1. Developmental Psychopathology
Clinical assessment I
dsm

2. Learning Objectives What does DSM stand for?
The characteristics of DSM
The evaluation of DSM
The history of DSM
The changes from DSM IV-TR to DSM 5

3. “Diagnostic and Statistical Manual of the American Psychiatric Association”

4. DSM Clinically derived classification system Categorical approach
“Statistical”
Consistent with the International Statistical Classification of Diseases and Related Health Problems (ICD)
Three major components:
The diagnostic classification
The diagnostic criteria sets
The descriptive text

5. Three Major Components
The diagnostic classification:
List of mental disorders
The diagnostic criteria sets:
Symptoms and durations necessary for diagnosis
Symptoms, disorders, and conditions that must not be present in order to qualify for a particular diagnosis.
The descriptive text:
Diagnostic features, associated features that support diagnosis
Gender, culture, and age features
Differential diagnosis
Risk and prognostic factors
Development and probable course of the disorder
Prevalence

6. Evaluation

7. Positive Evaluation Common diagnostic language
Facilitates communication
Structured set of rules for diagnosis
Biopsychosocial approach
Organizes data from multiple sources
Natural tendencies of humans to think in terms of categories

8. Negative Evaluation
Relatively little attention to what led to the problem
Categories may limit the information we seek, may not see individual’s strengths and weaknesses
Not adequately take into account the context in which a person is living
Having a fundamentally Euro-American outlook

9. Negative Evaluation-Cont.
Labeling:
Classifies disorders not people
Biased by labels
May influence how others perceive and react to the child/person with disorder
Stigma
Labels influence the perception of the person of himself/herself
Diagnoses can become internalized and affect an individual’s self-identity
Reluctance to seek help
Fears of exclusion for children and their parents/for person with disorder
A feeling of lower self-worth among children/ person with disorder

10. History

11. DSM Over Time 1952: DSM I 1968: DSM II 1980: DMS III 1987: DSM III-R
1994: DSM IV
2000: DSM IV-TR
2013: DSM 5

12. DSM I (1952)
The first official manual of mental disorders to focus on clinical utility
A glossary of descriptions of the diagnostic categories
All disorders with psychogenic origin or without clearly defined physical cause were considered as “reactions”
The use of the term “reaction” throughout DSM I reflected the influence of Adolf Meyer's psychobiological view

13. DSM I (1952)-Cont.
Very few classifications for the diagnosis of childhood problems:
Schizophrenic reaction:
Before puberty
Psychotic reactions
Manifestation of autism
Adjustment reaction:
Habit disturbance
Conduct disturbance
Neurotic traits

14. DSM II (1968) Similar to DSM I but elimination of the term “reaction”
Retaining the term “neurosis”
Both the DSM I and the DSM II reflected the predominant psychodynamic psychiatry with inclusion of biological perspectives
Provided brief descriptions of characteristic signs and symptoms of the disorders but no criteria as such
Problems with reliability

15. DSM III (1980)
A similar approach to the DSM II; but with some innovations;
Detailed description of major disorders
Observable diagnostic criteria for the various disorders
A multiaxial system: Evaluation of an individual in terms of several different domains of information
Better inter-rater reliability and evidence of predictive reliability

16. DSM III (1980)-Cont.
Specified a group of disorders as “usually first evident in infancy, childhood, or adolescence”
The psychodynamic or physiologic view was abandoned, in favor of a regulatory or legislative model
Many clinicians of the psychodynamic tradition objected to the atheoretical approach of the DSM-III and to the elimination of the term “neurosis”

17. DSM III-R (1987)
DSM III: Inconsistencies in the system and a number of instances in which the criteria were not entirely clear
A work group to revise DSM III
DSM III-R: The revisions and corrections of DSM III
Both the DSM III and the DSM III-R were criticized by some researchers, particularly regarding childhood diagnoses, due to limited evidence of validity

18. DSM IV (1994)
A comprehensive review of the literature to establish a firm empirical basis for making modifications
Data from researchers
Field trials relating diagnoses to clinical practice 
Numerous changes were made;
To the classification: Disorders were added, deleted, and reorganized
To the diagnostic criteria sets
To the descriptive text based on a careful consideration of the available research about the various mental disorders
A major change from previous versions was the inclusion of a clinical significance criterion

19. DSM IV-TR (2000) A “text revision” of the DSM-IV
The diagnostic categories and the vast majority of the specific criteria for diagnosis were unchanged
A five-part axial system:
Axis I: Clinical disorder or focus of treatment
Axis II: Mental retardation or personality disorders
Axis III: Relevant medical conditions
Axis IV: Psychosocial or environmental problems
Axis V: Global assessment of functioning (0-100)

