part 2 of a two part series elaborating the changes mde from the dsmIV to dsm5

1. Diagnostic and Statistical Manual
Of Mental Disorders
Changing from
DSM-IV to DSM-5
Part 11
DR .ABID RIZVI
M.D(psychiatry).
Registrar
Aligarh muslim university
india

2. RECAP
• 22 Chapters v/s 17 Chapters
• Chapters reorganized to reflects developmental lifespan.
• Multiaxial system discontinued.

3. NEURODEVELOPMENTAL
DISORDERS
• Autistic Spectrum Disorder (ASD)subtypes merged into one.
• ADHD 
 age increased from 7 to 12,
 comorbid diagnosis with ASD allowed.
 5 criteria for younger patients.
INTELECTUAL DISABILITY
• Severity based on adaptive functioning.

4. Schizophrenia Spectrum and Other
Psychotic Disorders:
• SHIZOTYPICAL personality disorder.
• Schizophrenia:
 elimination of bizarre delusions and two or more voices
commenting type hallucination.
 must be delusions, hallucinations, or disorganized speech.
 Elimination of subtypes.
• Schizoaffective Disorder- mojor mood episode for Majority of
the disorder.

5. • Catatonia – 3/12.
• Delusional Disorder- shared delusional disorder included. Bizzare
delusion included. (as specifier).
• Specifiers . For all disorder in this chapter.
1. Specify if – (after 1 year)
• First episode currently in acute episode.
• First episode currently in partial remission.
• First episode currently in full remission.
• Multiple episode currently in acute episode.
• Multiple episode currently in partial remission.
• Multiple episode currently in full remission.
• Continuous.
• Unspecified.

6. 2. Specify if
With catatonia (using additional code)
3. Specify current severity of delusion, hallucination, disorganized
speech, abnormal psychomotor behavior, negative symptom,
impaired cognition, depression and manic symptoms.

7. Bipolar and Related Disorders
• Manic/hypomanic Add to criterion A:
“Abnormally and persistently increased goal-directed activity
or energy Along with mood”.
• Bipolar I Disorder
• Bipolar II Disorder
• Cyclothymic disorder.

8. • ___.__ (___.__) Bipolar I Disordera
• ___.__ (___.__) Current or most recent episode manic
• 296.41 (F31.11) Mild
• 296.42 (F31.12) Moderate
• 296.43 (F31.13) Severe
• 296.44 (F31.2) With psychotic features
• 296.45 (F31.73) In partial remission
• 296.46 (F31.74) In full remission
• 296.40 (F31.9) Unspecified
• 296.40 (F31.0) Current or most recent episode hypomanic
• 296.45 (F31.73) In partial remission
• 296.46 (F31.74) In full remission
• 296.40 (F31.9) Unspecified
• ___.__ (___.__) Current or most recent episode depressed
• 296.51 (F31.31) Mild
• 296.52 (F31.32) Moderate
• 296.53 (F31.4) Severe
• 296.54 (F31.5) With psychotic features
• 296.55 (F31.75) In partial remission
• 296.56 (F31.76) In full remission
• 296.50 (F31.9) Unspecified
• 296.7 (F31.9) Current or most recent episode unspecified

9. 1. With anxious distress
2. With mixed features
3. With rapid cycling
4. With melancholic features
5. With atypical features
6. With mood-congruent psychotic features
7. With mood-incongruent psychotic features
8. With catatonia Coding note: Use additional code 293.89 (F06.1).
9. With peripartum onset
10. With seasonal pattern

10. • In partial remission- current full criteria are not met or duration
after full recovery is less than 2 months
• In full remission- during the last two months no s/s of disturbance
was present.
• MILD – just s/s necessary to make the diagnosis and symptom is
distressing but manageable an results in minor impairment of
functioning.
• Moderate- between mild and severe.
• Severe- s/s substantially in excess of that required to make the
diagnosis and marked interference in social and occupational
functioning

11. Bipolar disorder in mixed phase ???
• Bipolar I disorder Current OR more recent episode manic/
hypomanic/ depressed with mixed feature.
• If both depressive and manic criteria are equally fulfilled the
diagnosis will be BIPOLAR I disorder current episode mania with
mixed feature due to marked impairment and clinical severity of
manic feature.

