DSM-5 No Roman numerals Changes/Updates - 5.1, 5.2 … Print and electronic versions Severity scales - more specific Suicide risk will be discussed with many diagnoses Cultural context emphasized- section 3 - chapter on cultural formulation; structured interview Implementation date unclear- ICD 10 DSM-5 websites: www.dsm5.org and www.psychiatry.org/dsm5

NOS Eliminated • Other specified disorder • Other unspecified disorder • Provisional diagnoses – time limited

Multiaxial System Eliminated • Axis I-V eliminated • GAF eliminated Psychosocial and environmental problems eliminated Contributing medical conditions eliminated • V Codes still available • Decision trees in an appendix eliminated • Lots of specifiers are available • Online assessment measures at www.psychiatry.org/dsm5 )

Diagnostic Groupings 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. Disruptive, Impulse Control, and Conduct Disorders 9. Personality Disorders

Neurodevelopmental Disorders Category includes: Intellectual Disability Communication Disorders Autism Spectrum Disorder ADHD Specific Learning Disorder Motor Disorders

Intellectual Disability IQ not the sole diagnostic criteria IQ typically below 70 Severity is based upon adaptive functioning and IQ score Replaces Mental retardation - DSM-IV Borderline Intellectual Functioning is a V code Assess functional ability in 3 domains: Conceptual-language, reading, writing, math, reasoning, knowledge, memory Social-empathy, social judgment, interpersonal communication skills, friendships Practical-personal care, job responsibilities, money management, recreation, organizing school and work activities

Communication Disorders Language Disorder Difficulties in acquisition and use of language Speech Sound Disorder (was Phonological Disorder) Childhood-Onset Fluency Disorder (was Stuttering) Social (Pragmatic) Communication Disorder (new) Persistent difficulties in the social use of verbal and nonverbal communication Autism

Autism Spectrum Disorders (ASD) Asperger’s, Childhood Disintegrative Disorder, Rett’s Disorder, and Pervasive Developmental Disorder (PDD) NOS will be eliminated

Autism Spectrum Disorders Three domains in DSM-IV - Two in DSM-5: DSM-IV: 1. Qualitative impairment in social interaction 2. Qualitative impairments in communication 3. Restricted repetitive and stereotyped, patterns of behavior, interests, and activities (RRB’s) DSM-5: 1. Social and communication deficits 2. Restricted repetitive behaviors, interests, and activities (RRB’s)

ADHD Age of onset of symptoms will be raised from age 7 to age 12 Must have several symptoms two or more settings Can now have a comorbid diagnosis with autism Fewer symptoms needed for adults (5 instead of 6 for both inattention and hyperactivity/impulsivity) Greater emphasis on identifying adults (but onset must still be before age 12) Symptom lists basically unchanged

Specific Learning Disorder Specifiers: Reading (dyslexia) Mathematics (dyscalculia) Written Expression

Schizophrenia Spectrum and Other Psychotic Disorders Schizotypal Personality Disorder (also listed under personality disorders) Delusional Disorder Brief Psychotic Disorder Schizophreniform Disorder Schizophrenia Schizoaffective Disorder

Schizophrenia Spectrum and Other Psychotic Disorders The 5 subtypes of schizophrenia have been dropped. Paranoid Disorganized Catatonic Undifferentiated Residual

Bipolar and Related Disorders Bipolar I Disorder Presence or history of one or more manic episodes, may also have episodes of depression or hypomania Bipolar II Disorder Presence or history of one or more major depressive episodes Presence or history of at least one hypomanic episode There has never been a manic episode Cyclothymic Disorder

Depressive Disorders • Category includes: • Disruptive Mood Dysregulation Disorder (new) • Major Depressive Disorder • Persistent Depressive Disorder (was Dysthymia) • Premenstrual Dysphoric Disorder (new)

Depressive Disorders • Core criteria are little changed from DSM-IV • Prevalence: • 12-month=7% • 18-29 year olds 3x risk of people over 60 • Females 1.5-3x greater risk than males • Anxious Distress specifier (negatively impacts prognosis) • Keyed up/tense • Unusually restless • Decreased concentration • Fear of something awful happening • Fear of losing control

