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This is an intermediate-level course. After completing this course, mental health professionals will be able to:
The content in this Course is based on the most accurate information available to the author at the time of writing. The field of diagnostic psychopathology as reflected in the DSM-5 changes frequently and new information may emerge that supersedes these course materials (see psychiatry.org/dsm5). This course material will equip you with a basic understanding of the DSM-5 so as to facilitate your clinical utility. The course content is not assumed to cause any psychological reactions in the reader.
The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) continues a 60-year legacy as a standard reference for clinical practice in the mental health field. This practical, functional, and flexible guide is intended for use by trained clinicians in a wide diversity of contexts and facilitates a common language to communicate the essential characteristics of mental disorders manifest in their clients (DSM-5). When using the DSM-5, you will notice an expanded discussion of developmental and lifespan considerations; cultural issues; gender differences; integration of scientific findings from the latest research in genetics and neuroimaging; and enhanced use of course, descriptive, and severity specifiers for diagnostic precision (DSM-5). You will also notice a dimensional approach to diagnosis, consolidation, and restructuring of most mental disorders, a new definition of a mental disorder, and emerging assessments and monitoring tools so as to promote enhanced clinical case formulation.
The DSM-5 revision process began in 1999 with pre-planning white papers that addressed a research agenda for the DSM-5, age and gender considerations in psychiatric diagnosis, and cultural and spiritual issues that can affect diagnosis (see dsm5.org/about/Pages/Timeline.aspx). At that time, the American Psychiatric Association’s (APA) DSM-5 task force and work groups began critical discussion and extensive consumption of the scientific literature on mental disorders. According to Dr. John Oldman, a former APA president, the members of the work groups were not APA employees, were not paid by APA and were not under contract with APA. Their participation was strictly voluntary and based upon their interest in advancing the field of psychiatry and better serving patients.
Since initial publication in May 2013, the APA has made textual revisions to the DSM-5 that are promptly reflected in the electronic version (located at doi.org/10.1176/appi.books.9780890425596) with a corresponding rationale. Some of these revisions corrected undetected printing errors (e.g., spelling, grammatical, punctuation), corrected initial textual omissions, inconsistencies, and inaccuracies (e.g., sexual “violence” for posttraumatic stress disorder and sexual “violation” for acute stress disorder), updated changes to approved DSM-5 criteria and text (psychiatry.org/psychiatrists/practice/dsm/updates-to-dsm-5//updates-to-dsm-5-criteria-text), provided clarifying information based on user feedback (psychiatry.org/psychiatrists/practice/dsm/feedback-and-questions/provide-feedback), presented accepted proposal for changes (psychiatry.org/psychiatrists/practice/dsm/submit-proposals), and updated the ICD-10-CM codes (per the National Center for Health Statistics, a federal agency within the Centers for Disease Control and Prevention, oversees the International Statistical Classification of Diseases and Related Health Problems in the United States). Of particular interest may be learning more about the proposed addition of a new diagnosis, "prolonged grief disorder," to the depressive disorders chapter (to learn more, visit psychiatry.org/psychiatrists/practice/dsm/proposed-changes).
The revisions to this online course, Using the DSM-5: Try It, You'll Like It, provide you with quick access to these various textual changes to enhance your clinical practice, teaching, or research. (These changes are highlighted in the tables throughout this course.) Understanding and applying these changes is essential to differential diagnosis, cultural competency, and accurate clinical case formulation. Some of these important changes are reflected in the following disorders:
I have also provided expanded discussion of the appropriate use of “Other Specified” and “Unspecified” for all disorder categories.
Some clinicians may catastrophize by telling themselves, “The DSM-5 promotes the medicalization of normal life stressors and encourages people to use psychotropic medications instead of counseling to achieve mental health. I will no longer have a purpose as a clinician.” Other clinicians may over-generalize by thinking, “The DSM-5 lowers the diagnostic threshold on some disorders. Therefore, most of my clients will never be able to overcome their struggles.” Some clinicians may entertain all-or-nothing thinking, for example, “APA’s DSM-5 task force and work groups did not include clinicians, so I do not need to use this book in my counseling practice.” Mental filtering may be displayed in some clinicians who think, “The DSM-5 field trials were rushed and unreliable. Therefore, the entire book is flawed.” Other clinicians may jump to conclusions by telling themselves, “Money-driven pharmaceutical companies influenced the DSM-5 revision process.” Finally, some clinicians may experience magnification by claiming, “The DSM-5 revision process was sloppy, rushed, and biased.”
My suggestion to clinicians of all specialties is to brush up on their cognitive disputation skills as proposed by Albert Ellis and Aaron Beck. The DSM-5 is here, and it is not the end of the world.
In the DSM-5, the multiaxial system of previous editions is eliminated (to avoid compartmentalized or disconnected client conceptualization), and chapters are now arranged according to a lifespan or developmental approach (which aligns with major psychotherapy ethical standards requiring developmental and cultural sensitivity). Disorders affecting children appear first, and those more common in older individuals appear later. The intention throughout is to group disorders that are similar to one another across a range of validators, including symptoms; neurobiological substrates; familiarity; course of illness; and treatment response. With all of these changes, it is imperative that clinicians remember this mantra: The DSM-5 does not make diagnoses; clinicians, by systematically and objectively using standardized and non-standardized testing, specialized clinical assessment techniques, and case conceptualization procedures, make diagnoses that are developmentally and culturally sensitive.
Let me repeat: You determine a diagnosis, not the DSM-5. Keep in mind these words from the DSM-IV-TR: “The specific diagnostic criteria included in the DSM-IV are meant to serve as guidelines to be informed by clinical judgment and are not meant to be used in a cookbook fashion” (emphasis added). Furthermore, “a common misconception is that a classification of mental disorders classifies people, when actually what are being classified are disorders that people have.”(p. xxii). These principles help clinicians to promote client social justice, or equity for all people and groups, by being mindful of the historical and social prejudices in the diagnosis of pathology.
Individuals taking this course are encouraged to have their DSM-5 available for reference, in particular, the following:
To appreciate the rationale for the DSM-5 changes, you are encouraged to review the DSM-IV-TR discussion on limitations to the categorical approach (APA, 2000, pp. xxxi-xxxii) and the nonaxial format (p. 37). This sequencing of study will help you use the manual as intended and avoid making unintentional diagnostic errors via gender bias, unfair discrimination, microaggressions, and subtle personal value imposition.
As you use the DSM-5, you will also learn about the new clustering of disorders presented in a framework of “internalizing” factors (anxiety, depression, and somatic symptoms) and “externalizing” factors (impulsive, disruptive, and addictive symptoms) that influence clinical formulation. You will understand the new developmental and lifespan considerations that organize disorders in a framework beginning with those that occur in early life (neurodevelopmental and schizophrenia spectrum and other psychotic disorders). This is followed by disorders that occur in adolescence and young adulthood (depressive, bipolar, and anxiety disorders) and ends with diagnoses more relevant to adulthood and later life (personality disorders and neurocognitive disorders).
Moving to the next chapter in the DSM-5, Use of the Manual, you will learn about important guidelines to approach clinical case formulation. This chapter discusses the need to obtain a “careful clinical client history and concise summary” surrounding client biopsychosocial factors. This chapter also provides the new definition of “mental disorder” that focuses on clinically significant disturbances, developmental processes, culturally approved responses, and socially deviant behavior (DSM-5, p. 20). This definition links disorders and broadens their conceptualization based on common neurocircuitry, genetic vulnerability, and environmental exposures. With this new definition, the DSM-5 encourages you to use “clinical utility” to help determine client prognosis, develop sensitive treatment plans, and measure treatment outcomes. Those familiar with the DSM-IV-TR will find additional discussion on the greatly expanded elements of a diagnosis (there are more than 130 from which to choose), such as severity specifiers, descriptive specifiers, and course specifiers. Subtypes are used in the DSM-5 as a method to communicate mutually exclusive symptom presentations. You will still list the principal diagnosis first and use provisional diagnosis to indicate diagnostic uncertainty.
I also strongly encourage you to read the descriptive text that accompanies each disorder. The text of DSM-5 provides information about each disorder under the following headings:
In reading each of these aspects related to a disorder, you will become more adept at using the DSM-5 and display advanced clinical formulation skills. It is also advisable to carefully read each coding Note as well as coding and reporting procedures for each disorder. Remember that the DSM-5 is intended to serve as a practical, functional, and flexible guide for organizing information that can aid in the accurate diagnosis and treatment of mental disorders. The overarching goal of the DSM-5 is to promote diagnostic specificity, treatment sensitivity, and case formulation.
I encourage you to recognize the limitations of using the DSM-5 in forensic settings. The manual is not designed for “nonclinical professionals” and it does not meet the technical needs of the courts and legal professionals (DSM-5, p. 25). When using the DSM-5, it is not sufficient to check off the symptoms in the Diagnostic Criteria Set to make a diagnosis. Proper use of the manual requires clinical training to recognize when there is clear evidence that the client’s cognitive, emotional, behavioral, and physiological symptoms are associated with clinically significant distress or interfere with or reduce the quality of, social, academic, or occupational functioning.
A new and important change is the DSM-5’s use of “dimensional” rather than multiaxial assessment (DSM-5 pp. 12-13), in which the DSM-5 combines the first three DSM-IV-TR axes. The DSM-IV-TR provided us an important reminder that “the multiaxial distinction among Axis I, Axis II, and Axis III disorders does not imply that there are fundamental differences in their conceptualization, that mental disorders are unrelated to physical or biological factors or processes, or that general medical conditions are unrelated to behavioral or psychosocial factors or processes.” Unfortunately, too many professionals using the DSM-IV-TR developed an artificial culture of diagnostic hierarchy that stifled clinical utility. As such, and to align with the World Health Organization’s (WHO) International Classification of Diseases (ICD), the DSM-5 replaces the axis concept with a dimensional concept when communicating disorders to other professionals and third-party payers (DSM-5, pp. 16-17).
To assist with more personalized clinical formulations, DSM-5 includes over 130 Other Conditions That May Be a Focus of Clinical Attention (traditionally called “V-codes) on pages 715-727. These conditions and problems are not mental disorders; however, “their inclusion in DSM-5 is meant to draw attention to the scope of additional issues that may be encountered in routine clinical practice and to provide a systematic listing that may be useful to clinicians in documenting these issues” (DSM-5, p. 715). Some of these newly recordable conditions include:
In DSM-5, use of the Global Assessment of Functioning (GAF) scale, representing the clinician's judgment of the individual’s overall level of functioning was discontinued for “several reasons, including its conceptual lack of clarity (i.e., including symptoms, suicide risk, and disabilities in its descriptors) and questionable psychometrics in routine practice” (DSM-5, p. 16). The recommended GAF replacement is the World Health Organization’s Disability Assessment Schedule (WHODAS). The WHODAS was developed through a collaborative international approach with the aim of developing a single generic instrument for assessing health status and functional impairment across different cultures and settings. This psychometrically established measure covers six domains:
You can learn more about the background and appropriate use of the WHODAS by reading pages 745-748 of the DSM-5 (Section III: Emerging Measures and Models), by visiting the WHO website (who.int/classifications/icf/whodasii/en/), and by visiting the DSM-5 website (psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM5_WHODAS-2-Self-Administered.pdf).
