Diagnostic groupings in the DSM 5

Diagnostic groupings in IV-TR and 5

 In DSM-IV TR, the diagnostic groupings had a separate

category for children and adolescents.
 DSM 5 does not make a separate category for children and
adolescents
 In DSM-IV TR some of the categories had names that made
no sense-such as somatoform disorders
 DSM 5 attempts to simplify diagnostic category names
 DSM 5 organizes diagnostic categories into 20 chapters,
starting with diagnostic categories that are seen earlier in
life and progressing to those that are seen later in life
X
Changes throughout DSM

 Attention to severity assessment and specification of

severity for each diagnosis
 Inclusion of other specified disorder and unspecified
disorder as a diagnosis for each group (Replaces that
NOS)
 "Other specified disorder" permits clinician to
communicate sub threshold diagnoses and specific
reasons why client did not meet criteria for other
diagnoses within that group
DSM 5 changes in classification

 DSM 5 has 20 diagnostic groupings plus a group of

other conditions that might be a focus clinically (V
codes)
 DSM 5 organizes these categories beginning with
those that might be seen earlier in life and
progressing to those later in life
Neuro Neurocog
Sexual Disruptive
develop Bipolar Somatic nitive Paraphilia
Anxiety Eliminatio dysfunctio , impulse disorders
mental Trauma symptom disorders
n ns control
related related
disorders disorders

Schizophrenia Depr Obsessi Dissocia

Feeding and Sleep wake Substance Personality Others
essiv ve- tive Gender
eating disorders related and disorder
e compulsi dysphoria
ve and disorders addictive
related disorders

Younger Older

The progression from younger to older in the DSM is general and there are
specific disorders such as some early childhood feeding disorders that
clearly occur later
1. Neurodevelopmental disorders
2. schizophrenia spectrum and other
psychotic disorders
3. bipolar and related disorders
4. depressive disorders
5. anxiety disorders
6. obsessive-compulsive and related
disorders
7. Trauma and related disorders
8. dissociative disorders
9. Somatic symptom and related
disorders
10. feeding and eating disorders
11. elimination disorders
12. sleep wake disorders
13. sexual dysfunctions
14. gender dysphoria
15. disruptive, impulse control, and
conduct disorders
16. neurocognitive disorders
17. paraphilia disorders
Which are your top 7 or 8
 Changes in the groupings:
1. Neurodevelopmental disorders
SUMMARY

 Neurodevelopmental disorders-
1. mental retardation is removed intellectual disability is put
in.
2. Autism spectrum disorder is the new DSM 5 diagnosis
encompassing autistic disorder. Aspergers and childhood
disintegrative disorder as well as pervasive developmental
disorder.
3. Several changes have been made to ADHD- specifiers =
combined; inattententive type; hyperactive/impulsive type
 MENTAL RETARDATION = INTELLECTUAL DISABILITY
Severity level for intellectual disability
Severity Conceptual domain
level
Mild Preschool = no obvious differences. School-aged
children and adults = academic skills involving
reading writing math time or money. In adults
abstract thinking planning cognitive flexibility are
somewhat impaired impaired. Tendency toward
concrete thinking
Moderate Conceptual skills lag markedly language
development and pre-academic skills slow to
develop. School-age children = progress in reading
writing mass understanding of time and money
but slower than peers. Adults = academic skill
development is at an elementary level. Ongoing
assistance needed in conceptual decision-making
Severe Limited attainment of conceptual skills. Little or
no understanding of written language math, time
and money. Extensive support for problem solving
is needed
Profound No concept of symbolic processes, perhaps some
functional use of objects, although this might be
limited by disturbance and motor skills . people who were well known to them. Can
SEVERITY DETERMINED BY ADAPTIVE FUNCTIONING NOT IQ
Social domain
Immaturity and social interactions; some
difficulty picking up social cues
communication conversation in language
more concrete than peers. Possible
difficulties in emotional regulation and age-
appropriate behavior. Perhaps impairment in
risk assessment
Marked differences in social and
communication from peers. Spoken language
is much less complex than peers. Capacity for
relationships evident in familial friendship
ties. Problems with perceiving social cues in
social situations accurately. Social judgment
and decision-making limited. Help is needed
with life decisions
Spoken language is limited in terms of
vocabulary and grammar. Communication is
focused on the here and now an everyday
event. Relationships and relational ability is
considerable.
Might understand simple instructions and
cues. Social expression is often nonverbal.
Can respond and enjoy relationships with
initiate limited social interaction with such
people through gestures. Sensory and
physical impairments may prevent social
activities
Practical domain
Personal care may be age-appropriate, but more
complex tasks might require support. For
example grocery shopping, transportation home
and childcare organization food prep banking
and money management
Personal care is okay in adulthood. Adults
typically can participate in all household tasks
with teaching. Can work with considerable
support in the workplace
Support needed for all activities of daily living.
Supervision required at all times. We will not
make responsible decisions regarding well-
being .skill acquisition is very limited
Dependent on others for all aspects of daily
physical care. Participation in these activities is
limited.. Some simple concrete tasks such as
carrying dishes to the table might be
accomplished. Co-occurring physical and sensory
impairments are often barriers to participation
 Includes deficits in language speech and communication

1. Expressive language disorder Combined into "language disorder" (315.39) in

2. Receptive-expressive language disorder DSM 5
3. Phonological (articulation) disorder= speech sound disorder (315.39) In DSM 5
4. Stuttering AKA Childhood onset fluency disorder (315.35) In DSM 5
 Social pragmatic communication
disorder 315.39
A. Persistent difficulties in the social use of verbal and nonverbal communication as
manifested by all of the following;
deficits in using communication for searching purposes
A.impairments of the ability to change communications to match the context or needs of the listener
B.difficulties following rules for conversation and storytelling such as taking turns in conversation ,
rephrasing and knowing how to use verbal and nonverbal to regulate interaction
C.Difficulties in understanding what is not explicitly stated
B. Deficits result in functional limitations and effective communications. The onset is
in the early developmental. (But deficits aren't fully noticeable until later in life)
C. Not attributable to another medical condition or neurological condition and not
better explained by other neurodevelopmental disorders

Differential diagnoses should always consider the possibility of autism

spectrum disorder, in particular those with mild severity.
Primary deficits of ADHD can cause some impairments in social communication
social anxiety disorder and social phobia can often appear with similar
symptoms and again mild intellectual developmental disorder might also mask
symptoms
 LEARNING DISORDERS
 DEFINED INDEPENDENT FROM GENERAL INTELLIGENCE
 DIAGNOSED WHEN AN INDIVIDUAL’S ACHIEVEMENT ON
INDIVIDUALLY ADMINISTERED STANDARDIZED TESTS IN
READING, MATH OR WRITTEN EXPRESSION IS
SUBSTANTIALLY BELOW THAT FOR EXPECTED AGE AND
INTELLIGENCE
 DSM IV
 Dyslexia – reading disorder
 Dyscalculia – math disorder
 Dysgraphia – written expression disorder
DSM 5 criteria – no separation

A. Difficulty learning and using academic skills indicated by the presence of at least
one of the following symptoms for at least 6 months despite interventions.
1. Inaccurate or slow and effortful word reading
2. Difficulty understanding the meaning of what is read
3. Difficulties with spelling
4. Difficulties with written expression
5. Difficulties mastering number sense, number facts, or calculation
6. Difficulty with mathematical reasoning
B. Affected academic skills are substantially and quantifiably below those expected for
the individual's chronological age causing significant interference with performance
(quantifiable suggest testing)
C. The learning difficulties begin during school way cheers but might not become
apparent until those faculties require more regular use
D. Not better accounted for by intellectual disabilities visual or auditory deficits other
mental or neurological disorders etc.
X ADHD
 In DSM-IV TR, ADHD was grouped in the diagnostic
domain of "disruptive behavior disorders seen in
childhood and adolescence"
 DSM 5 has moved it to neurodevelopmental
disorders
 DSM-IV TR separated ADHD into 2 subtypes:
 predominantly attention deficit
 predominantly hyperactivity impulsivity
 DSM 5 has moved these two sub-types to specifiers
X Diagnostic Criteria for ADHD
(DSM-IV)

DSM
 Must5occur
has before
moved onset
age age limit to 12!
7 years
 Present for at least 6 months
 Causes impairment in at least 2 settings
Now requires “SEVERAL SYMPTOMS”
across settings

 Meets 6 of 9 symptoms of inattention

 AND/OR 6 of 9 symptoms of
hyperactivity/impulsivity
 – Must be developmentally inappropriate levels
X DSM 5 criteria
A. Persistent pattern of inattention and or hyperactivity-impulsivity that
interferes with functioning or development as characterized by
inattention and or hyperactivity/impulsivity
1. Inattention: 6 or more of the following symptoms have persisted for
at least 6 months to a degree that is inconsistent with developmental
level and that negatively impacts directly on social and academic
activities
A. Often fails to give close attention to details or makes careless mistakes in schoolwork
B. Has difficulty sustaining attention in tasks or play activitiesAnd remaining focused
C. Often does notseem to listen when spoken to directly
D. Does not follow through on instructions and fails to finish schoolwork chores or duties
E. Has difficulty organizing tasks and activities
F. Avoids dislikes or is reluctant to engage in tasks that require sustained mental effort
G. Loses things necessary for tasks or activities
H. Is easily distracted
I. Is forgetful in daily activities
 Specifiers

 314.01 – combined presentation

 314.00-predominantly inattentive presentation
 314.01 predominantly hyperactive impulsive
 In partial remission
 Severity level (mild moderate severe)
X Other important changes ADHD

 ADHD can now be co-morbid with Autism spectrum

 Symptom threshold has been specified for adults
 Adults require a minimum of 5 symptoms – not 6
 Developmentally appropriate example of symptoms
are offered
X Autism Spectrum disorder

 Represents a new classification of several disorders

that were considered different forms of autism
 Previously, these were separate diagnoses.
 Autistic disorder
 Retts disorder
 Childhood disintegrative disorder
 Aspergers
 PDD NOS
 PDDs in DSM IV TR
 Autistic disorder
 Retts disorder
 Childhood disintegrative disorder
 Aspergers
 PDD NOS

All characterized by severe deficits and

pervasive impairment in multiple areas of development
•Reciprocal social interaction
•Communication impaired
•Stereotyped behavior, interests and activities
X

With the new DSM 5. Those separate disorders have now been
consolidated and ASD is evaluated in terms of severity rather than
separate diagnosis

RETTS Disorder removed because it has been established as a

physical disease
 X major changes for ASD
Three domains from the DSM IV-TR became two: 1Social
interaction; 2 communication deficits; 3 repetitive
behavior/fixated interest =
1)     Social interaction/communication deficits
2)     Fixated interests and repetitive behaviors

