Changes from DSM-IV-TR to DSM-5

Dr. Hani Hamed Dessoki, M.D.Psychiatry
Prof. Psychiatry
Chairman of Psychiatry Department...
Schizophrenia Spectrum & Other
Psychotic Disorders
22 Chapters:
1. Neurodevelopmental
Disorders
2. Schizophrenia Spectrum &
Other Psychotic Disorders
3. Bipolar & Related Di...
Schizophrenia Spectrum & Other
Psychotic Disorders
A. Two (or more) of the following, each present for a
significant porti...
Schizophrenia

C. Continuous signs of the disturbance persist for at least 6
months. This 6-month period must include at l...
Schizophrenia Spectrum and Other
Psychotic Disorders:

Schizophrenia:
The elimination of bizarre delusions.
Rationale: Poo...
Schizophrenia Spectrum and Other
Psychotic Disorders
Cont…

Schizophrenia cont…
The DSM-IV subtypes of schizophrenia have ...
Reliability (
) is the degree to which an assessment tool
produces stable and consistent results.

Validity (
) refers to ...
Schizophrenia

Specify if: With catatonia (refer to the criteria for
catatonia associated with another mental disorder,
pp...
Schizophrenia Spectrum and Other
Psychotic Disorders
Cont…

Catatonia:
Catatonia is now a separate psychotic disorder that...
Delusional disorder

A. The presence of one (or more) delusions with a
duration of 1 month or longer.
B. Criterion A for s...
Schizophrenia Spectrum and Other
Psychotic Disorders
Cont…

Schizoaffective Disorder:
The primary change to schizoaffectiv...
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...
Bipolar Disorder
22 Chapters:
1. Neurodevelopmental
Disorders
2. Schizophrenia Spectrum &
Other Psychotic Disorders
3. Bipolar & Related Di...
Bipolar Disorders

Criterion A for manic and hypomanic episodes
now includes an emphasis on changes in activity
and energ...
bipolar I disorder, mixed episode, requiring that
the individual simultaneously meet full criteria for
both mania and maj...
Bipolar II disorder, another specified bipolar and
related disorder is that too few symptoms of
hypomania are present to ...
Depressive Disorder

DSM-5 contains several new depressive
disorders, including disruptve mood
dysregulaton disorder and ...
The frequency of diagnosis of bipolar disorder has
risen dramatically in children and adolescents.
The DSM-V has suggest...
DSM-5 conceptualizes chronic forms of
depression in a somewhat modified way.
What was referred to as dysthymia in DSM-IV...
Neither the core criterion symptoms applied to the
diagnosis of major depressive episode nor the
requisite duration of at...
In DSM-IV, there was an exclusion criterion for a
major depressive episode that was applied to
depressive symptoms lastin...
Specifers for Depressive Disorders

With suicide: suicidal thinking, plans, and the
presence of other risk factors
 “wit...
Discriminating primary clinical states in
bipolar disorder with a comprehensive
symptom scale.
Small subset of symptoms, ...
DEPRESSIVE DISORDERS
SUBSTANCE/MEDICATION-INDUCED DEPRESSIVE DISORDER



Removed Criterion A2:elevated, expansive or irri...
Somatic symptom and related
disorders

Somatoform disorders
22 Chapters:
1. Neurodevelopmental
Disorders
2. Schizophrenia Spectrum &
Other Psychotic Disorders
3. Bipolar & Related Di...
Somatic Symptom Disorders
Joel E. Dimsdale, M.D. Chair
James L. Levenson, M.D., Text Coordinator
Michael R. Irwin, M.D....
Somatic symptom and related disorders
Somatoform disorders are now called somatic
symptom and related disorders.
In DSM-...
Somatic symptom and related disorders

The DSM-5 classification reduces the number of these
disorders and subcategories t...
Somatic Symptom Disorder
In DSM-IV, the diagnosis undifferentiated
somatoform disorder did not prove to be a useful
clini...
Somatic Symptom Disorder