Using the DSM-5 nonaxial format (recording as many coexisting mental disorders, general medical conditions, and other factors as are relevant to the care and treatment of the individual) a potential clinical formulation may look as follows:
F34.1 Persistent Depressive Disorder (Dysthymia), With limited-symptom panic attacks, In partial remission, Early onset, with pure dysthymic syndrome, Moderate (principal diagnosis)
Z56.82 Problem Related to Current Military Deployment Status
F10.20 Moderate Alcohol Use Disorder
Moderate-mild functional impairment (87 per self-administered WHODAS 2.0)
F02.80 Possible Mild Neurocognitive Disorder Due to Traumatic Brain Injury (per I.E.D.), Without behavioral disturbance (provisional)
F60.89 Other Specified Personality Disorder (mixed personality features - dependent and avoidant symptoms)
K50.9 Crohn’s Disease Unspecified (per patient self-report)
Some additional reminders that I offer:
Diagnoses
Disorders
Emerging assessment measures are to be administered at the initial interview and used to monitor treatment progress, thus serving to advance the use of initial symptomatic status and reported outcome information (DSM-5). The DSM-5 cross-cutting symptom measures aid in a comprehensive assessment by drawing attention to clinical symptoms that “cut-across” disorder boundaries. Sleep disturbance is an example of a cross-cutting symptom as it is found in depressive disorders, bipolar disorders, anxiety disorders, and trauma-related disorders. More specifically,
Depression/Anxiety
- Initial insomnia (i.e., difficulty falling asleep)
- Middle insomnia (i.e., waking up during the night and having difficulty returning to sleep)
- Terminal insomnia (i.e., waking too early and being unable to return to sleep)
- Hypersomnia (non-restorative) (e.g., prolonged sleep episodes at night or increased daytime sleep – 10+ hours)
Mania/Hypomania
- Hyposomnia (restorative) (e.g., awakens several hours earlier than usual, feeling full of energy)
Cross-cutting assessments are not specific to any particular disorder; rather, they evaluate symptoms of high importance to nearly all clients in most clinical settings. According to Jones (2012):
The assessments are called crosscutting because they cut across the boundaries of any single disorder and represent symptoms commonly seen in clinical practices, regardless of a client’s subsequent diagnosis. They are designed to be administered to all clients at the initial evaluation to establish a baseline and on follow-up visits to monitor progress. (p. 483)
Cross-cutting measures have two levels.
Level 1 Measures offer a brief screening of 13 domains for adults (i.e., depression, anger, mania, anxiety, somatic symptoms, suicidal ideation, psychosis, sleep problems, memory, repetitive thoughts and behaviors, dissociation, personality functioning, and substance use) and 12 domains for children and adolescents (i.e., depression, anger, irritability, mania, anxiety, somatic symptoms, inattention, suicidal ideation/attempt, psychosis, sleep disturbance, repetitive thoughts and behaviors, and substance use).
Level 2 Measures provide a more in-depth assessment of elevated Level 1 domains to facilitate differential diagnosis and determine the severity of symptom manifestation. The DSM-5 disorder-specific severity measures correspond closely to the criteria that constitute the disorder definition and are intended to help identify additional areas of inquiry that may guide treatment and prognosis (DSM-5; Jones, 2012).
You can access these no-cost assessment measures at psychiatry.org/psychiatrists/practice/dsm/dsm-5/online-assessment-measures. The DSM-5 provides you with further information on the background and reasoning for the use of these emerging measures in clinical practice (DSM-5, pp. 733-748). I strongly recommend reading “Dimensional and Cross-Cutting Assessment in the DSM-5,” (Jones, 2012). Jones aptly discusses the problems with the DSM-IV-TR classification system, the excessive use of co-occurring disorders, and the excessive use of not otherwise specified categories, while providing a better understanding of the new DSM-5 dimensional and cross-cutting assessment procedures and their implications for clinical utility and user acceptability.
The official coding system in use in the United States as of the publication of the DSM-5 was the World Health Organization’s International Classification of Diseases (ICD) ICD-9-Clinical Modification (CM). Official implementation of the ICD-10-CM in the United States occurred October 1, 2015, and the strictly “numerical” codes (e.g., 291.89), which are shown parenthetically in the DSM-5, should no longer be used because all ICD-10-CM codes are “alpha-numeric” (e.g., F10.14). Both ICD-9-CM and ICD-10-CM codes are listed 1) preceding the name of the disorder in the classification and 2) accompanying the criteria set for each disorder. For some diagnoses (e.g., neurocognitive and substance/medication-induced disorders), the appropriate code depends on further specification and is listed within the criteria set for the disorder, as coding notes, and in some cases, further clarified in a section on recording procedures. The names of some disorders are followed by alternative terms enclosed in parentheses, which, in most cases, were the DSM-IV-TR names for the disorders. Contrary to common understanding, there are no DSM codes - all diagnostic codes listed in DSM since 1952 are ICD codes. In my opinion, DSM is a user’s manual for the ICD coding system.
This chapter in the DSM-5 represents the most substantial changes in all of the manual. Many of the disorders from the previously titled DSM-IV-TR chapter on disorders usually first diagnosed in infancy, childhood, or adolescence are relocated, reconceptualized, or removed. The neurodevelopmental disorders are reorganized based on shared symptoms, shared genetic and environmental risk factors, and shared neural substrates. They are also reorganized to stimulate new clinical perspectives and cross-cutting factor research, to align with developmental and lifespan considerations, and to harmonize with the ICD.
Following are some specific changes in location in the DSM-5:
One of the most important DSM-5 additions in this chapter is that “the neurodevelopmental disorders may include the specifier ‘associated with a known medical or genetic condition or environmental factor.” This specifier gives you an opportunity to document factors that may have played a role in the etiology of the disorder, as well as those that might affect the clinical course. Examples include genetic disorders, such as fragile X syndrome, tuberous sclerosis, and Rett syndrome; medical conditions such as epilepsy; and environmental factors, including very low birth weight and fetal alcohol exposure” (DSM-5, pp. 32-33).
May 2013 Publication |
Effective October 2016 |
Diagnostic Features Criterion A refers to intellectual functions that involve reasoning, problem solving, planning, abstract thinking, judgment, learning from instruction and experience, and practical understanding.
…Individuals with intellectual disability have scores of approximately two standard deviations or more below the population mean, including a margin for measurement error (generally ± 5 points). [see DSM-5, p. 37] |
Diagnostic Features Criterion A refers to intellectual functions that involve reasoning, problem solving, planning, abstract thinking, judgment, learning from instruction and experience, and practical understanding (Evans 2008; Gottfredson 1997; Harris 2006; King and Kitchner 2002; Margolis 1987; Schalock 2011; World Health Organization 2011). …Individuals with intellectual disability have scores of approximately two standard deviations or more below the population mean, including a margin for measurement error (generally ± 5 points). [see DSM-5, p. 37] |
This is the new name for DSM-IV-TR mental retardation. The title intellectual disability parallels with ICD’s use of intellectual developmental disorder and is the preferred term used by the American Association on Intellectual and Developmental Disabilities (AAIDD). “Moreover, a federal statute in the United States (Public Law 111-256, “Rosa’s Law”) replaces the term mental retardation with intellectual disability, and research journals use the term intellectual disability. Thus, intellectual disability is the term in common use by medical, educational, and other professions and by the lay public and advocacy groups.” (DSM-5, p. 33)
Because IQ measures are less valid in the lower end of the IQ range and “problems in adaptation are more likely to improve with remedial efforts than is the cognitive IQ, which tends to remain a more stable attribute” (DSM-IV-TR, p. 42), the DSM-5 changes the previous requirement that IQ score solely determines the severity rating for this disorder. Now, you determine severity rating (i.e., mild, moderate, severe, profound) by using both clinical evaluation and individualized, culturally appropriate, psychometrically sound measures to assess the individual’s conceptual functioning (academic skills), social functioning (social judgment), and practical functioning (self-management of behavior) as listed in the DSM-5 Table 1 Severity levels for intellectual disability (intellectual developmental disorder) located on pages 34-36. DSM-IV-TR mental retardation, severity unspecified becomes the DSM-5 unspecified intellectual disability (intellectual developmental disorder).
The DSM-5 changes include:
This new DSM-5 disorder is reserved for individuals under the age of five years who are unable to complete systematic assessments of intellectual functioning and it requires reassessment after a period of time; as such, no formal criteria are provided.
In the DSM-5, this disorder combines DSM-IV-TR expressive language disorder and mixed receptive-expressive language disorder, with completely reconceptualized criteria. “The core diagnostic features of language disorder are difficulties in the acquisition and use of language due to deficits in the comprehension or production of vocabulary, sentence structure, and discourse. The language deficits are evident in spoken communication, written communication, or sign language” (DSM-5, p. 42).
This is the new name for DSM-IV-TR’s phonological disorder. You are encouraged to read diagnostic criteria as it is completely reconceptualized to focus on children that experience difficulty with phonological knowledge of speech sounds or the ability to coordinate movements for speech in varying degrees.
The DSM-5 changes include:
Also referred to as pragmatic language impairment in the scientific literature, this new DSM-5 disorder classifies persistent difficulties in the social uses of verbal and nonverbal communication in children typically over age five. This condition is distinct from language and speech disorders, as syntax, articulation, pronunciation, and fluency are intact. Key diagnostic symptoms include marked and persistent deficits in the following areas:
Social (pragmatic) communication disorder is mutually exclusive with autism spectrum disorder and cannot be diagnosed in the presence of restricted repetitive behaviors, interests, and activities (the other component of autism spectrum disorder). The symptoms of some individuals diagnosed with DSM-IV-TR pervasive developmental disorder not otherwise specified may meet the DSM-5 criteria for social (pragmatic) communication disorder (research estimates up to 9%).
You are encouraged to watch this video youtu.be/Dk9kULgUkSQ from Dr. Courtenay Norbury, Professor in the Department of Psychology - Adult and Child Cognition at Royal Holloway, University of London, to learn more about the symptoms associated with Social (Pragmatic) Communication Disorder. |
Unspecified Communication Disorder This category applies to presentations in which symptoms characteristic of communication disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for communication disorder or for any of the disorders in the neurodevelopmental disorders diagnostic class.
May 2013 Publication |
Effective August 2015 |
Diagnostic Criteria
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Diagnostic Criteria
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As early as 1993, authors and researchers have referred to the various pervasive developmental disorders as an autism spectrum disorder (Rutter & Schopler, 1992; Shuster, 2012; Tanguay, Robertson, & Derrick, 1998). They have also called for use of a dimensional classification, rather than the categorical classification used in DSM-IV and DSM-IV-TR (Kamp-Becker et al., 2010). Unlike the dichotomous approach of the DSM-IV-TR categorical model, the dimensional approach uses three or more rating scales to measure severity, intensity, frequency, duration, or other characteristics of given diagnoses (Jones, 2012). The consensus in the research community for a spectrum classification is clearly demonstrated, in that 95% of publications in the past five years have used the term “autism spectrum disorder.” Hence, the DSM-5 uses the term spectrum and further informs clinicians that “autism spectrum disorder encompasses disorders previously referred to as early infantile autism, childhood autism, Kanner’s autism, high-functioning autism, atypical autism, pervasive developmental disorder not otherwise specified, childhood disintegrative disorder, and Asperger’s disorder” (DSM-5, p. 53). Consolidating the use of these dichotomous autism-based titles into a spectrum designation helps to avoid diagnostic confusion and to minimize fragmented treatment planning.