 Deficits in communication and social behaviors are inseparable and more

accurately considered as a single set of symptoms with contextual and
environmental specificities
 Delays in language are not unique nor universal in ASD and are more
accurately considered as a factor that influences the clinical symptoms of ASD,
rather than defining the ASD diagnosis
 Requiring both criteria to be completely fulfilled improves specificity of
diagnosis without impairing sensitivity
 Providing examples for subdomains for a range of chronological ages and
language levels increases sensitivity across severity levels from mild to more
severe, while maintaining specificity with just two domains
 Decision based on literature review, expert consultations, and workgroup
discussions; confirmed by the results of secondary analyses of data from CPEA
and STAART, University of Michigan, Simons Simplex Collection databases
X DSM 5 criteria for all ASD
A.    Persistent deficits in social communication and social interaction across contexts, not accounted for by general
developmental delays, and manifest by all 3 of the following:
1.     Deficits in social-emotional reciprocity; ranging from abnormal social approach and failure of normal back
and forth conversation through reduced sharing of interests, emotions, and affect and response to total
lack of initiation of social interaction,
2.     Deficits in nonverbal communicative behaviors used for social interaction; ranging from poorly integrated-
verbal and nonverbal communication, through abnormalities in eye contact and body-language, or deficits
in understanding and use of nonverbal communication, to total lack of facial expression or gestures.
3.     Deficits in developing and maintaining relationships, appropriate to developmental level (beyond those
with caregivers); ranging from difficulties adjusting behavior to suit different social contexts through
difficulties in sharing imaginative play and  in making friends  to an apparent absence of interest in people

B.    Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of  the
following:
1.     Stereotyped or repetitive speech, motor movements, or use of objects; (such as simple motor stereotypies,
echolalia, repetitive use of objects, or idiosyncratic phrases). 
2.     Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive
resistance to change; (such as motoric rituals, insistence on same route or food, repetitive questioning or
extreme distress at small changes).
3.     Highly restricted, fixated interests that are abnormal in intensity or focus; (such as strong attachment to or
preoccupation with unusual objects, excessively circumscribed or perseverative interests).
4.     Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment; (such as
apparent indifference to pain/heat/cold, adverse response to specific sounds or textures, excessive smelling
or touching of objects, fascination with lights or spinning objects).
C.    Symptoms must be present in early childhood (but may not become fully manifest until social demands
exceed limited capacities)
D.         Symptoms together limit and impair everyday functioning.
E. Symptoms are not better explained by intellectual developmental disorder or global developmental delay
X Specifiers

 With or without accompanying intellectual

impairment
 With her without accompanying language impairment
 Associated with a known medical or genetic condition
or environmental factor
 With catatonia
 Specify severity level
X severity
Severity level Social communication and Restricted interests and repetitive
ASD interaction behaviors

3.Requires very substantial
support
2 requires substantial support
I requires support
Severe deficits in verbal and
nonverbal social communication
skills cause severe impairments in
functioning; very limited initiation
of social interactions and minimal
response to social overtures from
others.   redirect from fixated interest or
Marked deficits in verbal and
nonverbal social communication
skills; social impairments apparent
even with supports in place;
limited initiation of social
interactions and reduced or
abnormal response to social
overtures from others
Without supports in place, deficits
in social communication cause
noticeable impairments.  Has
difficulty initiating social
interactions and demonstrates
clear examples of atypical or
unsuccessful responses to social
overtures of others.  May appear to
have decreased interest in social
Preoccupations, fixated rituals
and/or repetitive behaviors
markedly interfere with functioning
in all spheres.  Marked distress
when rituals or routines are
interrupted; very difficult to
returns to it quickly
RRBs and/or preoccupations or
fixated interests appear frequently
enough to be obvious to the casual
observer and interfere with
functioning in a variety of
contexts.  Distress or frustration is
apparent when RRB’s are
interrupted; difficult to redirect
from fixated interest
Rituals and repetitive behaviors
(RRB’s) cause significant
interference with functioning in
one or more contexts.  Resists
attempts by others to interrupt
RRB’s or to be redirected from
fixated interest.
X
ASD CONCERNS

 STIGMA - aspergers made autism respectable! Will it

continue to de-stigmatize or re-stigmatize

 Will clinicians and insurance companies “control for”

the intellectual disability bias?
 Prior co-morbid estimates with previous classification =
25-75%
 Drops to negligible with PDD and Aspergers
2. Schizophrenia
spectrum
 Schizophrenia spectrum and other
X psychotic disorders
1. The spectrum seems to emphasize degrees of psychosis
2. Change in criteria for schizophrenia now requires at least one
criteria to be either a. Delusions, b. Hallucinations or c.
Disorganized speech
3. Subtypes of schizophrenia were eliminated
4. Dimensional measures of symptom severity are now included
5. Schizoaffective disorder has been reconceptualized
6. Delusional disorder no longer requires the presence of “non-
bizarre" in delusions. There is now specifier for bizarre
delusions.
7. Schizotypal personality disorder is now considered part of the
spectrum
 2: schizophrenia and the DSM 5
X Overview of changes from DSM-IV
TR to the DSM five

 Schizophrenia and other disorders related to schizophrenia

are now grouped within a spectrum
 Overall definition of schizophrenia has not changed that
much
 Requirements that delusions must be bizarre and
hallucinations must be "first rank." (eg. Two or more
voices conversing together) have been eliminated.
 The four subtypes of schizophrenia (paranoid, catatonic,
disorganized and chronic undifferentiated) have been
eliminated.
 Rating of symptom severity is most important
 Spectrums
 ‘Spectrum’ as it applies to mental disorder is a range of linked
conditions, sometimes also extending to include singular
symptoms and traits. The different elements of a spectrum
either have a similar appearance or are thought to be caused
by the same underlying mechanism. In either case, a spectrum
approach is taken because there appears to be "not a unitary
disorder but rather a syndrome composed of subgroups". The
spectrum may represent a range of severity, comprising
relatively "severe" mental disorders through to relatively
"mild and nonclinical deficits".[1]
 In some cases, a spectrum approach joins together conditions
that were previously considered separately.(wikipedia)
 Spectrum suggests a progression from
Mild or brief Major or lengthy
Debilitation Debilitation
Severity severity

Attenuated Schizotypal delusional Brief Schizophreniform Schizophrenia Schizoaffective

psychosis personality disorder psychotic disorder disorder
Syndrome Disorder disorder
in conditions (Found in PD
for further Section)
study

In the following areas

1.Delusions
2.Hallucinations
3.Disorganized thinking/speech
4.Disorganized or abnormal motor behavior
5.Negative symptoms
 Attenuated psychosis syndrome
CRITERIA
A. At least one of the following symptoms is present in attenuated form and with relatively
intact reality testing. It is of sufficient severity or frequency to warrant clinical attention
1. Delusions
2. Hallucinations
3. Disorganized speech
B. Symptoms must have been present at least once per week for the last month
C. Symptoms have begun or worsened in the last year
D. Symptom is sufficiently distressing or disabling to the individual
E. Symptom is not better explained by another mental disorder including a depressive or
bipolar disorder with psychotic features and is not caused by a substance
F. Criteria for any other psychotic disorder have never been met

Symptoms are psychosis like, but below the threshold for a full psychotic disorder. Typically the
symptoms are less severe and more transient than in another psychotic disorder. Insight is
relatively intact this condition might be stress related. Typically the individual realizes that
these changes are taking place and something is wrong. Usually occurs in late adolescence
or early adulthood
DIAGNOSTIC FEATURES
 Schizotypal personality disorder
(Technically not in the spectrum)
Criteria
A. A pervasive pattern of social and interpersonal deficits marked by acute discomfort with and reduce capacity for
close relationships as well as by cognitive or perceptual distortions and eccentric cities of behavior beginning by
early adulthood and present in a variety of contexts as Indicated by 5 or more of the following:
1. Ideas of reference (excluding delusions of reference)
2. Odd beliefs or magical thinking that influences behavior; i.e. belief in clairvoyance, astral projection telepathy etc.
3. Unusual perceptual experiences, including bodily illusions
4. Odd thinking and speech
5. Suspicious or paranoid ideation
6. Inadequate or constricted affect
7. Behavior or appearance that is odd eccentric or peculiar
8. Lack of close friends or confidants
9. Excessive social anxiety that does not diminish

1. does not occur exclusively within the course of schizophrenia a bipolar disorder or depressive
disorder with psychotic features or another psychotic disorder or autism spectrum disorder

Pervasive pattern of social and it interpersonal deficits as well as eccentricities of behavior and
cognitive distortions. Such people usually have few close relationships and are considered odd.
They may be fascinated or preoccupied with paranormal phenomena and/or superstitions they
might believe that they have magical powers. They typically do not fit in and have difficulty
matching the norms of consensual social interaction. Typically these people do not become
psychotic and any psychotic symptoms are often transient and mild
 X Schizophrenia
DSM-5 Criteria and DSM-IV criteria are same:

CRITERION A.
2 or more characteristic symptoms present
for 1-month period over a 6-month
period:
1. Delusions
2. Hallucinations
3. Disorganized speech
4. disorganized behavior
X Except for
 Requirement of “bizarre delusions”and/or schneidnerian 1st
rank hallucinations is changed to
 At least 1 of the two below need to be from core positive
symptoms (delusions, hallucinations, disorganized speech)

1.Delusions
2. Hallucinations
3. Disorganized speech
4. disorganized behavior
5. Negative symptoms (personality
  B. Level of functioning in one or more areas-work,
X interpersonal relations, self care, vocation-is
markedly below the level of functioning prior to
the onset; social/ occupational dysfunction – cant
work or relate

 C. Continuous signs of the disturbance for at least

6 months (at east 1 month with symptoms from
category A. Duration is the main factor in
differentiating schizophrenia from similar illnesses

 D. have successfully ruled out schizoaffective

disorder and mood disorder (with psychotic
symptoms) b/c no evidence of mania or depression
 E. not due to substance abuse
 F. not due to Autism spectrum disorder
X Specifiers

 1st episode, currently in acute stage

 1st episode currently in partial remission
 1st episode in full remission
 multiple episodes, currently in acute episode
 multiple episodes currently in partial remission
 multiple episodes currently in full remission
 continuous
 with catatonia
 X
Schizophrenia
Diagnostic features
 Other symptoms outside the major diagnostic criteria include mood dysphoria, inappropriate affect sleep disturbance
depersonalization, derealization somatic concerns, vocational impairments

Lack of insight or awareness or even denial about the existence of the illness is also a symptom that commonly occurs.

