Inroduction to DSM-5

1. Introduction to DSM-5
Gary M. Henschen, M.D., Chief Medical Officer - Behavioral Health
Antoinette Cusick, M.D., Associate Medical Director, Florida Care Management Center

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2

3. Historical Perspective of DSM-5
How we arrived at this edition of the DSM

4. Historical Perspective
• A predecessor of the DSM was published by APA in 1844
– Established to classify institutionalized patients / promote
communication
• Four major editions after 1945
– Developed to describe essential features of mental disorders
• DSM-5 is built on DSM-IV
– Revisions began in 1999, DSM-5 was published May 18, 2013
– Use DSM-5/ICD-9 CM codes through September 30, 2014
– Use DSM-5/ICD-10 CM codes starting October 1, 2014
• APA and NIMH leadership agreed that DSM-5 will harmonize with ICD-11
4

5. The DSM-5 Development Process
• 1999-2002: The American Psychiatric Association (APA), National Institutes
of Mental Health (NIMH), World Health Organization (WHO), and the World
Psychiatric Association sponsored conferences to develop the research
agenda for DSM-5
– 13 diagnostic work groups convened
– 90 academic and mental health institutions – 30% international –
participated.
– Multidisciplinary participation included: 100 psychiatrists, 47
psychologists, two pediatric neurologists, three epidemiologists,
pediatrician, speech and hearing specialist, social worker, psychiatric
nurse, consumer and family representatives
• 2004-2008: APA, WHO, NIMH: 13 conferences
– 400 participants from 39 countries
– 10 monographs and hundreds of articles
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6. • APA worked with WHO for consistency with ICD-11
• Scientific review committee: guidance on strength of evidence supporting
changes
• Clinical utility, consistency and public health impact assessed
• Draft criteria released to public for comment three times – 11,000
comments
• Large academic medical centers and investigators tested DSM-5 feasibility
and utility
The DSM-5 Development Process
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7. What Is Included in DSM-5?
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8. DSM-5 Definition of a Mental Disorder
All elements must be included
• Mental disorder – syndrome characterized by a clinically significant
disturbance in cognition, emotion regulation or behavior – reflects
dysfunction in psychological, biological or developmental processes
underlying mental functioning.
• Associated with significant distress or disability in social, occupational or
other important activities. Expected cultural response to a common
stressor or loss – not a mental disorder.
• Socially deviant behavior (political, religious, sexual) and conflicts between
the individual and society – not mental disorders unless the deviance
results from dysfunction described above.
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9. • Much of DSM-5 is unchanged from DSM IV-TR
• Approximately the same number of diagnoses
• Some diagnoses reclassified
• Some diagnostic criteria clarified
• Only 15 new diagnoses added
• NO MORE AXES!
Diagnoses
9

10. No more axes in DSM-5
DSM-5 – non-axial documentation of diagnosis
Axis III – combined with Axes I and II; physical health conditions are to
be listed
Axis IV – eliminated; psychosocial and environmental issues – use ICD-
9 V codes and ICD-10 Z codes
Axis V GAF – eliminated; scale developed by WHO (WHODAS) is
recommended by DSM-5 task force – best global measure of disability
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11. Scientifically-validated Assessment Measures Encouraged!
• DSM-5 recommends scientifically validated assessment measures, rating
scales in diagnosis, monitoring and measuring treatment progress and
assessing impact of culture of key aspects of clinical presentation and care
• Examples included in DSM-5
– Adult or parent/guardian DSM-5 self-rated cross-cutting symptom
measure
– Disorder-specific severity measure (e.g., PHQ-9)
– Cultural Formulation Interview (CFI)
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12. DSM-5 Guiding Principles

13. • Research evidence to support any addition or
modification
• Maintain continuity with DSM-IV-TR if possible
• Routine clinical practices must be able to
implement changes
• No restraints in limiting degree of change
between DSM-5 and earlier editions
All criteria are based on an extensive review of the literature
13

14. Evidence to support changes must meet these tests:
Is the proposed diagnosis distinct
enough to warrant separate
consideration?
Any potential harm to individuals or
groups if the change was or was not
adopted?
Do the diagnostic criteria for a new
entity reflect a true mental disorder or
variations of normal behavior?
14

