI)• Self inflicted injury in the absence of suicidal intent

(NSSI) is included in Section 3 of DSM-5– Many practitioners wanted NSSI to be identified as a

specifier due to the recent rapid increase in SI in youth and across diagnoses. The need for early recognition, development of preventative measures, and concerns about associated medical risk may lead to stronger research and treatment implications in DSM5.1, .2

– DSM-5 Task Force concern: SI is inappropriately represented in DSM IV as associated with BPD even though it occurs in a variety of disorders

NSSI• Proposed criteria

– The individual engages in the self-injurious behavior with one or more of the following expectations:

• To obtain relief from a negative feeling or cognitive state.

• To resolve an interpersonal difficulty.

• To induce a positive feeling state.

• Note: The desired relief or response is experienced during or shortly after the self-injury, and the individual may display patterns of behavior suggesting a dependence on repeatedly engaging in it.

NSSI, cont’d

• The intentional self-injury is associated with at least one of the following:– Interpersonal difficulties or negative feelings or

thoughts, depression, anxiety, tension, anger, generalized distress, or self-criticism, occurring in the period immediately prior to the SI act.

– Preoccupation with the SI is difficult to control.– Thinking about SI occurs frequently, even when it

is not acted upon.– The SI is not socially sanctioned not restricted to

nail biting or picking a scab

Anxiety Disorders• Disorders in this group. (Disorders listed developmentally.)

– Separation Anxiety Disorder– Selective Mutism– Specific Phobia– Social Anxiety Disorder (Social Phobia)– Panic Disorder– Panic Attack Specifier– Agoraphobia– Generalized Anxiety Disorder– Substance/Medication-Induced…, … Due to Another Medical

Condition

– Other Specified…; Unspecified…

Anxiety Disorders, cont.• Major changes.

– DSM-IV Anxiety Disorders separated into three groups: • Anxiety Disorders (excessive fear and anxiety and

related behavioral disturbances); • Obsessive Compulsive and Related Disorders

(preoccupations and repetitive behaviors or mental acts in response to preoccupations);

• Trauma- and Stressor-Related Disorders (exposure to traumatic or stressful event leading to psychological distress of varying kinds). Sequential ordering reflects close relationship among these disorders.

Anxiety Disorders, cont.• Anxiety disorders differ from developmentally normative

fear/anxiety by being excessive or persisting beyond developmentally appropriate period.

• Anxiety disorders differ from transient fear/anxiety, often stress induced, by being persistent, though the > 6 month duration is a guide with some flexibility (shorter in children)

• Since people with anxiety disorders typically overestimate the danger in situations they fear/avoid, determination of excessive is made by clinician, considering cultural factors.

• Separation Anxiety Disorder and Selective Mutism moved from DSM-IV childhood disorders group and placed into Anxiety Disorders group.

Anxiety Disorders, cont.• Major changes, cont.

– Panic Disorder and Agoraphobia are diagnosed separately (unlinked) with separate criteria.

– Panic attacks may be added as a specifier to other DSM-5 disorders, e.g., depressive, bipolar, eating, psychotic, OCD.

– Panic Disorder requires 1 month of either persistent worry about additional panic attack OR a significant maladaptive change in behavior related to the attacks (e.g., designed to avoid having a panic attack, such as avoiding exercise, unfamiliar situations).

– Agoraphobia requires fears of > 2 situations—open spaces, public transportation, enclosed spaces, standing in a line or being in a crowd, or being outside of home.

Separation Anxiety & Selective Mutism– Changes to Separation Anxiety Disorder:

• Diagnosis applies to all ages. Typical onset is in childhood, yet it can persist into adulthood.

• Duration of the symptoms is specified as typically lasting at least 4 weeks in children and 6 months or more in adults

• Specifier of early onset before the age of 6 was eliminated

• Descriptions of age-related functional consequences and risk factors are provided.