The diagnosis of somatization disorder was
essentially based on a long and complex
symptom coun...
Somatic Symptom and Related
Disorders (161)
300.82 (F45.1)Somatic Symptom Disorder (161)
Specify if: With predominant pai...
Medically Unexplained Symptoms

The DSM-5 classification defines disorders on the
basis of positive symptoms (i.e., distr...
Somatic symptom and related disorders

In DSM-5, people with chronic pain can be diagnosed
with
somatic symptom disorder ...
Hypochondriasis and Illness Anxiety
Disorder J02
In DSM-5, individuals with high health anxiety
without somatic symptoms ...
Conversion Disorder (Functional
Neurological Symptom Disorder) J03
Criteria for conversion disorder (functional
neurologi...
Conversion Disorder (Functional
Neurological Symptom Disorder) (163)
 Specify symptom type:
(F44.4)With weakness or paral...
Psychological Factors Affecting Other
Medical Conditions and Factitious Disorder
 Psychological factors affecting other m...
Specific Changes Per Diagnostic
Category in DSM-5

Obsessive-Compulsive and Related Disorders
OCD is now a stand alone ca...
Factitious Disorder 300.19

Factitious Disorder (includes Factitious Disorder
Imposed on Self,
Factitious Disorder Impos...
Somatic Symptom and Related
Disorders
Somatic Symptom Disorder
Illness Anxiety Disorder
Conversion Disorder (Functional...
Personality Disorders
22 Chapters:
1. Neurodevelopmental
Disorders
2. Schizophrenia Spectrum &
Other Psychotic Disorders
3. Bipolar & Related Di...
Personality and Personality Disorders^
Andrew E. Skodol, M.D.Chair
John M. Oldham, M.D.Co-Chair
Robert F. Krueger, Ph.D...
Borderline personality disorder controversy
 In 2003, the Treatment and Research Advancements
National Association for Pe...
Diagnosing Personality Disorders

How can it be ―disordered‖?
 An enduring pattern of inner experience and behavior that
...
DSM-IV-TR Clusters
• Cluster A

: Odd or eccentric
– Schizoid, Paranoid, Schizotypal

• Cluster B

: Dramatic, emotional o...
Could Redefine ―Personality‖
DSM-IV: A pervasive pattern of thinking/
behaving/emotionality.
Perhaps? A personality diso...
DSM -5 and multiaxial system

DSM-5 moves from the multiaxial system to a new
assessment that removes the arbitrary bound...
Obvious Changes in DSM-5
The DSM-5 will discontinue the Multiaxial Diagnosis,
No more Axis I,II, III, IV & V-which means ...
New DSM 5 Classifications
DSM IV TR
Avoidant
Borderline
Narcissistic
Obsessive –Compulsive
Schizotypal
Antisocial
Paranoid...
Avoidant Personality Disorders

Pervasive pattern of social
inhibition, feelings of
inadequacy, extreme
sensitivity to neg...
Borderline Personality

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

Condition in whic...
Narcissistic Personality Disorder

Pervasive pattern of social inhibition, feelings of inadequacy, extreme
sensitivity to ...
Obsessive Compulsive Disorder
People have unwanted and repeated
thoughts, feelings, ideas, sensations
(obsessions), or beh...
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...
Personality Disorders in the DSM-5

The good news is that none of the criteria for
personality disorders have changed in ...
Specific Changes Per Diagnostic
Category in DSM-5
 Schizotypal Personality Disorder T03 also under
Schizophrenia and Othe...
The Big Six

Six specific personality disorder types
(antisocial, avoidant, borderline,
narcissistic, obsessive-compulsive...
Personality Disorders in the DSM-5
 A new hybrid personality model was introduced in the DSM5′s Section III (disorders re...
Personality Disorders in the DSM-5