15. DSM-5 Organization and Other Changes
• DSM-5 organized by the developmental lifespan
– Neurodevelopmental disorders in childhood
– Neurocognitive disorders in older adulthood
• Restructuring of chapters based on disorders’ relatedness to one another
• Restructuring based on symptom vulnerabilities and symptom
characteristics
• Moves away from categorical model – required clinician to determine
whether disorder present or absent
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16. DSM-5 Organization and Other Changes
• Sex differences – when variations are attributed to the presence of XX or XY
chromosome or reproductive organs
• Gender differences – variations result from biological sex and perceived
gender
• Uses dimensional approach – allows more latitude in assessing severity –
no concrete threshold between normality and disorder
• Replaces NOS designation
– Other specified disorder – used when reason specified
– Unspecified disorder– reason not specified
16

17. DSM-5 Chapters and Sequence
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 Stressor-Related Disorder
8. Dissociative Disorders
9. Somatic Symptom 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. Substance-Use and Addictive Disorders
17. Neurocognitive Disorders
18. Personality Disorders
19. Paraphilic Disorders
20. Other Disorders
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18. Highlights of Changes
DSM IV-TR to DSM-5
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19. Neurodevelopmental Disorders
• Intellectual Disabilities
• Communication Disorders
• Autism Spectrum Disorders
• Attention-deficit Hyperactivity Disorder
• Specific Learning Disorder
• Motor Disorders
• Other Specified Neurodevelopmental Disorder
• Unspecified Neurodevelopmental Disorder
• 319 (F70, F71, F72, F73)
• 315.39 (F80.9, 80.0, F80.81)
• 299.00 (F84.0)
• 314.00, 314.01 (F90.0, 90.1, 90.2)
• 315.00, 315.1, 315.2 (F81.0)
• 315.4, 307.xx (F82), 307.3 (F98.4)
• 315.8 (F88)
• 315.9 (F89)
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20. Intellectual Disability (Intellectual Developmental Disorder)
• Replaces the term “mental retardation”
• Requires adaptive-functioning assessments and cognitive capacity (IQ) for
diagnosis
• Considered to be two standard deviations below the population (IQ~70)
• Codes: ICD-9 319
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21. Communication Disorders
• Language Disorder (combines DSM-IV expressive and mixed receptive-
expressive language disorders) 315.39 (F80.9)
• Speech Sound Disorder (new name for phonological disorder) 315.39
(F80.0)
• Childhood-onset Fluency Disorder (formerly stuttering) 315.35 (F80.81)
• Social (Pragmatic) Communication Disorder – new disorder – persistent
difficulties in social uses of verbal and non-verbal communication 315.39
(F80.89)
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22. • New name for DSM-5
• Encompasses autistic disorder, Asperger’s disorder, childhood disintegrative
disorder, PDD-NOS
• Single disorder with differing levels of severity based on level of support
required
• Must show deficits in BOTH
– (Criterion A) social communication and social interaction and
– (Criterion B) restricted repetitive behaviors, interests
and activities
• Includes expanded specifiers associated with known medical
or genetic conditions
• Symptoms from early childhood
Autism Spectrum Disorder (ASD) 299.00 (F84.0)
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23. Specific Learning Disorder
• Specifiers related to deficits in reading, written expression and
mathematics with severity ratings
• Learning deficits commonly occur together – allows for all academic
domains and subskills that are impaired
– with impairment in reading 315.00 (F81.0)
– with impairment in written expression 315.2 (F81.81)
– with impairment in mathematics 315.1 (F81.2)
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24. Attention-Deficit/Hyperactivity Disorder (ADHD)
• Largely unchanged from DSM-IV
• Same 18 symptoms used in DSM-IV with additional examples applying to
adults
• Two symptom domains – inattention and hyperactivity/impulsivity
– 314.01 (F90.2) Combined presentation
– 314.00 (F90.0) Predominantly inattentive presentation
– 314.01 (F 90.1) Predominantly hyperactive/impulsive presentation
• Onset criterion changed from symptoms present before age 7 to several
symptoms present prior to age 12
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25. Attention-Deficit/Hyperactivity Disorder (ADHD)
• Inattentive, hyperactive and combined are used to describe the current
presentation rather than the subtype
• Comorbid diagnosis with ADHD allowed