– Changes to Selective Mutism• Applies to all ages, wording changed to “failure to speak

in specific social situations”

• Considered a precursor to Social Anxiety Disorder; can also be comorbid

Obsessive Compulsive and Related Disorders

• Disorders in this group.– Obsessive-Compulsive Disorder– Body Dysmorphic Disorder– Hoarding Disorder– Trichotillomania (Hair-Pulling Disorder)– Excoriation (Skin-Picking) Disorder– Substance/Medication-Induced…

– …Due to Another Medical Condition

– Other Specified…

– Unspecified…

Obsessive Compulsive and Related Disorders, cont.

• Major changes.– Separated from DSM-IV Anxiety Disorders.– Body Dysmorphic Disorder moved to this group

from DSM-IV Somatoform Disorders.– Trichotillomania order moved from DSM-IV

Impulse Control Disorders.– Hoarding Disorder added.– Skin-Picking Disorder added.

Obsessive Compulsive and Related Disorders, cont.

• Major Changes.– Specifiers

• Insight specifiers reflect full range of insight from good/ fair insight to poor insight to absent insight/delusional beliefs. No longer necessary to add diagnosis of delusional disorder. (applies to OCD, Hoarding, Body Dysmorphic Disorders.)

• With muscle dysmorphia (for Body Dysmorphic Disorder) preoccupation with the idea that body build is too small or insufficiently muscular.

• Tic-related (for OCD).

• With excessive acquisition (for Hoarding Disorder).

Trauma- and Stressor-Related Disorders

• Disorders in this group.– Reactive Attachment Disorder– Disinhibited Social Engagement Disorder– Posttraumatic Stress Disorder– Acute Stress Disorder– Adjustment Disorders– Other Specified Trauma- and Stressor-Related

Disorder– Unspecified Trauma- and Stressor-Related Disorder– [DESNOS not in DSM-5]

Trauma- and Stressor-Related Disorders• Major changes.

– Wide range of reactions to trauma and stress. Sometimes responses can be understood in the context of anxiety and fear. For other people the most prominent symptoms are anhedonic and dysphoric, externalizing angry and aggressive, dissociative, or some combination (with or without anxiety and fear). Because of this range of reactions, these disorders were placed in their own group based on precipitants rather than symptoms.

– Reactive Attachment Disorder moved to this group and Disinhibited Social Engagement added.

Trauma- and Stressor-Related Disorders• Major Changes.

– Adjustment Disorders moved to this group.– Different set of PTSD criteria for children < 6.– Sexual violence specifically included as a trauma.

Definition of trauma for PTSD and ASD are more explicit and no longer require reaction of intense fear, helplessness, or horror .

– Four symptom clusters for PTSD (3 clusters in DSM-IV): Re-experiencing and intrusive symptoms; Avoidance; Arousal and reactivity; Negative alterations in cognitions and mood added.

Trauma- and Stressor-Related Disorders• PTSD & ASD—Traumatic event:

– Exposure to actual or threatened death, serious injury, or sexual violence in > 1 of the following ways:

• Directly experiencing the traumatic event(s).

• Witnessing, in person, the event(s) as it occurred to others.

• Learning that the traumatic event(s) occurred to a close family member or close friend. In cases of actual or threatened death of a family member or friend, the event(s) must have been violent or accidental.

• Experiencing repeated or extreme exposure to aversive details of the traumatic event(s).

– Note: Criterion A4 does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.

PTSD in Children (6 or younger)• Criteria for Exposure almost identical to adults w/

changes in wording to match age & developmental level. – Vicarious: Learning that a trauma occurred “to a parent or caregiver”

acceptable,

– learning by electronic media does not meet diagnostic criteria

• Reacting with intense fear, helplessness or horror was omitted (Preschool kids react to trauma on a continuum from distress to overbright and “helplessness or horror ” not clear in young children)

• “in children traumatic reactivity may be expressed by disorganized or agitated behavior” was omitted, unclear open for question what constitutes disorganized or agitated behavior in children under the age of 6.