Based on factor structure models, the DSM-5 presents a major reconceptualization and reorganization of the DSM-IV-TR autistic disorder symptomatology (Guthrie, Swineford, Wetherby, & Lord, 2013). This new spectrum, or dimensional classification, helps you to properly assess:
This reconceptualization of autism in the DSM-5 provides you with a denser diagnostic cluster to reduce the excessive application of the DSM-IV-TR pervasive developmental disorder not otherwise specified classification that resulted in overdiagnosis and troubling prevalence rates (Maenner et al., 2014). According to Guthrie et al. (2013) in their article, Comparison of DSM-IV and DSM-5 factor structure models for toddlers with an autism spectrum disorder, the DSM-5 model was a better fit to the data than were the other models used during toddler assessment. Among the changes included in the DSM-5 and supported by their study:
The DSM-5 further recognizes autism due to Rett syndrome, Fragile X syndrome, Down syndrome, epilepsy, valproate, fetal alcohol syndrome or very low birth weight through the use of the specifier associated with a known medical or genetic condition or environmental factor. You also may use the specifiers with or without accompanying intellectual impairment and with or without accompanying language impairment. Examples of descriptive specifier usage include with accompanying language impairment – no intelligible speech or with accompanying language impairment – phrase speech. If catatonia is present, you record that separately as catatonia associated with an autism spectrum disorder.
Severity, or intensity of symptoms, for autism spectrum disorder are now communicated on three levels:
The level of interference in functioning and support required is communicated by using the DSM-5 Clinician-Rated Severity of Autism Spectrum and Social Communication Disorders scale (DSM-5, p. 52).
Examples of mild rating in the social communication psychopathological domain may include:
(a) Without supports in place, deficits in social communication cause noticeable impairments. (b) Has difficulty initiating social interactions and demonstrates clear examples of atypical or unsuccessful responses to social overtures of others. (c) May appear to have decreased interest in social interactions.
Examples of mild rating in the restricted interests and repetitive behaviors psychopathological domain may include:
a) Rituals and repetitive behaviors (RRBs) cause significant interference with functioning in one or more contexts. b) Resists attempts by others to interrupt RRBs or to be redirected from fixated interest.
Examples of moderate rating in the social communication psychopathological domain may include:
a) Marked deficits in verbal and nonverbal social communication skills b) Social impairments apparent even with supports in place c) Limited initiation of social interactions d) Reduced or abnormal response to social overtures from others
Examples of moderate rating in the restricted interests and repetitive behaviors psychopathological domain may include:
a) RRBs and/or preoccupations and/or fixated interests appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts b) Distress or frustration is apparent when RRBs are interrupted; difficult to redirect from fixated interest
Examples of severe rating in the social communication psychopathological domain may include:
a) Severe deficits in verbal and nonverbal social communication skills cause severe impairments in functioning b) Very limited initiation of social interactions and minimal response to social overtures from others.
Examples of severe rating in the restricted interests and repetitive behaviors psychopathological domain may include:
a) Preoccupations, fixed rituals and/or repetitive behaviors markedly interfere with functioning in all spheres b) Marked distress when rituals or routines are interrupted; very difficult to redirect from fixated interest or returns to it quickly
Note: I advise you to review Table 2 Severity Levels for Autism Spectrum Disorder displayed in the DSM-5 (p. 52).
Remember that individuals with one of these well-established DSM-IV-TR pervasive developmental disorders should be given the diagnosis of autism spectrum disorder. “Standardized behavioral diagnostic instruments with good psychometric properties, including caregiver interviews, questionnaires and clinician observation measures, are available and can improve reliability of diagnosis over time and across clinicians” (DSM-5, p. 55). For a discussion as to the role of clinicians during prediagnosis and postdiagnosis of ASD, read Christina Mann Layne’s 2007 article “Early Identification of Autism: Implications for Clinicians.”
Turygin and colleagues (2013) found no significant differences were observed between the DSM-5 and DSM-IV-TR groups with respect to composite and subscale scores on the externalizing, behavior severity index and adaptive behavior domains of the Behavior Assessment System for Children, 2nd Ed.
Huerta and colleagues (2012) found that based on just parent data, the proposed DSM-5 criteria identified 91% of children with clinical DSM-IV-TR PDD diagnoses. Sensitivity remained high in specific subgroups, including girls and children under 4. The specificity of the DSM-5 ASD was 0.53 overall, while the specificity of DSM-IV-TR ranged from 0.24, for clinically diagnosed PDD-NOS, to 0.53, for autistic disorder.
Mazefsky and colleagues (2013) found that utilizing combined Autism Diagnostic Observation Schedule & Autism Diagnostic Interview-Revised (ADOS/ADI-R) data, 93% of participants met the DSM-5 criteria.
Reszka and colleagues (2013) found that while the Childhood Autism Rating Scale, ADOS, and Social Responsiveness Scale-T/P are reliable and valid measures, there is some disagreement between measures with regard to child classification and the categorization of autism symptom severity.
Walter, a 22-year-old male, was referred to counseling by the State Office of Rehabilitation for career and vocational assistance, with a special focus on his mental health needs and confirming the presence of his previous diagnosis of Asperger’s disorder given in 2004. Clinicians working with adults presenting with autism spectrum symptoms will appreciate the DSM-5’s new adult textual narrative. Some of these additions help to understand adults, such as Walter, who:
- Must show symptoms from early childhood and be persistent and across multiple contexts
- Display difficulties processing and responding to complex social cues
- Suffer from the anxiety of consciously calculating what is socially intuitive for other adults
- Express difficulty in coordinating nonverbal communication with speech
- Struggle to understand what behavior is considered appropriate in one situation but not another
- Learn to suppress repetitive behavior in public
Following assessment procedures outlined in the DSM-5 to use “standardized behavioral diagnostic instruments with good psychometric properties, including caregiver interviews, questionnaires, and clinician observation measures” (DSM-5, p. 55) and by Jones (2010), clinical assessment of Walter included the following:
Biopsychosocial clinical interview of Walter with his mother, as an additional informant.
Level 1 Cross-Cutting Symptom Measure (see DSM-5 pp. 733-744). The Clinician-Rated Severity of Autism Spectrum and Social Communication Disorders (see DSM-5, p. 52).
Historical evaluations (prior psychological testing results).
Collateral reports from the referring vocational rehabilitation clinician.
Simon Baron-Cohen’s Autism Spectrum Quotient (Baron-Cohen, Wheelwright, Skinner, Martin, & Clubley, 2001; Ketelaars et al., 2008).
Adhering to the DSM-5 dimensional rather than DSM-IV-TR multiaxial classification (Jones 2012), I diagnosed Walter using this format:
F84.0 Autism Spectrum Disorder
Requiring Substantial Support for Social Communication and Social Interaction (Level 2 Moderate)
Requiring Support for Restricted Repetitive Behaviors, Interests and Activities (Level 1 Mild)
Without Accompanying Intellectual Impairment
Without Accompanying Language Impairment
Without Catatonia
Notice the diagnostic precision offered by the DSM-5 in comparison with Walter’s non-descriptive diagnosis using the DSM-IV-TR formulation:
Asperger’s Disorder (APA, 2000).
In contrast, the severity ratings for autism spectrum disorder are listed independently for social communication and restricted repetitive behaviors, rather than providing a global rating for both psychopathological domains (per the DSM-5, they are listed from most severe to least severe).
For Walter, his moderate severity rating of requiring substantial support for social communication means: “Marked deficits in verbal and nonverbal social communication skills; social impairments apparent even with supports in place; limited initiation of social interactions; and reduced or abnormal responses to social overtures from others” (DSM-5, p. 52). His mild severity rating of requiring support for restricted repetitive behaviors (RRBs) means: “Inflexibility of behavior causes significant interference in one or more contexts. Difficulty switching between activities. Problems of organization and planning hamper independence” (DSM-5, p. 52). The diagnostic formulation offered to you in the DSM-5 provides a richer contextual description of the client to support more personalized treatment planning. This attention to dimensional ratings and individualized treatment strategies is also captured in the newly conceptualized schizophrenia spectrum disorders.
ADHD is now classified in the DSM-5 as a neurodevelopmental disorder, whereas it was classified in the DSM-IV-TR as a disruptive behavior disorder. It is important to note that as early as 1999, the counseling literature has conceptualized ADHD as a neurodevelopmental disorder (Pollak, Levy, & Breitholtz, 1999). The DSM-5 uses the same DSM-IV-TR 18 symptoms that are divided into two symptom domains (inattention and hyperactivity/impulsivity), of which at least six symptoms in one domain are required for diagnosis. However, for older adolescents and adults (age 17 and older), only five symptoms are required both for inattention and for hyperactivity and impulsivity.
Compared to the DSM-IV-TR, new examples embedded in DSM-5’s symptom criteria include the following:
Additional DSM-5 changes include:
Use this category in situations in which you choose to communicate the specific reason that the presentation does not meet the criteria for attention-deficit/hyperactivity disorder or any specific neurodevelopmental disorder. This is done by recording “other specified attention-deficit/hyperactivity disorder” followed by the specific reason (e.g., “with insufficient inattention symptoms”).
The DSM-5 combines the DSM-IV-TR diagnoses of reading disorder, mathematics disorder, disorder of written expression, and learning disorder not otherwise specified. The new diagnostic criteria are to be met based on a clinical synthesis of the individual’s history (developmental, medical, family, educational), school reports, and psychoeducational assessment. The DSM-5 also acknowledges that specific types of reading deficits are described internationally in various ways as dyslexia and specific types of mathematics deficits as dyscalculia.
Because learning deficits in the areas of reading, written expression, and mathematics commonly occur together, coded specifiers for the deficit types in each area are included and you are to specify all academic domains and subskills that are impaired. For example, using the DSM-5, you would communicate the diagnosis as follows: specific learning disorder with impairment in reading, with impairment in reading rate or fluency, and impairment in reading comprehension.
Severity specifiers are new for this disorder, and include:
Mild (e.g., may be able to compensate or function well when provided with appropriate accommodations or support services, especially during the school years),
Moderate (e.g., unlikely to become proficient without some intervals of intensive and specialized teaching during the school years), and
Severe (e.g., unlikely to learn skills without ongoing intensive individualized and specialized teaching for most of the school years).
Finally, the DSM-5 added “…despite the provision of interventions that target those difficulties” to Criterion A. The provision of interventions is commonly referred to as responsiveness to intervention (RTI). You are encouraged to read “Identification of Learning Disabilities: Implications of Proposed DSM-5 Criteria for School-Based Assessment” (Cavendish, 2012)
The DSM-5 significantly changes the diagnostic criteria; therefore, you are encouraged to read this chapter to become acquainted with these modifications.
Because the onset of symptoms is in the early developmental period, the DSM-5 diagnostic criteria language is significantly revised to promote a developmentally accurate and culturally sensitive diagnosis. For example, the language used for Criterion A in the DSM-IV-TR, “Performance in daily activities that requires…and measured intelligence. This may be manifested by marked delays in achieving motor milestones…” is changed in the DSM-5 to “The acquisition and execution of…and opportunity for skill learning and use…as well as slowness and inaccuracy of performance of motor skills.” For Criterion B, DSM-5 added the following language: “motor skills deficit… and persistently… appropriate to chronological age… and impacts academic/school productivity, prevocational and vocational activities, leisure, and play.” To reduce social stigma or diagnostic prejudice, the DSM-5 removed the previously used DSM-IV-TR language “mental retardation.”