12. DEPRESSIVE DISORDERS
Bereavement exclusion” removed.
Persistent Depressive Disorder (Dysthymia)
• MDD may be present 2 years (previously excluded).
• Specifiers.
1. With anxious distress
2. With mixed features
3. With melancholic features
4. With atypical features
5. With mood-congruent psychotic features
6. With mood-incongruent psychotic features
7. With catatonia Coding note: Use additional code 293.89 (F06.1).
8. With peripartum onset
9. With seasonal pattern

13. Major Depressive Disordera (160)
___.__ (___.__) Single episode
296.21 (F32.0) Mild
296.22 (F32.1) Moderate
296.23 (F32.2) Severe
296.24 (F32.3) With psychotic features
296.25 (F32.4) In partial remission
296.26 (F32.5) In full remission
296.20 (F32.9) Unspecified
___.__ (___.__) Recurrent episode
296.31 (F33.0) Mild
296.32 (F33.1) Moderate
296.33 (F33.2) Severe
296.34 (F33.3) With psychotic features
296.35 (F33.41) In partial remission
296.36 (F33.42) In full remission
296.30 (F33.9) Unspecified

14. Anxiety Disorders
• Agoraphobia, Specific Phobia, and Social Anxiety Disorder
deletion of the requirement that individuals over age 18 years
recognize that their anxiety is excessive or unreasonable and
symptoms for atleast 6 month.
• Panic disorder and Agoraphobia are “unlinked” in DSM- 5

15. Obsessive Compulsive and Related
Disorders
• OCD
• Body dysmorphic disorder
• Hoarding disorder *,
• Trichotillomania.
• Excoriation (skin picking) disorder*.

16. Somatic Symptom and Related
Disorders
1. Somatic Symptom Disorder
2. Illness Anxiety Disorder:
3. Conversion Disorder:
4. Psychological Factors Affecting Other Medical Conditions
5. Factitious disorder.

17. Trauma- and Stressor-Related
Disorders
1. Reactive Attachment Disorder
2. Dis-inhibited Social Engagement Disorder*
3. PTSD (includes PTSD for children 6 years and younger)
4. Acute Stress Disorder
5. Adjustment Disorders

18. Dissociative Disorders
• Dissociative identity disorder.
• Dissociative amnesia
• Depersonalization/ derealization.
• Other specified
• Unspecified.

19. Somatic Symptom and Related
Disorders:
1. Somatic Symptom Disorder (persistent pain as specifier).
2. Illness Anxiety Disorder:
3. Conversion Disorder:
4. Psychological Factors Affecting Other Medical Conditions
5. Factitious disorder.

20. • Part 11

21. Feeding and Eating Disorders:
• DSM IV-TR chapter “Disorder Usually First Diagnosed in
Infancy Childhood, or Adolescence” has been eliminated.
• Therefore this chapter includes several disorders from DSM-IV
“Feeding and Eating Disorders of Infancy or Early Childhood”.

22. • Pica
• Rumination disorder
• Avoidant/restrictive food intake disorder.
• Anorexia nervosa
• Bulimia nervosa
• Binge eating disorder.

23. Feeding and Eating Disorders:
Cont…
Pica and Rumination Disorder:
• Criteria has been revised to allow diagnosis for individuals of
all ages.
Avoidant/Restrictive Food Intake Disorder:
• Previously feeding disorders of infancy or early childhood.
• Criteria is significantly expanded making it a broader category
to capture a wider range of clinical presentations.

24. Feeding and Eating Disorders:
Cont…
Anorexia Nervosa:
• The requirement for amenorrhea has been eliminated.
• Clarity and guidance re: how to judge if an individual is at
“significantly low weight” has been added.
• Criterion B has been expanded to include not only “overtly
expressed fear of weight gain” but also “persistent behavior
that interferes w/ weight gain”.

25. a. Restriction of energy relative to requirement LEADING TO
SIGNIFICANT LOW BODY WEIGHT.
b. Intense fear of weight gain or persistent behavior that interfere
with weight gain.
c. Disturbance in the way in which ones body weight or image is
experienced.
Specifier
Mild BMI > 17
Moderate BMI 16 – 16.99
severe BMI 15 – 15.99
extreme BMI < 15

26. Feeding and Eating Disorders:
Cont…
Bulimia Nervosa :
• The only change is the reduction in the required minimum
average frequency of binge eating & inappropriate
compensatory behavior frequency from twice to once weekly
for 3 months.

27. Feeding and Eating Disorders:
Cont…
Binge Eating Disorder:
• Elevated to main body of manual from appendix B in DSM-IV.
• The only change is the minimum average frequency of binge
eating required for diagnosis is once weekly over the last 3
months (identical to frequency criterion for bulimia nervosa).