PTSD in Preschoolers, cont’d• Presence of 1 or more intrusive symptoms

– Reenactment as a symptom of re-experiencing in DSM IV was identified as “Repetitive behavior.” In DSM-5 it was replaced by “play reenactment”

– Dissociative reactions ( flashbacks in young children) do occur on a continuum from trauma-specific reenactment play, to blocking eyes & ears, to loss of awareness of present surroundings.

– Marked physiological arousal to reminders of the traumatic event or intense & prolonged psychological distress to internal or external cues symbolizing some aspect of the trauma also are seen in young children

PTSD in Preschoolers, cont’d

• Lower symptom threshold; only 1 sx from either:– Persistent Avoidance

• avoidance of or efforts to avoid people, or interpersonal situations, or avoidance of places and activities assoc. w/ the trauma

• “inability to recall important aspects of the trauma and sense of foreshortened future” was omitted, isn’t applicable to < 6.

– Negative Alterations in Mood and Cognition• Addition of “constriction of play” to “marked, diminished

interest or participation in significant activities”

• “detachment or estrangement” replaced w/social withdrawal

• Substantial increased frequency of negative emotional states and decreased frequency in positive emotional states.

PTSD in Preschoolers, cont’d• “Negative alterations in cognition or mood” with

the condition “that increases after the traumatic experience”

• Changes to Increased Arousal:– Adding to the “extreme temper tantrums in young

children” the clarification of a departure from the norm. (“extreme tantrums have to be new for the child or onset after the trauma or worsened after the trauma” to be counted in the criteria for the DSM-5)

• Distress/impairment is anchored in relationships with parents, peers or caregivers or in school behavior

Trauma- and Stressor-Related Disorders• Reactive Attachment Disorder

– The two subtypes in DSM IV – inhibited and disinhibited- have been conceptualized as trauma-related and transformed into 2 separate disorders- one internalizing & one externalizing.

• In DSM-5 the dx of RAD is essentially the inhibited type and the new dx of Disinhibited Social Engagement Disorder ( (formerly the disinhibited type) but conceptualization changed to violations in boundaries

– Cause of disorders unchanged. Both disorders are presumably caused by insufficient care, comfort and affection or from neglect and deprivation.

Reactive Attachment Disorder

• The child rarely seeks comfort when distressed and shows emotional distress when others attempt to provide comfort evident before age 5, develop = 9 mos.

• Persistent social/emotional disturbance in at least 2:

– Minimal social and emotional responsiveness

– Limited positive affect

– Unexplained irritability, sadness, or fearfulness evident during nonthreatening interactions with caregivers

• Duration > 1 yr; severe if all sxs present & at high levels

Disinhibited Social Engagement Disorder

• The child is overly familiar with strangers and does not hesitate to leave familiar caregivers

• Has loose boundaries with people, reduced or absent reticence in approaching unfamiliar adults

• Doesn’t check back with caregiver after venturing away• Behavior patterns not limited to impulsivity but also

include socially disinhibited behavior• Pathogenic care is presumed to be responsible

• Child has developmental level of at least 9 months• Specifier of Persistent if duration > 12 months.

Trauma- and Stressor-Related Disorders

• Adjustment Disorders.– While criteria essentially unchanged, adjustment

disorders are now conceptualized as a diverse array of stress-response syndromes that occur after exposure to a distressing (either traumatic or non-traumatic) event, rather than as a residual category for individuals who exhibit clinically significant distress but whose symptoms do not meet criteria for a more discrete disorder (as in DSM-IV).

