1. The future of the DSM
Next revision of the DSM will likely see major changes like we have never seen before.
Focus of NIMH research in the future will be on underlying genetic/neurobiological causes that are common among psychological disorders. This is known as the Research Domain Criteria (RDoC) project.

2. The future of the DSM
“In brief, the RDoC is to define basic dimensions of functioning (such as fear circuitry or working memory) to be studied across multiple units of analysis, from genes to neural circuits to behaviors, cutting across disorders as traditionally defined. The intent is to translate rapid progress in basic neurobiological and behavioral research to an improved integrative understanding of psychopathology and the development of new and/or optimally matched treatments for mental disorders.” source: NIMH website

3. DSM-5 – Important Section
There is a section in DSM-5 titled:
Highlights of Changes from DSM-IV to DSM-5 (p. 809)

4. DSM-5 – Multiaxial System is Gone
AXIS I, II, and III – gone.
DSM-5 recognizes that separating things out in terms of AXIS I, II, and III really served no purpose because of the overlap of I, II, and III. Separating out could actually be misleading.

5. DSM-5 – Multiaxial System is Gone
AXIS IV is gone. Instead of writing out social problems, environmental problems, etc., the list of V codes (p. 715) has been expanded significantly to cover anything that would have gone under AXIS IV
Very important to have a solid working knowledge of V codes

6. DSM-5 – Multiaxial System is Gone
AXIS V – gone.
For many of the disorders in DSM-5 severity rating specifiers have been added
These specifiers are much better in helping to explain the severity of specific disorders, rather than trying to explain overall functioning via the AXIS V, GAF, which was not reliable across clinicians

7. A very brief case study
Leroy is 40-years-old. He just lost his job, which has caused a financial strain. He is experiencing marital distress. Leroy has been depressed off and on for 10 years. He is considering suicide, and has attempted suicide in the past. He worries constantly, and he cannot concentrate. He drinks a 6 pack every night.

8. DSM-5 Diagnosis – Case Study - The Way It Should Be Done
Major Depressive Disorder, Recurrent, Severe
Alcohol Use Disorder, Severe
Generalized Anxiety Disorder
V61.10 Relationship Distress With Spouse or Intimate Partner
V60.2 Low Income
V15.59 Personal History of Self-Harm

9. DSM-5 Diagnosis
The primary diagnosis (listed first) will be the most acute condition that requires the most intensive professional services.

10. DSM-5 ICD-9 Codes
Note: The ICD-9 codes in the DSM-5 will be used until October 1, After this time, the ICD-10 codes will be used.
The ICD-10 codes are in gray and in parenthesis after each ICD-9 code.
For example:
(F21) Schizotypal Personality Disorder

11. DSM-5 – no more NOS categories
With DSM-5, the NOS categories are no more.
DSM-5 includes for each group of related disorders “Other Specified” and “Unspecified” categories
Other Specified category – the clinician can specify why the person does not meet the full diagnostic criteria for a disorder
Unspecified category – the clinician does not specify why the full diagnostic criteria is not met for a disorder

12. DSM-5 – Other Specified and Unspecified Category Examples
300.3 Other Specified Obsessive-Compulsive and Related Disorder, Body-focused repetitive behavior disorder (nail and lip biting)
Will likely use Other Specified category most often
300.3 Unspecified Obsessive-Compulsive and Related Disorder
Will likely use Unspecified category less often; when the category is used, it is often in emergency settings, when there is not enough time for full assessment

13. Neurodevelopmental Disorders
Intellectual Disability
no longer called Mental Retardation
Severity no longer determined by IQ, but rather adaptive functioning

14. Neurodevelopmental Disorders
Communication Disorders
Language Disorder – combines what was called Expressive and Mixed Receptive-Expressive Language Disorders
Speech Sound Disorder – fka Phonological Disorder
Childhood-onset Fluency Disorder – fka Stuttering
Social (pragmatic) Communication Disorder – a new disorder; difficulties in social uses of verbal/nonverbal communication

15. Neurodevelopmental Disorders
Autism Spectrum Disorder
A new DSM-5 diagnosis
Encompasses several DSM-IV diagnoses:
Autism
Asperger’s
Childhood Disintegrative Disorder
Rett’s Disorder
Pervasive Developmental Disorder NOS
Deficits in two core domains:
1. social communication and social interaction
2. restrictive, repetitive patterns of behavior, interests, and activities

