1. Chuck Pistorio, Ph.D. Laura Tejada, Ph.D. Shedeh Tavakoli, Ph.D.
DSM – 5: A Brief Overview
Chuck Pistorio, Ph.D.
Laura Tejada, Ph.D.
Shedeh Tavakoli, Ph.D.

2. Overview Outline significant changes Chapter organizations
New categories
New Diagnoses
Eliminated diagnoses
Review specific changes for some of the most commonly diagnosed disorders
Overall process of diagnosis and case conceptualization as learned in this program have not changed

3. Changes in Philosophy Greater emphasis on culture
Cultural Formulation Inventory (CFI)
Awareness of international use
ICD, WHO
Validity rather than reliability
More emphasis on client’s experiences and reported symptoms/needs
Once we get past the newness, will be able to appreciate some positive changes in the DSM

4. Changes to Chapters Chapters reorganized
Organized by common etiologies
More dimensional approach
Diagnosis is ongoing
Reflects developmental lifespan
Removed Disorders Usually Diagnosed in Infancy, Childhood & Adolescence
Individual chapters organized developmentally
Allow us to work within broader categories, not so much ‘boxing in’ of clients, or separation of disorders.
EX: Child who meets criteria for “ODD” also able to combine dx and treatment with symptoms of anxiety and Sensory Integration Disorder
Chapts. Organized developmentally allows for broader look across the lifespan of d/o, such as ADHD, LD

5. Changes to Five-Axis System
DSM-IV Five-Axis System
DSM-5 Equivalent
Axis I: Mental Health Disorders
Record on diagnosis line
List primary reason for visit first
Axis II: Personality Disorders & Mental Retardation
Axis III: General Medical Conditions
List those most important to understanding mental health first
Axis IV: Psychosocial & Environmental
Problems
V, Z, or T codes from chapter “Other Conditions that May be of Clinical Attention” (p. 715)
Axis V: Global Assessment of Functioning [GAF]
Optional use of World Health Organization Disability Schedule [WHODAS] (p. 745)
Concern over disappearance of axis system not warranted. Process has not changed!
Allows for more consideration of V codes as part of diagnostic picture

6. Changes to Five-Axis System
DSM-IV Five-Axis System
DSM-5 Equivalent
Axis I: PTSD, with delayed onset; Major Depressive Disorder, recurrent, moderate, with mild anxious distress
Axis II: No diagnosis
Axis III: No diagnosis
Axis IV: V Personal history of spouse or partner violence, physical
V60.1 Inadequate housing;
V60.2 Extreme poverty
Axis V: GAF score
PTSD, with delayed onset
Major Depressive Disorder, recurrent, moderate, with mild anxious distress
V15.41 Personal history of spouse or partner violence, physical
V60.1 Inadequate housing
Highlight that after Axis II easy to not pay attn. Notice how list places items, such as V codes, that used to be lost in axis system, ‘higher’ for more consideration.

7. Changes to NOS Unspecified Not Elsewhere Classified [NEC]
Specific symptoms with code
Other Specified
Allows documentation of why client does not meet specific diagnostic criteria
Unspecified
Significant distress but does not meet criteria
Insufficient information (crisis, ER)
Allows clinician to put in specific symptoms that are present in overall diagnostic picture without having to meet diagnosis for inclusion on treatment plans
Back to example of child with “ODD” who is also experiencing anxiety and some sensory-integration difficulties but does not meet criteria for those dxs. Now more relevant and more able to include in tx planning.
Other Specified: allows clinician to detail specific manifestation of d/o by client
Unspecified: excellent for crisis settings or crisis intakes in agency setting

8. Organization & Content
Section I
Orientation
Historical back ground
Development of DSM-5
How to use it
Section II
Diagnostic Criteria and codes
“Medication-induced Movement Disorders”
“Other Conditions That May be a Focus of Clinical Attention.”

