What has changed in the DSM-5? Jessica Shelton, M.S.Ed., LPC, LMFT June 4, 2015

Why were there changes in the first place? The new ICD-10 codes will be required in the U.S. as of 10/1/15 The DSM-IV used ICD-9 codes The DSM-5 includes both ICD-9 and ICD-10 codes to help with the transition period Increased call for standardization in diagnostic and research terminology Criteria is more objective to help bring consistency There have been many advances in research, especially in area of neuroscience, since the previous edition. Changes in understanding led to changes in diagnostic criteria

So what’s different? The title includes a numeral instead of a Roman numeral to facilitate more frequent updates instead of huge overhauls (i.e., DSM-5.1) The multi-axial system is different (Not everyone has converted to this yet) Axis I, II, and III are now combined The former Axis IV (psychosocial or environmental factors) may still be noted The former Axis V Global Assessment of Functioning (GAF) scale is gone; the World Health Organization Disability Assessment Schedule (WHODAS) is to be used instead

So what’s different? Section I of the DSM-5 contains overview information and instructions on using the manual Section II includes the diagnoses and their criteria Section III of the DSM-5 includes assessments to be used by clinicians, including the WHODAS Not all assessments were included. More can be found online, along with supplemental diagnostic information This section also contains information on cultural considerations in diagnosing mental illness and a list of possible future disorders (Internet Gaming Disorder, Nonsuicidal Self-Injury, etc.)

So what’s different? Many chapters have a Dx for “Substance/Medication-Induced ______ Disorder” and “______ Disorder Due to Another Medical Condition,” rather than these disorders being listed in their own chapter “Not Otherwise Specified” is no longer an option: “Other Specified Disorder” – when the client does not meet full criteria for the disorder, the clinician can specify with this Dx and the reason the full Dx is not met “Unspecified Disorder” – when the client does not meet the full criteria and the clinician does not want to specify why the Dx is not met

So what’s different? Diagnoses were added, deleted, reorganized, or had diagnostic criteria changed Subtypes – used to differentiate among mutually exclusive Dx Ex. – AD/HD predominantly inattentive, predominantly hyperactive/impulsive, or combined Specifiers – used to describe the Dx further (not mutually exclusive) Ex. – In partial remission Note: many codes for subtypes and specifiers are not coded in ICD 9 or 10

DSM-IV Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence Chapter is now called Neurodevelopmental Disorders Includes Intellectual Disabilities, Communication Disorders, ASD, AD/HD, Specific Learning Disorder, and Motor Disorders Mental Retardation is now called Intellectual Disability Expressive Language Disorder and Mixed Receptive-Expressive Language Disorder have been combined into Language Disorder Phonological Disorder is now called Speech Sound Disorder Stuttering is now called Childhood-Onset Fluency Disorder

DSM-IV Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence New Dx: Social Communication Disorder May encompass many of those formerly diagnosed with Pervasive Developmental Delay NOS Autism, Childhood Disintegrative Disorder, Asperger’s, and PDD NOS have been combined into Autism Spectrum Disorder (ASD) Biological causes such as Down Syndrome or Rett Syndrome are specifiers AD/HD criteria have changed slightly

DSM-IV Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence Reading, Mathematics, Written Expression, and Learning Disorders are now all called Specific Learning Disorder Type is listed as a specifier Motor Disorder still includes Developmental Coordination Disorder but now also includes Stereotypic Movement Disorder and Tic Disorders (Tourette’s, Persistent Motor or Vocal Tic Disorder, and Provisional Tic Disorder)

DSM-IV Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence Conduct Disorder and Oppositional Defiant Disorder moved to a new chapter called Disruptive, Impulse-Control, and Conduct Disorders Joins with some of the disorders from the DSM-IV chapter called Impulse-Control Disorders Not Elsewhere Classified: Intermittent Explosive Disorder, Pyromania, and Kleptomania Pathological Gambling is now called Gambling Disorder and was moved from this DSM-IV chapter to the chapter now called Substance-Related and Addictive Disorders Trichotillomania is in a new chapter called Obsessive-Compulsive and Related Disorders, along with OCD, Body Dysmorphic Disorder, Hoarding Disorder, and Excoriation

DSM-IV Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence Elimination Disorders (encopresis and enuresis) moved to their own chapter Pica, Rumination Disorder, and Feeding Disorder of Infancy or Childhood (now called Avoidant/Restrictive Food Intake Disorder) joined Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder in the chapter now called Feeding and Eating Disorders