 Aggression, sometimes associated with delusions is common in males, although not as a rule

 Although there are many brain and genetic abnormalities that have been identified, there are no “absolute” biological
markers

 Schizophrenia is often overdiagnosed in the poor

 There is a high rate of suicide among schizophrenics-6%. With a suicide attempt rate of close to 20%

 Still thought to be a lifelong illness although the occurrence of "positive symptoms" seem to diminish with age
 Depression often shows up over time
 Schizophreniform disorder
X
Diagnostic features
 * At least one third of people who receive this diagnosis recover. However
the other two thirds will eventually be diagnosed with schizophrenia
 Meets all the diagnostic criteria for Schizophrenia, except duration
 Diagnosed when duration is less than six months (Absence of criterion B)
(this includes prodromal, active and residual phase)_
 Make this diagnosis when someone is having an episode longer than
one month, but it has not yet lasted 6 months (call it ‘provisional)
 The 'Tweener' disorder in terms of length. The period of active psychotic
symptoms (delusions, hallucinations, disorganized thinking, disorganize
motor behavior) is longer than a brief psychotic episode, but not as long as
schizophrenia
 Make this diagnosis when an individual Has already recovered And the
episode lasted between 1 and 6 months
 Schizophreniform
X Diagnostic criteria – 295.40

A. 2 or more of the following present for a significant portion of time. At least one of
these must be one 2 or 3
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Disorganized motor behavior
5. Negative symptoms
B. Lasts at least one month but less than 6 months. When diagnosis is made before
recovery, specify "provisional“
C. Schizoaffective disorder, depressive disorder or bipolar disorder with psychotic
features have been ruled out because either no major mood episodes have
occurred with the psychotic symptoms or if they have occurred, their occurrence
was infrequent
D. Not attributable to substances or another medical condition
 X Schizoaffective disorder
Diagnostic criteria295.70
A. An uninterrupted. period which there is a major mood episode con current
with criterion A of schizophrenia
1. Delusions
2. Hallucinations
3. Disorganized thinking
4. Grossly abnormal motor behavior
5. Negative symptoms of schizophrenia
B. In addition, Delusions or hallucinations must occur for two or more weeks
with an absence of a major mood episode during the lifetime duration
of the illness
C. Symptoms that meet criteria for major mood episode be present for the
majority of the duration of the Active, and residual portions of the illness
D. Not attributable to the effects of a substance medication or other medical
condition

The requirement that a major mood disorder must be present for the majority
Of the duration of illness AFTER criterion A is met, makes this alongitudinal
Illness or bridge on spectrum
X Subtypes
Specify whether:
295.70-bipolar type
295.70-depressive type
Specify if:
with catatonia
1st episode currently in acute episode
1st episode currently in partial remission
1st episode currently in full remission
multiple episodes currently in acute episode
multiple episodes currently in partial remission
multiple episodes currently in full remission
continuous
severity level-use. Clinician related dimensions of psychotic
symptoms
 PSYCHOTICISM
X HIGH
SCHIZO-
AFFECTIVE
SCHIZOPHRENIA
ACUTE MOOD DISORDERWITH
PSYCHOTIC FEATURES

A
F
F NONE HIGH

E SCHIZOPHRENIA
PARTIAL REMISSION
C MOOD DISORDER

NONE
X 3. Bipolar and related disorders
summary
 Diagnosis must now include both changes in mood and changes in
activity/energy level
 Some particular conditions can now be diagnosed under "other specified
bipolar and related disorders“
 An "anxiety" specifier has now been included
 Attempts made to clarify definition of 'hypomania". However it was not
successful
 Bipolar I mixed episode –no longer requires full criteria for depressed
and mania or hypomania
 New specifier is “mixed features”.
X
Some particular conditions can now be diagnosed under
"other specified bipolar and related disorders”
These do not meet full criteria for bipolar diagnosis
1. No history of major depression with hypomanic
episode05-

2. Short durations. Cyclothymic (less than 24 months).

3. Multiple episodes of hypomanic symptoms that do

not meet criteria and multiple episodes of
depressive symptoms that you might meet criteria

4. History of major depressive disorder

• Hypomanic symptoms present but not of
sufficient duration (less than 4 days)
• Insufficient number of hypomanic
symptoms
 Problems

 Severity Criteria are unclear

 "Severity is based on the number of criterion symptoms,
Francis severity of those symptoms and the degree of
functional disability." (Page 154)
 Dimensional measures for both mania and depression exist
as level II crosscutting measures. These could be used to
measure severity.
 Bipolar I Coding for severity
Bipolar I Current or Current or Current or Current or
disorder most recent most recent most recent most recent
episode-manic episode- episode- episode-
hypomanic depressed unspecified

Mild 296.41 Not applicable 296.51 Not applicable

Moderate 296.42 Not applicable 296.52 Not applicable

Severe 296.43 Not applicable 296.53 Not applicable

Mild = few if any symptoms in excess of those required to meet the diagnostic criteria are
present. The intensity is distressing that manageable. Symptoms resulting minor
impairment of social and occupational functioning

Moderate = number of symptoms and intensity and/or functional impairment are between
those specified for mild and severe

Severe = number of symptoms is substantially in excess of those required to make DX.

Intensity of symptoms is seriously distressing and unmanageable. Symptoms interfere
The dimensional Alternative assessment
of mania and hypomania

 DSM 5 offer some assistance

 Suggests 1st using the level I crosscutting symptoms
scale-PP.734 – 735.
 That the answers to question 9 and 10-increased energy
anddecreased need for sleepare positive then
 Move to use of the Altman self rating mania scale
(ASRM) - See next slide
Level 2
Dimensional
Measure for
Mania

Level II
measures are
more in-depth
than level I
measures. The
level I measure
shown in week 1
measured a
number of
different
symptoms. Level
II focuses in on
only one
subgroup. In this
case mania
 Instructions for the mania scale
Instructions to Clinicians
The DSM-5 Level 2—Mania—Adult measure is the Altman Self-Rating Mania Scale. The ASRM is a 5-item se rating mania scale
designed to assess the presence and/or severity of manic symptoms. The measure is completed by the individual prior to a
visit with the clinician. If the individual receiving care is of impaired capacity and unable to complete the form (e.g., an
individual with dementia), a knowledgeable informant complete the measure. Each item asks the individual (or informant) to
rate the severity of the individual’s manic symptoms during the past 7 days.
 
Scoring and Interpretation
Each item on the measure is rated on a 5-point scale (i.e., 1 to 5) with the response categories having differ anchors
depending on the item. The ASRM score range from 5 to 25 with higher scores indicating greater severity of manic symptoms.
The clinician is asked review the score on each item on the measure during th clinical interview and indicate the raw score for
each item in the section provided for “Clinician Use”. The r scores on the 5 items should be summed to obtain a total raw
score and should be interpreted using the Interpretation Table for the ASRM below:
 
Interpretation Table for the ASRM
- A score of 6 or higher indicates a high probability of a manic or hypomanic condition
- A score of 6 or higher may indicate a need for treatment and/or further diagnostic workup
- A score of 5 or lower is less likely to be associated with significant symptoms of mania
 

Instructions: for client

On the DSM-5 Level 1 cross-cutting questionnaire you just completed, you indicated that during the past 2 weeks you (the
individual receiving care) have been bothered by “sleeping less than usual, but still having a lot of energy” and/or “starting lots more projects than
usual or doing more risky things than usual” at a mild or greater level of severity. The five statement groups or questions below ask about these
feelings in more detail.
 
1. Please read each group of statements/question carefully.
2. Choose the one statement in each group that best describes the way you (the individual receiving care) have been feeling for the past week.
3. Check the box (P or x) next to the number/statement selected.
4. Please note: The word “occasionally” when used here means once or twice; “often” means several times o more and frequently” means most
of the time.
 
 Coding and recording procedures for
bipolar one disorder
 Coding is complicated
 Must specify the following in the order presented below
1. Bipolar I disorder
2. Type of current episode (manic or depressive)
3. Severity level
4. Current state of most recent episode (active, in partial
remission, in full remission, unspecified)
5. Psychotic features present
6. Presence of other specifiers (uncoded)
 Bipolar I Coding for Current state of episode
& psychosis
Bipolar I disorder Current or Current or most Current or most Current or most
most recent recent episode- recent episode- recent episode-
episode- hypomanic* depressed unspecified**
manic

Not applicable Not applicable

W/ psychotic 296.44 296.54
features
In Partial 296.45 296.45 296.55 Not applicable

remission
In full remission 296.46 296.46 296.56 Not applicable

Unspecified 296.40 296.40 296.50 Not applicabl

*Do not code severity and psychotic features if current or most recent
episode is hypomanic. **Do not code severity and psychotic features if
current or most recent episode = unspecified.
X 4. Depressive disorders
SUMMARY

 New diagnosis included = "disruptive mood

dysregulation disorder-use for children up to age 18
 New diagnosis included = "premenstrual dysphoric
disorder“
 What used to be called dysthymic disorder is now
"persistent depressive disorder“
 Bereavement is no longer excluded
 MDD: Specifiers
X
 Severity
 With anxious distress
 With mixed features
 Melancholic Features
 Atypical Features
 Catatonic
 Postpartum
 Seasonal
 With Psychotic Features(Mood congruent or incongruent)
 Depression is mainly coded by
severity and recurrence
Severity/course specifier Single episode Recurrent episode

Mild 296.21 296.31

Moderate 296.22 296.332
Severe 296.23 296.33
With psychotic features 296.24 296.34
In partial remission 296.25 296.35
In full remission 296.26 296.36
Unspecified 296.20 296.30
Mild = few if any symptoms in excess of those required to meet the diagnostic criteria are present.
The intensity is distressing that manageable. Symptoms resulting minor impairment of social and
occupational functioning

Moderate = number of symptoms and intensity and/or functional impairment are between those
specified for mild and severe

Severe = number of symptoms is substantially in excess of those required to make DX. Intensity of
symptoms is seriously distressing and unmanageable. Symptoms interfere markedly with social
 Problems with severity

 Severity Criteria are unclear

 "Severity is based on the number of criterion symptoms,
Francis severity of those symptoms and the degree of
functional disability." (Page 154)
 Dimensional measures for both mania and depression exist
as level II crosscutting measures. These could be used to
measure severity.
LEVEL ii CROSS-CUTTING MEASURE FOR DEPRESSION. The questions below ask about these
feelings in more detail and especially how often you (the individual receiving care) have been
bothered by a list of symptoms during the past 7 days. Please respond to each item by marking ( or
x) one box per row.
Instructions to Clinicians
The DSM-5 Level 2—Depression—Adult measure is the 8-item PROMIS
Depression Short Form that assesses the pure domain of depression in
individuals age 18 and older. The measure is completed by the individual prior
to a visit with the clinician. If the individual receiving care is of impaired
capacity and unable to complete the form (e.g., an individual with dementia), a
knowledgeable informant may complete the measure as done in the DSM-5
Field Trials. However, the PROMIS Depression Short Form has not been
validated as an informant report scale by the PROMIS group. Each item asks
the individual receiving care (or informant) to rate the severity of the
individual’s depression during the past 7 days.