• Threshold for adult diagnosis – adjusted to five symptoms in either domain
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26. Motor Disorders – Largely Unchanged from DSM-IV
• Developmental Coordination Disorder 315.4 (F82)
• Stereotypic Movement Disorder 307.3 (F98.4)
• Tic Disorders
– Tourette’s Disorder 307.23 (F95.2)
– Persistent Chronic Motor or Vocal Tic Disorder 307.22 (F95.1)
• Tics may “wax and wane in frequency, but have persisted for more than a
year.”
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27. Schizophrenia and Other Psychotic Disorders
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28. Schizophrenia Spectrum and Other Psychotic Disorders
• Schizotypal (Personality) Disorder 301.22 (F21)
• Delusional Disorder 297.1 (F22)
• Brief Psychotic Disorder 298.8 (F23)
• Schizophreniform Disorder 295.40 (F20.81)
• Schizophrenia 295.90 (F20.9)
• Schizoaffective Disorder (bipolar or depressive type) 295.70 (F25.0, F25.1)
• Substance/Medication-Induced Psychotic Disorder – see substance-
specific codes
• Psychotic Disorder Due to Another Medical Condition (with delusions or
with hallucinations) 293.81, 293.82 (F06.2, F06.0)
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29. Schizophrenia Spectrum and Other Psychotic Disorders
• Catatonia Associated with Another Mental Disorder 293.89 (F06.1)
• Catatonic Disorder Due to Another Medical Condition 293.89 (F06.1)
• Unspecified Catatonia 293.89 (F06.1)
• Other Schizophrenia Spectrum and Other Psychotic Disorder (other
specified or unspecified) 298.8 (F28)
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30. General Changes in This Section
• Eliminates subtypes of schizophrenia such as paranoid, disorganized,
catatonic, undifferentiated and residual types
• Limited diagnostic stability, low reliability and poor validity
• Catatonia specifier – can be used for psychotic, depressive and bipolar
disorders. Requires three catatonic symptoms for this designation:
– Stupor Stereotypy
– Catalepsy Agitation, not influenced by internal stimuli
– Waxy flexibility Grimacing
– Mutism Echolalia
– Negativism Echopraxia
– Posturing Mannerism
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31. General Changes in This Section
• Schizoaffective Disorder
– Requires a major mood episode be present for the majority of the
disorder’s duration
– Bipolar type 295.70 (F25.0)
– Depressive type 295.70 (F25.1)
• Delusional Disorder 297.1 (F22)
– No longer requires that delusions must be non-bizarre
– No longer separates Delusional Disorder from Shared Delusional
Disorder
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32. Bipolar and Related Disorders
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33. Bipolar and Related Disorders Categories
• Bipolar I Disorder 296.40-296.46 (F31 series), 296.50-56 (F31 series)
• Bipolar II Disorder 296.89 (F31.81)
• Cyclothymic Disorder 301.13 (F34.0)
• Substance/Medication-Induced Bipolar and Related Disorder – see
substance abuse section
• Bipolar Disorder Due to Another Medical Condition 293.83 (F06.33,
F06.34)
• Other Bipolar and Related Disorder 296.89 (F31.89)
• Unspecified Bipolar and Related Disorder 296.80 (F31.9)
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34. General Changes in This Section
• Bipolar and related disorders
– Bipolar disorder includes emphasis on changes in activity and energy;
not just mood
– Anxious distress specifier for bipolar disorder
• Bipolar I Disorder
– Mixed type has been eliminated
– Now includes “mixed state” specifier when mania episodes include
depressive symptoms and for depression that includes mania or
hypomania
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35. General Changes in This Section
• Other Specified Bipolar and Related Disorders
– This designation – individuals with history of major depressive
disorder who meet all criteria for hypomania except duration (four
days)
– Too few symptoms of hypomania to meet criteria for full bipolar II
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36. Introduction to DSM-5, Part II
Gary M. Henschen, MD, Chief Medical Officer, Behavioral Health
Steven J. Lari, MD, Associate Medical Director, Southeast Care Management Center

37. • ICD-10 deadline is October 1, 2014
• Magellan will transition to ICD-10-CM at that time
• ICD-10-CM uses 3 to 7 digits instead of 3 to 5
digits as in ICD-9
• Affects all health care providers and payers in the
United States
• ICD-10 does not affect CPT coding for outpatient
procedures
• ICD-10-PCS may affect some inpatient procedures
in behavioral health
The ICD-10 Transition
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38. Depressive Disorders

