Hanipsych, dsm 5

Changes from DSM-IV-TR to DSM-5

Dr. Hani Hamed Dessoki, M.D.Psychiatry
Prof. Psychiatry
Chairman of Psychiatry Department

Beni Suef University
Supervisor of Psychiatry Department
El-Fayoum University
APA member

Schizophrenia Spectrum & Other
Psychotic Disorders

22 Chapters:
1. Neurodevelopmental
Disorders
2. Schizophrenia Spectrum &
Other Psychotic Disorders
3. Bipolar & Related Disorders
4. Depressive Disorders
5. Anxiety Disorders
6. Obs-Compulsive & Related
7. Trauma- & Stressor-Related
8. Dissociative Disorders
9. Somatic Symptom Disorders
10.Feeding & Eating Disorders
11.Elimination Disorders
12.Sleep/Wake Disorders

13. Sexual Dysfunctions
14. Gender Dysphoria
15. Disruptive, Impulse-Control
& Conduct Disorders
16. Substance Related &
Addictive Disorders
17. Neurocognitive Disorders
18. Personality Disorders
19. Paraphilic Disorders
20. Other Mental Disorders
21. Medication-induced
Movement…Med Effects
22. Other Conditions (v codes)

Schizophrenia Spectrum & Other
Psychotic Disorders
A. Two (or more) of the following, each present for a
significant portion of time during a 1-month period (or less
if successfully treated). At least one of these must be (1),
(2), or (3):
1.Delusions.
2.Hallucinations.
3.Disorganized speech (e.g., frequent derailment or incoherence).
4.Grossly disorganized or catatonic behavior.
5.Negative symptoms (i.e., diminished emotional expression
or avolition)
.B. For a significant portion of the time since the onset of the
disturbance, level of functioning in one or more major
areas, such as work, interpersonal relations, or self-care,

Schizophrenia

C. Continuous signs of the disturbance persist for at least 6
months. This 6-month period must include at least 1
month of symptoms(or less if successfully treated) that
meet Criterion A (i.e., active-phase symptoms) and may
include periods of prodromal or residual symptoms.
During these prodromal or residual periods ,the signs of the
disturbance may be manifested by only negative
symptoms or by two or more symptoms listed in Criterion
A present in an attenuated form (e.g., odd beliefs, unusual
perceptual experiences).

Schizophrenia Spectrum and Other
Psychotic Disorders:

Schizophrenia:
The elimination of bizarre delusions.
Rationale: Poor reliability in distinguishing bizarre vs. nonbizarre delusions.

Psychotic Disorders
Cont…

Schizophrenia cont…
The DSM-IV subtypes of schizophrenia have been
eliminated.
Instead a dimensional approach to rating severity for the
core symptoms of schizophrenia is included in DSM-5
Section III.
Rationale: Limited diagnostic stability, low reliability, and
poor validity.

Reliability (
) is the degree to which an assessment tool
produces stable and consistent results.

Validity (
) refers to how well a test measures what it is
purported to measure.

Schizophrenia

Specify if: With catatonia (refer to the criteria for
catatonia associated with another mental disorder,
pp. 60–61, for definition).

Coding note: Use additional code 293.89 (F06.1)
catatonia associated with schizophrenia to indicate
the presence of the comorbid catatonia.

Psychotic Disorders
Cont…

Catatonia:
Catatonia is now a separate psychotic disorder that can
be associated with other mental or medical disorders.
The criteria for catatonia is now uniform for all contexts
and requires 3 sx from a total of 12.

Delusional disorder

A. The presence of one (or more) delusions with a
duration of 1 month or longer.
B. Criterion A for schizophrenia has never been
met. Note: Hallucinations, if present, are not
prominent and are related to the delusional theme
(e.g., the sensation of being infested with insects
associated with delusions of infestation).
- Bizzare is Ok.

Psychotic Disorders
Cont…

Schizoaffective Disorder:
The primary change to schizoaffective disorder is that a
major mood episode be present for the majority of the
disorders total duration after criterion A has been met.
Rationale: To improve reliability, diagnostic stability, and
validity of this disorder.