Scoring and Interpretation

Each item on the measure is rated on a 5-point scale (1=never; 2=rarely;
3=sometimes; 4=often; and 5=always) with a range in score from 8 to 40 with
higher scores indicating greater severity of depression. The clinician is asked
to review the score on each item on the measure during the clinical interview
and indicate the raw score for each item in the section provided for “Clinician
Use.” The raw scores on the 8 items should be summed to obtain a total raw
score. Next, the T-score table should be used to identify the T-score
associated with the individual’s total raw score and the information entered in
the T-score row on the measure.
Note:
This look-up table works only if all items on the form are answered. If 75% or more of the
questions have been answered; you are asked to prorate the raw score and then look up the
conversion to T-Score. The formula to prorate the partial raw score to Total Raw Score is:
(Raw sum x number of items on the short form)
Number of items that were actually answered
If the result is a fraction, round to the nearest whole number. For example, if 6 of 8 items were
answered and the sum of those 6 responses was 20, the prorated raw score would be 20 X 8/
6 = 26.67. The T-score in this example would be the T-score associated with the rounded
whole number raw score (in this case 27, for a T-score of 64.4).
The T-scores are interpreted as follows:
Less than 55 = None to slight
55.0—59.9 = Mild
60.0—69.9 = Moderate
70 and over = Severe
Note: If more than 25% of the total items on the measure are
 Explanation of other specifiers
 With anxious distress = 1. Tense, 2. Restless 3. Excessive worry 4. Fear of catastrophe 5. Fear of losing control
 If present, Code severity of anxiety
 Mild = 2 symptoms
 moderate = 3 symptoms
 moderate- severe = 4 or 5 symptoms
 With mixed features = prominent dysphoria or depressed mood, diminished interest or pleasure, psychomotor retardation and/or other symptoms found in depressive
episodes

 With melancholic features = loss of pleasures and all activities, lack of reactivity to pleasurable experiences. 3 or more of the following; depressed mood that is worse in
the morning, early-morning awakening mark psychomotor agitation or retardation, significant weight loss, excessive guilt

 With atypical features = mood improves in response to positive events (mood reactivity) 2 or more of the following; weight gain or increase in appetite, hypersomnia,
heavy feeling in arms or legs heightened sensitivity to interpersonal rejection

 Mood congruent psychotic features = with depression, delusions and hallucinations are often punitive, self punishing and rejecting. Perhaps delusions of persecution
or annihilation.

 Mood incongruent psychotic features = delusions and hallucinations are not consistent with mood being displayed

 With postpartum onset = onset of mood symptoms occurs during pregnancy or in the 4 weeks following delivery. Depressive episodes are far more common than
manic episodes

 Seasonal pattern = regular temporal correlation between the onset of manic, hypomanic or depressive episodes and a particular time of year, usually without the
presence of psychosocial stressors
 With anxiety
 Anxiety is very common with depression
 anxious distress =
 1. Tense
 2. RelentlessRestlessness
 3. Excessive worryOr concern that is unwarranted
 4. Excessive concern regarding the occurrence of a major negative
event-
 5. Fear of losing control
 If present, Code severity of anxiety
 Mild = 2 symptoms
 moderate = 3 symptoms
 moderate- severe = 4 or 5 symptoms
XPersistent depressive disorder 300.4
Formerly known as dysthymic disorder

• In The DSM-IV TR, dysthymia was considered a depressive

disorder that that was
A. long-lasting (chronic) and
B. did not meet the full criteria for a major depressive episode- a
milder form of depression
XPersistent depressive disorder in the DSM 5
Combines dysthymia and a chronic form of
major depressive disorder (without certain
symptoms
Persistent depressive disorder
X
Dysthymia vs MDD

 Chronic sense of inadequacy

 Depression is not as intense as with MDD
 Symptoms are typically not as “acute” as with MDD
 MDD = depressed mood, most of day, nearly every day for two
weeks
 Dys = depressed mood more days than not over a period of 2
years
 Seems more like a personality disorder “dissatisified
personality”

N
XDysthymic Disorder and Chronic
major depressive disorder

 2 or more of the following associated Symptoms Along

with depressed mood
1. Change in appetite
2. Change in sleep
3. Decreased energy
4. Decreased self worth
5. Poor concentration
6. Hopelessness
.
X
 Please note that there are 3 major symptoms missing from
this list that are included in major depressive disorder;
 1. Absence of pleasure (anhedonia)
 2. Recurrent thoughts of suicide
 3. Psychomotor retardation or agitation
This suggests that only a particular type of major depressive
disorder-1 without suicidal ideation, anhedonia and lethargy
qualify for this diagnosis
 X PDD: Specifiers
 Severity
 With anxious distress
 With mixed features
 Melancholic Features
 Atypical Features
 Psychosis-mild (mood congruent or incongruent)
 Postpartum
 Partial remission
 Full remission
 Late onset-21 or older
 Early onset

 With pure dysthymic syndrome-criteria for major depression is not been met
 With persistent major depressive episode-full criteria have been met, excluding anhedonia, psychomot
retardation and suicidal ideation
 Intermittent major depressive episodes with or without current episode
 X The bereavement exclusion is gone
In DSM-IV, there was an 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 (i.e., the bereavement exclusion). This
exclusion is omitted in DSM-5 for several reasons. The first is to remove the
implication that bereavement typically lasts only 2 months when both
physicians and grief counselors recognize that the duration is more
commonly 1–2 years. Second, bereavement is recognized as a severe
psychosocial stressor that can precipitate a major depressive episode in a
vulnerable individual, generally beginning soon after the loss. When major
depressive disorder occurs in the context of bereavement, it adds 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, which is now
described with explicit criteria in Conditions for Further Study in DSM-5
Section III. Third, bereavement-related major depression is most likely to
occur in individuals with past personal and family histories of major
depressive episodes. It is genetically influenced and is associated with similar
personality characteristics, patterns of comorbidity, and risks of chronicity
and/or recurrence as non–bereavement-related major depressive episodes.
Finally, the depressive symptoms associated with bereavement-related
depression respond to the same psychosocial and medication treatments as
non–bereavement-related depression.
X
Disruptive mood dysregulation disorder
296.99

 The purpose of this diagnosis was to provide a category for

children that created an alternative to the diagnosis of bipolar
disorder
 Evidence for such a diagnosis has long been available. Earlier
proposals were "severe mood dysregulation“
 Evidence suggests that children with this type of mood
dysregulation will not go on to be bipolar, but more likely
suffer from major depression
 Diagnostic criteria
A. Severe recurrent temper outburst manifested verbally or behaviorally; grossly out of
proportion to the situation to the situation
B. Outbursts are inconsistent with developmental level
C. Outbursts occur 3 or more times a week
D. Mood between temper outburst is persistently irritable or angry most of the day, nearly
every day.
E. Criterion a through D have been present for 12 or more months
F. Criteria a through D are present in at least 2 or more settings
G. Initial Diagnosis can be made between the ages of 6 to 18
H. Age of onset-established her history or observation-must be before the age of 10
I. No presence of manic or hypomanic episode
J. These behaviors do not occur during an episode of major depression and are not better
explained by another mental disorder
K. Symptoms are not attributable to the effects of a substance, another medical or neurological
condition
X
Diagnostic features

 Chronic, severe persistent irritability with the

following:
 Frequent temper outbursts in response to frustration
over a sustained period of time and are developmentally
inappropriate
 Anger and irritability remains constant even after
temper outbursts of stopped
X

 Prevalence estimates range between 2% and 5%

 Affects males more than females
 such children seem to be extremely temperamental in
prodromal manifestation
 sometimes diagnosed as oppositional defiant disorder
 5. Anxiety disorders, 6. obsessive-
compulsive disorder and 7. trauma-
related disorders
SUMMARY

Anxiety disorders
Panic disorder
Agoraphobia
Generalized anxiety disorder Acute stress disorder
Social phobia
Specific phobia
PTSD
Specified anxiety disorder
Acute Stressanxiety
Unspecified disorderdisorder
Obsessive compulsive disorder Obsessive compulsive disorder
Separation anxiety disorder
selectivemutism
Stress and trauma related disorders
Disinhibited social engagement dis.
Reactive attachment
Reactive attachment disorder
disorder
Adjustment disorders
PTSD
Obsessive-compulsive related disorders
ocd w/ poor insight
Hoarding disorder
Hair-pulling disorder
Skin-picking disorder
Body dysmorphic disorder
Medication-induced ocd
Other specified/unspecified ocd
 5. Anxiety disorders
 Obsessive-compulsive disorder has been moved
out of this category
 PTSD has been moved out of this category
 Acute stress disorder has been moved out of this
category
 Panic attacks can now be used as a specifier within
any other disorder in the DSM
 Separation anxiety disorder has been moved to this
group
 Selective mutism has been moved to this group
 Other changes and anxiety
disorders
 Criteria for specific phobia, and social anxiety disorder that requires that
individuals over 18 recognize that their anxiety is excessive or
unreasonable has been deleted
 I don't know I don't see it in here. I don't know. I had a lot of awareness
requirement is now that anxiety must be out of proportion to the actual
danger or threat in a situation after a cultural context is considerED
 Panic disorder and agoraphobia are unlinked in the DSM 5
 THE “generalized” specifier for social anxiety disorder has been
deleted and replaced with her “performance only” specifier
 X
6. Obsessive-compulsive and related
disorders

 A completely new diagnostic grouping category

 Hoarding disorder-new diagnosis
 Excoriation (skin picking) disorder-new diagnosis
 Substance induced obsessive-compulsive disorder-new diagnosis
 Tic specifier has been added
 Muscle dysphoria is now a specifier within body dysmorphic disorder
 Obsessive-compulsive disorder-refined to allow distinction between
individuals with good to fair poor or “absent/delusional”
 OCD Specifiers

 In DSM-IV TR a requirement for the diagnosis was that the

person suffering realized that the worries and behaviors
were excessive
 Now insight is a specifier
 With good or fair insight-individual recognizes that beliefs
and behaviors are not true and will not work
 With poor insight-individual believes that behaviors and
beliefs will help
 With absent insight/delusional beliefs-individual is zealous in
thinking that thoughts and behaviors must happen
 X Hoarding disorder 300.3
A. Persistent difficulty discarding her, parting with possessions,
regardless of their actual value
B. Difficulty is due to perceived need to save the items and due to
distress associated with discarding them
C. To difficulty discarding results in the accumulation of possessions
that congest and clutter active living areas and compromise their
intended use
D. Causes clinically significant distress or impairment in social,
occupational or other Areas of functioning
E. Not attributable to another medical condition
F. Not better accounted for by….
Specifiers
 With excessive acquisition-in addition to keeping things, this type
actively seeks out more(80 to 90% of all hoarders)
 With good or fair insight
 With poor insight
 With absent insight and delusional beliefs – this would trump
delusional disorder
 Excoriation (skin picking)
disorder 698.4

A. Recurrent skin picking resulting in lesions

B. Repeated attempts to stop or decrease behavior
C. Causes clinically significant distress or impairment in
social, occupational…
D. Not attributable to the effects of a substance or
medication
E. Not better explained by…
X Substance/medication induced
obsessive-compulsive and related
disorder

A. Obsessions, compulsions, skin picking, hair pulling or

other body focused repetitive behaviors occur
B. Evidence that symptoms began during or soon after
substance use, withdrawal or medication exposure.
Substance or medication is capable of producing
obsessive-compulsive symptoms
C. Not better accounted for by OCD that is not
substance/medication induced
D. Does not occur exclusively during delirium
E. Causes clinically significant distress
 OCD due to another medical
condition 294.8
A. Obsessions, compulsions, skin picking, hair pulling
or other body focused repetitive behaviors occur
B. Evidence that symptoms began during or soon
after Another medical condition that could cause
the symptomsNot better accounted for by OCD
that is not substance/medication induced
C. Does not occur exclusively during delirium
D. Causes clinically significant distress

Specify if
•With the possessive compulsive disorder like symptoms
•With appearance. Preoccupation
•With hoarding symptoms
•With hair pulling symptoms
•With skin picking symptoms
Other specified obsessive-compulsive
and related disorder 300.3

 Use when OCD symptoms are there and cause

clinically significant distress, but do not meet full
criteria for an OCD related diagnoses
 Specify
 Body dysmorphia with actual flaws
 Body dysmorphia without repetitive behaviors
 Body dysmorphia with repetitive behaviors
 obsessional jealousy
X
Substance-Related Disorders

The distinction between

:
Dependence and abuse disorders
 Substance Use Disorders has been eliminated in the DSM 5
 Substance Dependence
 Substance Abuse

 Substance-Induced Disorders
 Substance Intoxication
 Substance Withdrawal
 Substance induced mental disorder
 X
Substance use disorders maladaptive pattern
leading to clinically significant impairment or
distress for at least 12 months
Must have at least 2 of the following11:
1. Substance taken in larger amount (need more for
increased effect)
2. Persistent desire or efforts to quit
3. Time spent to obtain, use, recover from effects
4. Cravings Or urges to use
5. Failure to fulfill significant roles
6. Continued use despite persistent and recurrent
problems
7. Important social/occupational activities are reduced
8. Recurrent use in physically hazardous situations
9. Use continues despite knowledge of impact of the
problem
10. Tolerance, as defined by a. Increased amounts needed
to achieve intoxication or b. Diminished effect
11. Withdrawal
 X
Substance-related disorders

Substance use dis. Substance induced dis.