DSM-IV Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence Separation Anxiety Disorder and Selective Mutism moved to the Anxiety Disorders chapter, along with Specific Phobias, Social Anxiety Disorder, Panic Disorder, Agoraphobia (now its own Dx), and Generalized Anxiety Disorder The two subtypes of Reactive Attachment Disorder were made separate diagnoses (RAD and Disinhibited Social Engagement Disorder); they moved to a new chapter called Trauma- and Stressor-Related Disorders, along with PTSD, Acute Stress Disorder, and Adjustment Disorders

DSM-IV Delirium, Dementia, and Amnestic and Other Cognitive Disorders Now called Neurocognitive Disorders, and is one of the last chapters instead of one of the first Delirium criteria have been mildly updated Dementia and Amnestic Disorder are now together as Major or Mild Neurocognitive Disorder There are criteria for the specifiers (Alzheimer’s, Vascular, Parkinson’s, etc.)

DSM-IV Substance-Related Disorders This chapter is now called Substance-Related and Addictive Disorders Includes Gambling Disorder (with more non-substance addictions likely to follow as research grows) Polysubstance Dx has been removed; diagnose multiple substances separately Physiological specifier has been removed Can specify if client is in a controlled environment, or if they are on maintenance therapy

DSM-IV Substance-Related Disorders The DSM-IV diagnoses of Substance Abuse and Substance Dependence are gone; the new Dx is Substance Use Disorder Depending on the number of criteria endorsed, Dx is listed as mild, moderate, or severe Criteria groups include impaired control, social impairment, risky use, and pharmacological criteria (tolerance and withdrawal) At least 2 criteria are now required instead of 1 Recurrent legal trouble was removed; craving was added

DSM-IV Substance-Related Disorders Covers 10 classes of drugs: alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedatives/hypnotics/anxiolytics, stimulants, tobacco, and other (or unknown) The diagnoses are made depending on class of drugs (i.e., Alcohol Use Disorder, Caffeine Withdrawal, etc.) Use the specific substance in the name of the Dx, not the class name (i.e., Secobarbital Use Disorder, not Sedatives/Hypnotics/Anxiolytics Use Disorder) Not all substance classes have each Dx (i.e., no Tobacco Intoxication)

DSM-IV Schizophrenia and Other Psychotic Disorders This chapter is now titled Schizophrenia Spectrum and Other Psychotic Disorders Schneiderian symptoms were removed due to the level of discrepancy in diagnosing, so now there must be at least two Category A symptoms, and one must be delusions, hallucinations, or disorganized speech The subtypes from DSM-IV have been removed; severity is to be listed and other specifiers (including catatonia) are available

DSM-IV Schizophrenia and Other Psychotic Disorders The other disorders in this chapter had some minor changes to diagnostic criteria: Delusional Disorder Brief Psychotic Disorder Schizophreniform Disorder Schizoaffective Disorder Catatonia

DSM-IV Mood Disorders This chapter has been divided into two: 1. Bipolar and Related Disorders Bipolar I Disorder Bipolar II Disorder Cyclothymic Disorder The DSM-IV diagnosis of Bipolar Disorder with Mixed Features is gone; now “mixed features” is a specifier

DSM-IV Mood Disorders 2. Depressive Disorders Disruptive Mood Dysregulation Disorder (new Dx) Major Depressive Disorder Persistent Depressive Disorder (formerly Dysthymia) Premenstrual Dysphoric Disorder (new Dx) The Bereavement exclusion has been removed There are specifiers for these diagnoses as well

DSM-IV Anxiety Disorders OCD, PTSD, and Acute Stress Disorder moved to other chapters Some of the diagnostic criteria have changed slightly Criteria that adult recognizes the anxiety as unreasonable or excessive has been removed Agoraphobia is now separate from Panic Disorder Panic attack categories have been simplified to “expected” or “unexpected” Selective Mutism and Separation Anxiety are in this chapter now

DSM-IV Somatoform Disorders New chapter is called Somatic Symptom and Related Disorders The number of diagnoses has been reduced to avoid overlap and erroneous diagnosis Somatization Disorder, Hypochondriasis, and Pain Disorder were removed Somatic Symptom Disorder is similar to Somatization Disorder, but there must be maladaptive thoughts, feelings, or behaviors related to the physical symptoms

DSM-IV Somatoform Disorders Those with previous Dx of Hypochondriasis would likely qualify for Illness Anxiety Disorder Dx Factitious Disorder went from being its own chapter to being included in Somatic Symptoms and Related Disorders New Dx: Psychological Factors Affecting Other Medical Conditions Ex. Anxiety affects course of asthma Conversion Disorder criteria only changed slightly Body Dysmorphic Disorder moved to Obsessive-Compulsive and Related Disorders chapter