Other important aspects

Brief PD & schizoaffective no major change but
emphasis on positive active symptoms

Other Specified Schizophrenia Spectrum
and Other Psychotic Disorder
1.Persistent auditory hallucinations
.2.Delusions with significant overlapping mood
episode
.3.Attenuated psychosis syndrome: This syndrome
is characterized by psychotic-like symptoms that are
below a threshold for full psychosis (e.g., the
symptoms are less severe and more transient, and
insight is relatively maintained)
.4.Delusional symptoms in partner of individual
with delusional disorder:

Bipolar Disorders

Criterion A for manic and hypomanic episodes
now includes an emphasis on changes in activity
and energy as well as mood.

bipolar I disorder, mixed episode, requiring that
the individual simultaneously meet full criteria for
both mania and major depressive episode, has
been removed.
 Instead, a new specifier, ―with mixed
features,‖ has been added that can be applied
to the episodes when mixed features are present.

Bipolar II disorder, another specified bipolar and
related disorder is that too few symptoms of
hypomania are present to meet criteria for the full
bipolar II syndrome, although the duration is
sufficient at 4 or more days.

Depressive Disorder

DSM-5 contains several new depressive
disorders, including disruptve mood
dysregulaton disorder and premenstrual
dysphoric disorder.
It is included for children up to age 18 years who
exhibit persistent irritability and frequent episodes
of extreme behavioral dyscontrol.

The frequency of diagnosis of bipolar disorder has
risen dramatically in children and adolescents.
The DSM-V has suggested a new diagnosis termed
disruptive mood dysregulation disorder (DMDD)
(formerly temper dysregulation disorder with
dysphoria) to reduce the rate of false diagnosis of
bipolar disorder in young people.
(Margulies et al,Bipolar Disord, Aug 2012; 14(5):
488-96. )

DSM-5 conceptualizes chronic forms of
depression in a somewhat modified way.
What was referred to as dysthymia in DSM-IV
now falls under the category of persistent
depressive disorder, which includes both
chronic major depressive disorder and the
previous dysthymic disorder.

Neither the core criterion symptoms applied to the
diagnosis of major depressive episode nor the
requisite duration of at least 2 weeks has
changed from DSM-IV.

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.

Specifers for Depressive Disorders

With suicide: suicidal thinking, plans, and the
presence of other risk factors
 “with anxious distress”

Discriminating primary clinical states in
bipolar disorder with a comprehensive
symptom scale.
Small subset of symptoms, several of which are
absent in DSM-IV-TR criteria and traditional rating
scales for bipolar studies, aid in distinguishing
mixed episodes from depressive or
manic/hypomanic episodes.
Most anxiety items were more severe in mixed
subjects.
(Singh et al,Acta Psychiatr Scand, Jul 2012)

DEPRESSIVE DISORDERS
SUBSTANCE/MEDICATION-INDUCED DEPRESSIVE DISORDER



Removed Criterion A2:elevated, expansive or irritable mood

OTHER SPECIFIED DEPRESSIVE DISORDER
Lists a few examples
UNSPECIFIED DEPRESSIVE DISORDER
e.g. insufficient information
SPECIFIERS
With Anxious distress
PostPartum onset now peripartum onset (includes
during/following pregnancy)

Somatic symptom and related
disorders

Somatoform disorders

Somatic Symptom Disorders
Joel E. Dimsdale, M.D. Chair
James L. Levenson, M.D., Text Coordinator
Michael R. Irwin, M.D.
Francis J. Keefe, Ph.D. (2007-2011)
Arthur J. Barsky III, M.D.
Sing Lee, M.D.
Francis Creed, M.D.
Michael Sharpe, M.D.
Nancy Frasure-Smith, Ph.D. (2007-2011)
Lawson R. Wulsin, M.D.