28. Elimination Disorders:
• No significant changes have been made to elimination
disorders.
• The disorders in this chapter (enuresis & encopresis) were
previously under “Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence” in DSM-IV and are now
independent classifications in DSM-5.

29. Sleep-Wake Disorders:
• Sleep disorder related to another mental disorder and sleep
disorder related to a general medical condition have been
removed.
Insomnia Disorder:
• Previously named primary insomnia.
• Rationale: to avoid the differentiation between primary &
secondary insomnia.

30. Sleep-Wake Disorders:
Cont…
Narcolepsy:
• Is now distinguished from other forms of hypersomnolence.
Breathing-Related Sleep Disorders:
• Now divided into 3 distinct disorders: obstructive sleep apnea
hypopnea; central sleep apnea; and sleep related
hypoventilation.
• Rationale: reflects the growing understanding of
pathophysiology in these disorders.

31. Sleep-Wake Disorders:
Cont…
Circadian Rhythm Sleep-Wake Disorders:
• Subtypes expanded to include: advanced sleep phase
syndrome; irregular sleep-wake type; and non-24 hr sleep
wake type.
* Jet lag has been removed.
Rapid Eye Movement Sleep Behavior Disorder
Restless Legs Syndrome
• Both are now independent disorders.

32. Sexual Dysfunctions
•“a group of disorders that are characterized by clinically significant
disturbance in a person’s ability to respond sexually”
•In DSM -5 gender-specific sexual dysfunctions have been added
•For purpose of diagnostic precision
-Criteria require a minimum duration
• of six months
-Criteria for severity are more precisely defined
• as mild, moderate, or severe.

33. • Delayed ejaculation
• Erectile disorder
• Female orgasmic disorder.
• Female sexual interest/arousal disorder.
• Genito-pelvic pain /penetration disorder.
• Male hypoactive sexual desire disdoder.
• Premature ejaculation

34. Gender Dysphoria
•New diagnostic class in DSM-5
•Reflects change in definition, emphasizes “gender incongruence” rather
than cross-gender identification.
•In DSM-IV, three disparate diagnostic classes grouped in one chapter,
“Sexual and Gender Identity Disorders”
•Gender Identity Disorder is neither a sexual dysfunction nor a
paraphilia.

35. Gender Dysphoria
–Is considered a multi-category concept, not a dichotomy
–Separate criteria sets are provided for gender dysphoria in children,
and in adolescents and adults
–Terminology changes include:
-“the other sex” is replaced by “some alternative gender”
-“gender” is used instead of “sex”

36. DISRUPTIVE, IMPULSE-CONTROL, AND CONDUCT
DISORDERS
More detailed
• Opposional defiant disorder.
• IED.
• Conduct disorder.
• Antisocial personality disorder.
• Pyromania.
• Kleptomania.

37. Disruptive, Impulse-Control, and Conduct Disorders
Oppositional Defiant Disorder
• Criteria exhibited “with at least one individual who is not a
sibling”
• “Spiteful or vindictive twice in 6 months”
• Severity: Mild, moderate, severe
• <5years most days for 6 months;
>5 years, weekly

38. Disruptive, Impulse-Control, and Conduct Disorders
Conduct Disorder
• Adds specifier “With limited prosocial emotions”
• Persistently in 12 months (2 of 4)
1. Lack of Remorse/ guilt
2. Callous—lack of empathy
3. Unconcerned about performance
4. Shallow or deficient affect

39. Disruptive, Impulse-Control, and Conduct Disorders
Intermittent Explosive Disorder
• Verbal aggression 2x weekly for 3 months
• Destruction or assault: 3x in 12 months
• 6 years +
• Not premeditated

40. Disruptive, Impulse-Control, and Conduct Disorders
• AntiSocial Personality Disorder
(criteria in PD chapter) “Dual coded”
• Pyromania
• Kleptomania
• Other DICCD
• Unspecified DICCD

41. Substance-Related and Addictive Disorders:
• DSM-5 consolidates substance abuse and dependence into one disorder:
substance use disorder accompanied by criteria for: intoxication,
withdrawal, substance-induced disorders, and unspecified related
disorders.
• Criteria are nearly identical to DSM-IV w/ exception of:
-Recurrent substance-related legal problems criterion has been deleted
from DSM-5.
-And new criterion: craving, or a strong desire or urge to use a substance
added.
• The threshold is set at 2 or more criteria vs. 1 or more for abuse and 3 or
more for dependence in the DSM-IV.