The DSM-5 changes include:
Tic disorders comprise four diagnostic categories: Tourette’s disorder, persistent (chronic) motor or vocal tic disorder, provisional tic disorder, and other specified and unspecified tic disorders.
The DSM-5 changes include:
The DSM-5 changes include:
The DSM-5 changes include:
The other specified tic disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for a tic disorder or any specific neurodevelopmental disorder. This is done by recording “other specified tic disorder” followed by the specific reason (e.g., “with onset after age 18 years”).
Use this category for situations in which symptoms characteristic of a tic disorder cause clinically significant distress or impairment in social, occupational, or other important areas of functioning, but do not meet the full criteria for any of the disorders listed in this diagnostic classification (chapter), and you are not able to specify because there is insufficient information to make a more specific diagnosis.
The other specified neurodevelopmental disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific neurodevelopmental disorder. This is done by recording “other specified neurodevelopmental disorder” followed by the specific reason (e.g., “neurodevelopmental disorder associated with prenatal alcohol exposure”).
In 2013, Cosgrove and Suppes published “Informing DSM-5: Biological boundaries between bipolar I disorder, schizoaffective disorder and schizophrenia”. For the DSM-5, existing nosological boundaries between bipolar disorder and schizophrenia were retained. In addition, schizoaffective disorder was preserved as an independent diagnosis because the biological data are not yet compelling enough to justify a move to a more neurodevelopmentally continuous model of psychosis. The authors also noted that family studies suggest a clear genetic link between all three disorders. Most important, hallucinations and delusions are typically considered the hallmark of schizophrenia, but mood fluctuations are central to bipolar disorder.
Although bipolar mood episodes may have an inherent episodic rhythm, all three disorders can be chronic, lifelong conditions that cause significant functional impairment. Yet the symptoms of bipolar disorder, but not schizophrenia, are often responsive to mood-stabilizing medications such as lithium and other anticonvulsants. Because of this “top-down” effect in which antipsychotic medications are used to treat both schizophrenia and bipolar disorders, the DSM-5 lists bipolar-related disorders in sequence after schizophrenia disorders. In addition, schizoaffective disorder is listed as the final psychotic disorder in the schizophrenia spectrum disorders chapter because it serves as a bridge to the bipolar-related disorders chapter in the DSM-5.
Clients presenting with psychotic and schizophrenia spectrum disorders are challenging and diagnostically complex. To assist with these difficulties, the DSM-5 presents a new conceptualization to facilitate clinical utility and to streamline diagnostic formulations (Bruijnzeel & Tandon, 2011). Similar to autism, schizophrenia has been referenced as a spectrum disorder since 1995 (Kendler, Neale, & Walsh, 1995) and the DSM-5 marks the official recognition of this spectrum conceptualization by embedding the word in the diagnostic title. Essential to competent practice in this area is reading Key Features That Define the Psychotic Disorders on pages 87-88 of the DSM-5 (e.g., delusions, hallucinations, disorganized thinking, grossly disorganized or abnormal motor behavior, and negative symptoms). Further critical reading is the new Clinician-Rated Dimensions of Psychosis Symptom Severity (CRDPSS) on the DSM-5 pages 89-90. These pages describe the heterogeneity of psychotic disorders and the dimensional framework for the assessment of primary symptom severity within the psychotic disorders. This spectrum conceptualization differs from the DSM-IV-TR categorical and mutually exclusive diagnostic system that assumed “mental disorders are discrete entities, with relatively homogeneous populations that display similar symptoms and attributes of a disorder” (Jones, 2012, p. 481).
The new CRDPSS is used to understand the personal experience of the client, to promote individualized treatment planning, and to facilitate prognostic decision-making (Flanagan et al., 2012; Heckers et al. 2013). You can obtain the CRDPSS in the DSM-5, pages 742-744 or psychiatry.org/psychiatrists/practice/dsm/dsm-5/online-assessment-measures. The CRDPSS is an eight-item measure used to assess the severity of mental health symptoms that are important across psychotic disorders.
According to the DSM-5, proper use of the CRDPSS may include clinical neuropsychological assessment (especially of client cognitive functioning) to help guide diagnosis and treatment. Clinician “assessment of client cognition, depression and mania symptom domains can further assist with making critically important distinctions between the various schizophrenia spectrum and other psychotic disorders” (DSM-5, p. 98). To track changes in client symptom severity over time, the CRDPSS may be completed at regular intervals as clinically indicated, depending on the stability of client symptoms and treatment status. Consistently high scores on a particular domain may indicate significant and problematic areas for the client that might warrant further assessment (mental status examination), treatment (counseling and pharmacological), and follow-up (case management).
Cultural and socioeconomic factors must be considered during a client’s assessment and diagnostic process, including sensitivity to emotional expression, eye contact, body language, and visual or auditory hallucinations with a religious content. The DSM-5’s life span developmental focus informs you that in children, delusions and hallucinations may be less elaborate than in adults, while visual hallucinations are more common and should be distinguished from normal fantasy play. Overall, these changes should improve diagnosis and characterization of your clients with psychotic disorders, while facilitating measurement-based treatment and permitting a more precise future delineation of the schizophrenia spectrum and other psychotic disorders (for more information, see the 2013 article by Tandon et al., “Definition and description of schizophrenia in the DSM-5”).
You are encouraged to watch this video youtu.be/VR485DRyzAY to watch David Thompson and his associated psychotic symptoms, then to rate severity in all 8 domains using the DSM-5 Clinician-Rated Dimensions of Psychosis Symptom Severity. |
Criteria and text for schizotypal personality disorder can be found in the chapter “Personality Disorders.” Because this disorder is considered part of the schizophrenia spectrum of disorders, and is labeled in this section of ICD-9 and ICD-10 as schizotypal disorder, it is listed in this chapter and discussed in detail in the DSM-5 chapter “Personality Disorders.”
May 2013 Publication |
Effective August 2015 |
Subtypes …Most common is the belief that the individual emits a foul odor; that there is an infestation of insects on or in the skin; that there is an internal parasite; that certain parts of the body are misshapen or ugly; or that parts of the body are not functioning. [see DSM-5, p. 92] |
Subtypes …Most common is the belief that the individual emits a foul odor; that there is an infestation of insects on or in the skin; that there is an internal parasite; [see DSM-5, p. 92] |
In the DSM-5, delusional disorder is retained as listed in DSM-IV-TR, including its classic subtypes of erotomanic, grandiose, jealous, persecutory, and somatic. Criterion A for delusional disorder no longer requires delusions to be nonbizarre. A specifier for bizarre-type delusions provides continuity with the DSM-IV-TR. The demarcation of delusional disorder from psychotic variants of obsessive-compulsive disorder and body dysmorphic disorder is explicitly noted in the DSM-5 with a new exclusion criterion stating that the symptoms must not be better explained by these conditions.
The DSM-5 no longer separates delusional disorder from shared delusional disorder. If criteria are met for delusional disorder, then that diagnosis is made. If the diagnosis cannot be made but shared beliefs are present, then the diagnosis “other specified schizophrenia spectrum and other psychotic disorder” is used.
May 2013 Publication |
Effective August 2015 |
Specify if: With postpartum onset: [see DSM-5, p. 94] |
Specify if: With [see DSM-5, p. 94] |
The only change in the DSM-5 is to Criterion A that requires delusions, hallucinations, or disorganized speech as one of the two minimum symptoms. DSM-IV-TR specifiers are retained. Some textual updates occur that place emphasis on disorganized or catatonic behavior.
Schizophreniform disorder in the DSM-5 parallels the description in the DSM-IV-TR. Diagnostic precision for schizophrenia in the DSM-5 is communicated with new course specifiers that can be used after a one-year “duration of the disorder and if they are in contradiction to the diagnostic course criteria” (p. 99). These new course specifiers communicate a time period in which the symptom criteria are fulfilled (acute), a period of time during which an improvement after a previous episode is maintained and in which the defining criteria of the disorder are only partially fulfilled (partial remission), or a period of time after a previous episode during which no disorder-specific symptoms are present (full remission). You also can communicate these specifiers based on first episode, multiple episodes, continuous episodes, or unspecified. Use of these specifiers assists you to determine the intensity, frequency, and duration of clinical intervention services that are more person-centered.
Unlike the DSM-IV-TR, the DSM-5 does not contain the following exception clause to diagnose schizophrenia: “Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s behavior or thoughts, or two or more voices conversing with each other” (APA, 2000, p. 312). Removal of this language restricts classification to avoid excessive classification in nonclinical profiles and due to the nonspecificity of these symptoms and the poor reliability in distinguishing bizarre from nonbizarre delusions. With the DSM-5, the traditional five schizophrenia subtypes (catatonic, disorganized, paranoid, residual, and undifferentiated) are no longer used to specify psychotic presentations. This is because the DSM-5 represents a shift from categorical or dichotomous-oriented classification to dimensional or spectrum-oriented classification, such as previously discussed with use of the CRDPSS. Other reasons for removing the subtypes:
Catatonia (marked psychomotor disturbance such as unresponsiveness to agitation) is now a specifier that can be used outside of schizophrenia spectrum and other psychotic disorders, such as with neurodevelopmental disorders, bipolar disorders, depressive disorders, neurocognitive disorders, medical disorders, and as a side effect of some psychotropic medications. For clients to receive this specifier, three of 12 symptoms must be present (without a specific time duration or frequency).
Also new to the DSM-5 are descriptive and course specifiers applicable after 12 months to all schizophrenia spectrum and other psychotic disorders except for brief psychotic disorder (subsides after one month) and schizophreniform disorder (replaced with schizophrenia disorder after a duration of six months). These specifiers include the following:
Although the DSM-5 acknowledges that “there is growing evidence that schizoaffective disorder is not a distinct nosological category” (DSM-5, pp. 89-90; see also Malaspina et al., 2013), this disorder is retained, with some textual refinements added to more stringently define the clinical syndrome. These changes include the following:
Criterion B: “…lifetime duration of the illness.”
Criterion C: Major mood episode must be present for the “majority of the total duration for the active and residual portion of the illness” instead of the DSM-IV-TR’s focus on “substantial portion” for the active and residual portion of the illness.
According to the APA, the primary change to schizoaffective disorder is the requirement that a major mood episode be present for a majority of the disorder’s total duration after Criterion A is met. This change was made on both conceptual and psychometric grounds, making schizoaffective disorder a longitudinal instead of cross-sectional diagnosis (more comparable with schizophrenia, bipolar disorder, and major depressive disorder, which are bridged by this condition). The change was also made to improve the reliability, diagnostic stability and validity of the disorder, while recognizing that the characterization of clients with both psychotic and mood symptoms, either concurrently or at different points in their illness, is a clinical challenge.
May 2013 Publication |
Effective October 2018 |
Diagnostic Criteria Coding note: …Note that the ICD-10-CM code depends on whether or not there is a comorbid substance use disorder present for the same class of substance. [see DSM-5, p. 111] |
Diagnostic Criteria Coding note: …Note that the ICD-10-CM code depends on whether or not there is a comorbid substance use disorder present for the same class of substance.In any case, an additional separate diagnosis of a substance use disorder is not given… [see DSM-5, p. 111] |
No changes from DSM-IV-TR.