39. Depressive Disorders
• Disruptive Mood Dysregulation Disorder 296.99 (F34.8)
• Major Depressive Disorder
8
Severity/course
specifier
Single episode Recurrent episode
Mild 296.21 (F32.0) 296.31 (F33.0)
Moderate 296.22 (F32.1) 296.32 (F33.1)
Severe 296.23 (F32.2) 296.33 (F33.2)
With psychotic
features
296.24 (F32.3) 296.34 (F33.3)
In partial remission 296.26 (F32.4) 296.35 (33.41)
In full remission 296.26 (F32.5) 296.36 (F33.42)
Unspecified 296.20 (F32.9) 296.30 (F33.9)

40. Depressive Disorders
• Persistent Depressive Disorder (Dysthymia) 300.4 (F34.1)
• Premenstrual Dysphoric Disorder 625.4 (N94.3)
• Substance/Medication Induced Depressive Disorder
– Codes are substance-specific and in the substance use section of DSM-5
• Depressive Disorder Due to Another Medical Condition 293.83
• With depressive features (F06.31)
• With major depressive-like episode (F06.32)
• With mixed features (F06.34)
• Other Specified Depressive Disorder 311 (F32.8)
• Unspecified Depressive Disorder 311 (F32.9)
9

41. General Changes in this Section
• Major Depressive Disorder 296.210-296.36 (F32.0-F33.9)
– Coexistence of at least three manic symptoms now acknowledged by
specifier “with mixed features”
– Bereavement exclusion to MDD criteria omitted
– Bereavement—now a severe psychosocial stressor—can precipitate a
major depressive episode in a vulnerable individual after the loss
– Bereavement in MDD - most likely in individuals with past history of
family history of MDD
– Bereavement-related MDD responds to traditional treatments for
MDD
10

42. General Changes in this Section
• Disruptive Mood Dysregulation Disorder (DMDD) 296.99 (F34.8)
– New disorder in DSM-5
– Addresses concerns about overdiagnosing bipolar disorder in children
– Included for children up to age 18 with persistent irritability and
frequent episodes of extreme dyscontrol
• Premenstrual Dysphoric Disorder 625.4 (N94.3)
– New disorder in DSM-5
– Moved from DSM-IV Appendix B to main body
11

43. General Changes in this Section
• Persistent Depressive Disorder 300.4 (F34.1)
– New “umbrella” disorder
– Combines previous dysthymic disorder and chronic MDD
• Suicidality
– Proposed criteria in “Conditions for Further Study”
– Suicidal Behavior Disorder, Non-suicidal Self-injury
– Gives clinicians guidance on assessment of suicidal thinking, plans,
presence of other risk factors
12

44. Anxiety Disorders
13

45. Anxiety Disorders
• Separation Anxiety Disorder 309.21 (F93.0)
• Selective Mutism 312.23 (F94.0)
• Specific Phobia 300.29
– Animal (F40.218)
– Natural Environment (F40.228)
– Blood-injection-injury
• Fear of blood (F40.230)
• Fear of injections and transfusions (F40.231)
• Fear of other medical care (F40.232)
• Fear of injury (F40.233)
– Situational (F40.248)
– Other (F40.298)

46. Anxiety Disorders
• Social Anxiety Disorder (Social Phobia) 300.23 (F40.10)
• Panic Disorder 300.01 (F41.0)
• Agoraphobia 300.22 (F40.00)
• Generalized Anxiety Disorder 300.02 (F41.1)
• Substance/Medication-Induced Anxiety Disorder
– Codes are substance-specific and in the substance use section of DSM-5
• Anxiety Disorder Due to Another Medical Condition 293.84 (F06.4)
• Other Specified Anxiety Disorder 300.09 (F41.8)
• Unspecified Anxiety Disorder 300.00 (F41.9)
15

47. General Changes in this Section
• Anxiety Disorders
– Two former diagnoses in this category—reclassified
• Obsessive-compulsive disorder - now has own section
• Post-Traumatic Stress Disorder (PTSD) and Acute Stress Disorder
(ASD) now in Trauma and Stressor-Related Disorders
• Located after anxiety disorders to show close relationship
• Agoraphobia, Specific Phobia and Social Anxiety Disorder (Social Phobia)
300.22, 300.29, 300.23 (F40.00, F40.218-40.298, F40.10)
– Important modifications made
• Deleted-requirement that individuals over 18 recognize their
anxiety is excessive or unreasonable
• 6-month duration of symptoms required for all ages
16