42. Substance-Related and Addictive Disorders:
Cont…
New disorders in substance-related & addictive disorders
chapter of DSM-5:
• Gambling Disorder (non-substance related disorder)
• Cannabis Withdrawal
• Caffeine Withdrawal
* The dx of polysubstance dependence has been eliminated.

43. Substance-Related and Addictive Disorders:
Cont…
Specifiers:
• In DSM-5 severity for substance use disorders is based on the
number of criteria endorsed:
-mild= 2-3 criteria
-moderate = 4-5 criteria
-Severe= 6 or more criteria
• The DSM-IV specifier for psychological subtype has been
eliminated.

44. Substance-Related and Addictive Disorders:
Cont…
• In DSM-5 early remission is defined as at least 3 but less then
12 months without substance use disorder criteria (except
craving).
• Sustained remission is defined as at least 12 months without
criteria (except craving).
• New specifiers include:
-in a controlled environment
-on maintenance therapy

45. Neurocognitive Disorders:
• Dementia and amnestic disorder are now included under
neurocognitive disorder (NCD).
• Rationale: dementia has been associated w/ the older
population whereas NCD will capture etiologies occurring in
younger adults as well.
• The term dementia is not excluded from use in etiological
subtypes.

46. Neurocognitive Disorders:
Cont…
• DSM-5 now recognizes a less severe level of cognitive
impairment, mild NCD, allowing a dx of a less disabling
syndrome that may be a focus of concern and treatment.
• Diagnostic criteria are provided for both mild NCD and major
NCD, followed by diagnostic criteria for the different
etiological subtypes.

47. Neurocognitive Disorders:
Cont…
• The DSM-5 also provides an updated listing of neurocognitive
domains to establish presence of NCD, level of impairment
(mild or major), and etiological subtypes.

48. A. Evidence of significant cognitive decline from a previous level of
performance in one or more cognitive domains (complex attention,
executive function, learning and memory, language, perceptual-
motor, or social cognition) based on:
1. Concern of the individual, a knowledgeable informant, or the
clinician that there has been a significant decline in cognitive
function; and
2. A substantial impairment in cognitive performance, preferably
documented by standardized neuropsychological testing or, in its
absence, another quantified clinical assessment.
B. The cognitive deficits interfere with independence in everyday
activities (i.e., at a minimum, requiring assistance with complex
instrumental activities of daily living such as paying bills or
managing medications).
C. The cognitive deficits do not occur exclusively in the context of a
delirium.
D. Not better explained by another mental disorder.

49. • Alzheimer’s disease
• Frontotemporal lobar degeneration
• Lewy body disease
• Vascular disease
• Traumatic brain injury
• Substance/medication use
• HIV infection
• Prion disease
• Parkinson’s disease
• Huntington’s disease
• Another medical condition
• Multiple etiologies.
• Unspecified

50. Specify if
• Without behavioral disturbance
• With behavioral disturbance.

51. Delirium: Criteria for delirium has been updated and clarified to reflect
currently available evidence.
• A disturbance of attention and awareness
• Develop over short period and tend to fluctuate .
• Additional disturbance of cognition

52. Personality Disorders
Initially proposed
• Retain 6 personality disorder diagnoses of 10
• Move from a categorical to a
trait-based, dimensional
classification system.
• measuring a variety of
traits on a continuum.

53. Personality Disorders
• Voted down: Not adequately validated
• Included in a separate chapter in Section 3 of DSM-5 to
stimulate further research
• In the field trials, only borderline personality disorder had
good interrater reliability
• obsessive-compulsive personality disorder and antisocial
personality disorder were in the questionable reliability range

54. Personality Disorders
10 PD’s retained; Add
Personality Change Due to Another Medical Condition
Other Specified Personality Disorder
Unspecified Personality Disorder

55. Paraphilic Disorders
• Distinguishes between paraphilic behaviors (paraphilias), and
paraphilic disorders.
• A Paraphilic Disorder :
"paraphilia that is currently causing distress or impairment to the
individual or a paraphilia whose satisfaction has entailed personal
harm, or risk of harm, to others.“
• Demedicalizes and destigmatizes unusual sexual preferences and
behaviors .