9. Organization & Content
Section III
Emerging Measures and Models
Assessment measures assessment-measures
Cultural formulation
Alternative DSM-5 model for personality disorders
“Criteria Sets for Conditions for Further Study”
Appendix
Highlights of changes from DSM-IV to DSM-5
Glossary of technical terms
Glossary of cultural terms
Alpha & numeric listings of diagnoses and codes
List of advisors and contributors

10. Structure for Each Diagnosis
Diagnostic Criteria
Subtypes and/or specifiers
Severity
Codes and recording procedures
Explanatory text (new or expanded)
DSM-5 combines the first three DSM-IV-TR axes into one list that contains all mental disorders, including personality disorders and intellectual disability, as well as other medical diagnoses. Other conditions that are a focus of the current visit or help to explain the need for a treatment or test may also be coded, usually as ICD-9-CM V-codes or, starting on October 1, 2014 as ICD-10- CM Z-codes. A list of these other conditions can be found on pp of DSM-5.

11. Structure for Each Diagnosis
Diagnostic and associated features
Prevalence
Development and course
Risk and prognosis
Culture- and gender-related factors
Diagnostic markers
Functional consequences
Differential diagnosis
Comorbidity

12. New Disorders Social (Pragmatic) Communication Disorder
Disruptive Mood Dysregulation Disorder
Premenstrual Dysphoric Disorder
Hoarding Disorder
Excoriation (Skin‐Picking) Disorder
Disinhibited Social Engagement Disorder (split from Reactive Attachment Disorder)
Binge Eating Disorder

13. New Disorders Central Sleep Apnea Sleep-Related Hypoventilation
Rapid Eye Movement Sleep Behavior Disorder
Restless Legs Syndrome
Caffeine Withdrawal
Cannabis Withdrawal
Major Neurocognitive Disorder with Lewy Body Disease (Dementia Due to Other Medical Conditions)
Mild Neurocognitive Disorder

14. Eliminated
Sexual Aversion Disorder
Polysubstance-Related Disorder

15. Diagnostic Changes New categories:
Obsessive-Compulsive and Related Disorders
Trauma- and Stressor-Related Disorders
Transformed:
Neurodevelopmental Disorders
(Infancy, adolescence, childhood)
Somatic Symptom and Related Disorders

16. Combined: Insomnia Disorder Language disorders Alcohol use disorder
Autism spectrum
Cannabis use disorder
Specific Learning Disorder
Stimulant Intoxication
Delusional disorder
Panic Disorder
Stimulant withdrawal
Substance/medication- induced disorders
Dissociative Amnesia
Somatic Symptom

17. Examples of Changes

18. Trauma and Stress-Related Disorders
New chapter in DSM-5 brings together anxiety disorders that are preceded by a distressing or traumatic event
Reactive Attachment Disorder
Disinhibited Social Engagement Disorder (new)
PTSD (includes PTSD for children
6 years and younger)
Acute Stress Disorder
Adjustment Disorders
Distress after trauma is very different for each person. While some cases symptoms can be well understood within an anxiety- or fear based context, it is clear, however that many individuals who have been exposed to a traumatic or stressful event exhibit a phenotype in which, rather than anxiety- or – fear based symptoms the most prominent clinical characteristics are anhedonic and dysphoric symptoms, externalizing angry and aggressive symptoms, or dissociate symptoms. Thus the separate category.

19. Posttraumatic Stress Disorder (PTSD)
There are 8 criterion
Criteria (A)- Exposure to actual or threatened death, serious injury, or sexual violence
Four symptom clusters, rather than three
Re-experiencing (B)
Avoidance (C)
Persistent negative alterations in mood and cognition (D)
Arousal- describes behavioral symptoms (E)
Duration of B, C, D, and E is more than 1 month
Causes clinically significant distress
Not attributed to substance use or medical condition
Emotional reactions to the traumatic event (e.g. fear, helplessness, horror) are no longer a part of criterion A.