48. General Changes in this Section
• Separation Anxiety Disorder 309.21 (F93.0)
– New positioning in DSM-5
– Was classified under DSM-IV “Disorders Usually First Diagnosed in
Infancy, Childhood, or Adolescence”
– Core features unchanged from DSM-IV
– Better descriptors for adult expression of separation anxiety from
home or major attachment
– No longer specify that age onset must be before 18 years of age
– Duration should typically last for 6 months or more
• Specific Phobia 300.29 (F40.218-F40.298)
– Core features unchanged from DSM-IV
– Age of onset and symptom duration noted above
17

49. General Changes in this Section
• Social Anxiety Disorder (Social Phobia) 300.23 (F40.10)
– Essential features remain the same
– The “generalized” specifier from DSM-IV (“fears related to most social
situations”) has been deleted
– A “performance only” specifier - new feature in DSM-5; coded when
fear is restricted to speaking or performing in public
• Selective Mutism 312.23 (F94.0)
– New positioning in DSM-5
– Was classified in “Disorders Usually First Diagnosed in Infancy,
Childhood or Adolescence”
– The majority of these children are anxious, so place in this category
– Diagnostic criteria unchanged from DSM-IV
18

50. General Changes in this Section
• Panic Disorder 300.01 (F41.0)
– Unlinked with agoraphobia in DSM-5
– Panic Disorder and Agoraphobia are now separate diagnoses with
distinct criteria
– A significant number of individuals with agoraphobia do not
experience panic symptoms
• Panic Attack Specifier
– Can be listed as a specifier that is applicable to all DSM-5 disorders
– Modifications include
• Criteria terminology clearer and less complicated
• Different types of panic attacks termed “expected” or
“unexpected”
• Panic attacks - marker and prognostic factor for severity of
diagnosis, course, comorbidity for many disorders
19

51. General Changes in this Section
• Agoraphobia 300.22 (F40.00)
– DSM-5 requires manifestation of fear, intense anxiety
– Triggered by at least two of the following:
• Public transportation
• Open spaces
• Enclosed spaces
• Standing in line
• Being in a crowd
• Being outside of the home alone
• Generalized Anxiety Disorder 300.02 (F41.1)
– Unchanged from DSM-IV
20

52. Obsessive-Compulsive and Related Disorders
21

53. Obsessive-Compulsive and Related Disorders
• Obsessive-Compulsive Disorder (specify if Tic-related) 300.3 (F42)
• Body Dysmorphic Disorder (specify if with muscle dysmorphia)
300.7 (F45.22)
• Hoarding Disorder (specify if with excessive acquisition) 300.3 (F42)
• Trichotillomania (Hair-pulling Disorder) 312.39 (F63.2)
• Excoriation (Skin-picking Disorder) 698.4 (L98.1)
• Substance/Medication-induced Obsessive-Compulsive and Related Disorder
– Codes are substance-specific and in the substance use section of DSM-5
22

54. Obsessive-Compulsive and Related Disorders
• Obsessive-Compulsive and Related Disorder Due to Another Medical
Condition 294.8 (F06.8)
– Specify if with
• Obsessive-compulsive-like symptoms
• Appearance preoccupations
• Hoarding symptoms
• Hair-pulling symptoms
• Skin-picking symptoms
• Other Specified Obsessive-Compulsive and Related Disorder 300.3 (F42)
• Unspecified Obsessive-Compulsive and Related Disorder 300.3 (F42)
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55. General Changes in this Section
• Obsessive-Compulsive and Related Disorders
– New category and chapter in DSM-5
– New disorders and repositioning of older diagnoses reflect evidence of
relatedness to one another
• Symptoms
• Neurobiological substrates
• Familiality
• Course of illness
• Treatment response
– Clinical features – drivenness and repetitive behaviors common feature
– New specifier – ‟with poor insight” added with cognitive component
– Allows for distinction between individuals with good or fair insight and absent
insight/delusional OCD beliefs - but not psychotic disorder
– Tic-related specifier important – comorbidity affects clinical management
24