56. Paraphilic Disorders
Voyeuristic Disorder
• nonconsenting person, or distress/ impairment
• >18
• Specifier: controlled environment or in remission
Exhibitionistic Disorder
• nonconsenting person, or distress/ impairment
• Specifiers: children, adults, or both; controlled environment or in
remission

57. Paraphilic Disorders
Frotteuristic disorder
• Nonconsenting person, or distress/impairment
• Specifier: controlled environment or in remission
Sexual Masochism disorder
• Specifier: with asphyxiophilia;
controlled environment or in remission
Sexual Sadism disorder
• Nonconsenting person, or distress/impairment
• Specifier: with asphyxiophilia;
controlled environment or in remission

58. Paraphilic Disorders
Pedophilic Disorder
• Acted on urges, or distress/impairment, or interpersonal
difficulty
Fetishistic Disorder
• (Add to “nonliving objects”):
“highly specific focus on nongenital body parts”
• Specifiers:
Body part(s),nonliving object(s)
Other
controlled environment or in remission

59. Paraphilic Disorders
Transvestic Disorder
• No longer specifies “In a heterosexual male”
• Specifiers:
(Gender Dysphoria now separate section)
With fetishism
With autogynephilia
controlled environment or in remission

60. Other Mental Disorders
Four disorders in this chapter
“This residual category applies to presentation
of symptoms characteristic of mental disorders, which cause clinically
significant distress or impairment, but do not meet the full criteria for
any other mental disorder”
Other Specified Mental Disorder Due to Another Medical Condition
-Unspecified Mental Disorder Due to Another Medical Condition
-Other Specified Mental Disorder
-Unspecified Mental Disorder

61. Medication-Induced Movement Disorders
and the Adverse Effects of Medication
These disorders are included in Section II of
DSM-5 “because of the importance of
1.The management by medication of mental disorders or other medical
conditions
2.The differential diagnosis of mental disorders”

62. Other Conditions that may be a
Focus of Clinical Attention
“The conditions and problems listed in this chapter are
not mental disorders.”
“They may be included in the medical record as useful
information that may affect client’s care. “
Inclusion in the DSM-5 draws attention to the scope of
issues encountered in clinical practice

63. OtherConditionsthatmaybea
Focusof ClinicalAttention
Commonly referred to as “the V codes”
Child Maltreatment and Neglect
Adult Maltreatment and Neglect
Relational Problems
Educational Problems
Occupational Problems
Housing Problems
Economic Problems

64. Problem with current psychiatric
classification.
• Current, diagnosis based on clinical observation and patients’
phenomenological symptom reports.
• This system, has served well to improve diagnostic reliability in
both clinical practice and research at the cost of validity.
• current diagnostic system is not informed by recent
breakthroughs in genetics; and molecular, cellular and systems
neuroscience

65. • symptom-based diagnosis, once common in other areas of
medicine, has been largely replaced in the past half century as we
have understood that symptoms alone rarely indicate the best
choice of treatment.
• Consider chest pain as a disease.

66. • Alzheimer disease, diabetes mellitus, inflammatory bowel disease,
multiple sclerosis or Parkinson disease are all complex traits,
typically less heritable than major psychiatric disorders, but their
genetic research has advanced faster..
• difficulty matching artificial diagnostic categories with biological
findings
• longitudinal studies suggesting that severe psychiatric disorders
develop in stages characterized by varying clinical
presentation(duffy A et al).

67. • A diagnostic approach based on the biology as well as the
symptoms must not be constrained by the current DSM categories.
• Mental disorders are biological disorders involving brain circuits
that implicate specific domains of cognition, emotion, or behavior.
• Each level of analysis needs to be understood across a dimension
of function.
• Mapping the cognitive, circuit, and genetic aspects of mental
disorders will yield new and better targets for treatment.

68. • we cannot design a system based on biomarkers or cognitive
performance because we lack the data.
• we cannot succeed if we use DSM categories as the “gold
standard.
• Imagine deciding that EKGs were not useful because many
patients with chest pain did not have EKG changes

69. Director of the National Institute of Mental Health (NIMH)
Thomas Insel
• NIMH Research Domain Criteria (RDoC),
a possible future replacement diagnostic tool incorporates genetics,
imaging, and other data into a new classification system and as "a
first step towards precision medicine."
• "what may be realistically feasible today for practitioners is no
longer sufficient for researchers."

70. Director of the National Institute of Mental Health (NIMH)
Thomas Insel
BUT
[DSM & ICD (International Classification of Diseases)]
“remain the contemporary consensus standard to how mental
disorders are diagnosed and treated," …
"DSM-5 and RDoC represent complementary, not competing,
frameworks for this goal."

71. references
• DSM 5 APA
• POSITION STATEMENT OF NIMH ON DSM-5