Somatic symptom and related disorders
Somatoform disorders are now called somatic
symptom and related disorders.
In DSM-IV, there was significant overlap across the
somatoform disorders and a lack of clarity about their
boundaries.

These disorders are primarily seen in medical settings,
and nonpsychiatric physicians found the DSM-IV
somatoform diagnoses problematic to use.


The DSM-5 classification reduces the number of these
disorders and subcategories to avoid problematic
overlap.
Diagnoses of somatization disorder, hypochondriasis,
pain disorder, and undifferentiated somatoform
disorder have been removed.

Somatic Symptom Disorder
In DSM-IV, the diagnosis undifferentiated
somatoform disorder did not prove to be a useful
clinical diagnosis.

The distinction between somatization disorder
and undifferentiated somatoform disorder was
arbitrary.

Somatic Symptom Disorder

The diagnosis of somatization disorder was
essentially based on a long and complex
symptom count of medically unexplained
symptoms.
DSM-5 criteria for somatic symptom disorder
includes the maladaptive thoughts, feelings, and
behaviors that define the disorder, in addition to
their somatic symptoms.

Somatic Symptom and Related
Disorders (161)
300.82 (F45.1)Somatic Symptom Disorder (161)
Specify if: With predominant pain
Specify if: Persistent
Specify current severity: Mild, Moderate,
Severe

Medically Unexplained Symptoms

The DSM-5 classification defines disorders on the
basis of positive symptoms (i.e., distressing
somatic symptoms plus abnormal thoughts,
feelings, and behaviors in response to these
symptoms).
Medically unexplained symptoms do remain a key
feature in conversion disorder and pseudocyesis.


In DSM-5, people with chronic pain can be diagnosed
with
somatic symptom disorder with predominant
pain;
or psychological factors that affect other medical
conditions;
or with an adjustment disorder.

Hypochondriasis and Illness Anxiety
Disorder J02
In DSM-5, individuals with high health anxiety
without somatic symptoms would receive a
diagnosis of illness anxiety disorder (unless their
health anxiety was better explained by a primary
anxiety disorder, such as generalized anxiety
disorder).
Specify whether: Care seeking type,
Care avoidant type

Conversion Disorder (Functional
Neurological Symptom Disorder) J03
Criteria for conversion disorder (functional
neurological symptom disorder) are modified to
emphasize the essential importance of the
neurological examination, and in recognition that
relevant psychological factors may not be
demonstrable at the time of diagnosis.

Conversion Disorder (Functional
Neurological Symptom Disorder) (163)
 Specify symptom type:
(F44.4)With weakness or paralysis
(F44.4)With abnormal movement
(F44.4)With swallowing symptoms
(F44.4)With speech symptom
(F44.5)With attacks or seizures
(F44.6)With anesthesia or sensory loss
(F44.6)With special sensory symptom
(F44.7)With mixed symptoms
Specify if: Acute episode, Persistent
Specify if: With psychological stressor (specifystressor), Without
psychological stressor

Psychological Factors Affecting Other
Medical Conditions and Factitious Disorder
 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.”
Specify current severity: Mild, Moderate, Severe, Extreme

Specific Changes Per Diagnostic
Category in DSM-5

Obsessive-Compulsive and Related Disorders
OCD is now a stand alone category
Body Dysmorphic Disorder listed under OCD as
F01
Added Hoarding under category of OCD as F02
Trichotillomania now called Hair-Pulling Disorder is
listed under OCD as F03
Skin Picking Disorder moved under OCD as F04

Factitious Disorder 300.19

Factitious Disorder (includes Factitious Disorder
Imposed on Self,
Factitious Disorder Imposed on Another) (165)

Specify Single episode,
Recurrent episodes

Somatic Symptom and Related
Disorders
Somatic Symptom Disorder
Illness Anxiety Disorder
Conversion Disorder (Functional Neurological
Symptom Disorder)
Psychological Factors Affecting Other Medical
Conditions
Factitious Disorder
Other Specified Somatic Symptom and Related
Disorder
Unspecified Somatic Symptom and Related Disorder