20. DSM 5 (2013) Revision to the DSM IV-TR
The Roman numerals numbering system has been discontinued to allow for greater clarity in regard to revision numbers
Multiaxial diagnosis system is no longer used
Axes 1-3 are combined
Subtypes, severity and specifiers are added
Personality traits are added

21. The changes from DSM IV-TR to DSM V Specific To The Disorders

22. Anxiety Disorders Agoraphobia Specific Phobia
Social Anxiety Disorder (Social Phobia)
Panic Attack
Panic Disorder (and Agoraphobia)
Separation Anxiety Disorder
Selective Mutism

23. Anxiety Disorders No inclusion of;
Obsessive-compulsive Disorder (which is included under the heading of the “Obsessive-compulsive and Related Disorders”)
Posttraumatic Stress Disorder (which is included under the heading of the “Trauma- and Stressor-related Disorders”)
Acute Stress Disorder (which is included under the heading of the “Trauma- and Stressor-related Disorders”)

24. Agoraphobia, Specific Phobia, and Social Anxiety Disorder (Social Phobia)
Deletion of the requirement that individuals over age 18 years should recognize that their anxiety is excessive or unreasonable
The anxiety must be out of proportion to the actual danger or threat in the situation, after taking cultural contextual factors into account.
The 6-month duration, which was limited to individuals under age 18 in DSM IV, is now extended to all ages.
Can be referred to as specifiers.

25. Social Anxiety Disorder (Social Phobia)
The “generalized” specifier has been deleted and replaced with a “performance only” specifier.
The DSM IV generalized specifier was problematic in that “fears include most social situations” was difficult to operationalize.
Individuals who fear only performance situations (i.e., speaking or performing in front of an audience) appear to represent a distinct subset of social anxiety disorder in terms of etiology, age at onset, physiological response, and treatment response.

26. Panic Attack
The complicated DSM IV terminology for describing different types of panic attacks (i.e., situationally bound/cued, situationally predisposed, and unexpected/uncued) is replaced with the terms
Panic attacks: Marker and prognostic factor for severity of diagnosis, course, and comorbidity across an array of disorders, including but not limited to anxiety disorders.

27. Panic Disorder and Agoraphobia
Panic disorder and agoraphobia are unlinked in DSM 5.
Thus, the former DSM IV diagnoses of panic disorder with agoraphobia, panic disorder without agoraphobia, and agoraphobia without history of panic disorder are now replaced by two diagnoses, panic disorder and agoraphobia, each with separate criteria.
Due to recognition that a substantial number of individuals with agoraphobia do not experience panic symptoms.
The co-occurrence of panic disorder and agoraphobia is now coded with two diagnoses.
Endorsement of fears from two or more agoraphobia situations is now required for distinguishing agoraphobia from specific phobias.
The criteria for agoraphobia should be consistent with criteria sets for other anxiety disorders (e.g., clinician judgment of the fears as being out of proportion to the actual danger in the situation, with a typical duration of 6 months or more).

28. Separation Anxiety Disorder
DSM IV: Under the section “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence”
DSM 5: Classified as an anxiety disorder.
The wording of the criteria has been modified to more adequately represent the expression of separation anxiety symptoms in adulthood.
The diagnostic criteria no longer specify that age at onset must be before 18 years
Because a substantial number of adults report onset of separation anxiety after age 18.
A duration criterion—“typically lasting for 6 months or more”—has been added for adults

29. Selective Mutism
DSM IV: Under the section “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence”
DSM 5: Classified as an anxiety disorder.
Because a large majority of children with selective mutism are anxious.

30. Mood Disorders
Distinction between “Depressive Disorders” and “Bipolar and Related Disorders”

31. Depressive Disorders Several new depressive disorders
Disruptive Mood Dysregulation Disorder
Premenstrual Dysphoric Disorder
For children up to age 18 years who exhibit persistent irritability and frequent episodes of extreme behavioral dyscontrol
Premenstrual Dysphoric Disorder (PMDD)
It has been moved from DSM IV Appendix B, “Criteria Sets and Axes Provided for Further Study,” to the main body of DSM 5.
A condition in which a woman has severe depression symptoms, irritability, and tension before menstruation.
The symptoms of PMDD are more severe than those seen with premenstrual syndrome (PMS).