Pathological pattern of
4. Pharmacological effects
behaviors related to use
of the substance Increased tolerance
1.Impaired control
2.Social impairment Substance Substance
3.Risky use
Withdrawal Induced
Substance
Physiological and Mental
Intoxication
psychological disorder.
Recent
symptoms due to Recent
ingestion.
decreased use or ingestion
Reversible
cessation followed by
symptoms
symptoms
= related to
of another
ingestion
= does occur also M.D.
Delirium; persisting dementia; persisting amnesia;
Psychotic disorder; mood dis; anxiety dis; sexual dys; sleep dis.
 X
11 criteria four areas – USE Dx
1. Substance taken in larger amount (need more for increased effect)
Impaired 2. Persistent desire or efforts to quit
Control 3. Time spent to obtain, use, recover from effects
4. Cravings Or urge to use
social 5. Failure to fulfill significant roles
Impairment 6. Continued use despite persistent and recurrent problems
7. Important social/occupational activities are reduced
Risky 8. Recurrent use in physically hazardous situations
use 9. Use continues despite knowledge of impact of the problem
10. Tolerance, as defined by a. Increased amounts needed to achieve
Pharmacological intoxication or b. Diminished effect
effects 11. Withdrawal
X 1. Criteria for Substance Use disorder
A. A maladaptive pattern of substance use leading to
impairment or distress, as seen in 2 of the following in
the same 12-mo. period:
1. Substance taken in larger amount (need more for increased
effect)
2. Persistent desire or efforts to quit
3. Time spent to obtain, use, recover from effects
4. Cravings Or urges to use
5. Failure to fulfill significant roles
6. Continued use despite persistent and recurrent problems
7. Important social/occupational activities are reduced
8. Recurrent use in physically hazardous situations
9. Use continues despite knowledge of impact of the problem
10. Tolerance, as defined by a. Increased amounts needed to
achieve intoxication or b. Diminished effect
11. Withdrawal
DSM 5 use = 2 or more crit. DSM IV
Abuse = 1 or more
1Failure to fulfill major role obligations at work, school,
home such as repeated absences or poor work performance
related to substance use;
#5 DSM 5

2. Frequent use of substances in situation which iis

physically hazardous
#8 dsm 5

3Frequent legal problems (e.g. arrests, disorderly conduct)

for substance abuse removed

4. Continued use despite having persistent or recurrent

social or interpersonal problems #6 dsm 5
Dependence = 3 or more
5. Tolerance or markedly increased amounts of the
substance to achieve intoxication or desired effect or
markedly diminished effect with continued use of the same
amount of substance #10 DSM 5

6 Withdrawal symptoms or the use of certain substances to

avoid withdrawal symptoms #11 DSM 5

7. Use of a substance in larger amounts or over a longer

period than was intended #1 DSM 5

8.persistent desire or unsuccessful efforts to cut down or

control substance use #2 DSM 5

9. Involvement in chronic behavior to obtain the substance,

use the substance, or recover from its effects #3 DSM 5

10. .Reduction or abandonment of social, occupational or

recreational activities because of substance use #7 DSM 5
X
Specifiers for use disorders
Severity
Mild = presence of 2-3 symptoms
moderate = presence of four – five symptoms
severe = presence of six or more symptoms

Course specifiers
In early remission = after full criteria were previously met
none of the criteria have been met for at least three months but
less than 12 (with the exception of craving)
In sustained remission = after full criteria were
previously met none exists except craving during the period of 12
months or more
X Can also diagnose intoxication, withdrawal and induced mental disor

Simple substance dx
Mental disorders that can be induced by substances

I/W
I/W

I
X
7. Trauma and stress related
disorders

 For diagnosis of acute stress disorder, it must be

specified whether the traumatic events were
experienced directly or indirectly
 Adjustment disorders (a separate class in the DSM-IV)
are included here as various types of responses to
stress
 Major changes in the criteria for the diagnosis of PTSD
XDiagnostic criteria has gotten more
detailed and specific = more
complicated diagnosis
The basics
A. Exposure to trauma-direct or indirect
Traumatic
events B. Presence of intrusive thoughts, memories, flashbacks,
dreams, triggers that cause distress, or other external cues
that remind one of the trauma
C. Avoidance of stimuli associated with the traumatic event
Subsequent D. Changes (usually increased sensitivity) in thought processes
reactions and emotions associated
E. Increased arousal or reactivity associated with the traumati
event with the traumatic event
 X
PTSD changes
 Criterion A - the stressor criterion is more explicit with regard to how an individual experienced “traumatic”
events.
 Criterion A2 (subjective reaction) has been eliminated.
 Three major symptom clusters in DSM-IV—reexperiencing, avoidance/numbing, and arousal—
 Now four symptom clusters in DSM-5, because the avoidance/numbing cluster is divided into two distinct
clusters: avoidance and persistent negative alterations in cognitions and mood. This latter category, which
retains most of the DSM-IV numbing symptoms, also includes new or reconceptualized symptoms, such as
persistent negative emotional states. The final cluster—alterations in arousal and reactivity—retains most of
the DSM-IV arousal symptoms. It also includes irritable or aggressive behavior and reckless or self-destructive
behavior. Posttraumatic stress disorder is now developmentally sensitive in that diagnostic thresholds have
been lowered for children and adolescents. Furthermore, separate criteria have been added for children age
6 years or younger with this disorder.
 Reactive Attachment
 X PTSD 309.81
A . Exposure to actual or threatened death, serious injury or sexual violence in one of the following ways
1. Directly experiencing the traumatic events
2. Witnessing in person. The event is it occurred to others
3. Learning that the traumatic events occurred to a close family member or close friend
4. Experiencing repeated or extreme exposure to aversive details of the traumatic events; a form of Vicarious exposure experienced by police
officers or 1st responders
B. Presence ofone or more of the following intrusion symptoms associated with the traumatic events beginning after the event occurred
1. Recurrent, involuntary and intrusive distressing memories of the event
2. Recurrent distressing dreams in which the content is related to the event
3. Dissociative reactions (flashbacks) where individual feels or acts as if the event were recurring
4 intense-prolonged psychological distress when exposed to internal or external cues
5. Marked physiological reactions to internal or external cues
C. Persistence avoidance of stimuli associated with the traumatic events beginning after the event occurred
1. Avoidance or efforts to avoid distressing memories, thoughts or feelings associated with the event
2. Avoidance or efforts to avoid external reminders-people, places, conversations that might arouse distressing memory starts her
feelings associated with the event
D. Negative alterations in cognitions and mood associated with the events beginning or worsening after the events
1. Inability to remember an important aspect of the traumatic event. This is not caused by a head injury help call or drugs, but dissociative
amnesia related to the event
2. Persistent exaggerated negative beliefs or expectations about oneself, Others and the world-I am bad, No one can be trusted, the world
sucks
3. Distorted cognitions that lead to self blame where the blame of others.
4. Persistent negative emotional state
5. Diminished interest or participation in significant activities
6. Feelings of detachment or estrangement from others
7. Persistent inability to experience positive emotions
 X PTSD 309.81-Continued
E. Significant alterations in arousal and reactivity associated with the traumatic event
1. Irritable behavior in angry outbursts with little or no provocation-started after the event, usually
directed toward people or objects
2. Reckless or self-destructive behavior
3. Hypervigilance
4. Exaggerated startle response
5. Problems with concentration
6. Sleep disturbance
F. Duration of the disturbance is longer than one month
G. Causes clinically significant distress or impairment
H. The disturbance is not attributable to the physiological effects of a substance or another medical condition

Specifiers
Specify whether:
Dissociative symptoms are present
Depersonalization = experience of feeling detached from, and disconnected from one self. Often described as
feeling as if one were outside observing oneself or as though in a dream.A sense or feeling of unreality
regarding oneself-with the knowledge that this is not true
Derealization= Experience of unreality of surroundings-the world feels unreal, dreamlike, distant her
distorted. However, one realizes this is not true
Specify if
Expression of symptoms is delayed = the full drive gnostic criteria are not met until at least 6 months or
more after the event

Please note the presence of anxiety, fear and avoidance. 3 conditions that we find in generalized anxiety disorder
 PTSD In children-6 or younger
XAvoidance and alterations in cognition collapsed into one criterion group
A . Exposure to actual or threatened death, serious injury or sexual violence in one of the following ways
1. Directly experiencing the traumatic events
2. Witnessing in person. The event is it occurred to others
3. Learning that the traumatic events occurred to a close family member or close friend
B. Presence ofone or more of the following intrusion symptoms associated with the traumatic events beginning after the event occurred
1. Recurrent, involuntary and intrusive distressing memories of the event
2. Recurrent distressing dreams in which the content is related to the event
3. Dissociative reactions (flashbacks) where individual feels or acts as if the event were recurring
4 intense-prolonged psychological distress when exposed to internal or external cues
5. Marked physiological reactions to internal or external cues
C. One or more of the following symptoms involving either avoidance or negative alterations in cognition are made - must be Present
1. Avoidance or efforts to avoid distressing memories, thoughts or feelings associated with the event
2. Avoidance or efforts to avoid external reminders-people, places, conversations that might arouse distressing memory starts her feelings associated
with the event
3. Increase of negative emotional states
4. Diminished interest or participation in significant activities
5. Socially withdrawn Behavior
6. Reduction in expression of positive emotions
D. alterations in arousal and reactivity associated with the traumatic event
1. Irritable behavior in angry outbursts with little or no provocation-
2. Hypervigilance
3. Exaggerated startle response
4. Problems with concentration
5. Sleep disturbance
E.. Duration of the disturbance is longer than one month
F. Causes clinically significant distress or impairment
G.. The disturbance is not attributable to the physiological effects of a substance or another medical condition
X PTSD 309.81-Children
Specifiers are the same
Specifiers
Specify whether:
Dissociative symptoms are present
Depersonalization = experience of feeling detached from, and disconnected from one self. Often described as
feeling as if one were outside observing oneself or as though in a dream.A sense or feeling of unreality
regarding oneself-with the knowledge that this is not true
Derealization= Experience of unreality of surroundings-the world feels unreal, dreamlike, distant her
distorted. However, one realizes this is not true
Specify if
Expression of symptoms is delayed = the full drive gnostic criteria are not met until at least 6 months or
more after the event
In DSM-IV RAD was divided into
subtypes