Personality and Personality Disorders^
Andrew E. Skodol, M.D.Chair
John M. Oldham, M.D.Co-Chair
Robert F. Krueger, Ph.D., Text Coordinator
Renato D. Alarcon, M.D.,
Carl C. Bell, M.D.
Donna S. Bender, Ph.D.
Lee Anna Clark, Ph.D.
W. John Livesley, M.D., Ph.D. (2007-2012)
Leslie C. Morey, Ph.D.
Larry J. Siever, M.D.
Roel Verheul, Ph.D. (2008-2012)

Borderline personality disorder controversy
 In 2003, the Treatment and Research Advancements
National Association for Personality Disorders (TARA-APD)
campaigned to change the name and designation
of borderline personality disorder in DSM-5.

 “The name BPD is confusing, imparts no relevant or
descriptive information, and reinforces existing stigma...".
Instead, it proposed the name "emotional regulation
disorder" or "emotional dysregulation disorder".
 There was also discussion about changing borderline
personality disorder, an Axis II diagnosis (personality
disorders and mental retardation), to an Axis I diagnosis
(clinical disorders).

Diagnosing Personality Disorders

How can it be ―disordered‖?
 An enduring pattern of inner experience and behavior that
deviates markedly from the expectations of the individual's
culture, is pervasive and inflexible, has an onset in
adolescence or early adulthood, is stable over time, and
leads to distress or impairment.

DSM-IV-TR Clusters
• Cluster A

: Odd or eccentric
– Schizoid, Paranoid, Schizotypal

• Cluster B

: Dramatic, emotional or erratic
– Antisocial, Borderline, Narcissistic, Histrionic

• Cluster

C

: Anxious, fearful
– Avoidant, Dependent, Obsessive-Compulsive

Could Redefine ―Personality‖
DSM-IV: A pervasive pattern of thinking/
behaving/emotionality.
Perhaps? A personality disorder reflects "adaptive
failure" involving:
 "Impaired sense of self-identity" or
 "Failure to develop effective interpersonal functioning."

DSM -5 and multiaxial system

DSM-5 moves from the multiaxial system to a new
assessment that removes the arbitrary boundaries
between personality disorders and other mental
disorders.

Obvious Changes in DSM-5
The DSM-5 will discontinue the Multiaxial Diagnosis,
No more Axis I,II, III, IV & V-which means that
Personality Disorders will now appear as diagnostic
categories and there will be no more GAF score or
listing of psychosocial stressor or contributing medical
conditions.
The Multi-axial model will be replaced by Dimensional
component to diagnostic categories.

New DSM 5 Classifications
DSM IV TR
Avoidant
Borderline
Narcissistic
Obsessive –Compulsive
Schizotypal
Antisocial
Paranoid
Schizoid
Histrionic
Dependent
Personality Disorder NOS

DSM 5
Avoidant
Borderline
Narcissistic
Obsessive Compulsive
Schizotypal
Antisocial
Personality Disorder Trait Specified

Avoidant Personality Disorders

Pervasive pattern of social
inhibition, feelings of
inadequacy, extreme
sensitivity to negative
evaluation, and avoidance
of social interaction

Borderline Personality

longturbulent
about
These inner
them to take
chaotic
about their
values
rapidly

Condition in which people have
term patterns of unstable or
emotions, such as feelings
themselves and others.
experiences often cause
impulsive actions and have
relationships uncertain
identity. Interests and
may change

Narcissistic Personality Disorder

Pervasive pattern of social inhibition, feelings of inadequacy, extreme
sensitivity to negative evaluation, and avoidance of social interaction

Obsessive Compulsive Disorder
People have unwanted and repeated
thoughts, feelings, ideas, sensations
(obsessions), or behaviors that make them
feel driven to do something (compulsions).
Often the person carries out the behaviors to
get rid of the obsessive thoughts, but this
only provides temporary relief. Not
performing the obsessive rituals can cause
great anxiety.