32. Depressive Disorders-Cont.
DSM 5 conceptualizes chronic forms of depression in a somewhat modified way.
Dysthymia in DSM IV now falls under the category of “Persistent Depressive Disorder”
Persistent Depressive Disorder
Chronic major depressive disorder
Dysthymic disorder
Their combination with specifiers included to identify different pathways to the diagnosis and to provide continuity with DSM IV.

33. Depressive Disorders-Cont.
Major Depressive Disorder
No changes:
The core criterion symptoms
The requisite duration of at least 2 weeks
The coexistence within a major depressive episode of at least three manic symptoms (insufficient to satisfy criteria for a manic episode) is now acknowledged by the specifier “with mixed features.”
Can be applied to episodes of mania or hypomania when depressive features are present, and to episodes of depression in the context of major depressive disorder or bipolar disorder when features of mania/hypomania are present

34. Depressive Disorders-Cont.
The omission of the bereavement exclusion
Exclusion criterion for a major depressive episode that was applied to depressive symptoms lasting less than 2 months following the death of a loved one
Because;
Bereavement is more commonly lasted for 1–2 years.
A severe psychosocial stressor that can precipitate a major depressive episode in a vulnerable individual, generally beginning soon after the loss.
An additional risk for suffering, feelings of worthlessness, suicidal ideation, poorer somatic health, worse interpersonal and work functioning, and an increased risk for persistent complex bereavement disorder.
Bereavement-related depression: Most likely to occur in individuals with past personal and family histories of major depressive episodes.
Genetically influenced and associated with similar personality characteristics, patterns of comorbidity, and risks of chronicity and/or recurrence as non–bereavement-related major depressive episodes.
The same psychosocial and medication treatments as non–bereavement-related depression.

35. Depressive Disorders-Cont.
Guidance on the assessment of suicidal thinking, plans, and the presence of other risk factors in order to make a determination of the prominence of suicide prevention in treatment planning for a given individual.
The “with anxious distress” specifier gives the clinician an opportunity to rate the severity of anxious distress in all individuals with bipolar or depressive disorders.
To identify patients with anxiety symptoms that are not part of the diagnostic criteria.
Anxiety is relevant to prognosis and treatment decision making.

36. Bipolar and Related Disorders
Bipolar Disorders
An emphasis on changes in activity and energy as well as mood.
To enhance the accuracy of diagnosis
The DSM IV diagnosis of Bipolar I Disorder, mixed episode has been removed.
Bipolar I Disorder, mixed episode: The individual simultaneously meet full criteria for both mania and major depressive episode.
Instead, a new specifier, “with mixed features,” has been added.
Other Specified Bipolar and Related Disorders:
About hypomania
Categorization for individuals with a past history of a major depressive disorder who meet all criteria for hypomania except the duration criterion.
Too few symptoms of hypomania are present to meet criteria for the full bipolar II syndrome, although the duration is sufficient at 4 or more days.

37. Disruptive, Impulse-Control, and Conduct Disorders
Oppositional Defiant Disorder
Conduct Disorder
Intermittent Explosive Disorder
Pyromania
Kleptomania
Antisocial personality disorder
Other specified disruptive, impulse-control, and conduct disorder
Unspecified disruptive, impulse-control, and conduct disorder

38. Disruptive, Impulse-Control, and Conduct Disorders
Includes disorders that were previously included in the chapter “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence”
Oppositional Defiant Disorder
Conduct Disorder
Disruptive Behavior Disorder Not Otherwise Specified (now categorized as “Other Specified and Unspecified Disruptive, Impulse-control, and Conduct Disorders”)
Addition of “Impulse-Control Disorders Not Otherwise Specified”
Intermittent Explosive Disorder
Pyromania
Kleptomania
Problems in emotional and behavioral self-control
Because of its close association with conduct disorder, antisocial personality disorder has dual listing in this chapter and in the chapter on personality disorders.

39. Oppositional Defiant Disorder
Symptoms are now grouped into three types:
Angry/irritable mood
Argumentative/defiant behavior
Vindictiveness
The exclusion criterion for conduct disorder has been removed
A note has been added to the criteria to provide guidance on the frequency typically needed for a behavior to be considered symptomatic of the disorder
Because many behaviors associated with symptoms of oppositional defiant disorder occur commonly in normally developing children and adolescents
A severity rating has been added to the criteria to reflect research showing that the degree of pervasiveness of symptoms across settings is an important indicator of severity.

