Tiffany Wynn, MA, PCC

Prescott College

August 2013

DSM-IV-TR to DSM-V; What you might want to know

Workshop for practitioners and students who are already familiar with the DSM-IV-TR. Including:

• Content

• Use

• Limitations

• Solely for the purpose of facilitating the first step in transitioning from DSM-IV-TR to DSM-V

• Disclaimer

Purpose

Conceptual Development

DSM-I Presumed Etiology

DSM-IIGlossary Definitions

DSM-IIIReconceptualizationExplicit Criteria

DSM-III-RCriteria Broadened

DSM-IVRequires Clinically

Significant Distress

Impairment

• New approaches considered

• Dimensional Spectra

• Developmental structures included

• Culture Included

• Impairment

• Considered a living document

• Intentional move away from expert consensus and relying more on empirical data

DSM-V

• High rates of comorbidity

• High use of NOS category

• Treatment non-specificity

• Inability to find laboratory markers/ tests

• DSM is starting to hinder research progress

Perceived shortcomings in DSM-IV

Multi-Axial Diagnosis

NO MORE

A mental disorder is a syndrome characterized by clinically significant disturbance in a individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.

Definition of a Mental Disorder

• Consider contextual information (course, differential), distress, clinical judgment, culture

• Diagnosis is given, DSM-V provides severity assessments that can help you differentiate and specify

• Apply codes and follow coding and recording procedures

• Develop a treatment plan and outcome monitoring approach

When making a diagnosis

DSM-IV- TR DSM-V

Disorders usually first diagnosed in childhood

Neurodevelopmental disorders

Delirium, Dementia, and Amnestic and other cognitive disorders

Schizophrenia Spectrum and other Psychotic Disorders

Mental Disorders due to e a general medical condition

Bipolar and related disorders

Mood disorders Depressive disorders

Anxiety disorders Anxiety disorders

Somatoform disorders Obsessive compulsive and related disorders

Factitious disorders Trauma and stressor-related disorders

Dissociative disorders Dissociative disorders

Sexual and gender identity disorders

Somatic symptom related disorder

Chapter Structure DSM-IV to V

DSM-IV- TR DSM-V

Eating disorders Somatic symptoms and related disorders

Sleep disorders Feeding and eating disorders

Impulse control not elsewhere classified

Elimination disorders

Adjustment disorders Sleep-Wake disorders

Personality disorders Sexual dysfunctions

Other conditions that may be a focus of clinical attention

Gender dysphoria

Disruptive, impulse control, conduct disorders

Substance related and addictive disorders

Personality disorders

Chapter Structure DSM-IV to V

DSM-IV- TR DSM-V

Paraphilic Disorders

Other disorders

Medication induced movement disorders and other adverse effects of medication

Other conditions that may be a focus of lcincial attention

Chapter Structure DSM-IV to V

DSM-IV-TR

• Total 172 specific mental disorders

DSM-V

• Total 157 specific mental disorders

Net Change

New Disorders

1. Social (pragmatic) Communication Disorder

2. Disruptive Mood Disorder

3. Premenstrual Dysphoric Disorder

4. Hoarding Disorder

5. Excoriation (Skin picking) Disorder

6. Disinhibited Social Engagement Disorder (split from RAD)

7. Binge eating disorder

8. Central Sleep Apnea (split from breathing related disorder)

9. Rapid Eye Movement Sleep Behavior Disorder

10.Restless Legs Syndrome (Dyssmnia NOS)

New and eliminated in DSM-V

New Disorders

11. Caffeine withdrawal

12. Cannabis Withdrawal

13. Major Neurocognitive Disorder with Lewy Body Disease (Dementia Due to Other Medical Conditions)

Eliminated Disorders

1. Sexual Aversion Disorder

2. Polysubstance-Related Disorder

New and eliminated in DSM-V

• Dissociative Disorders, there are however a number of changes made regarding increased awareness and acceptance of cultural and religiuos practices.