No changes from DSM-IV-TR.
This classification may be used when criteria are met for catatonia during the course of a neurodevelopmental, psychotic, bipolar, depressive, or other mental disorder. The catatonia specifier is appropriate when the clinical picture is characterized by marked psychomotor disturbance and involves at least three of the 12 diagnostic features listed in Criterion A:
Stupor (i.e., no psychomotor activity; not actively relating to the environment) |
Mannerism (i.e., odd, circumstantial caricature of normal actions) |
Catalepsy (i.e., passive induction of a posture held against gravity) |
Stereotypy (i.e., repetitive, abnormally frequent, non-goal-directed movements) |
Waxy flexibility (i.e., slight, even resistance to positioning by the examiner) |
Agitation (not influenced by external stimuli) |
Mutism (i.e., no, or very little, verbal response [exclude if known aphasia]) |
Grimacing (i.e., off and on inappropriate facial expressions unrelated to the situation) |
Negativism (i.e., opposition or no response to instructions or external stimuli) |
Echolalia (i.e., mimicking another’s speech) |
Posturing (i.e., spontaneous and active maintenance of a posture against gravity) |
Echopraxia (i.e., mimicking another’s movements) |
Use this classification when there is evidence from the history, physical examination, or laboratory findings that the disturbance is the direct pathophysiological consequence of another medical condition. This was listed as a catatonic disorder due to a general medical condition in DSM-IV-TR.
This category applies to presentations in which symptoms characteristic of catatonia cause clinically significant distress or impairment in social, occupational, or other important areas of functioning but either the nature of the underlying mental disorder or other medical condition is unclear, full criteria for catatonia are not met, or there is insufficient information to make a more specific diagnosis (e.g., in emergency room settings).
Use this category to communicate the specific reason that the presentation does not meet the criteria for any specific schizophrenia spectrum and other psychotic disorder. This is done by recording “other specified schizophrenia spectrum and other psychotic disorder” followed by the specific reason (e.g., “persistent auditory hallucinations”).Other examples include:
Delusions with significant overlapping mood episodes
Attenuated psychosis syndrome (also see DSM-5, pp. 783-786)
Delusional symptoms in partner of individual with delusional disorder
Read more about these culturally sensitive descriptions on page 122 in your DSM-5.
Unspecified Schizophrenia Spectrum and Other Psychotic Disorder
Use this category for situations in which symptoms characteristic of a schizophrenia spectrum and other psychotic disorder cause clinically significant distress or impairment in social, occupational, or other important areas of functioning, but do not meet the full criteria for any of the disorders listed in this diagnostic classification (chapter), and you are not able to specify because there is insufficient information to make a more specific diagnosis.
Ryan, a 22-year-old Caucasian male, presented with an extensive history of auditory hallucinations, and erotomanic and paranoid delusions. In the spirit of the DSM-5, he was administered the CRDPSS six times beginning with the onset of counseling and then at various counseling sessions during his treatment. Use of the CRDPSS promotes clinical utility. For example, Ryan is able to identify trends and patterns related to life stressors and symptom elevations and reductions. This level of clinical assessment provides a framework for targeted treatment planning and clinical intervention. Ryan also feels empowered over his mental illness and obtains a more positive perspective regarding his self-efficacy with coping skills to manage his psychotic symptoms. Most important, the CRDPSS encourages measurement-based care in the burgeoning era of practice-based evidence requirements (Tandon et al., 2013). Adhering to the DSM-5 dimensional classification, I diagnosed Ryan using this format:
F25.0 Schizoaffective Disorder, Bipolar Type, severe hallucinations, moderate delusions (erotomanic and persecutory), moderate abnormal psychomotor behavior, moderate negative symptoms, equivocal disorganized speech, continuous episode, currently in partial remission, without catatonia.
Compare the DSM-5 clinical formulation to the DSM-IV-TR diagnostic formulation:
295.70 Schizoaffective Disorder, Bipolar Type.
The DSM-5 diagnostic conceptualization offers a contextualized framework in “developing a comprehensive treatment plan that is informed by the individual’s cultural and social context” (p. 19) by rating primary symptoms of psychosis in order of severity so as to promote prognostic decision-making.
See Appendix 2: Schizophrenia Spectrum and Other Psychotic Disorders Differential Diagnosis
The DSM-5 retains the fourth edition’s bipolar I, bipolar II and cyclothymic disorders. The new language for the DSM-5 indicates that adults with bipolar I disorder have high rates of serious and/or untreated co-occurring medical conditions” (p. 132). In addition, bipolar II disorder “is no longer thought to be a ‘milder’ condition than bipolar I disorder, largely because of the number of times individuals with this condition spend in depression and because the instability of mood experienced by individuals with bipolar II disorder is typically accompanied by serious impairment in work and social functioning” (p. 123). Cyclothymic disorder is still considered to be a milder or subthreshold form of bipolar disorder in the DSM-5.
The cardinal symptoms evident in manic and hypomanic episodes remain unchanged in the DSM-5. However, some important linguistic clarifications are added to curtail the trend of diagnosing children and adolescents with a bipolar-related disorder for manifesting impairing irritability, marked anger, and physical aggression. According to the fourth edition of the DSM, children and adolescents manifest depression, not mania or hypomania, through an irritable and cranky mood expressed by “persistent anger, a tendency to respond to events with angry outbursts or blaming others, or an exaggerated sense of frustration of minor matters” (APA, 1994). This description aligns with research from Kessler (2010) indicating that irritability in major depressive disorder is associated with early age of onset, lifetime persistence, comorbidity with anxiety and impulse-control disorders, fatigue and self-reproach during episodes. In the opinion of Ellen Leibenluft, a National Institute of Mental Health senior investigator who researches whether children with impairing irritability (severe mood dysregulation) should be diagnosed with bipolar disorder, the vast majority of irritability in children is not bipolar disorder. Her longitudinal data in both clinical and community samples indicate that nonepisodic irritability in children and adolescents is common. According to Leibenluft, who served on the DSM-5 Childhood and Adolescent Disorders Work Group, nonepisodic irritability is associated with an elevated risk for anxiety and unipolar depressive disorders in adulthood, but not bipolar disorder. Her data also suggest that children and adolescents with impairing irritability have lower familial rates of bipolar disorder than do those with bipolar disorder, as well as different brain mechanisms mediating pathophysiologic abnormalities. Because of these factors, she advocates for thorough assessment and differential diagnosis in this population by spending ample time with the child and parents, obtaining abundant information, and carefully considering all relevant clinical material (see her 2011 article, “Severe mood dysregulation, irritability and the diagnostic boundaries of bipolar disorder in youths.”)
You are encouraged to watch this video youtu.be/2OfNPiZz3Lw of Dr. Ellen Leibenluft discussing the clinical profile of legitimate bipolar disorder in children and adolescents - especially when impairing irritability is the focus. |
The DSM-5 retains the dichotomous distinction between bipolar I and bipolar II disorders. To recap, bipolar I disorder is characterized by manic episodes, while bipolar II is characterized by hypomanic episodes. By definition, hypomanic episodes manifest with a shorter symptom duration requirement of four days as compared with manic episodes that manifest with a longer symptom duration requirement of seven days. But what really differentiates mania from hypomania is the severity, duration and, from a psychological point of view, experience of each client. According to the DSM-5, a hypomanic episode has to be “clearly different from the usual nondepressed mood.” The three most important criteria that refer to functional impairment essentially summarize the major differences between manic and hypomanic episodes (as listed for bipolar II disorder):
Criterion C: “The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.”
Criterion D: “The disturbance in mood and the change in functioning are observable by others.”
Criterion E. “The episode is not severe enough to cause marked impairment in social or occupational functioning or to necessitate hospitalization. If there are psychotic features, the episode is, by definition, manic.”
Mania, or affective psychosis as described by German psychiatrist Emil Kraepelin in the 19th century, may manifest as acute, delusional, or delirious. The transition from hypomania to acute mania (rapid onset and/or a short course) is marked by a severe exacerbation of the symptoms seen in hypomania and the appearance of delusional symptoms (fixed beliefs that are not amenable to change in light of conflicting evidence). Prominent delusions in this state may include the following:
Persecutory: The belief that one is going to be harmed, harassed or otherwise mistreated by an individual, organization or other groups
Referential: The belief that certain gestures, comments, environmental cues and so forth are directed at oneself
Grandiose: The belief that one has exceptional abilities, wealth, or fame
Erotomanic: When an individual believes falsely that another person is in love with him or her
Nihilistic: The conviction that a major catastrophe will occur
Somatic: Preoccupations regarding health and organ function
Bizarre: Clearly implausible beliefs that are not understandable to same-culture peers and that do not derive from ordinary life experiences
Keep in mind that it is difficult to make the distinction between a delusion and a strongly held idea. The distinction depends, in part, on the degree of conviction with which the belief is held despite clear or reasonable contradictory evidence regarding its veracity. The transition to delirious mania is marked by restlessness; confusion; incoherence of thought and speech; and intensification of the symptoms seen in acute mania, especially hallucinations (perception-like experiences that occur without an external – such as auditory, visual, tactile, gustatory, or olfactory – stimulus).
The depressive episodes seen in bipolar disorder, in contrast to those typically seen in major depression, tend to come on fairly acutely, over perhaps a few weeks and often occur without any significant precipitating factors. The DSM-5 provides further distinctions between manic episodes and hypomanic episodes induced by antidepressant treatment:
“A full manic episode that emerges during antidepressant treatment (e.g., medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a bipolar I diagnosis” (DSM-5, p. 124).
This condition is considered an indicator of true bipolar disorder, not substance/medication-induced bipolar and related disorder (DSM-5, pp. 142-145).
“However, caution is indicated so that one or two symptoms (particularly increased irritability, edginess, or agitation following antidepressant use) are not taken as sufficient for diagnosis of a hypomanic episode, nor necessarily indicative of a bipolar diathesis” (DSM-5, p. 125).