56. General Changes in this Section
• Body Dysmorphic Disorder 300.7 (F45.22)
– New criterion and new specifier added
– Requires repetitive behaviors or mental acts done in response to
preoccupations with perceived defects or flaws in appearance
– Descriptors for above include
• Mirror checking, excessive grooming, skin picking, reassurance-
seeking
• Comparing appearance with that of others
• “Muscle dysphoria” specifier - individual preoccupied with idea
that body build too small or insufficiently muscular
• Hoarding Disorder 300.3 (F42)
– New disorder in DSM-5
– Research - not a variant of OCD
– Prevalent causes - impairment and distress
25

57. General Changes in this Section
• Excoriation (Skin Picking) Disorder 698.4 (L98.1)
– New disorder in DSM-5
– Prevalent disorder, causes distress and impairment (lesions and infection)
– Not attributable to another disorder
• Substance/Medication-induced OCD and Related Disorder* & Obsessive-
Compulsive and Related Disorder Due to Another Medical Condition
294.8 (F06.8)
– Both changes consistent with intent of DSM-5
– Both replace former specifier “with OC symptoms” in diagnoses of anxiety
disorders due to a general medical condition and substance-induced anxiety
disorder
– Reflect recognition that substances, medication and medical conditions can
present with symptoms similar to primary OC and related disorders such as
pediatric acute-onset neuropsychiatric syndrome (PANS)
* Codes are substance-specific and in the substance use section of DSM-5
26

58. General Changes in this Section
• Other Specified Obsessive-Compulsive and Related Disorder 300.3 (F42)
– Presentation characteristic of these disorders but do not meet full
criteria
– Includes many various presentations
• Body-dysphoric-like disorder with actual flaws
• Body dysphoric-like disorder without repetitive behaviors
• Nail biting, lip biting, cheek chewing, other body-focused
repetitive behaviors
• Obsessional jealousy
• Excessive fear of having deformity
• Fear that sexual organs will recede into body
• Fear of offensive body odor
27

59. Trauma and Stressor-Related Disorders
28

60. Trauma and Stressor-Related Disorders
• Reactive Attachment Disorder 313.89 (F94.1)
• Disinhibited Social Engagement Disorder 313.89 (F94.2)
• Post-traumatic Stress Disorder 309.81 (F43.10)
• Acute Stress Disorder 308.3 (F43.0)
• Adjustment Disorders Specify whether:
– With depressed mood 309.0 (F43.21)
– With anxiety 309.24 (F43.22)
– With mixed anxiety and depressed mood 309.28 (F43.23)
– With disturbance of conduct 309.3 (F43.24)
– With mixed disturbance of emotions and conduct 309.4 (F43.20)
– Unspecified 309.9 (F43.20)
29

61. • Other Specified Trauma and Stressor-Related Disorder 309.89 (F43.8)
• Unspecified Trauma and Stressor-Related Disorder 309.9 (F43.9)
Trauma and Stressor-Related Disorders
30

62. General Changes to this Section
• Trauma and Stressor-Related Disorders
– A new chapter in DSM-5
– Brings together anxiety disorders preceded by a distressing or
traumatic event
– New criteria - variability of psychological distress following exposure to
traumatic event
– Anxiety or fear based
– Anhedonic/dysphoric symptoms
– Externalized anger/aggression or dissociative symptoms
31

63. General Changes to this Section
• Acute Stress Disorder 308.3 (F43.0)
– The stressor criterion (Criterion A) has been changed
– Requires qualifying the traumatic events - experienced directly,
witnessed or experienced indirectly)
– DSM-IV Criterion A2 - subjective reaction to the traumatic event -
eliminated
– DSM-IV emphasis on dissociative symptoms - overly restrictive
– Now may meet 9:14 symptoms in the following categories:
• Intrusion
• Negative mood
• Dissociation
• Avoidance
• Arousal
32

64. General Changes to this Section
• Adjustment Disorders 309.0-309.9 (F43.20-F43.25)
– The grouping has been reconceptualized from DSM-IV
– Heterogeneous array of stress-response syndromes after exposure to a
distressing, traumatic or non-traumatic event
– DSM-IV subtypes retained and unchanged
• Post-Traumatic Stress Disorder (PTSD) 309.81 (F43.10)
– Significant differences in criteria from DSM-IV
– Stressors criterion (Criterion A) more explicit with regard to how an individual
experiences a “traumatic event”- subjective reaction has been eliminated
– PTSD diagnostic thresholds - developmentally sensitive - lowered for children
ages 6 and under
– Four symptom clusters (DSM-IV had only 3 clusters):
• Re-experiencing
• Avoidance
• Persistent negative alterations in cognitions and mood
• Arousal
33