Persistent Depressive Disorder (Dysthymia) Symptoms are a consolidation of chronic major depression and dysthymia Early or late onset (age 21 is dividing line) Prevalence 1%

Suicide Primary cause of psychiatric malpractice suits but discussed rarely in DSM-IV U.S. Preventive Services Task Force has determined that risk scales are not predictive of who will commit suicide Active suicidal ideation (SI) is no more predictive than passive SI When assessing risk look at: Long-term factors Recent factors (past 3 months) Current factors (past week)

Disruptive Mood Dysregulation Disorder New diagnosis Similar to Bipolar Disorder with extreme temper and rage, also similar to Oppositional Defiant Disorder, but more severe Prevalence 2-5%

Disruptive Mood Dysregulation Disorder Severe recurrent temper outbursts Verbal or behavioral Inconsistent with developmental level Mood between outbursts is persistently irritable or angry Present in at least 2 settings, severe in at least one Don’t diagnose before age 6 or after age18 Frequency of at least 3 times weekly Duration 12 months, no more than 3 months symptom-free

Premenstrual Dysphoric Disorder Symptoms usually begin during the week before the menstrual cycle starts and terminate with the onset of menses About 1.8-5.8% prevalence Must happen in at least two cycles

Anxiety Disorders PTSD and OCD no longer in this category Category includes: Separation Anxiety Disorder (can diagnose with adult onset) Selective Mutism Specific Phobia Social Anxiety Disorder (Social Phobia) Panic Disorder Panic Attack (now just a specifier) Agoraphobia (now a stand-alone diagnosis, doesn’t need to be linked with Panic Disorder) Generalized Anxiety Disorder

Trauma and Stressor-Related Disorders Category includes: Reactive Attachment Disorder Disinhibited Social Engagement Disorder PTSD Acute Stress Disorder Adjustment Disorders

Reactive Attachment Disorders Disorders develop out of insufficient care, comfort, and affection or neglect and deprivation, Reactive Attachment Disorder The child rarely seeks comfort when distressed and shows emotional distress when others attempt to provide comfort Minimal social and emotional responsiveness Limited positive affect Unexplained irritability, sadness, or fearfulness This is rare, affecting about 10% of severely neglected children

Disinhibited Social Engagement Disorder The child is overly familiar with strangers and does not hesitate to leave familiar caregivers The child has loose boundaries with people, little reticence with strangers Doesn’t check back with caregiver after venturing away This is rare, about 20% of severely neglected children

PTSD DSM-IV 3 symptom clusters – Re-experiencing – Avoidance and numbing – Arousal DSM-5 4 symptom clusters – Re-experiencing and intrusive symptoms – Avoidance – Arousal and reactivity – Negative alterations in cognitions and mood

Trauma and Stressor-Related Adjustment Disorders Begins within 3 months, lasts no longer than 6 months after the stressor has ceased Most symptoms are similar to DSM-IV Prevalence in outpatient mental health is 5-20% Acute Stress Disorder With Acute Stress Disorder early intervention can help prevent PTSD Only half of people with ASD develop PTSD. It’s not predictive.

Disruptive, Impulse-Control, and Conduct Disorders Trichotillomania and Gambling moved Category includes: Oppositional Defiant Disorder Intermittent Explosive Disorder (must be at least 18) Conduct Disorder Pyromania Kleptomania Antisocial Personality Disorder (dually listed here and in personality disorders section)

Limited Prosocial Emotions Specifier Specifier for use with Conduct Disorder Lack of remorse or guilt Unconcerned about performance Shallow or deficient affect Callous, lack of empathy Less sensitive to punishment cues Thrill-seeking, less inhibited More proactive and reactive aggression Traits can diminish when quality of parenting improves

Personality Disorders Cluster A (odd and eccentric): Paranoid Schizoid Schizotypal Cluster B (dramatic, emotional, erratic): Antisocial Borderline Histrionic Narcissistic Cluster C (anxious and fearful): Avoidant Dependent Obsessive-Compulsive (personality disorder, not OCD)