May 2013 Publication |
Effective August 2015 |
Manic Episode A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary). F. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment). [see DSM-5, pp. 124-125] |
Manic Episode A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased F. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or another medical condition. [see DSM-5, pp. 124-125] |
May 2013 Publication |
Effective October 2018 |
Specify if: With mood-congruent psychotic features (p. 152)
With mood-incongruent psychotic features (p. 152)
[see DSM-5, p. 127] |
Specify if: With mood-congruent psychotic features (p. 152; applies to manic episode and/or major depressive episode) With mood-incongruent psychotic features (p. 152; applies to manic episode and/or major depressive episode) [see DSM-5, p. 127] |
The DSM-5 added the following verbiage to help you identify the important behavioral changes that accompany mood shifts in manic episodes:
Criterion A “…and abnormally and persistently increased activity or energy…”
Criterion B “…and represent a noticeable change from usual behavior…"
May 2013 Publication |
Effective August 2015 |
Hypomanic Episode F. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment). [see DSM-5, pp. 125 & 133] |
Hypomanic Episode F. The episode is not attributable to the physiological effects of a substance (e.g., a drug of abuse, a medication, other treatment) or another medical condition. [see DSM-5, pp. 125 & 133] |
Specify if: With anxious distress (p. 149) With mixed features (pp. 149-150) With rapid cycling (pp. 150-151)
With seasonal pattern (pp. 153-154): Applies only to the pattern of major depressive episodes. Specify severity if full criteria for a mood episode are currently met: [see DSM-5, p.135] |
Specify if: With anxious distress (p. 149) With mixed features (pp. 149-150) With rapid cycling (pp. 150-151) With melancholic features p. 151) With atypical features (pp. 151-152) With seasonal pattern (pp. 153-154): Specify severity if full criteria for a major depressive [see DSM-5, p.135] |
May 2013 Publication |
Effective October 2018 |
Specify if: With mood-congruent psychotic features (p. 152) With mood-incongruent psychotic features (p. 152) [see DSM-5, p. 135] |
Specify if: With mood-congruent psychotic features (p. 152; applies to manic episode and/or major depressive episode) With mood-incongruent psychotic features (p. 152; applies to manic episode and/or major depressive episode) [see DSM-5, p. 135] |
To further distinguish irritability as a nonpsychiatric marker for mania and hypomania, the DSM-5 added the following verbiage to the symptom descriptions:
Criterion A: “…and abnormally and persistently increased activity or energy…”
Criterion B: “…and represent a noticeable change from usual behavior…”
The following verbiage was added to the symptom descriptions in the DSM-5:
Criterion A: “…that do not meet criteria for a hypomanic episode…”
Criterion B: “…the hypomanic and depressive periods have been present for at least half the time…”
Criterion C: “Criteria for a major depressive, manic, or hypomanic episode have never been met.” (The DSM-5 removed the DSM-IV-TR “note” that allowed manifestation of these episodes after the initial two years.)
May 2013 Publication |
Effective October 2018 |
Diagnostic Criteria Coding note: …Note that the ICD-10-CM code depends on whether or not there is a comorbid substance use disorder present for the same class of substance.
[see DSM-5, p. 142] |
Diagnostic Criteria Coding note: …Note that the ICD-10-CM code depends on whether or not there is a comorbid substance use disorder present for the same class of substance.In any case, an additional separate diagnosis of a substance use disorder is not given… [see DSM-5, p. 142] |
No changes from DSM-IV-TR.
No changes from DSM-IV-TR.
Use this category to communicate the specific reason that the presentation does not meet the criteria for any specific bipolar and related disorder. This is done by recording “other specified bipolar and related disorder” followed by the specific reason (e.g., “short-duration cyclothymia”). Other examples include:
Read more about these culturally sensitive descriptions on page 148 in your DSM-5.
Use this category for situations in which symptoms characteristic of a bipolar and related disorder cause clinically significant distress or impairment in social, occupational, or other important areas of functioning, but do not meet the full criteria for any of the disorders listed in this diagnostic classification (chapter), and you are not able to specify because there is insufficient information to make a more specific diagnosis.
May 2013 Publication |
Effective August 2015 |
Specifiers for Bipolar and Related Disorders Specify if: With seasonal pattern: D. Note: … Major depressive episodes that occur in a seasonal pattern are often characterized by prominent, hypersomnia, overeating, weight gain, and a craving for carbohydrates…. Specify if: In partial remission: Symptoms of the immediately previous manic, hypomanic, or depressive episode are present but full criteria are not met, or there is a period lasting less than 2 months without any significant symptoms of a manic, hypomanic, or major depressive episode following the end of such an episode.
[see DSM-5, p. 154] |
Specifiers for Bipolar and Related Disorders Specify if: With seasonal pattern: D. Note: … Major depressive episodes that occur in a seasonal pattern are often characterized by Specify if: In partial remission: Symptoms of the immediately previous manic, hypomanic, or major depressive episode are present but full criteria are not met, or there is a period lasting less than 2 months without any significant symptoms of a manic, hypomanic, or major depressive episode following the end of such an episode. Specify current severity of manic episode: Severity is based on the number of criterion symptoms, the severity of those symptoms, and the degree of functional disability. Mild: Minimum symptom criteria are met for a manic episode. Moderate: Very significant increase in activity or impairment in judgment. Severe: Almost continual supervision is required in order to prevent physical harm to self or others. Specify current severity of major depressive episode: [see DSM-5, p. 154] |
May 2013 Publication |
Effective October 2018 |
Specifiers for Bipolar and Related Disorders Specify if: With psychotic features:
[see DSM-5, p. 152] |
Specifiers for Bipolar and Related Disorders Specify if: With psychotic features: When applied to current or most recent major depressive episode (in bipolar I disorder or bipolar II disorder): With mood-congruent psychotic features: The content of all delusions and hallucinations is consistent with the typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment. With mood-incongruent psychotic features: The content of the delusions or hallucinations does not involve typical depressive themes of personal inadequacy, guilt, disease, death, nihilism, or deserved punishment, or the content is a mixture of mood-incongruent and mood-congruent themes. [see DSM-5, p. 152] |
Section III of the DSM-5 provides emerging measures to facilitate client assessment and development of a comprehensive case formulation. In turn, this will contribute to a diagnosis and treatment plan that is tailored to the individual presentation and clinical context (DSM-5, pp. 733-737). As noted on page 24 of the DSM-5:
Cross-cutting symptom and diagnosis-specific severity measures provide quantitative ratings of important clinical areas that are designed to be used at the initial evaluation to establish a baseline for comparison with ratings on subsequent encounters to monitor changes and inform treatment planning.
With this in mind, I recommend using the Altman Self-Rating Mania Scale (Level 2 – Mania – Adult and Level 2 – Mania – Child Age 11-17) to facilitate the diagnosis of bipolar-related disorders. This cross-cutting symptom measure is a five-item self-rating mania scale designed to assess the presence and/or severity of manic symptoms. This instrument contains the following instructions for clients:
On the DSM-5 Level 1 cross-cutting questionnaire you just completed, you indicated that during the past 2 weeks you (the individual receiving care) have been bothered by ‘sleeping less than usual, but still having a lot of energy’ and/or ‘starting lots more projects than usual or doing more risky things than usual’ at a mild or greater level of severity. The five statement groups or questions below ask about these feelings in more detail in the following areas:
Feeling happier or more cheerful
Self-confidence
Sleep patterns
Talking
Activity levels – socially, sexually, at work, home or school
Traditional psychometrically sound instruments, such as the Minnesota Multiphasic Personality Inventory for adults and adolescents and the Millon Clinical Multiaxial Inventory for adults and adolescents, can further detect the presence of mania or hypomania and anchor your bipolar and related disorder diagnosis. Regarding differential diagnostic procedures – especially to avoid “double counting” of symptoms toward borderline personality disorder – the DSM-5 requires you to suspend diagnosing a personality disorder during an untreated mood episode (DSM-5, p. 132). To assist with this important and sometimes complicated process, I recommend Gregory Hatchett’s 2010 article, “Differential diagnosis of borderline personality disorder from bipolar disorder.”
The DSM-5 retains the following descriptive specifiers from the DSM-IV-TR for bipolar-related disorders: with melancholic features, with atypical features, with psychotic features, and with catatonia. The DSM-5 also adds two new descriptive specifiers: with anxious distress and with mixed features.
The specifier with anxious distress is intended to identify clients with anxiety symptoms that are not part of the bipolar diagnostic criteria. Important differences exist between bipolar disorder with and without comorbid anxiety. Lifetime comorbid bipolar disorders and anxiety are associated with a decreased likelihood of recovery, poorer role functioning and quality of life, less time experiencing euthymia, and a greater likelihood of suicide attempts. The presence of higher levels of anxiety during manic or hypomanic episodes appears to mark an illness of substantially greater long-term depressive morbidity. Overall, the outcome of bipolar-related disorders is worse in the presence of comorbid anxiety. The coexistence of anxiety presents a particularly difficult challenge in the treatment of bipolar-related disorder illness because antidepressants, the mainstay of pharmacologic treatments for anxiety, may adversely alter the course of the illness.
In the DSM-IV-TR, a diagnosis of mixed episode required a client to simultaneously meet all criteria for an episode of major depression and an episode of mania. During its review of the latest research, the DSM-5 Mood Disorders Work Group recognized that individuals rarely meet full criteria for both episode types at the same time. To be diagnosed with the new mixed features specifier in the case of major depression, the DSM-5 requires the presence of at least three manic or hypomanic symptoms that do not overlap with symptoms of major depression. In the case of mania or hypomania, the specifier requires the presence of at least three symptoms of depression in concert with the episode of mania or hypomania. According to the APA, this specifier will allow you to more accurately diagnose clients who may be suffering from concurrent symptoms of depression and mania or hypomania, as well as better tailor treatment to their behaviors. This is especially important because many clients with mixed features, depending on their predominant symptoms, demonstrate a poor response to lithium or become less stable when taking antidepressants. Additionally, more accurately identifying these concurrent behaviors may allow you to recognize clients with a unipolar disorder who are at increased risk of progression to bipolar disorder.
The DSM-5 also retains the following course specifiers from the DSM-IV-TR: with rapid cycling, with seasonal pattern, and with peripartum onset. However, the DSM-5 contains a new note regarding the appropriate use of with seasonal pattern because the pattern of onset and remission of episodes must have occurred during at least a two-year period, without any nonseasonal episodes occurring during that time. Peripartum onset was formally referred to as postpartum in the DSM-IV-TR. The DSM-5 contains a new note indicating that 50 percent of postpartum major depressive episodes actually begin prior to delivery.
In conclusion, I recommend that clinicians read Severus and Bauer’s (2013) article Diagnosing bipolar disorders in DSM-5 and Treating Bipolar Disorder: A Clinician’s Guide to Interpersonal and Social Rhythm Therapy by Frank (2005), a member of the DSM-5 Mood Disorders Work Group.
See Appendix 3: Bipolar Related Disorders Differential Diagnosis
In the DSM-5, depressive disorders are listed independently from the bipolar-related disorders because of the absence of manic or hypomanic symptoms and “the presence of sad, empty, or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual’s capacity to function” (DSM-5, p. 155). However, depressive disorders are a neighboring chapter to bipolar-related disorders because “of symptomatology, family history and genetics” (DSM-5, p. 123). For example, major depressive episodes commonly precede manic episodes in bipolar I disorder, and a current or past major depressive episode is required for a diagnosis of bipolar II disorder. Cyclothymic disorder contains numerous depressive symptoms that do not meet the criteria for a major depressive episode.
May 2013 Publication |
Effective August 2015 |
Development and Course …Because the symptoms of disruptive mood dysregulation disorder are likely to change as children mature, use of the diagnosis should be restricted to age groups similar to those in which validity has been established (7 - 18 years). Approximately half of children with severe, chronic irritability will have a presentation that continues to meet criteria for the condition 1 year later. Rates of conversion from severe, nonepisodic irritability to bipolar disorder are very low.
[see DSM-5, p. 157] |
Development and Course …Because the symptoms of disruptive mood dysregulation disorder are likely to change as children mature, use of the diagnosis should be restricted to age groups similar to those in which validity has been established (6 - 18 years). Approximately half of children with severe, chronic irritability will have a presentation that continues to meet criteria for the condition 1 year later (Brotman et al., 2006). Rates of conversion from severe, nonepisodic irritability to bipolar disorder are very low (Stringaris et al., 2009; Stringaris et al., 2010). [see DSM-5, p. 157] |
During the past two decades, the prevalence of pediatric bipolar disorder has dramatically increased. Many clinicians, acting with good intent to help children and adolescents, have incorrectly diagnosed them with bipolar disorder and recommended the use of antipsychotic medication for the treatment of chronic and distressing irritable mood. However, Ellen Leibenluft, M.D. (senior investigator and chief of the Section on Bipolar Spectrum Disorders and of the Emotion and Development Branch at the National Institute of Mental Health Intramural Research Program) tracked a large group of young adolescents diagnosed with bipolar disorder into their 30s. She found no evidence that chronic irritability was a predictor of bipolar disorder in adults.