65. General Changes to this Section
• Post-Traumatic Stress disorder (PTSD) - continued
– Negative alterations in cognitions and mood - retains most of DSM-IV numbing
symptoms
– Includes new, reconceptualized symptoms
– Retains symptoms delineated in DSM-IV for arousal and reactivity
– Includes irritable or aggressive behavior and reckless or self-destructive
behavior
• Reactive Attachment Disorder 313.89 (F94.1)
– DSM-IV subtypes are now distinct disorders
– Emotionally withdrawn/inhibited, indiscriminately social/disinhibited subtypes
now discrete entities
• Reactive attachment disorder
• Disinhibited social engagement disorder
– Both disorders - result of social neglect, limit child’s forming selective
attachments
– Dampened positive affect - lack of attachments to caregiving adults
34

66. General Changes to this Section
• Disinhibited Social Engagement Disorder 313.89 (F94.2)
– Occurs in children who do not lack attachment
– May have established secure attachment
– Closely resembles ADHD in DSM-5
– Correlates, course and response to intervention - differs from reactive
attachment disorder
35

67. Dissociative Disorders

68. Dissociative Disorders
• Dissociative Identity Disorder 300.14 F44.81
• Dissociative Amnesia 300.12 F44.0
– With Dissociative Fugue 300.13 F44.1
• Depersonalization/Derealization Disorder 300.6 F48.1
• Other Specified Dissociative Disorder 300.15 F44.89
• Unspecified Dissociative Disorder 300.15 F44.9
37

69. General Changes to this Section
• Dissociative Identity Disorder 300.14 (F44.81)
– Criterion A expanded (“disruption of identity…two or more distinct
personality states”)
• Includes certain possession-form phenomena and certain
neurological symptoms
• Accounts for more diverse presentations
• More reflective of diverse cultural presentations
• Transitions in identity - may be observable by others OR self-
reported
– Criterion B - gaps in recall for everyday events - not just traumatic
experiences
38