• Somatic Symptom and Related Disorders, medically unexplained symptoms and disorders

• Binge eating: IT has been elevated to the main body of the DSM-V and is under eating and feeding disorders

• Anorexia: no Longer requires amenorrhea

• Avoidant/ restrictive food intake disorder: This is the new name for what was feeding disorders of childhood

• Sleep wake disorders: primary insomnia renamed insomnia disorder, Rapid eye movement disorder and restless leggs syndrome moved to the main body of the DSM

I am not going to cover the following:

• Circadian Rhythm Sleep disorders

• Breathing Related Sleep Disorders

• Sexual Dysfunctions: Vaginismus and dyspareunia and merged into genito-pelvic pain penetration disorder

• Neurocognitive Disorders: replace dementia and has a newly added Mild NCD; NCD subtypes are now present frontotemporal dementia, Lewy bodies

• Paraphilic Disorders: separated into paraphilia's that do not involve non-consenting victims (transvestism) are not necessarily indicative of mental disorder…requires distress, impairment or abuse of non-consenting victim. Now has new specifier: in a controlled environment, in remission

I am not going to cover the following:

• Mental Retardation was renamed intellectual disability

• Greater emphasis on adaptive functioning deficits rather than IQ score

Intellectual Disability (Intellectual Developmental Disorder)

ASD replaces DSM-IV’s autistic disorder, Asperger’s disorder, childhood disintegration disorder, and pervasive developmental disorder not other wise specified

Autism Spectrum Disorder

• Age of onset was raised from 7 to 12 years

• Symptom threshold for adults age 17 years and older was reduced to five criteria

Attention deficit/ Hyperactivity Disorder

Now presented as a single disorder with specifies for: Reading, Writing and Mathematics

Specific Learning Disorder

Schizophrenia(Schizophrenia Spectrum and Other Psychotic Disorders)

• Elimination of special treatment of bizarre delusions and “Special” hallucinations in Criterion A

• At least one of two required symptoms to meet Criterion A must be delusions, hallucinations, or disorganized speech

• Deletion of specific subtypes

• Inclusion of increased energy. Activity as a Criterion A symptom of mania and hypomania

• Mixed Episode is replaced with mixed features• Specifier for manic, hypomanic and major depressive episodes

• With anxious distress also added as a specifier for bipolar and depressive disorders

Mania and Hypomania(Bipolar and Related Disorders)

• Newly added to DSM-V

Disruptive Mood Dysregulation Disorder (DMDD)

Anxiety Disorders• Separation of DSM-IV anxiety disorders chapter into four distinct chapters

• Anxiety can be a specifier code for most other disorders now

• Panic Attack Specifier: Now a specifier for any mental disorder

Obsessive Compulsive and Related Disorders

Hoarding Disorder• Newly added to DSM-V

Body Dysmorphic Disorder• Newly calssified as as an OCD-related disorder rather than a

somatic dosorder

~ All now include expanded specifiers to indicate degree of insight present(i.e. good or fair; poor, absent or delusional

• PTSD• Stressor Criterion is more explicit

• Expansion to four symptom clusters: intrusion symptoms, avoidance symptoms, negative alterations in mood and cognition and alterations in arousal and reactivity

• Separate criteria are now available for PTSD occurring in preschool-age children (6 and younger)

Trauma and Stress Related Disorders

RAD and DSED

• Reactive Attachment subtypes are now two distinct sdisorders• RAD

• Disinhibited Social Engagement Disorder

T & SR Disorders Continued

• Newly added separate diagnostic class

• Now includes two separate sets of diagnostic criteria for children and adult/adolescents

Gender Dysphoria

Provides more specific criteria to define types of outbursts and the frequency needed to meet threshold.

CANNOT diagnosis before age 6

Intermittent explosive disorder

Substance Use Disorder

• Consolidated substance abuse with substance dependence

• Will be coded with severity

• Removal of legal criteria for abuse diagnosis

• Added craving or strong desire or urge to use the substance

Substance-Related and Addictive Disorders

ALL 10 DSM-IV PDs remain intact, there is a shift to an alternate trait based approach to assessing personality and PDs that includes specific types.

This means features can be identified and present in any diagnostic conceptualization but do not necessarily require a diagnosis.

Personality Disorders

Tiffany Wynn, MA, PCC, NCC

twynn@prescott.edu

Skype: Tiffany_Wynn; Galloway, Ohio

Thank you!