Feeding and Eating Disorders• Category includes the following disorders and

presentations across the lifespan – Pica– Rumination Disorder– Avoidant/Restrictive Food Intake Disorder (this was

Feeding Disorder of Infancy yet with changes in conceptualization - lifespan, restricted intake w/out body image distortions, orthorexia …)

– Anorexia– Bulimia – Binge Eating Disorder ( has been in the Appendix of

DSM IV), in DSM-5 included as a coded diagnosis

Disruptive, Impulse Control, and Conduct Disorders

• Includes– Oppositional Defiant Disorder– Conduct Disorder– Intermittent Explosive Disorder– Antisocial Personality Disorder (this disorder is also

included and criteria listed in the Personality Disorders Grouping)

– Pyromania– Kleptomania– Other Specified and Unspecified Disorders

• ODD minor changes only- symptom criteria “grouped” by behaviors (argumentative/defiant), emotions (angry, irritable mood), or vindictiveness.– The grouping has some discriminative validity for determining

other disorders (i.e. mood) that can be comorbid or are moving in direction of comorbidity.

– Symptoms must be observed toward others who are not siblings and fall outside a range that is normative for developmental level, gender and culture.

– Specifiers for current severity have been added (mild, moderate, severe) and are based on the number of settings (1, 2, 3 or more) in which symptoms are present

– ODD and CD comorbidity allowed in DSM-5

Changes to Oppositional Defiant Disorder & Conduct Disorder

New Specifier for CD “With LimitedProsocial Emotions”

• To qualify for this specifier, the individual– Must have displayed at least 2 of the following

characteristics persistently over at least 12 months and in multiple relationships and settings. ( Multiple information sources are necessary)

• Lack of remorse or guilt

• Callous – lack of empathy (unconcerned about his/her impact on others even when results in substantial harm to others)

• Unconcerned about performance at school, work, or other activity

• Shallow or deficient affect (insincere, used to manipulate)

Rationale for the New Specifier • CD classification in DSM IV represents a

heterogeneous group ( severity, course & etiology)– Research into psychopathy has highlighted 3 “traits”

• behavior (i.e. severe aggression, destructive)

• affect (lack of empathy, shallow) and

• interpersonal (using others for own gain )

– Research findings for > 20 yrs indicate that individuals displaying the affect and interpersonal traits differ from those primary displaying behaviors w/ respect to course of the disorder and response to treatment

• Interpersonal could be subdivided into callous-unemotional, narcissistic & impulsive with the callous-unemotional predictive of severe & prolonged antisocial pathology.

Intermittent Explosive Disorder• Changes/Additions to Criteria

– Frequency of 2x a week, on average for a period of 3 months without damages to people, animals or property; if damages, frequency of 3 times in 12 mos.

– Aggressive outbursts are not premediated ; they are anger-based with no tangible objective

– Outbursts cause distress to the individual (interpersonal, financial or otherwise)

– Must be at least 6 years old or developmental equivalent – r/o aggressive behavior during Adjustmt Dis in 6-18 y.o.

• Exclusion Added: DMDD supersedes I.E.D.

Substance Use and Addictive Disorders• Disorders in this group:

– Substance Use Disorders.– Substance Induced Disorders

• Intoxication.

• Withdrawal.

• Other Substance Induced Disorders (psychotic disorders, bipolar and related disorders, depressive disorders, anxiety disorders, obsessive-compulsive and related disorders, sleep disorders, sexual dysfunctions, delirium, and neurocognitive disorders). Described in group with disorders with which they share phenomenology.

– Gambling Disorder

Substance Use and Related Disorders, cont.• Major changes.

– Collapses abuse and dependence into a single diagnosis “Substance Use Disorder” (e.g., Cocaine Use Disorder, Alcohol Use Disorder)

• Abuse & dependence seen as a single disorder with a continuum of severity. Severity specifier: Mild = 2-3, Moderate = 4-5, Severe > 6 symptoms.

– Dependence and Abuse symptoms combined. Craving added as symptom, and recurrent legal problems deleted.

– Adds criteria for Cannabis Withdrawal.

– Gambling (moved from impulse control disorder).

Neurocognitive Disorders• Disorders in this group

– Neurocognitive Domains– Delirium– Other Specified Delirium– Unspecified Delirium– Major and Mild Neurocognitive Disorders

• Specify underlying pathology, where known, e.g., Major or Mild Neurocognitive Disorder due to Alzheimer’s Disease.