20. PTSD DSM 5 more clearly defines what constitutes traumatic event
Sexual assault is specifically included
Recurring exposure, that could apply to first responders
Recognition of PTSD in young children
Developmentally sensitive:
Criteria have been modified for children 6 and younger
Thresholds- number of symptoms in each cluster have been lowered
Risk and Prognostic actors:
Pretraumatic factors
Per traumatic factors
Posttraumatic factors

21. Substance-Related and Addictive Disorders
DSM-5 consolidates substance abuse and dependence into one disorder:
substance use disorder accompanied by criteria for: intoxication, withdrawal, substance-induced disorders, and unspecified related disorders.
Criteria are nearly identical to DSM-IV w/ exception of:
-Recurrent substance-related legal problems criterion has been deleted from DSM-5.
-And new criterion: craving, or a strong desire or urge to use a substance added.
The threshold is set at 2 or more criteria vs. 1 or more for abuse and 3 or more for dependence in the DSM-IV. 21

22. Substance-Related and Addictive Disorders
New disorders in substance-related & addictive disorders chapter of DSM-5:
Gambling Disorder (non-substance related disorder)
Cannabis Withdrawal
Caffeine Withdrawal
* The dx of polysubstance dependence has been eliminated.

23. Substance-Related and Addictive Disorders
Specifiers:
In DSM-5 severity for substance use disorders is based on the number of criteria endorsed:
-mild= 2-3 criteria
-moderate = 4-5 criteria
-Severe= 6 or more criteria
The DSM-IV specifier for psychological subtype has been eliminated.

24. Substance-Related and Addictive Disorders
In DSM-5 early remission is defined as at least 3 but less then 12 months without substance use disorder criteria (except craving).
Sustained remission is defined as at least 12 months without criteria (except craving).
New specifiers include:
-in a controlled environment
-on maintenance therapy

25. Neurodevelopmental Disorders
DSM-IV TR – “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence”
Intellectual Disability (vs mental retardation) – Rosa’s Law
Assess cognitive capacity (IQ) and adaptive functioning (the primary determinant of severity).
Autism Spectrum Disorder (gone – Asperger’s, childhood disintegrative disorder, pervasive developmental disorder)
Addition – Social (Pragmatic) Communication Disorder

26. Neurodevelopmental Disorders
Attention-Deficit/Hyperactive Disorder (prior to age 12 vs age 7, less symptoms for adults, option for comorbid with ASD)
Specific Learning Disorder (DSM-IV TR = Academic Skills Disorders; greater detail in diagnosis, e.g., word reading, fluency, comprehension; clarify requirements for Low Achievement criterion)
Specifiers – greater detail on severity (e.g., ID – mild, moderate, severe, profound; ASD – Levels 1, 2, 3)
Removed – Separation Anxiety Disorder, Pica and Rumination Disorder, Feeding Disorder of Infancy or Early Childhood, Oppositional Defiant Disorder, Conduct Disorder

27. Personality Disorders
Criteria for PD’s in Section II of DSM-5 not changed from DSM-IV
No longer exist as an Axis II disorder (i.e., dropped multiaxial evaluation system)
PD now coded at same level as other mental disorders
No longer marginalized and treated differently

28. Personality Disorders
NOS dropped in favor of: (1) Other specified PD and (2) Unspecified PD
New, alternative approach to diagnosing PD developed for further study and included in separate section (Section III)
Personality Change Due to Another Medical Condition included in PD chapter (vs. DSM-IV’s Mental Disorders Due to a General Medical Condition)

29. Alternative DSM-5 Model for Personality Disorders
New model for assessment of personality disorders and traits
Includes Categorical and Dimensional approaches
Model not accepted by APA for inclusion in Section II
Decision –include in Section III as the “Alternative DSM-5 Model for Personality Disorders”
Rationale: the model “preserve(s) continuity with current clinical practice, while also introducing a new approach that aims to address numerous shortcomings of the current approach to personality disorders.”
Six PDs (vs. ten) – antisocial, avoidant, borderline, narcissistic, obsessive- compulsive, and schizotypal)

30. Alternative DSM-5 Model for Personality Disorders
Based on Five Factor model of personality (Neuroticism, Extraversion, Openness, Agreeableness, and Conscientiousness)
PD Model (Negative affectivity, Detachment, Antagonism, Disinhibition, and Psychoticism)
Negative Affectivity Neuroticism
Detachment Introversion
Antagonism Antagonism
Disinhibition Low Conscientiousness
Psychoticism Openness
25 Facets (traits): e.g., Anxiousness, Attention Seeking, Depressivity, Emotional Lability, Hostility, Impulsivity, Separation Insecurity, Withdrawal

31. QUESTIONS? ?
? QUESTIONS?