To address concerns expressed by parents and mental health professionals about the overdiagnosis and treatment of bipolar disorder in children, a new diagnosis, disruptive mood dysregulation disorder (DMDD), was added to the DSM-5. The diagnosis applies to children and refers to the presentation of persistent irritability and frequent episodes of extreme behavioral dyscontrol. The following symptoms characterize DMDD:
I must emphasize that the hallmark DMDD symptom is very severe, nonepisodic irritability that is persistent, frequent, and extreme, and is differentiated from a pattern of irritability when frustrated. Assessment of irritable mood and temper outburst severity, frequency, and chronicity are essential with this disorder. Moreover, developmentally appropriate mood elevation, such as what occurs in the context of a highly positive event or its anticipation, should not be considered a symptom of mania or hypomania. If the child’s irritable mood is episodic or fluctuates over time and in multiple environments, and the irritable mood is comorbid with increased grandiose energy and activity characteristic of hypomanic or manic episodes, then a diagnosis of bipolar disorder may be indicated. If the child is older than six and has impulsive anger-based outbursts with no comorbid mood fluctuations and no persistent irritability, then a diagnosis of intermittent explosive disorder may be warranted if the outbursts (temper tantrums, tirades, verbal arguments, or fights) occur two times per week for three months.
Keep in mind that DMDD is mutually exclusive with bipolar disorder, intermittent explosive disorder, posttraumatic stress disorder, and oppositional defiant disorder. Yet, DMDD can coexist with attention-deficit/hyperactivity disorder, conduct disorder, substance use disorder, and major depressive disorder if clear-cut changes between these disorders and DMDD are reported and observable. Because children and adolescents may develop an irritable or cranky mood rather than a sad or dejected mood during depressive episodes, DMDD is listed in the DSM-5 depressive disorder chapter instead of the disruptive, impulse control and conduct disorders chapter. However, making a clear distinction between DMDD and the more common non-mood-based, disruptive behavioral disorders can be challenging.
Copeland and colleagues (2013) determined that DMDD prevalence rates will range from 0.8 percent to 3.3 percent with children displaying elevated rates of social impairments, school suspension, service use, and poverty. They also found that DMDD frequently co-occurs with other psychiatric disorders yet meets common standards for psychiatric “caseness” by identifying children with severe levels of both emotional and behavioral dysregulation.
Axelson and colleagues (2012) found that 26 percent of study participants formally diagnosed with bipolar disorder met the operational DMDD criteria. DMDD participants had higher rates and more severe symptoms of oppositional defiant disorder (58 percent) and conduct disorder (61 percent) but did not differ in the rates and severity of mood, anxiety, or attention-deficit/hyperactivity disorders. DMDD was not associated with new-onset of mood or anxiety disorders or with parental psychiatric history. Overall, they found that DMDD could not be delimited from oppositional defiant disorder and conduct disorder and had limited diagnostic stability.
Margulies and colleagues (2012) found that 30.5 percent of psychiatric hospital inpatient children met the criteria for DMDD by parent report and 15.9 percent by inpatient unit observation. Fifty-six percent of the children had parent-reported manic symptoms. Of those, 45.7 percent met criteria for DMDD by parent report, though only 17.4 percent met the criteria when observed on the inpatient unit. Although the addition of DMDD does decrease the diagnosis rate of bipolar disorder in children, much of that reduction depends on whether the clinician uses client history or observation during the assessment process.
Aaron is a 9-year-old Caucasian boy brought into treatment by his mother and father, Shari and Wayne, who were at their “wit’s end” regarding what to do with him. Aaron presents with angry and destructive outbursts that appear uncontrollable and result in emotional and physical upheaval in the home. A week prior to Shari and Wayne calling for the initial consult, Aaron threw his sister’s backpack through a plate glass window because she would not change the TV channel to a program he wanted to watch. This happened despite clear family rules about the use of the TV and it was his sister’s turn to watch her favorite show. When Shari tried to intervene, Aaron grabbed her hair, pulled it violently and punched her in the arm. In the initial intake, Shari says, “I have learned to get good at protecting myself and have even taken some self-defense courses at the local gym. I just never dreamed I would be defending myself against my 9-year-old son.”
Aaron is grumpy and irritable most of the time. He has outbursts in the morning when he is forced to wake up and right before he goes to bed. His parents have developed a strategy of winding down two hours before bedtime to let Aaron know he needs to prepare himself for bed. Despite this strategy, they say that 80 percent of the time, a disruptive event takes place that prevents everyone from going to bed peacefully. When asked how long this has been happening, they indicate Aaron has been acting this way for the past 13 months. When asked why they waited that long before getting help, they both respond that they thought Aaron was going through a stage they had hoped he would outgrow.
They also describe several incidents in which Aaron has acted in a violent and explosive manner. A month previous, Aaron was with Shari and his younger sister at Walmart. He went into the store’s video games section while his mother and sister shopped for needed supplies. Shari engaged in her preventative speech, which included describing how Aaron has not respected time limits in the past, how her shopping will take only about five minutes and how she does not have time to wait for him to look at video games. During this speech, Aaron became agitated and said, “Whatever!” and then left for the video games department. Shari went after him and said, “I will be leaving in five minutes, and you better be at the car by the time I leave!”
Shari noted in the intake that she will not grab Aaron or physically try to restrain him because, “That is when he ‘loses it’ and gets really violent.” Shari and her daughter finished shopping, went to the car and waited 15 minutes for Aaron to meet them so they could leave. Aaron walked slowly out of the store and to the car. Shari met Aaron outside of the car and said, “I told you five minutes and we have been waiting here for 15 minutes. You will have no TV time tonight after dinner.” Upon hearing this, Aaron yelled, “You are a f------ bitch! I hate you and this whole damned family!” He then kicked Shari in the shin and jumped in the back of the car where his sister was sitting. He kicked the seat violently most of the way home.
When they arrived home, Shari told Aaron to go to his room. He went through the den where his older sister was watching TV. When Aaron looked at her, she rolled her eyes. He immediately became furious, overturning a bookshelf and hitting and kicking the walls on the way to his bedroom. He slammed the door and could be heard yelling and tearing the posters off his bedroom walls.
This event is representative of the outbursts Aaron has engaged in for more than a year. When questioned why she didn’t leave Aaron at home while she went to the store, Shari says she doesn’t dare because Aaron may get violent with his older sister Corey. Shari explains that Aaron and Corey have the most contentious relationship. Corey is at the stage where she is embarrassed about her brother’s behavior and will ridicule him in front of her friends. Shari describes Aaron’s relationship with Marie, his younger sister, as the most loving. She notes that Aaron acts very protective of Marie and has never threatened her.
When asked how Aaron behaves in other environments and social situations, particularly school, Shari acknowledges there have been outbursts at school and that Aaron’s teachers report he is a “problem student.” When other disruptive students act out, Aaron joins in with them. Teachers note that Aaron’s level of concentration appears to be strong and consistent, but he is especially sensitive to criticism.
Aaron’s parents say they can’t identify any severe mood swings that appear to be abnormal. Rather, Aaron is just cranky and irritable all the time. He can be compliant and even helpful around the house, they say, but those times are rare and can dissipate without warning. When asked about the nature of his violent outbursts, both Shari and Wayne note their belief that he acts out of frustration, as though he doesn’t know what to do with his emotions. They both deny mania, increased energy, grandiose ideation, increase in risky behaviors, delusions, or a decreased need for sleep even though Aaron frequently wants to stay up past his bedtime.
When asked about depressive symptoms, both parents report that though Aaron seems to enjoy activities with friends, there are times when he isolates himself at home and has reduced interest in interacting with others. During these times, he would rather play video games in his room or watch TV. Aaron does not appear to have any attention problems. He is able to concentrate at school and get his schoolwork done, even though he complains about doing homework.
In completing the DSM-5 Early Development and Home Background form and Level 1 Cross-Cutting Symptom Measures for children 6-17, Aaron produced elevated scores. This indicated the need for Level 2 Cross-Cutting Symptom Measures:
Score on Depression – Parent/Guardian of Child Age 6-17 (PROMIS Emotional Distress – Depression – Parent Item Bank): 66.6 (moderate)
Score on Irritability – Parent/Guardian of Child Age 6-17 (Affective Reactivity Index): 12 (severe)
Score on Anger – Parent/Guardian of Child Age 6-17 (PROMIS Emotional Distress – Calibrated Anger Measure – Parent): 85.2 (severe)
Score on Mania – Parent/Guardian of Child Age 6-17 (Adapted from the Altman Self-Rating Mania Scale): 5 (mild)
The combination of biopsychosocial information, the mental status examination, the teacher report, the clinical interview, and cross-cutting symptom measures (parent, child, and clinician-rated) justifies a DSM-5 diagnosis for Aaron of:
F34.81 Disruptive Mood Dysregulation Disorder
Z62.820 Parent-Child Relational Problem
Z62.891 Sibling Relational Problem
In conclusion, even though some of the emerging research indicates that DMDD may be justified as a distinct nosology, I am not convinced that we need this disorder. Dysthymia (now titled “persistent depressive disorder” in the DSM-5) is a viable option to designate chronic irritable mood lasting a minimum of 12 months in children, and that is mutually exclusive with a history of hypomania or mania (as required in the DSM-IV-TR and retained in the DSM-5). In my professional opinion, the American Psychiatric Association should have added a “disruptive mood dysregulation” descriptive specifier (requiring the same severity, frequency, and chronicity of irritable mood and temper outbursts) to dysthymia.
The DSM-5 retains this classic psychiatric syndrome with virtually no changes from the DSM-IV-TR description. The only modification is the addition of the word “hopeless” to Criterion A: “… (e.g., feels sad, empty, hopeless) …” However, you are encouraged to carefully read the revised descriptive text for this disorder, especially as it relates to the culture-related diagnostic issues, gender-related diagnostic issues, and suicide risk. Remember to use the online assessment measures for the depressive disorders to determine the symptom intensity levels of mild, moderate, or severe. These cross-cutting symptom severity measures, accessible at psychiatry.org/psychiatrists/practice/dsm/dsm-5/online-assessment-measures, include:
Level 2 – Depression – Adult (PROMIS Emotional Distress – Depression – Short Form)
Level 2 – Depression – Parent/Guardian of Child Age 6-17 (PROMIS Emotional Distress – Depression – Parent Item Bank)
Level 2 – Depression – Child Age 11-17 (PROMIS Emotional Distress – Depression – Pediatric Item Bank)
Severity Measure for Depression – Adult (Patient Health Questionnaire [PHQ-9])
Severity Measure for Depression – Child Age 11-17 (PHQ-9 modified for Adolescents [PHQ-A] – Adapted)
An important change to major depressive disorder in the DSM-5 is removal of the former Criterion E that read: “The symptoms are not better accounted for by bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than two months, or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.” The rationale for removing that criterion was threefold:
Essentially, this means you should default to the standard major depressive episode criteria when individuals present with clinical symptoms resulting from a significant loss, including bereavement, financial ruin, losses from a natural disaster, and a serious medical illness or disability.