70. General Changes to this Section
• Dissociative Amnesia 300.12 (F44.0)
– Criteria largely unchanged from DSM-IV
– Dissociative Fugue 300.13 (F44.1)
• Purposeful travel or bewildered wandering
– Associated with amnesia for identity or other autobiographical
information
• No longer a separate diagnosis
• Specifier to diagnosis of dissociative amnesia
• Depersonalization/Derealization Disorder 300.6 (F48.1)
– Derealization included in name and symptom structure of DSM-IV
depersonalization disorder
– In DSM-5, essential feature - persistent or recurrent episodes of
depersonalization, derealization, or both
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71. Somatic Symptom and Related Disorders
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72. Somatic Symptom and Related Disorders
• Somatic Symptom Disorder 300.82 (F45.1)
• Illness Anxiety Disorder 300.7 (F45.21)
• Conversion Disorder (Functional Neurological Symptom Disorder)
300.11
With weakness or paralysis (F44.4)
With abnormal movement (F44.4)
With swallowing symptoms (F44.4)
With speech symptom (F44.5)
With anesthesia or sensory loss (F44.6)
With special sensory symptom (F44.6)
With mixed symptoms (F44.7)
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73. Somatic Symptom and Related Disorders
• Psychological Factors Affecting Other Medical Conditions 316 (F54)
• Factitious Disorder 300.19 (F68.10)
• Other Specified Somatic Symptom and Related Disorder 300.89 (F45.8)
• Unspecified Somatic Symptom and Related Disorder 300.82 (F45.9)
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74. General Changes to this Section
• New chapter - brings together disorders with:
– Disproportionate thoughts, feelings, behaviors related to somatic
symptoms
• Were named Somatoform Disorders in DSM-IV
• Eliminates the following diagnoses:
– Somatization disorder
– Hypochondriasis
– Pain disorder
– Undifferentiated somatoform disorder
• Removes centrality of medically unexplained symptoms
• Somatic symptom disorders CAN accompany diagnosed medical conditions
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75. General Changes to this Section
• Somatic Symptom Disorder 300.82 (F45.1)
– Merging of two DSM-IV diagnoses: Somatization Disorder &
Undifferentiated Somatoform Disorder
– No specific number of somatic symptoms required
– Most individuals previously diagnosed Somatization Disorder will meet
criteria for Somatic Symptom Disorder, but…
– Only if they have maladaptive thoughts, feelings, behaviors in addition
to their somatic symptoms
• Illness Anxiety Disorder 300.7 (F45.21)
– High health anxiety WITHOUT somatic symptoms
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76. General Changes to this Section
• Conversion Disorder 300.11 (F44.4-F44.7)
– Emphasizes essential importance of neurological examination
– Relevant psychological factors may not be demonstrable at diagnosis
– Emphasizes somatic symptoms not compatible with recognized
medical or neurological conditions
• Psychological Factors affecting Other Medical Conditions (PFAMC)
316 (F54)
– In DSM-IV, “Other Condition That May Be a Focus of Clinical Attention”
– One or more clinically significant psychological or behavioral factors
that adversely affect a medical condition
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77. General Changes to this Section
• Factitious Disorder 300.19 (F68.10)
– DSM-IV distinctions on the psychological or medical nature of falsified
symptoms have been removed
– Factitious Disorder Imposed on Self
– Factitious Disorder Imposed on Another (by Proxy)
– “by Proxy” had been classified in DSM-IV as Factitious Disorder NOS
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78. Eating and Feeding Disorders
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79. Eating and Feeding Disorders
• Pica 307.52
– In children (F98.3)
– In adults (F50.8)
• Rumination Disorder 307.53 (F98.21
• Avoidant/Restrictive Food Intake Disorder 307.59 (F50.8)
• Anorexia Nervosa 307.1
– Restricting type (F50.01)
– Binge-eating/purging type (F50.02)
• Bulimia Nervosa 307.51 (F50.2)
• Binge-Eating Disorder 307.51 (F50.8)
• Other Specified Feeding or Eating Disorder 307.59 (F50.8)
• Unspecified Feeding or Eating Disorder 307.50 (F50.9)
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80. General Changes to this Section
• Chapter renamed - several disorders from DSM-IV chapter “Disorders
Usually Diagnosed in Infancy, Childhood or Adolescence” included
• Binge Eating Disorder now recognized - many previously diagnosed with
Eating Disorder NOS in DSM-IV.
• Other Specified Feeding or Eating Disorder - brief descriptions and
preliminary diagnostic criteria - atypical anorexia nervosa, bulimia nervosa
of low frequency and/or limited duration, binge-eating disorder of low
frequency and/or limited duration, purging disorder and night eating
syndrome
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81. General Changes in this Section
• Pica and Rumination Disorder 307.52 (F98.3, F50.8)
– Diagnoses can be made at any age
– Previous criteria reworded for clarity
• Avoidant/Restrictive Food Intake Disorder 307.59 (F50.8)
– New name for DSM-IV diagnosis “Feeding Disorder of Infancy or Early
Childhood”
– Criteria expanded - individuals who restrict food intake and experience
significant associated physiological or psychosocial problems but do
not meet criteria for any other eating disorder
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82. General Changes to this Section
• Anorexia Nervosa 307.1 (F50.01, F50.02)
– Amenorrhea requirement eliminated
– Criteria focuses on behaviors (restricting calorie intake)
– No longer includes “refusal” in terms of weight maintenance
– Criteria no longer uses “maintenance at less than 85% IBW”
– Denotes “significantly low weight” using WHO Body Mass Index
percentiles
– Guidance provided to judge whether individual at or below
significantly low weight
– Criterion B - expanded to include not overtly expressed fear of weight
gain, but also persistent behavior that interferes with weight gain
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83. General Changes to this Section
• Bulimia Nervosa 307.51 (F50.2)
– Reduces frequency of binge eating, compensatory behaviors that must
be exhibited at least once/weekly over the previous 3 months
– DSM-IV required twice weekly for 6 months
• Binge-Eating Disorder 307.51 (F50.8)
– Research supported clinical validity
– Individuals who experience persistent, recurrent episodes of
overeating marked by loss of control and significant clinical distress
– Binge eating at least once weekly for the last 3 months
– Cites differences between binge eating and simple overeating
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84. Questions?
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The information presented in this presentation is confidential and expected to be used for the sole purpose of considering the
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without the prior written consent of the Company.
Confidential Information
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