40. Conduct Disorder A descriptive features specifier has been added
For individuals who meet full criteria for the disorder but also present with limited prosocial emotions
Those with conduct disorder who show a callous and unemotional interpersonal style across multiple settings and relationships
The specifier is based on research showing that individuals with conduct disorder who meet criteria for the specifier tend to have a relatively more severe form of the disorder and a different treatment response

41. Intermittent Explosive Disorder
The type of aggressive outbursts
DSM IV: Physical aggression
DSM 5: Verbal aggression and non-destructive/non-injurious physical aggression also meet criteria
The aggressive outbursts are impulsive and/or anger based in nature
They must cause marked distress or impairment in occupational or interpersonal functioning, or be associated with negative financial or legal consequences.
A minimum age of 6 years (or equivalent developmental level) is now required
Due to the potential difficulty of distinguishing these outbursts from normal temper tantrums in young children.
The relationship of this disorder to other disorders (e.g., ADHD, disruptive mood dysregulation disorder) has been further clarified, especially for youth.

42. Neurodevelopmental Disorders
Attention-Deficit/Hyperactivity Disorder
Autism Spectrum Disorder
Intellectual Disability (Intellectual Developmental Disorder)
Communication Disorders
Specific learning disorder
Motor disorders (Included Tic disorders)
Other neurodevelopmental disorders

43. Attention-Deficit/Hyperactivity Disorder (ADHD)
ADHD was placed in the “Neurodevelopmental Disorders” chapter
To reflect brain developmental correlates with ADHD
To eliminate the DSM IV chapter that includes all diagnoses usually first made in infancy, childhood, or adolescence
The diagnostic criteria for ADHD in DSM 5 are similar to those in DSM IV
The same 18 symptoms
Divided into two symptom domains
Inattention
Hyperactivity/impulsivity
At least six symptoms in one domain are required for diagnosis
Examples have been added to the criterion items to facilitate application across the life span
The cross-situational requirement has been strengthened to “several” symptoms in each setting

44. Attention-Deficit/Hyperactivity Disorder (ADHD)-Cont.
The onset criterion has been changed from symptoms before age 7 years to symptoms prior to age 12
A comorbid diagnosis with Autism Spectrum Disorder is now allowed
A symptom threshold change has been made for adults, to reflect their substantial evidence of clinically significant ADHD impairment
With the cutoff for ADHD of five symptoms, instead of six required for younger persons, both for inattention and for hyperactivity and impulsivity.

45. Autism Spectrum Disorder (ASD)
DSM IV-TR: Pervasive Developmental Disorder
Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS)
Autism
Asperger Syndrome
Rett Syndrome
Childhood Disintegrative Disorder
DSM 5: Autism Spectrum Disorder, new name.
Four previously separate disorders (with the exclusion of Rett syndrome) are actually a single condition with different levels of symptom severity in two core domains.
ASD is characterized by;
Deficits in social communication and social interaction
Restricted repetitive behaviors, interests, and activities (RRBs).
Because both components are required for diagnosis of ASD, Social Communication Disorder is diagnosed if no RRBs are present.
Social (Pragmatic) Communication Disorder, a new condition for persistent difficulties in the social uses of verbal and nonverbal communication

46. Intellectual Disability (Intellectual Developmental Disorder-ICD)
Diagnostic criteria: The need for an assessment of both
DSM IV: Mental retardation
DSM 5: Intellectual disability
The deficits in cognitive capacity beginning in the developmental period, with the accompanying diagnostic criteria, are considered to constitute a mental disorder.

47. Feeding and Eating Disorders
Pica and Rumination Disorder
Avoidant/Restrictive Food Intake Disorder
Anorexia Nervosa
Bulimia Nervosa
Binge-Eating Disorder

48. Eating Disorders Anorexia Nervosa
The requirement for amenorrhea has been eliminated.
In DSM IV, individuals with this disorder are required to be at a significantly low body weight for their developmental stage.
The wording of the criterion has been changed for clarity,
Guidance regarding how to judge whether an individual is at or below a significantly low weight is now provided in the text
In DSM 5, Criterion B is expanded to include not only overtly expressed fear of weight gain but also persistent behavior that interferes with weight gain.

49. Eating Disorders-Cont.
Bulimia Nervosa
The reduction in the required minimum average frequency of binge eating and the required inappropriate compensatory behavior frequency from twice to once weekly
Binge-Eating Disorder
The minimum average frequency of binge eating required for diagnosis has been changed
From at least twice weekly for 6 months to at least once weekly over the last 3 months, which is identical to the DSM 5 frequency criterion for bulimia nervosa

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