– Criteria for Delirium are quite similar to DSM-IV. Changes clarify some criteria.

Neurocognitive Disorders, cont.• Major changes.

– Group renamed. Replaces DSM-IV, Dementia, Delirium, Amnestic, and Other Cognitive Disorders.

– Disorders in this group attributable to changes in brain structure, function, or chemistry. Etiologies will be coded as subtypes, e.g., Alzheimer’s.

– “Dementia is subsumed under the newly named entity major neurocognitive disorder, although the term dementia is not precluded from use in the etiological subtypes in which that term is standard.”

– Mild neurocognitive disorder added—similar to Mild Cognitive Impairment (MCI).

Neurocognitive Disorders, cont.• Domains of cognitive function. (Note: domains not

entirely independent, boundaries are indistinct, variable definitions in literature):– Complex attention (ability to sustain, divide, &

selectively focus attention; processing speed)

– Executive function (planning, decision making, working memory, responding to feedback/error correction, over-riding habits/inhibition, mental flexibility)

– Learning & memory (immediate & recent memory [includes both free & cued recall, recognition memory], very long-term memory, implicit learning)

Neurocognitive Disorders

• Domains of cognitive functioning, cont.– Language (expressive language [including naming,

word finding, fluency, grammar, & syntax] and receptive language)

– Perceptual-motor (includes abilities subsumed under visual perception, visuo-constructional, perceptual-motor, praxis, and gnosis)

– Social cognition (recognition of emotions, theory of mind)

Neurocognitive Disorders, cont.• Major neurocognitive disorder.

– Evidence of significant cognitive decline [distinguishes from neurodevelopmental disorders] from a previous level of performance in one or more cognitive domains based on:

• Concern of the individual, a knowledgeable informant (e.g., family member, caregiver), or the clinician that there has been a significant decline in cognitive function; and

• A substantial impairment in cognitive performance.

– The cognitive deficits interfere with independence in everyday activities (IADL’s) (i.e., the individual requires assistance in performing complex IADL’s).

Neurocognitive Disorders, cont.• Mild Neurocognitive Disorder

– Evidence of modest cognitive decline from a previous level of performance in one or more cognitive domains…

– The cognitive deficits do not interfere with capacity for independence in everyday activities (i.e., complex IADL’s are preserved, but greater effort, compensatory strategies, or accommodation may be required).

• Specifiers for Neurocognitive Disorders.– With or Without Behavioral Disturbance.– Severity– Presumed etiology.

Personality Disorders• Personality disorders are listed in two sections.

– “The criteria for personality disorders in Section II have not changed from those in DSM-IV.”

– Section III includes the alternative dimensional model for personality disorders. This model, an alternative to the categorical approach, reflects a dimensional perspective that personality disorders represent maladaptive variants of personality traits that merge imperceptibly into normality and into one another.

– Personality Change due to Another Medical Condition added to group.

Gender Dysphoria• “Gender dysphoria refers to the distress that may

accompany the incongruence between one’s experienced or expressed gender and one’s assigned gender….Gender assignment refers to the initial assignment , usually at birth, as male or female….Many are distressed if the desired physical interventions by means of hormones or surgery are not available. The current term is more descriptive than the previous DSM IV term, gender identity disorder, and focuses on dysphoria as the clinical problem, not identity per se.” (DSM-5, p.451)

Gender Dysphoria, cont.• Gender Dysphoria can be diagnosed in children,

adolescents and adults if it causes significant distress to the individual.

• Gender Identity Disorder has been eliminated – desire is to reduce stigma and retain coverage for

treatment yet insurance companies may refuse to pay if the word “disorder” is omitted.

• Gender nonconformity itself is not considered to be a mental disorder.

• Instead of the wording “the other sex”, the wording “some alternative gender” is used.