Schizotypal

Schizotypals believe
they have
magical powers

Antisocial




When I

left, I joined the army, and when I
took the service
exam my psych profile fit a
certain... moral
flexibility would be the only
way to describe it...
and I was loaned out to a
CIA-sponsored
program, and we sort of
found each other. That's how it works.


I know what I do
isn't... moral, per se...

Personality Disorders in the DSM-5

The good news is that none of the criteria for
personality disorders have changed in the DSM-5.
Based on feedback from a multilevel review of
proposed revisions, the American Psychiatric
Association Board of Trustees ultimately decided to
retain the DSM-IV categorical approach with the
same 10 personality disorders.

Specific Changes Per Diagnostic
Category in DSM-5
 Schizotypal Personality Disorder T03 also under
Schizophrenia and Other Psychotic Disorders B02
 Antisocial Personality Disorder T04 also under Disruptive
Impulse Control and Conduct Disorders as Dyssocial
Personality Disorder Q07.

The Big Six

Six specific personality disorder types
(antisocial, avoidant, borderline,
narcissistic, obsessive-compulsive
and schizotypal) are defined by criteria based
on typical impairments in personality functioning and
pathological personality traits in one or more trait
domains.

 A new hybrid personality model was introduced in the DSM5′s Section III (disorders requiring further study) that included
evaluation of impairments in personality functioning.
 In the new proposed model, clinicians would assess
personality and diagnose a personality disorder based on an
individual’s particular difficulties in personality functioning and
on specific patterns of those pathological traits.


The hybrid methodology retains six personality
disorder types:
Borderline Personality Disorder
Obsessive-Compulsive Personality Disorder
Avoidant Personality Disorder
Schizotypal Personality Disorder
Antisocial Personality Disorder
Narcissistic Personality Disorder

According to the APA, each type is defined by a
specific pattern of impairments and traits.
This approach also includes a diagnosis of
Personality Disorder—Trait Specified (PD-TS)
that could be made when a Personality Disorder
is considered present, but the criteria for a
specific personality disorder are not fully met (PDTS) replaces personality disorder not otherwise.

Personality Disorders

The criteria for personality disorders in Section II
(clinical) of DSM-5 have not changed from those
in DSM-IV.
Section III (research) includes the proposed
research model for personality disorder diagnosis
and conceptualization developed by the DSM-5
Personality and Personality Disorders Work
Group.


APA hopes that inclusion of the new methodology
in Section III of DSM-5 will encourage research
that might support this model in the diagnosis and
care of patients, as well as contribute to greater
understanding of the causes and treatments of
personality disorders.

Personality Disorders –
The way it almost was
• Personality types defined by personality
domains and facets:
– Negative affect (facets: lability,anxiety/ insecurity,
hostility)
– Detachment (facets: withdrawal/depression,
suspicion)
– Antagonism (facets: difficult to get along with:
manipulative, deceitful, hostile)
– Disinhibition (facets: impulsive/irresponsible)
– Psychoticism (facets: unusual/bizarre experiences,
eccentric)

PDTS Levels of Personality
Functioning Scale
The diagnosis of Personality Disorder Trait
Specified (PDTS) is defined by significant
impairment in personality functioning, as
measured by the Levels of Personality
Functioning Scale, and one or more pathological
personality trait domains or trait facets

Guide to Implementation
1. Is impairment in personality functioning (self and interpersonal)
present or not?
2. If so, rate the level of impairment in self (identity or self-direction)
and interpersonal (empathy or intimacy) functioning on the Levels of
Personality Functioning Scale.
3. Is one of the 6 defined types present?
4. If so, record the type and the severity of impairment.
5. If not, is PD-Trait Specified present?
6. If so, record PDTS, identify and list the trait domain(s) that are
applicable, and record the severity of impairment.
7. If a PD is present and a detailed personality profile is desired and
would be helpful in the case conceptualization, evaluate the trait
facets.
8. If neither a specific PD type nor PDTS is present, evaluate the trait
domains and/or the trait facets if these are relevant and helpful in the
case conceptualization.

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