The hybrid methodology retains six personality
disorder types:
Borderline Personality...
Personality Disorders in the DSM-5
According to the APA, each type is defined by a
specific pattern of impairments and tr...
Personality Disorders

The criteria for personality disorders in Section II
(clinical) of DSM-5 have not changed from tho...
Personality Disorders in the DSM-5

APA hopes that inclusion of the new methodology
in Section III of DSM-5 will encourag...
Personality Disorders –
The way it almost was
• Personality types defined by personality
domains and facets:
– Negative af...
PDTS Levels of Personality
Functioning Scale
The diagnosis of Personality Disorder Trait
Specified (PDTS) is defined by si...
Guide to Implementation
1. Is impairment in personality functioning (self and interpersonal)
present or not?
2. If so, rat...
Hanipsych, dsm 5
Hanipsych, dsm 5
Hanipsych, dsm 5
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Hanipsych, dsm 5

  1. 1. 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
  2. 2. Schizophrenia Spectrum & Other Psychotic Disorders
  3. 3. 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)
  4. 4. 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,
  5. 5. 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).
  6. 6. Schizophrenia Spectrum and Other Psychotic Disorders: Schizophrenia: The elimination of bizarre delusions. Rationale: Poor reliability in distinguishing bizarre vs. nonbizarre delusions.
  7. 7. Schizophrenia Spectrum and Other 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.
  8. 8. 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.
  9. 9. 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.
  10. 10. Schizophrenia Spectrum and Other 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.
  11. 11. 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.
  12. 12. Schizophrenia Spectrum and Other 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.
  13. 13. Other important aspects Brief PD & schizoaffective no major change but emphasis on positive active symptoms
  14. 14. 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:
  15. 15. Bipolar Disorder
  16. 16. 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)
  17. 17. Bipolar Disorders Criterion A for manic and hypomanic episodes now includes an emphasis on changes in activity and energy as well as mood.
  18. 18. 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.
  19. 19. 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.
  20. 20. 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.
  21. 21. 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. )
  22. 22. 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.
  23. 23. 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.
  24. 24. 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.
  25. 25. Specifers for Depressive Disorders With suicide: suicidal thinking, plans, and the presence of other risk factors  “with anxious distress”
  26. 26. 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)
  27. 27. 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)
  28. 28. Somatic symptom and related disorders Somatoform disorders
  29. 29. 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)
  30. 30. 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.
  31. 31. 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.
  32. 32. Somatic symptom and related disorders 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.
  33. 33. 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.
  34. 34. 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.
  35. 35. 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
  36. 36. 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.
  37. 37. Somatic symptom and related disorders 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.
  38. 38. 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
  39. 39. 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.
  40. 40. 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
  41. 41. 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
  42. 42. 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
  43. 43. Factitious Disorder 300.19 Factitious Disorder (includes Factitious Disorder Imposed on Self, Factitious Disorder Imposed on Another) (165) Specify Single episode, Recurrent episodes
  44. 44. 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
  45. 45. Personality Disorders
  46. 46. 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)
  47. 47. 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)
  48. 48. 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).
  49. 49. 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.
  50. 50. 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
  51. 51. 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."
  52. 52. 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.
  53. 53. 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.
  54. 54. 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
  55. 55. Avoidant Personality Disorders Pervasive pattern of social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation, and avoidance of social interaction
  56. 56. 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
  57. 57. Narcissistic Personality Disorder Pervasive pattern of social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation, and avoidance of social interaction
  58. 58. 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.
  59. 59. Schizotypal Schizotypals believe they have magical powers
  60. 60. 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...
  61. 61. 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.
  62. 62. 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.
  63. 63. 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.
  64. 64. Personality Disorders in the DSM-5  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.
  65. 65. Personality Disorders in the DSM-5 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
  66. 66. Personality Disorders in the DSM-5 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.
  67. 67. 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.
  68. 68. Personality Disorders in the DSM-5 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.
  69. 69. 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)
  70. 70. 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
  71. 71. 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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