1. D Green MD, Psychiatry Jan 6 2016 The DSM-5 Comparisons with the DSM-IV-R

3. Background 12 year process to create DSM-5 APA believes that DSM must evolve to reflect research advances Broad recognition that a too-rigid categorical system does not capture clinical experience or scientific observations Recognize also that the boundaries between many disorder “categories’ are more fluid over the life course and many symptoms assigned to one disorder may occur in many other disorders Argue for a more dimensional approach to mental disorders

4. Organization of DSM-5 Organized on developmental and lifespan basis Begins with diagnoses that manifest early in life (e.g. neurodevelopmental and schizophrenia spectrum and other psychotic disorders) Followed by diagnoses that more commonly manifest in adolescence and young adulthood (e.g. bipolar, depressive and anxiety disorders) and ends with diagnoses relevant to later life (e.g. neurocognitive disorders) Classification also based on internalizing (emotional and somatic) disorders and externalizing (antisocial, conduct, addictions, and impulse control) disorders

5. Multiaxial system DSM-5 noted multiaxial system was not required to make a mental disorder diagnosis DSM-5 has moved to a nonaxial documentation of diagnosis (formerly Axis I, II and III) with separate notations for important psychosocial factors (formerly Axis IV) and disability (formerly Axis V) GAF score dropped and replaced with WHODAS (for further study)

7. Neurodevelopmental disorders Term Intellectual disability replaces mental retardation Autism spectrum disorder encompasses DSM-IV autistic disorder (autism), Asperger’s disorder, childhood disintegrative disorder and pervasive developmental disorder and are defined by: 1. Deficits in social communication and social interaction 2. Restricted repetitive behaviours, interests and activities

8. Neurodevelopmental disorders ADHD Diagnostic criteria are similar Onset criteria as been changed from “symptoms that caused impairment before age 7 years” to several inattentive or hyperactive-impulsive symptoms were present prior to age 12” Symptom threshold for adults of 5 vs. 6 for younger persons

9. Schizophrenia Spectrum and Other Psychotic Disorders Removal of DSM-IV Criterion A special attribution of bizarre delusions and Schneiderian first-rank auditory hallucinations (e.g. two or more voices conversing) Addition of requirement in Criterion A that the individual must have at least one of these three symptoms: delusions, hallucinations, and disorganized speech

10. Schizophrenia Spectrum and Other Psychotic Disorders DSM-IV subtypes of schizophrenia (paranoid, disorganized, catatonic, undifferentiated, and residual) have been eliminated Delusional disorder diagnosis no longer requires that delusions be non-bizarre

11. Bipolar and related disorders Criterion A for manic and hypomanic episodes now includes an emphasis on changes in activity and energy as well as mood DSM-IV diagnosis of bipolar I disorder, mixed episode requiring that the individual simultaneously meet full criteria for both mania and major depressive episode, has been removed, and replaced with specifier “with mixed features”

12. Depressive Disorders DSM-5 contains several new depressive disorders: Disruptive mood dysregulation disorder Used for children up to age 18 who exhibit persistent irritability and frequent episodes of behavioural dyscontrol Premenstrual dysphoric disorder New term Persistent depressive disorder includes and replaces chronic major depressive disorder and dysthymic disorder

13. Depressive Disorders Major Depressive Disorder Bereavement exclusion (applied to depressive symptoms lasting less than 2 months following the death of a loved one) has been eliminated Why? 1. Bereavement lasts longer than 2 months 2. Bereavement is recognized as a severe psychosocial stressor that can precipitate a MDE 3. Likely to occur in individuals with past personal and family histories of MDEs 4. Depressive symptoms associated with bereavement respond to the same psychosocial treatments as non-bereavement-related major depressive episodes

14. Anxiety Disorders No longer includes obsessive-compulsive disorder or posttraumatic stress disorder and acute stress disorder Panic disorder and agoraphobia are unlinked Recognizes that a substantial number of individuals with agoraphobia do not experience panic symptoms Separation anxiety disorder is now classified as an anxiety disorder

15. Obsessive-compulsive and Related Disorders New category in DSM-5 New disorders include:  Hoarding disorder  Excoriation (skin-picking) disorder  Substance-/medication-induced  Due to another medical condition  Trichotillomania moved from impulse-control disorders to this category  Body dysmorphic disorder moved from Somatoform disorders ( a chapter that no longer exists) in DSM-IV

16. Trauma- and Stressor-Related Disorders Includes: Acute stress disorder Adjustment disorders Posttraumatic stress disorder Criterion A for Acute Stress Disorder and PTSD requires being explicit at to whether traumatic events were experienced directly, witnessed for experienced indirectly Criterion regarding subjective reaction to the traumatic event has been removed

17. Trauma- and Stressor-Related Disorders Now 4 symptom clusters in PTSD rather than 3 Avoidance/numbing cluster is divided into two distinct clusters: Avoidance Persistent negative alterations in cognition and mood Final cluster- alterations in arousal and reactivity- also includes irritable or aggressive behaviour and reckless or self- destructive behaviour

18. Somatic Symptom and Related Disorders Replaces Somatoform Disorders in DSM-IV Diagnoses of somatization disorder, hypochondriasis, and pain disorder have been removed Category includes:  Somatic symptom disorder (individuals with somatic symptoms plus abnormal thoughts, feelings and behaviours may or may not have a diagnosed medical condition)  Illness anxiety disorder  Conversion disorder  Psychological factors affecting other medical conditions  Factitious disorder

19. Feeding and Eating Disorders Core criteria for Anorexia Nervosa conceptually unchanged except requirement for amenorrhea has been eliminated For Bulimia Nervosa only change is reduction in the required minimum average frequency of binge eating from twice to once weekly Binge-Eating Disorder added

20. Gender Dysphoria New diagnostic class and emphasizes “gender incongruence” rather than cross-gender identification as was the case in the DSM-IV gender identity disorder (which was included in the chapter “Sexual and Gender Identity Disorders”) Unique condition in that it is a diagnosis made by mental health providers, although a large proportion of the treatment is endocrinological and surgical

21. Substance-Related and Addictive Disorders Gambling Disorder added DSM-5 does not separate the diagnoses of substance abuse and dependence Incorporates DSM-IV substance abuse and dependence into single list with two exceptions: Recurrent legal problems has been deleted Craving or strong desire to use has been added Mild (2-3 criteria), Moderate (4-5) and Severe (6 or more) severity Tobacco use disorder added

22. Neurocognitive Disorders DSM-IV diagnoses of dementia and amnestic disorder are subsumed under the newly named major neurocognitive disorder (NCD) Term dementia is not precluded from use in the etiological subtypes where that term is standard Recognizes also a less severe level of cognitive impairment, mild NCD

24. Personality Disorders Criteria for personality disorders in Section II of DSM-5 have not changed from those in DSM-IV An alternative approach was developed for DSM-5 for further study and can be found in Section III which has a greater emphasis on personality functioning and trait-based criteria

26. Thank you!