 Subtypes = inhibited type and disinhibited type (criterion A),

 Inhibited = Persistent failure to initiate or respond in a developmentally

appropriate fashion to most social interactions, as manifest by excessively
inhibited, hypervigilant, or highly ambivalent and contradictory responses (e.g.
the child may respond to caregivers with a mixture of approach, avoidance, and
resistance to comforting, or may exhibit "frozen watchfulness", hypervigilance
while keeping an impassive and still demeanor). Such infants do not seek and
accept comfort at times of threat, alarm or distress, thus failing to maintain
"proximity", an essential element of attachment behavior

 Disinhibited = Diffuse attachments as manifest by indiscriminate sociability with

marked inability to exhibit appropriate selective attachments (e.g., excessive
familiarity with relative strangers or lack of selectivity in choice of attachment
figures). There is therefore a lack of "specificity" of attachment figure
 Disinhibited = 313.89 disinhibited
social engagement disorder
A. A pattern of behavior in which a child actively approaches and interacts with unfamiliar
adults and exhibits at least 2 of the following
1. Reduced or absent reticence in approaching and interacting with unfamiliar adults
2. Overly familiar verbal or physical behavior that is not consistent with age-appropriate
social boundaries
3. Diminished or absent "checking back" behaviors
4. Willingness to go with an unfamiliar adult with minimal or no hesitation
B. Behaviors in criterion a are not limited to impulsivity such as that seen in ADHD
C. The child has experienced a pattern of extremes of insufficient care, as evidenced by at least
one of the following
1. Social neglect or deprivation in the form of persistent lack of having basic emotional
needs for comfort stimulation and affectation met by caregivers
2. Repeated changes of primary caregivers that limit opportunities for stable attachment
3. Rearing in unusual settings
D. The criterion C is presumed to be responsible for the disturbed behavior in criterion A
E. The child has a developmental age of at least 9 months
A.
313.89 RAD
A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers manifested by
both of the following
1. The child rarely or minimally seeks comfort when distressed
2. The child rarely or minimally responds to comfort. When distressed
B. A persistent social and emotional disturbance characterized by at least 2 of the following
1. Minimal social and emotional responsiveness to others
2. Limited positive affect
3. Episodes of unexplained irritability, sadness or fearfulness that are evident even during nonthreatening
interactions with caregivers
C. The child has experienced the pattern of extremes or insufficient care, as evidenced by at least one of the
following
1. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort
stimulation and affection met by caregiving adults
2. Repeated changes a primary caregivers that limit opportunities to form stable attachment
3. Rearing in unusual settings that severely limit opportunities to form attachments
D. To carry in criterion C is presumed to be responsible for the disturbed behavior in criterion a
E. Criterion are not met for autism spectrum disorder
F. Disturbance is evident before age 5
G. Child has a developmental age of at least 9 months
Adjustment Disorders

In DSM-5, adjustment disorders are reconceptualized as a

heterogeneous array of stress-response syndromes that occur
after exposure to a distressing (traumatic or nontraumatic) event,
rather than as a residual category for individuals who exhibit
clinically significant distress without meeting criteria for a more
discrete disorder (as in DSM-IV ). DSM-IV subtypes marked by
depressed mood, anxious symptoms, or disturbances in conduct
have been retained, unchanged.

•Stressor can be of any severity or type (unlike PTSD Criterion A)

•Much more flexible diagnosis then PTSD or acute stress disorder
•Diagnose adjustment disorder when:
• PTSD criteria are not met
• Criterion A for PTSD stressors not met
• Subthreshold for acute stress disorder & PTSD
• Symptoms do not last longer than 6 months after stressor.-
A transitional state that is longer than acute stress disorder,
but typically not as intense
 8. Dissociative disorders
SUMMARY

 Depersonalization disorder has been relabeled

“Depersonalization/Derealization disorder“
 Dissociative fugue is no longer a separate diagnosis
but is now specifier within the diagnosis of
"dissociative amnesia“
 Changes in criteria for the diagnosis of "dissociative
identity disorder"
 DID
 Criterion A has been expanded to include certain possession-
form phenomena and functional neurological symptoms to
account for more diverse presentations of the disorder.
 Criterion A now specifically states that transitions in identity
may be observable by others or self-reported.
 Criterion B, individuals with dissociative identity disorder may
have recurrent gaps in recall for everyday events, not just
for traumatic experiences. Other text modifications clarify
the nature and course of identity disruptions.
 Diagnostic criteria – DSM 5 300.14
A. Presence of two or more distinct Personality states, which may be described in
some cultures as an experience of possession. This disruption and identity involves
marked discontinuity in sense of self and personal agency. This is accompanied by
alterations (often sudden) in affect, behavior, consciousness, memory, perception
and/or sensorimotor functioning. These signs and symptoms may be observed by
others or reported by the individual

B. Inability to recall important personal information Or gaps in recall of everyday

events. Important personal information or traumatic events. AKA dissociative
amnesia

C. Cause clinically significant distress , And/or impairment

D. Not a part of broadly accepted cultural or religious practice
E. Not due to a substance or general medical condition
 Note the difference in the
Diagnostic criteria –IV TR

A. Presence of two or more distinct identities, each

with its own relatively stable pattern of personality
traits
B. At least two of these ‘alters’ take control of the
person’s behavior
C. Inability to recall important personal information
that is too extensive to be explained by ordinary
forgetfulness
D. Not due to a substance or general medical condition
X
9. Somatic symptom and related
disorders

 This is a new name for what was previously called

"somatoform disorders“
 The number of diagnoses in this category has been
reduced. The diagnoses of somatization disorder,
hypochondriasis, pain disorder and undifferentiated
somatoform disorder have all been removed
 "Illness anxiety disorder" has been an added
diagnosis and replaces hypochondriasis
 Factitious disorder is now included in this group
X
Some definitions

 Factitious disorder: conscious and intentional feigning or production of symptoms,

because of a psychological need to assume the sick role to obtain emotional gain
 Malingering: conscious and intentional production or exaggeration of symptoms for
material gain, such as money, lodging, food, drugs, avoidance of military service, or
escape from punishment
 Somatization: recurrent and multiple symptoms (eg, pain, GI, sexual,
pseudoneurological) with no organic basis, believed to be due to unconscious
expressions of suppressed emotional conflict or stress; unlike factitious disorders, the
symptoms are not created by voluntary, conscious behavior
 Hypochondriasis: obsession with fears that one has a serious, undiagnosed disease,
presumably based on misinterpretation of bodily sensations - See more at:
http://www.psychiatrictimes.com/articles/factitious-disorder-detection-diagnosis-and-
forensic-implications#sthash.trRTuLQM.dpuf
 X Somatic Symptom Disorder
 Individuals with somatic symptoms plus abnormal thoughts, feelings, and behaviors may or may not have a diagnosed
medical condition.
 The relationship between somatic symptoms and psychopathology exists along a spectrum.
 high symptom count required for DSM-IV somatization disorder did not accommodate this spectrum.
 The diagnosis of somatization disorder was essentially based on a long and complex symptom count of medically unexplained
symptoms.
 Individuals previously diagnosed with somatization disorder will usually meet DSM-5 criteria for somatic symptom
disorder, but only if they have the maladaptive thoughts, feelings, and behaviors that define the disorder, in addition
to their somatic symptoms.
 In DSM-IV, the distinction between “undifferentiated somatoform disorder” had been created in recognition that
“somatization disorder” would only describe a small minority of “somatizing” individuals, but this disorder did not
prove to be a useful clinical diagnosis.
 They are merged in DSM-5 under somatic symptom disorder, and no specific number of somatic symptoms is required.
 X Somatic Symptom Disorder300.82
Diagnostic Criteria:
A.One or more somatic symptoms that are distressing and result in
significant disruption of daily life
B.Excessive thoughts, feelings or behaviors related to the symptoms or
associated health concerns, as manifested by at least one of the
following:
1. Disproportionate and persistent thoughts about the seriousness of symptoms
2. Persistently high level of anxiety about health or symptoms
3. Excessive time and energy devoted to the symptoms or health concerns
C.The state of being symptomatic is persistent (typically more than 6
months)
 Specifiers

 Specify if:
 with predominant pain (previously classified as pain disorder and DSM-IV)

 Specify if:
 persistent: severe symptoms lasting longer than 6 months

 Specify current severity:

 mild = only one of the symptoms specified in criterion B is the filled
 moderate = 2 or more of the symptoms in criterion beer for filled
 Severe = 2 or more of the symptoms are fulfilled. Plus, there are multiple other somatic
complaints
X
300. 7 Illness anxiety disorder criteria
Previously hypochondriasis
A. Preoccupation with having or acquiring a serious illness
B. No evidence of somatic symptoms or extremely mild symptoms present
C. High anxiety about health and health status
D. Excessive health related behaviors or avoidant health related behaviors
E. Illness preoccupation present for at least 6 months
F. not better explained by another disorder

Specify whether:
care seeking type: medical care, including physician visits frequently used
care avoidant type: medical care is rarely if ever used
X Pain Disorder removed from
DSM 5
 DSM-IVpain disorder diagnoses assume that some pains are associated solely with
psychological factors, some with medical diseases or injuries, and some with both.
 lack of evidence that such distinctions can be made with reliability and validity, and a
large body of research has demonstrated that psychological factors influence all forms of
pain.
 individuals with chronic pain attribute pain to a combination of factors, including
somatic, psychological, and environmental influences-not either/or
 DSM-5 some individuals with chronic pain could be DXd
 having somatic symptom disorder, with predominant pain
 316.0psychological factors affecting other medical conditions
 adjustment disorder
 Psychological Factors Affecting
Other Medical Conditions

 Psychological factors affecting other medical conditions is a

new mental disorder in DSM-5, having formerly been included
in the DSM-IV chapter “Other Conditions That May Be a Focus
of Clinical Attention.” This disorder and factitious disorder are
placed among the somatic symptom and related disorders
because somatic symptoms are predominant in both
disorders, and both are most often encountered in medical
settings. The variants of psychological factors affecting other
medical conditions are removed in favor of the stem
diagnosis.
 Psychological Factors Affecting
Other Medical Conditions
 A. Medical symptom or condition is present
 B. psychological or behavioral factors adversely affect the medical condition in one of
the following ways
 The factors that influence the course of the medical condition as shown by a close temporal
association between a psychological factors and the development or exacerbation of medical
condition
 The factors interfere with the treatment of the medical condition
 The factors constitute additional well-established health risk for the individual
The factors influence the underlying psychopathology precipitating or exacerbating
symptoms or necessitating medical attention
 C. psychological and behavioral factors in criterion B are not better explained by
another mental disorder
X
300.19 Factitious disorder criteria
Self-imposed
A.Falsification of physical or psychological signs or symptoms or induction of injury or disease. In order to deceive
B.Individual present self to others, as if impaired or injured