DSM-IV Dissociative Disorders Dissociative Identity Disorder and Dissociative Amnesia had minor changes to their criteria DID includes that behaviors can be reported instead of just observed, and it discusses cultural relevance Dissociative Fugue is no longer a separate disorder but is a specifier for Dissociative Amnesia Depersonalization Disorder is now called Depersonalization/Derealization Disorder

DSM-IV Sexual and Gender Identity Disorders The three main sections of this chapter are now three separate chapters: Sexual Dysfunctions Paraphilic Disorders Gender Dysphoria

DSM-IV Sexual and Gender Identity Disorders Sexual Dysfunctions Gender-specific disorders have been added and subtypes/specifiers have changed Sexual Desire Disorder and Arousal Disorder in females in now called Female Sexual Interest/Arousal Disorder Vaginismus and Dyspareunia have been combined into Genito- Pelvic Pain/Penetration Disorder Gender Dysphoria is different from Gender Identity Disorder in that it’s not the mere incongruence in gender identity that is the Dx; it’s the dysphoria the person may experience

DSM-IV Sexual and Gender Identity Disorders Paraphilic Disorders DSM-5 makes a distinction between a paraphilia (an erotic preference that is consensual and does not cause distress) and a Paraphilic Disorder (either it causes distress for the individual or their partner or includes risk or harm, including breaking the law) The diagnosis names are now different (i.e. Fetishistic Disorder vs. Fetishism) All Paraphilic Disorders have the specifiers of “in a controlled environment” and “in remission”

DSM-IV Eating Disorders The chapter is now called Feeding and Eating Disorders Includes Pica, Rumination Disorder, and Feeding Disorder of Infancy or Childhood (now called Avoidant/Restrictive Food Intake Disorder) from Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence chapter in DSM-IV For Anorexia Nervosa, requirement of amenorrhea has been eliminated Binge Eating Disorder is now a full Dx For BED and Bulimia Nervosa, binge criteria changed from 2x/week over 6 months to 1x/week over 3 months

DSM-IV Sleep Disorders Now called Sleep-Wake Disorders Sleep disorders related to medical or mental conditions have been removed Ten diagnoses in this chapter: Insomnia Disorder Hypersomnolence Disorder Narcolepsy Breathing-Related Sleep Disorders Nightmare Disorder Circadian Rhythm Sleep-Wake Disorders Restless Leg Syndrome Non-REM Sleep Arousal Disorders REM Sleep Behavior Disorder Substance/Medication Induced Sleep Disorder

DSM-IV Impulse-Control Disorders Intermittent Explosive Disorder, Kleptomania, and Pyromania are in the new chapter called Disruptive, Impulse-Control and Conduct Disorders Conduct Disorder and Oppositional Defiant Disorder from Childhood/Infancy chapter moved here as well Criteria have been revised to be clearer Pathological Gambling is now Gambling Disorder in the Substance-Related and Addictive Disorders chapter Trichotillomania is in the Obsessive-Compulsive and Related Disorders chapter

DSM-IV Adjustment Disorders Adjustment Disorder is now found in the new Trauma and Stressor-Related Disorders chapter This new chapter also includes PTSD and Acute Stress Disorder from the former Anxiety Disorders chapter, as well as Reactive Attachment Disorder from the former Childhood chapter Disinhibited Social Engagement Disorder is a new Dx; was a subtype of Reactive Attachment Disorder in DSM- IV

DSM-IV Adjustment Disorders In both PTSD and Acute Stress Disorder, diagnostic criteria look at how the person experienced the trauma (directly, witness, etc.) In PTSD the diagnostic criteria went from 3 categories to 4 The subjective criteria in A2 has been removed

DSM-IV Personality Disorders Criteria for the disorders have not changed Some Personality Disorders are cross-listed Antisocial PD is also in the Disruptive, Impulse-Control, and Conduct Disorders chapter Schizotypal PD is also in the Schizophrenia Spectrum and Other Psychotic Disorders chapter

New DSM-5 Chapters Not Yet Covered Obsessive-Compulsive and Related Disorders Specifiers focus on insight, since that has implications for other diagnoses Tic-related specifier is also added due to high comorbidity Body Dysmorphic Disorder moved from Somatoform Disorders chapter Trichotillomania moved from Impulse Control Disorders Hoarding Disorder and Excoriation are new Dx

PHEW! Now we can see why people are dragging their heels to implement changes! What questions do you have?

References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, D.C.: Author. American Psychiatric Association. (2013). Highlights of changes from DSM-IV-TR to DSM-5. Retrieved from http://www.psychiatry.org/dsm5 American Psychiatric Association DSM-5 Development. (n.d.). Retrieved May 30, 2015, from http://www.dsm5.org/Pages/Default.aspx