16. Neurodevelopmental Disorders
ADHD
Under DSM-5 must see symptoms prior to age 12 (used to be age 7 under DSM-IV)
For adults (17 and older), only have to meet 5 symptoms of inattention and/or hyperactivity/impulsivity
For children, threshold is higher, must meet 6 criteria

17. Neurodevelopmental Disorders
Specific Learning Disorder
Used to be separate learning disorders (Reading, Disorder of Written Expression, etc.) under DSM-IV
Under DSM-5, the diagnosis is Specific Learning Disorder, and then there are specifiers for each type
Example: Specific Learning Disorder, with impairment in reading (reading rate)

18. Schizophrenia Spectrum and Other Psychotic Disorders
In DSM-5, the subtypes of Schizophrenia have been eliminated (e.g., Schizophrenia, Paranoid Type)
They were eliminated because of low reliability and poor validity
The subtypes have been replaced with the Clinician-Rated Dimensions of Psychosis Symptom Severity (p. 743) to help gauge the degree of types and severity of symptoms – see handout

19. Schizophrenia Spectrum and Other Psychotic Disorders
Catatonia - rather than being a subtype of Schizophrenia as seen under DSM-IV, Catanonia is now its own diagnosis.
Example:
Schizoaffective Disorder, Depressive Type
Catatonia Associated with Schizoaffective Disorder

20. Depressive Disorders
There was significant concern that Bipolar D/O was being over diagnosed in children
For this reason, a new diagnosis, Disruptive Mood Dysregulation Disorder was created.
cannot diagnose over age 18
Persistent irritability
Frequent episodes of extreme lack of behavioral control

21. Depressive Disorders Premenstrual Dysphoric D/O is new to DSM-5
Persistent problems with mood around the time of menses

22. Depressive Disorders
No longer a diagnosis of Dysthymia, the diagnosis is now called: Persistent Depressive Disorder (Dysthymia)
The disorder encompasses what was called Dysthymia under DSM-IV
Disorder also includes Chronic Major Depressive Disorder, never a break in depressive symptoms of at least two months
Note: If a break in depressive symptoms for at least 2 months, then diagnose MDD, Recurrent

23. Depressive Disorders
On p. 161 of DSM-5, there is a lengthy footnote describing how to distinguish characteristics of Bereavement and MDD
If Bereavement, then there are a couple of diagnostic possibilities:
Other Specified Trauma- and Stressor-Related Disorder, Persistent Complex Bereavement Disorder or
V62.82 Uncomplicated Bereavement

24. Anxiety Disorders
Anxiety Disorders under DSM-5 no longer includes the following:
OCD – has been moved to Obsessive-Compulsive and Related Disorders
PTSD and Acute Stress Disorder – have been moved to Trauma and Stressor-Related Disorders

25. Anxiety Disorders Now included under Anxiety Disorders in DSM-5:
Separation Anxiety Disorder
Wording has been modified to better fit when SAD occurs in adulthood
Wording removed that you must be under 18
Selective Mutism

26. Anxiety Disorders Panic Attacks
Panic attacks can now be listed as a potential specifier for all psychological disorders
Example: PTSD with Panic Attacks

27. Anxiety Disorders Under DSM-5, no longer the following diagnoses:
Panic Disorder with Agoraphobia
Panic Disorder without Agoraphobia
Agoraphobia without a history of Panic Disorder
Under DSM-5, the diagnoses are now:
Panic Disorder
Agoraphobia
Note: you could have one diagnosis without the other

28. Obsessive-Compulsive and Related Disorders
This new section in DSM-5 includes the following newly created disorders:
Hoarding Disorder
Excoriation (skin-picking) Disorder
Substance/Medication-induced Obsessive-Compulsive and Related Disorder
Obsessive-Compulsive and Related Disorder due to Another Medical Condition
Trichotillomania (hair-pulling disorder) – moved from Impulse Control Disorders in DSM-IV; the term in parentheses has been added in DSM-5

29. Trauma and Stessor-Related Disorders
PTSD – diagnostic thresholds have been lowered for children
Separate criteria in the DSM-5 have been added for children age 6 and under
These criteria are better descriptions of how PTSD presents in childhood (e.g., reliving events during play)