C.No apparent or obvious external rewards

D., Not better accounted for by…

Imposed on others
A.Falsification of physical or psychological signs or symptoms or induction of injury or disease. In order to deceive
B.Individual presents another individual to others as you know, impaired or injured
C.No apparent external rewards
D.Not better accounted for by…
E.When imposed on others. Diagnosis is given to the perp

Specify if
single episode
recurrent episodes
X

 Somatic symptoms – major focus on symptoms experienced as

well as anxiety- symptoms can have a physical cause, but the pt.
experiences no relief
 Illness anxiety – major focus on anxiety and what “might”
happen. Symptoms might or might not be present- but are mild
if there.
 Conversion disorder – symptoms present. Of a neuro-perceptual
type; blindness paralysis
 Factitious – symptoms intentionally produced – no apparent
gain-assess motivation
 Malingering (v code)– intentional gain can be documented-
assess motivation
X
Somatic symptoms
Inauthentic –authentic illnesses
 Psychogenic illness – the mind causes symptoms that are
experienced by the patient but have no “real” presence
 Unconscious
 Somatic symptomDiagnosed in part by LACK of evidence
 Illness anxiety
 conversion
 Conscious
 Factitious
 malingering Diagnosed by evidence
X
When to suspect factitious
disorder

 The person's medical history doesn't make sense

 No believable reason exists for the presence of an illness or injury
 The illness does not follow the usual course
 There is a lack of healing for no apparent reason, despite
appropriate treatment
 There are contradictory or inconsistent symptoms or lab test
results
 The person is caught in the act of lying or causing his or her injury
X

http://www.psychiatrictimes.com)
The Case of Factitious Disorder Versus Malingering
(2009] Courtney B. Worley,
MPH ; Marc D. Feldman, MD and James C. Hamilton, PhD
X
Without detailing the full DSM diagnostic criteria sets for these
disorders and their relations, the
following is a summary of how DSM instructs psychiatrists to
diagnose cases of inauthentic illness
behavior:

1. In the absence of overwhelming affirmative evidence of

intentional medical deception (eg, caught
on video, evidence from a room search), diagnose a somatoform
disorder.

2. If there is traditional forensic evidence of overt medical

deception, diagnose malingering or
factitious disorder.

3. If there is any significant material or instrumental benefit from

the intentional medical deception
(eg, financial settlement, disability determination, access to
narcotic medicine), diagnose malingering.
http://www.psychiatrictimes.com)
The Case of Factitious Disorder Versus Malingering
(2009] Courtney B. Worley,
MPH ; Marc D. Feldman, MD and James C. Hamilton, PhD
10. Feeding and eating disorders

 "Binge eating disorder' is now included as a separate

diagnosis

 also includes a number of diagnosis that were

previously included in a DSM-IV TR in the chapter
"disorders usually 1st diagnosed during infancy
childhood and adolescence“.
 Pica and rumination disorder are 2 examples
 11. Elimination disorders
 Originally classified in chapters on childhood and infancy.
Now have separate classification
12. Sleep wake disorders
 Primary insomnia renamed "insomnia disorder«
 Narcolepsy now distinguished from other forms of
hypersomnia
 Breathing related sleep disorders have been broken into 3
separate diagnoses
 Rapid eye movement disorder and restless leg syndrome are
now independent diagnoses within this category
 13. Sexual dysfunctions
 Some gender related sexual dysfunctions have been outed
 Now only 2 subtypes-acquired versus lifelong and
generalized versus situational

 New diagnostic class and the DSM 5

 Include separate classifications for children adolescents and
adults
 The construct of gender has replaced the construct of sex
14. GENDER DYSPHORIA DSM 5
 Attempted to eliminate the stigma involved in the
previous diagnosis of gender identity disorder
 Likely that more research is needed. Prevalence is
remarkably low
Gender Dysphoria in Adolescents
and adults
A. Mark incongruence between one's experienced/expressed
gender and assigned gender. At least 6 months duration, as
manifested by at least 2 of the following
1. Marked incongruence between one's experienced/expressed gender and primary and/orsecondary sex
characteristics
2. Strong desire to be rid of one's primary and/or secondary sex characteristics because of marked incongruence
with one's experienced/expressed gender
3. Strong desire for the primary and/or secondary sex characteristics of the other gender
4. Strong desire to be of the other gender
5. Strong desire to be treated as the other gender
6. Strong conviction that one has the typical feelings and reactions of the other gender

B. Condition is associated with clinically significant distress or

impairment
Specify if "post-transition“ = the individual has transition to full-time living in the desired gender (with or
without legalization of gender change), and has undergone or is preparing to have at least one cross-
section medical procedure or treatment regimen
 X
Disruptive, impulse control and
conduct disorders

 New diagnostic grouping and DSM 5

 Combines a group of disorders previously included in disorders of
infancy and childhood such as conduct disorder oppositional
defiant disorder with a group previously known as impulse control
disorders not otherwise classified
 Oppositional defiant disorder now has 3 subtypes
 Intermittent explosive disorder no longer requires physical
violence but can include verbal aggression
X 15. Disruptive, impulse control,
and conduct disorders

Disruptive ones Impulsive ones

oppositional defiant disorder Intermittent explosive disorder
conduct disorder pyromania
Intermittent explosive disorder kleptomania
Gambling disorder
 Major dynamic in all ICDs
Impulsive
act

Immediate release in tension,

Experience of pleasure
Spike (steep rise)
or gratification
In tension immediately
Before the act

Tension and stress

Begins to build
X
ODD 313.81
A. Pattern of angry/irritable mood, argumentative/defiant behavior, Vindictiveness, lasting at least
6 months; evidenced by at least 4 symptoms for many of the following categories and exhibited
during interaction with at least one individual, not a sibling.
Angry, irritable mood
1. Often loses temper
2. Is often touchy or easily annoyed.
3. Often angry and resentful
Argumentative, defiant behavior
4. Often argues with authority figures.
5. Actively defies or refuses to comply with requests from authority figures.
6. Deliberately annoys others.
7. Blames others for his or her mistakes
Vindictive behavior
8. Has been spiteful or vindictive at least twice within the past 6 months

B. Causes distress in person, and others

 Does not occur during the course of another disorder

Changes from DSM IV

ODD & conduct disorder are not mutually exclusive
3 symptom type groupings
guidance re: how to distinguish from developmental norms
severity measure included
X
Specifiers

 Mild
 Moderate
 Severe
Severity can be measured through intensity, frequency,
or pervasiveness. For example, if the behavior occurs
in more than one setting, it is more pervasive and
thus more severe. Usually occurs in the home and
not across settings
X
Dimensional severity assessment for
ODD

Instructions to clinicians for ODD

The Clinician-Rated Severity of Oppositional Defiant Disorder assesses the severity of the OPPOSITIONAL DEFIANT
symptoms for the individual based on their pervasiveness across settings. The measure is intended to capture meaningful
variation in the severity of symptoms, which may help with treatment planning and prognostic decision-making. The
measure is completed by the clinician at the time of the clinical assessment. The clinician is asked to rate the severity of
oppositional defiant problems as experienced by the individual in the past seven days.

Scoring and interpretation for ODD scale

The Clinician-Rated Severity of Oppositional Defiant Disorder is rated on a 4-point scale (Level 0=None; 1=Mild;
2=Moderate; and 3=Severe). The clinician is asked to review all available information for the individual and,
based on his or her clinical judgment, select ( ) the level that most accurately describes the severity of the
individual’s condition.

Frequency of use for ODD scale

To track changes in the individual’s symptom severity over time, the measure may be completed at regular intervals as
clinically indicated, depending on the stability of the individual’s symptoms and treatment status. Consistently high scores
on a particular domain may indicate significant and problematic areas for the individual that might warrant further
assessment, treatment, and follow-up. Your clinical judgment should guide your decision.
X
ODD dimensional assessment
X
Problems with diagnosis

 Differentiating this from developmental and/or

environmental stress related behavior
 Differentiating from other diagnoses such as bipolar 2
 Biased reporting or reporting based on reputation
 Expectation induced disruptive behaviors
 Behavior is often confined to one way one setting (for
example, the home)
 Little or no insight is present on the part of the suffer.
See self is victim
X Conduct disorder unchanged
Diagnostic criteria
A. Repetitive and persistent pattern of behavior in which the basic rights of others or major
age-appropriate societal norms and rules are violated, as manifested by the presence of
at least 3 of the following 15 criteria in the past 12 months. For many of the categories
below, with at least one criteria present in the last 6 months
Aggression to people or animals
1 bullies, threatens or intimidates
2 often initiates physical fights
3 used weapons that can cause serious physical harm
4. been physically cruel to people
5. Been physically cruel to animals
6. Has stolen while confronting a victim
7. Forced someone into sexual activity
destruction of property
8. Has deliberately engaged in fire setting with intent of causing damage
9. Deliberately destroyed others property
deceitfulness or theft
10. Broken into someone else's home building car
11. lies or deceives to obtain goods or favors
12. Has stolen nontrivial items without confronting victim – shoplifting etc.
serious violation of rules
13. Stays out at night. Despite parental prohibitions. Begins before 13
14. Has run away from home at least twice
15. Often truant, beginning before age 13
B. Causes clinically significant impairment
C. If age 18 or over, not attributable to antisocial personality disorder
X
16. Neuro-cognitive disorders

 New diagnostic group

 Dementia and amnestic disorder are included in this
new group
 Mild NCD is a new diagnosis
X

 Term "dementia" has been deemphasized

 done to lessen stigma
 Deemphasize irreversibility
 Broadens category in a more neutral way (see The following
points below)
 Mild neurocognitive disorder has been added
 Distinguished from Major (severe) neurocognitive disorder
X Diagnostic criteria for delirium
unchanged
 A. disturbance Inattention (reduced ability to direct, focused, sustain
and shift attention and awareness); reduced orientation to environment
 B. . develops over a short period of time and fluctuates during the day
 C. Add a disturbance in cognition (usually marked) – such as memory
deficit, disorientation, agitation, language or perceptual disturbance
 D. The criteria from A&C are Not better explained by a preestablished
neurocognitive disorder or evolving neurocognitive disorder
 E. evidence from the history, physical examination or lab findings thate
disturbances are direct consequence of another medical condition,
substance, intox or w/drawal
 Specifiers
 Substance intoxication delirium = when criteria in A and C predominate during a period
of intoxication
 Substance withdrawal delirium = should be made it instead of substance withdrawal
when the symptoms in criterion a and C predominate in the clinical picture
 Medication induced delirium = should be made when the symptoms in criteria a and C
arises a side effect of the medication taken as prescribed
 Delirium due to another medical condition = evidence that the disturbance is attributable
to the physiological consequences of another medical condition
 Delirium due to multiple etiologies = evidence that the delirium has more than one cause
or causal condition

