2. 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

3. Anxiety Disorders

4. Anxiety Disorders
The anxiety must be out of proportion to the actual
danger or threat in the situation”
This chapter no longer includes OCD and PTSD
DSM 5 creates new chapters for OCD and PTSD
Chapter is arranged developmentally.

Sequenced by age of onset

Now includes Separation Anxiety and
Selective Mutism

5. Anxiety Disorders
Split into 3 chapters:
– Anxiety Disorders:
• Fight or flight system (Amygdala).
– Trauma- & Stressor-Related Disorders.
• Greater focus on affective response to external stressors.
– OCD & Related Disorders.
• Based on imaging and genetic studies, and treatment response.
• Basal ganglia – movement circuit – focus on urge and behavior,
less on anxiety.

6. Anxiety Disorders
The DSM-5 chapter on anxiety disorder no longer
includes obsessive-compulsive disorder (which is
included with the obsessive-compulsive and related
disorders) or posttraumatic stress disorder and acute
stress disorder (which is included with the traumaand stressor-related disorders).
However, the sequential order of these chapters in
DSM-5 reflects the close relationships among them.

7. Anxiety Disorders
 Separation Anxiety Disorder
 Selective Mutism
 Specific Phobia
 Social Anxiety Disorder (Social Phobia)
 Panic Disorder
 Panic Attack (Specifier)
 Agoraphobia
 Generalized Anxiety Disorder
 Substance/Medication-Induced Anxiety Disorder
 Anxiety Disorder Due to Another Medical Condition
 Other Specified Anxiety Disorder
 Unspecified Anxiety Disorder

8. Agoraphobia, Specific Phobia, and Social
Anxiety Disorder (Social Phobia)
Changes in criteria :
1.
Clients over 18 do not have to recognize
that their anxiety is excessive or
unreasonable.
2.
Duration of 6 months or longer is required
for all ages

9. Panic Attack
The essential features of panic attacks remain
unchanged
DSM-IV terminology for describing different types of
panic attacks is replaced with the terms unexpected
and expected panic attacks.
 panic attack can be listed as a specifier that is
applicable to all DSM-5 disorders.

10. Panic Disorder and
Agoraphobia
Panic disorder and agoraphobia are unlinked in
DSM-5.
 are now replaced by two diagnoses, panic
disorder and agoraphobia, each with separate
criteria.

11. Specific Phobia
The core features of specific phobia remain the same
 but there is no longer a requirement that individuals
over age 18 years must recognize that their fear and
anxiety are excessive or unreasonable.
 the duration requirement (“typically lasting for 6
months or more”) now applies to all ages.
they are now referred to as specifiers,
the different types of specific phobia have essentially
remained unchanged.

12. Social Anxiety Disorder (Social
Phobia)
The essential features of social anxiety disorder remain the
same.
 However, a number of changes have been made:
1. deletion of the requirement that individuals over age 18
years must recognize that their fear or anxiety is
excessive or unreasonable
2. duration criterion of “typically lasting for 6 months or
more” is now required for all ages.
3. the “generalized” specifier has been deleted and
replaced with a “performance only” specifier.

13. Separation Anxiety Disorder
In DSM-IV, separation anxiety disorder was classified
in the section “Disorders Usually First Diagnosed in
Infancy, Childhood, or Adolescence,” it is now
classified as an anxiety disorder.
 The core features remain mostly unchanged,
 the wording of the criteria has been modified to
more adequately represent the expression of
separation anxiety symptoms in adulthood.
 the diagnostic criteria no longer specify that age at
onset must be before 18 years.
 a duration criterion—“typically lasting for 6 months
or more”—has been added for adults to minimize
over diagnosis of transient fears.

14. Selective Mutism
In DSM-IV, selective mutism was classified in the
section “Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence.” It is now classified as an
anxiety disorder.
 The diagnostic criteria are largely unchanged from
DSM-IV.

15. Obsessive-Compulsive & Related
Disorders





OCD.
Hoarding Disorder.
Excoriation (Skin Picking Disorder).
Trichotillomania (Hair Pulling Disorder)
Substance/Medication Induced ObsessiveCompulsive & Related Disorder.
 Due to Another Medical Condition.

16. OCD
The chapter on obsessive-compulsive and
related disorders, which is new in DSM-5.
 New disorders include hoarding disorder,
excoriation (skin-picking) disorder, substance/medicaton-induced obsessive-compulsive
disorder.
trichotillomania is now termed trichotillomania
(hair-pulling disorder) and has been moved
from a DSM-IV classifcation of impulse-control
disorders.

17. Hoarding is no longer a variant of obsessivecompulsive disorder.
Separate diagnosis of hoarding disorder,
reflects persistent difficulty discarding or parting
with possessions due to a perceived need to save
the items and distress associated with discarding
them.
Hoarding disorder may have unique
neurobiological correlates.