30. Trauma and Stessor-Related Disorders
Under DSM-IV, there were two subtypes of Reactive Attachment Disorder.
Under DSM-V, these subtypes are now considered separate disorders:
Reactive Attachment Disorder
Disinhibited Social Engagement Disorder

31. Dissociative Disorders
Under DSM-IV, Dissociate Fugue was a separate diagnose, but under DSM-5, it is considered a specifier of the disorder, Dissociative Amnesia

32. Somatic Symptom and Related Disorders
In DSM-5, there is no longer the following diagnoses:
Somatization disorder
Hypochondriasis
Pain Disorder
Undifferentiated Somatoform Disorder
New to DSM-5:
Somatic Symptom Disorder – most with Somatization D/O will now fall here
Illness Anxiety Disorder – most with Hypochondriasis will now fall here

33. Feeding and Eating Disorders
Disorders that fell under Feeding and Eating Disorders of Infancy and Early Childhood, now fall under this category in DSM-5 – for example, Pica and Rumination Disorder
New disorder: Avoidant/Restrictive Food Intake Disorder – used to be called Feeding Disorder of Infancy or Early Childhood

34. Feeding and Eating Disorders
Anorexia Nervosa
Criteria for amenorrhea, 3 missed menstrual cycles has been removed
Bulimia Nervosa
Criteria for bingeing and compensatory behavior has been reduced from 2 x’s to 1 x weekly
Binge-eating Disorder – a new disorder

35. Sleep Wake Disorder Two new disorders:
Rapid Eye Movement Sleep Behavior Disorder
Restless Leg Syndrome

36. Sexual Dysfunctions Females
Sexual Desire Disorder and Sexual Arousal Disorder in DSM-IV have been combined in DSM-5:
Female sexual interest/arousal disorder
Vagnisimus and Dyspareunia have been combined in DSM-5:
Genito-pelvic pain/penetration disorder

37. Disruptive, Impulse-Control, and Conduct Disorders
This is a new category to DSM-5
The following DSM-IV diagnoses now fall under this DSM-5 category:
Oppositional Defiant Disorder
Conduct Disorder
Disruptive Behavior Disorder NOS
Intermittent Explosive Disorder – must be at least age 6 has been added
Pyromania
Kleptomania

38. Disruptive, Impulse-Control, and Conduct Disorders
Conduct Disorder – a specifier has been added called “Limited Prosocial Norms”; under this specifier, you can get more specific:
Lack of remorse or guilt
Callous – lack of empathy
Unconcerned about performance
Shallow or deficient affect
These specifiers make it look more like a mini-version of Antisocial Personality Disorder

39. Substance-Related and Addictive Behaviors
Gambling Disorder – new to this category
Cannabis Withdrawal – new disorder
Caffeine Withdrawal – new disorder
Polysubstance Dependence – deleted from DSM-5; now diagnose each substance disorder separately

40. Substance-Related and Addictive Behaviors
No longer separate diagnoses for Substance Abuse and Substance Dependence.
Everything is now considered a Substance Use Disorder
Substance Use Disorder criteria/specifiers include the following:
Intoxication
Withdrawal
Substance-Induced Disorders

41. Neurocognitive Disorders
Major Neurocognitive Disorder – new disorder
Previous DSM-IV diagnoses of Dementia and Amnestic Disorder now fall under this diagnosis
Mild Neurocognitive Disorder – new disorder for less disabling syndromes

42. Personality Disorders
No changes in criteria for Personality Disorders from DSM-IV to DSM-5

43. Personality Disorders
DSM-5 presents an alternative approach to diagnosing Personality Disorders for further study
Due to the approaches thoroughness, I would STRONGLY encourage you to look at this section of DSM-5 (p. 761) prior to diagnosing any client with a personality disorder
The assessment measures the following:
Level of personality functioning
Pathological personality traits
Pervasiveness and stability of traits
Possible alternative explanations for personality pathology

44. New Useful Tools in DSM-5
FREE assessment measures for psychological disorders that can be found online (
See p. 733 in DSM-5 for more information
Forms to be used when trying to assess the cultural variables in relation to psychological disorders
See p. 749 in DSM-5