Course =
acute: lasting a few hours or days
persistent: lasting weeks or months
X Diagnostic criteria for Major NCD
AKA DEMENTIA
 A. Evidence of significant decline from her previous level of
performance in one or more cognitive domains.: (Cognitive attention,
Memory impairment, Learning, attention, recognition (Aphasia, agnosia), apraxia , Language,
perceptual/motor problems , Social cognition and/or other disturbance of executive functions)

 B. cause significant impairment in social, vocational

functioning; is a marked decline from previous functioning
And require assistance, and activities. If daily living, because
they interfere with independence in every day activities
 C. Are not caused or related to by delirium
 D. Not better explained by…
X
Mild neurocognitive disorder
A. Evidence of modest cognitive decline for previous data performance in one or
more cognitive domains-cognitive attention, executive function, learning and
memory, language, perceptual motor or social cognition. Evidence based on
1. Concern of individual, a knowledgeable informant or the clinician that there is been a mild decline
in cognitive function and
2. Modest impairment in cognitive performance preferably documented by standardized
neuropsychological testing or another quantified clinical assessment
B. The cognitive deficits do not interfere for capacity with independence in every
day activities, but greater effort compensatory strategies or accommodations
may be required
C. The cognitive deficits do not occur exclusively in the context of a delirium
D. Not better accounted for by another mental disorder (major depression,
schizophrenia
XSpecifiers whether (Sub-types) of Mild NCD
(dementia) are classified by etiology in DSM
 Alzheimer’s type
 Frontotemporal deterioration
 Lewy body disease
 Vascular (multi-infarct) dementia
 Related to HIV
 Head trauma Or TBI
 Substance medication induced
 Huntington’s disease
 Parkinson’s diseases
 Pick’s disease
 Prions disease
 Multiple etiologies
 Unspecified
 17. Difference between
paraphilia's and paraphilia
disorders
 Paraphilia describes the experience of intense Sexual
arousal to atypical objects, situations, or individuals.
 Paraphilic behavior (such as Pedophilia, zoophilia,
voyeurism and exhibitionism and may be illegal in
some jurisdictions, but may also be tolerated.
 A paraphilia is NOT a paraphilic disorder
 Paraphilia disorder requires the generation of clinically
significant distress, impairment or acting them out
with the nonconsenting person. (Criterion B)
X

Personality disorders
Nothing changes
X
DSM 5 promised major changes in
criteria

 Promised dimensional focus

 Promised reduction in number of personaliity
disorders to five
 Changes did not occur
 Dimensional focus for personality disorders was
moved to section 3
X
Primary Criteria in DSM 5
(Unchanged from DSM-IV TR)

A. Enduring pattern of inner experience & behavior that

deviates markedly from expectations of the culture. This
pattern is manifested in 2 or more of the following areas
A. Cognition;
B. Affect;
C. Interpersonal;
D. Impulse control

B. Inflexible & pervasive across situation

C. Distress or impairment in social, occupational
interpersonal..…
D. Long-standing (back to adolescence or early adulthood)
X
DSM IV & 5 and personality
clusters
Cluster C
Cluster A Cluster B Anxious/fearful
Odd/eccentric Dramatic, erratic
Self-involved
Paranoid Dependent
Schizoid Anti-social Avoidant
schizotypal Histrionic Obsessive-compulsive
Narcissistic
Borderline
X
Dimensional classification of
personality disorders

 Authors of DSM 5 had planned to use dimensional

measures to diagnose personality disorders
 They plan to reduce personality disorders from 10 to 5
 This changed in a closed-door meeting
 Dimensional measures are now in section 3
X
ANTI_SOCIAL

 A) There is a pervasive pattern of disregard for and violation of the rights of

others occurring since age 15 years, as indicated by three or more of the
following:
1. failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly
performing acts that are grounds for arrest;
2. deception, as indicated by repeatedly lying, use of aliases, or conning others for personal profit
or pleasure;
3. impulsiveness or failure to plan ahead;
4. irritability and aggressiveness, as indicated by repeated physical fights or assaults;
5. reckless disregard for safety of self or others;
6. consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior
or honor financial obligations;
7. lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or
stolen from another;
 B) The individual is at least age 18 years.
 C) There is evidence of conduct disorder with onset before age 15 years.
 D) The occurrence of antisocial behavior is not exclusively during the course of
schizophrenia or a manic episode.
X
OR Mnemonic: “CALLOUS MAN”
Diagnostic Criteria for Antisocial PD

 Conduct disorder before age 15; current age at least 18

 Antisocial activities; commits acts that are grounds for arrest
 Lies frequently
 Lacunae—lacks a superego
 Obligations not honored (financial, occupational etc.)
 Unstable—can’t plan ahead
 Safety of self and others is ignored

 Money– recklessness with money; spouse and children are not

supported because he bought a motorcycle
 Aggressive, Assaultive
 Not occurring during schizophrenia or mania
X
Antisocial signs

 Glibness, shallow emotion

 Requires constant stimulation
 Criminal versatility
 Promiscuity
 Poor impulse control
 Avoids responsibility for actions
X

 Millon identified five subtypes of Anti-Social

Personality Disorder
 covetous antisocial – variant of the pure pattern where
individuals feel that life has not given them their due –
including paranoid features.
 reputation-defending antisocial – including narcissistic
features
 risk-taking antisocial – including histrionic features
 nomadic antisocial – including schizoid, avoidant features
 malevolent antisocial – including sadistic, paranoid
features.
X
BORDERLINE PD

A. A pervasive pattern of instability of interpersonal relationships, self-image and

affects, as well as marked impulsivity, beginning by early adulthood and present
in a variety of contexts, as indicated by five (or more) of the following:
1. Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or self-
injuring behavior covered in Criterion 5
2. A pattern of unstable and intense interpersonal relationships characterized by alternating
between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g., promiscuous sex,
excessive spending, eating disorders, binge eating, substance abuse, reckless driving). Note: Do
not include suicidal or self-injuring behavior covered in Criterion 5
5. Recurrent suicidal behavior, gestures, threats or self-injuring behavior such as cutting, interfering
with the healing of scars or picking at oneself (excoriation) .
6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria,
irritability or anxiety usually lasting a few hours and only rarely more than a few days).
7. Chronic feelings of emptiness
8. Inappropriate anger or difficulty controlling anger (e.g., frequent displays of temper, constant
anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation, delusions or severe dissociative symptoms
X
OR Mnemonic for Diagnostic Criteria:
“I RAISED A PAIN”

 Identity disturbance

 Relationships are unstable

 Abandonment is frantically avoided
 Impulsive
 Self-mutilation, suicidal threats/attempts; splitting - as a predominant defense mechanism is used
 Emptiness is a description of their inner selves
 Dissociative symptoms

 Affective instability

 Paranoid instability
 Anger is poorly controlled
 Idealization of others, followed by devaluation (splitting – person is either all good or all bad)
 Negativistic—undermine their own efforts and those of others
X

 First called “as if” personality because or changes

in direction or interest
 Term “borderline” is unfortunate. Originally
referred to being on the ‘border’ between
psychotic and neurotic
 Label is often used pejoratively among mental
health professionals
 Misunderstood and mis-labeled as “manipulative”
X
Borderline Themes

 Parental neglect and abuse

 Impulsivity
 Fears of abandonment
 Frequent suicide ideation or gestures
 Substance abuse or dependence
 Legal difficulties
 Disrupted education relationships, vocations,
vacations
 X Propose general criteria for
personality disorder
A. Moderate or greater impairment in personality (self interpersonal
functioning)
B. One or more pathological personality traits
C. The impairments in personality functioning are inflexible and pervasive
across a broad range of personal and social situations

D. The impairments in personality functioning are relatively stable across time

E. The impairments in personality function are not better explained by another
medical condition or substance
F. Impairments in personality functioning are not better understood as normal
for individuals developmental stage, or sociocultural environment
X
Dimensional classification of
personality disorders

 Authors of DSM 5 had planned to use dimensional

measures to diagnose personality disorders
 They plan to reduce personality disorders from 10 to 5
 This changed in a closed-door meeting
 Dimensional measures are now in section 3
 X
Proposed changes in assessment Two
broad dimensions

Overall 5 Broad
personality Pathological
functioning Trait Domains
Negative Psychoticism
Interpersonal
Detachment Antagonism Disinhibition
self affectivity

Self Empathy
Identity Intimacy
direction
How to deal with uncertainty
2 dimensions required for all DSM
diagnosis

1. Clarity of symptoms
2. Specified length of time for symptoms
 4 basic levels of diagnostic warrant
High

clarity
Symptom
Diagnostic plausibility Diagnostic certainty

symptom pattern over

Unclear time Clear
unstable stable

Diagnostic uncertainty or Diagnostic possibility

Diagnostic confusion

low
 Diagnostic certainty

 The likelihood that a “plausible” diagnosis is

“probable”
 Clinicians often diagnoses based on “clinical hunches”,
which are a form of bias
 They select one or 2 salient characteristics –rather than
the complete 7 to 9- and make assumptions (Paris, 2013)
 This is a form of “fast thinking” or quick judgment that
leads to “framing effects” (Kahneman, 2011) sometimes
called the “clinicians illusion”.
 Easy for clinicians to conflate
probability with plausibility

 Plausibility = the likelihood that an event or

events are representative of
something more; clinicians tend
to focus on this

 Probability = the statistical likelihood of an

event; researchers focus on this

Kahneman, 2011
2 conditions necessary for Diagnostic
certainty

 When symptoms are clear and stable over time

 When the relationship between plausibility and
probability has been considered
Plausibility- these symptoms represent X
Probability – the likelihood of X occurring
 High

clarity
Symptom
Diagnostic plausibility Diagnostic certainty
probability
symptom pattern over time
Unclear Clear
unstable stable

Diagnostic uncertainty or Diagnostic possibility

Diagnostic confusion

low
 Progression of domains of diagnostic certainty
over time

Diagnostic Diagnostic Diagnostic Diagnostic Diagnostic

uncertainty possibilities plausibility probabilities certainty

Ethical issues arise here when:

•Clinician unknowingly or unwittingly is in the
wrong domain (incompetence)
•Clinician knowingly chooses the wrong domain
 Progression of diagnostic certainty over time
Documentation can help

Diagnostic Diagnostic Diagnostic Diagnostic Diagnostic

uncertainty possibilities plausibility probabilities certainty

What leads Why are What Why am I

What am I
me to be these makes this certain?
seeing that
unsure? The a How do I
is so
Do I know possibilities probability know that I
compelling?
What don’t ? and others know?
What am I
I How do I not?
missing?
Know? know that Where is
Why am I
other DXs my
missing?
 Progression of diagnostic certainty over time

Diagnostic Diagnostic Diagnostic Diagnostic Diagnostic

uncertainty possibilities plausibility probabilities certainty

The more uncommon or

unusual a diagnosis is, the
more time
and care one must take in
differentiating or excluding
other – more common -
(statistically) diagnoses