18. Specifiers
DSM-5 to allow a distinction between individuals
with good or fair insight, poor insight, and “absent
insight/delusional” obsessive-compulsive
disorder beliefs (i.e., complete conviction that
obsessive-compulsive disorder beliefs are true).
This warrants a diagnosis of the relevant
obsessive-compulsive or related disorder, rather
than a schizophrenia spectrum and other
psychotic disorder.

19. OCD and Related Disorders
Specifiers listed for each OCD disorder
-Specifier “with poor insight” in DSM- IV has
been expanded in DSM- 5
-New Specifiers are
- “with good or fair insight”
- “with poor insight”
- “with absent insight/delusional beliefs”
Intent of these specifiers is to improve
differential diagnoses

20. Body dysmorphic disorder
“with muscle dysmorphia” specifier has been
added to reflect a growing literature on the
diagnosis.
The delusional variant of body dysmorphic
disorder (is no longer coded as both delusional
disorder, somatic type, and body dysmorphic
disorder; in DSM-5 this presentation is designated
only as body dysmorphic disorder with the absent
insight/delusional beliefs specifier.

21. DSM-5 includes new categories for
substance-/medication-induced obsessivecompulsive and related disorder and
 for obsessive-compulsive and related
disorder due to another medical condition.

22. Other Specified and Unspecified
Obsessive-Compulsive and Related
Disorders
DSM-5 includes conditions in this chapter such as
Body-focused repetitive behavior disorder
- other than excoriation and trichotillomania
i.e. nail biting, lip chewing
Obsessional jealousy

23. Truama and Stress related disorder
Qualifying traumatic events were experienced
directly, witnessed, or experienced indirectly.
individuals may meet diagnostic criteria in DSM-5
for acute stress disorder if they exhibit any 9 of 14
listed symptoms in these categories: intrusion,
negative mood, dissociaition, avoidance, and
arousal.

24. Trauma- and Stressor-Related
Disorders
New chapter in DSM-5 brings together anxiety
disorders that are preceded by a distressing or
traumatic event
Reactive Attachment Disorder
Disinhibited Social Engagement Disorder
(new)
PTSD (includes PTSD for children
6 years and younger)
Acute Stress Disorder
Adjustment Disorders

25. Trauma- and Stressor-Related
Disorders
Disinhibited Social Engagement Disorder
“The essential feature of disorder is a pattern of
behavior that involves culturally inappropriate,
overly familiar behavior with relative strangers.
This behavior violates the social boundaries of the
culture.” DSM-5, p. 269

26. Trauma- and Stressor-Related
Disorders
Acute Stress Disorder
-Stressor criterion in DSM -5 is changed
-Criterion requires being explicit whether qualifying
traumatic events were experienced directly,
witnessed, or experienced indirectly.
-DSM-IV Criterion A2 regarding reaction to the
event- “the person’s response involved intense fear,
helplessness, or horror” –
has been eliminated

27. Trauma- and Stressor-Related
Disorders
Adjustment Disorders -DSM-5
Adjustment Disorders are redefined as an array of
stress-response syndromes occurring after exposure
to a distressing event.
Adjustment Disorder subtypes are unchanged
- with depressed mood
- with anxiety
- with disturbance of conduct

28. PTSD
Postraumatic stress disorder is now
developmentally sensitive in that diagnostic
thresholds have been lowered for children and
adolescents and separate criteria have been
added for children age 6 years or younger.

29. Trauma- and Stressor-Related
Disorders
Changes in PTSD Criteria
Four symptom clusters, rather than three
-Re-experiencing
-Avoidance
-Persistent negative alterations in
mood and cognition
-Arousal: describes behavioral symptoms

30. Trauma- and Stressor-Related
Disorders
Changes in PTSD Criteria
DSM-5 more clearly defines what constitutes a
traumatic event
Sexual assault is specifically included
Recurring exposure, that could apply to first
responders

31. Trauma- and Stressor-Related
Disorders
Changes in PTSD Criteria
Recognition of PTSD in Young children
Developmentally sensitive:
Criteria have been modified for children age
6 years and younger
Thresholds – number of symptoms in each
cluster - have been lowered

32. Exploration of Delayed-Onset
Posttraumatic Stress Disorder After
Severe Injury
 Approximately half of the patients with delayedonset PTSD had minimal PTSD symptoms at 3
months; therefore, their delayed-onset PTSD
could not be accounted for by a small number of
fluctuating symptoms. As we move toward DSMV, it is important that research continues to
explore the factors that underpin the development
of delayed-onset PTSD.
(O’Donnell et al,Psychosom Med, Jan 2013; 75:
68 - 75)