Although the grieving process is natural and unique to each individual and shares some of the same features of depression, including intense sadness and withdrawal from customary activities, grief and depression are also different in important aspects. With grief, painful feelings come in waves and are often intermixed with positive memories of the deceased; with depression, mood and ideation are almost constantly negative. In addition, with grief, self-esteem is typically preserved. With major depressive disorder, corrosive feelings of worthlessness and self-loathing are common.
I encourage you to read the DSM-5 footnote on page 161 to help you distinguish grief from a major depressive episode. In addition, page 289 provides an option for you to diagnose severe and persistent grief and mourning reactions lasting longer than 12 months as persistent complex bereavement disorder or as other specified trauma- and stressor-related disorder (see also pp. 789-792). Finally, you can reference uncomplicated bereavement, described on pages 716-717 in the DSM-5 chapter on Other Conditions That May Be a Focus of Clinical Attention.
May 2013 Publication |
Effective August 2015 |
Differential Diagnosis Major depressive disorder …If the symptom criteria are sufficient for a diagnosis of a major depressive episode at any time during this period, then the diagnosis of major depression should be noted, but it is coded not as a separate diagnosis but rather as a specifier with the diagnosis of persistent depressive disorder. [see DSM-5, pp. 170-171] |
Differential Diagnosis Major depressive disorder …If the symptom criteria are sufficient for a diagnosis of a major depressive episode at any time during this period, then the diagnosis of major depression should be made and also noted [see DSM-5, pp. 170-171] |
This disorder encompasses the DSM-IV-TR’s former chronic specifier for a major depressive episode, which required the full criteria for a major depressive episode being met continuously for at least the past two years. Core diagnostic symptoms, with associated intensity, frequency, and duration, are unchanged in the DSM-5. Remember that major depression may precede persistent depressive disorder, major depressive episodes may occur during persistent depressive disorder, and early-onset (prior to age 21) persistent depressive disorder is strongly associated with personality disorders.
New to the DSM-5 are the following course and descriptive specifiers available for use with this disorder (see p. 169 for the complete description):
Andrew is a 14-year-old male who presented with long-term depression and anxiety symptoms, resulting in family relationship disruption, school challenges, and impaired social/peer interactions.
Per a clinical interview and testing using a variety of psychological instruments (Youth Outcome Questionnaire, Millon Adolescent Clinical Inventory, the SNAP-IV Rating Scale, and the DSM-5 Level 2 – Depression – Child Age 11-17 and Parent), I have diagnosed Andrew with the following DSM-5 disorder:
300.4 Persistent depressive disorder (dysthymia), early onset
With atypical features (mood reactivity, hypersomnia, and a long-standing pattern of extreme sensitivity at perceived interpersonal rejection)
With anxious distress (feeling unusually restless, difficulty concentrating because of worry)
With pure dysthymic syndrome, severe
What follows is a letter I drafted for his physician in support of psychotropic medication treatment:
Andrew has engaged with me in psychotherapy off and on for the past 18 months and remains committed to future treatment. My recommendation is that he be prescribed Wellbutrin to target his co-occurring depressive and anxiety symptoms, and to assist with attention abilities. I have tested Andrew for ADHD (using the Conners Continuous Performance Test), and he presents with some mild symptoms in the inattentive domain, but not enough to warrant a diagnosis. Andrew also presents with mood fluctuations, some of which are characteristic of hypomanic features, but not sufficient for a bipolar diagnosis. If Andrew is nonresponsive to Wellbutrin, I am supportive he try a selective serotonin reuptake inhibitor (e.g., Celexa) and second-generation antipsychotic (e.g., Abilify) combination to augment his chronic depressive mood treatment. Please note that Andrew does not present with suicide intent/self-injurious behaviors, psychotic symptoms, and substance abuse.
This disorder was listed in DSM-IV-TR Appendix B: Criteria Sets and Axes Provided for Further Study. Almost 20 years of additional research on this condition has confirmed a specific and treatment-responsive form of depressive disorder with a marked impact on functioning that begins sometime following ovulation and remits within a few days of menses. Premenstrual syndrome is defined as recurrent moderate psychological and physical symptoms that occur during the luteal phase of menses and resolve with menstruation. It affects 20 to 32 percent of premenopausal women. Women with premenstrual dysphoric disorder experience affective or somatic symptoms that cause severe dysfunction in social or occupational realms. The disorder affects 3 to 8 percent of premenopausal women.
According to C. Neill Epperson and colleagues’ (2012) article Premenstrual dysphoric disorder: Evidence for a new category for the DSM-5, the DSM-5 Mood Disorders Work Group charged a panel of experts in women’s mental health to:
The work group included eight individuals from various countries, six of whom possessed specialty expertise in premenstrual dysphoric disorder or reproductive mood disorders. The panel thoroughly vetted the literature, leading to its recommendation that premenstrual dysphoric disorder be moved from the appendix and classified as a diagnosis in the depressive disorders section of the DSM-5.
To be a diagnosable condition, an individual must have a minimum of five of the 11 available symptoms for a duration of one year. To help properly diagnose this condition, I encourage you to carefully read the descriptive text in the DSM-5 to understand the antecedent validators (familial aggregation), concurrent validators (biological markers), and predictive validators (response to treatment and course of illness). I further recommend review of Lustyk and Gerrish (2010) Premenstrual syndrome and premenstrual dysphoric disorder: Issues of quality of life, stress and exercise.
Regarding valid and reliable psychometric assessment procedures, you can use a number of scales, including Jean Endicott and Wilma Harrison’s Daily Record of Severity of Problems (DRSP). The DRSP provides sensitive, reliable, and valid measures of the symptoms and impairment criteria for premenstrual dysphoric disorder. The DRSP aligns with the 11 diagnostic criteria listed in the DSM-5. It also aligns with Criterion F, which requires confirmation of Criterion A by prospective daily ratings during at least two symptomatic cycles. You can download the DRSP.
In addition, Steiner and Streiner’s Visual Analogue Scales for Premenstrual Mood Symptoms is commonly used in clinical trials for premenstrual dysphoric disorder. Finally, Steiner and colleagues’(1980)Premenstrual Tension Syndrome Rating Scale, which features a self-report and an observer version, is widely used to measure illness severity in women who have premenstrual dysphoric disorder.
May 2013 Publication |
Effective October 2018 |
Diagnostic Criteria Coding note: …Note that the ICD-10-CM code depends on whether or not there is a comorbid substance use disorder present for the same class of substance.
[see DSM-5, p. 142] |
Diagnostic Criteria Coding note: …Note that the ICD-10-CM code depends on whether or not there is a comorbid substance use disorder present for the same class of substance. In any case, an additional separate diagnosis of a substance use disorder is not given… [see DSM-5, p. 142] |
No changes from DSM-IV-TR.
No changes from DSM-IV-TR.
May 2013 Publication |
Effective October 2018 |
Other Specified Depressive Disorder Major depressive disorder This category applies to presentations in which symptoms characteristic of a depressive disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the depressive disorders diagnostic class…
[see DSM-5, p. 183] |
Other Specified Depressive Disorder Major depressive disorder This category applies to presentations in which symptoms characteristic of a depressive disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the depressive disorders diagnostic class, and do not meet criteria for adjustment disorder with depressed mood or adjustment disorder with mixed anxiety and depressed mood… [see DSM-5, p. 183] |
Use this category to communicate the specific reason that the presentation does not meet the criteria for any specific depressive disorder. This is done by recording “other specified depressive disorder” followed by the specific reason (e.g., “short-duration depressive episode”). Other examples include:
Read more about these culturally sensitive descriptions on pages 183-184 in your DSM-5.
See Appendix 4: Disruptive and Depressive Disorders Differential Diagnosis
May 2013 Publication |
Effective October 2018 |
Other Specified Depressive Disorder Major depressive disorder This category applies to presentations in which symptoms characteristic of a depressive disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the depressive disorders diagnostic class…
[see DSM-5, p. 183] |
Other Specified Depressive Disorder Major depressive disorder This category applies to presentations in which symptoms characteristic of a depressive disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the depressive disorders diagnostic class, and do not meet criteria for adjustment disorder with depressed mood or adjustment disorder with mixed anxiety and depressed mood… [see DSM-5, p. 183] |
Use this category for situations in which symptoms characteristic of a depressive disorder cause clinically significant distress or impairment in social, occupational, or other important areas of functioning, but do not meet the full criteria for any of the disorders listed in this diagnostic classification (chapter), and you are not able to specify because there is insufficient information to make a more specific diagnosis.
May 2013 Publication |
Effective August 2015 |
Specify if: With mixed features: At least three of the following manic/hypomanic symptoms are present nearly every day the majority of days of a major depressive episode: [see DSM-5, p. 182] With seasonal pattern: D. Note: … Major depressive episodes that occur in a seasonal pattern are often characterized by prominent, hypersomnia, overeating, weight gain, and a craving for carbohydrates…. [see DSM-5, p. 187] |
Specify if: With mixed features: At least three of the following manic/hypomanic symptoms are [see DSM-5, p. 182] With seasonal pattern: D. Note: … Major depressive episodes that occur in a seasonal pattern are often characterized by [see DSM-5, p. 187] |
For enhanced cultural sensitivity and individualized treatment planning, you can use six descriptive specifiers retained from the DSM-IV-TR and two new descriptive specifiers (DSM-5, pp. 184-188):
You may also use the retained DSM-IV-TR course specifiers, in partial remission and in full remission, as well as the severity specifiers, mild, moderate, and severe.
See Appendix 4: Disruptive and Depressive Disorders
The chapter on anxiety disorders in the DSM-5 includes important refinements and new conceptualizations, while also attending to the cultural needs of our clients. The anxiety disorders chapter no longer includes obsessive-compulsive disorder (now in the obsessive-compulsive and related disorders chapter) or posttraumatic stress disorder and acute stress disorder (now included with the trauma- and stressor-related disorders chapter). The sequential order of these chapters in the DSM-5 reflects the close relationships among them, however.
I want to emphasize that because obsessive-compulsive disorder, posttraumatic stress disorder, and acute stress disorder are not technically referred to as “anxiety disorders,” anxiety is still pronounced in their presentation (DSM-5, pp. 235-236). Even so, fear and phobia, which are cardinal signs of anxiety disorders, are not manifest in these disorders. The reason for their new diagnostic home is because “the disorders included in the DSM-5 were reordered into a revised organizational structure meant to stimulate new clinical perspectives” (DSM-5, p. xli). Furthermore, the revised chapter structure was informed by recent research in neuroscience (common neurocircuitry) and by emerging genetic linkages (genetic vulnerability and environmental exposure) between diagnostic groups. The anxiety disorders chapter is arranged developmentally with disorders sequenced according to the typical age of onset.
I want to discuss several across-the-board changes to all seven of the anxiety disorders before I address each independently.
First, the DSM-5 requires minimum symptom duration of six months for each anxiety disorder before a diagnosis can be assigned. The only exception is with separation anxiety disorder and selective mutism, which require symptom duration of at least one month in children and adolescents.
Second, for all anxiety disorders, the client’s subjective and manifest anxiety must be out of proportion to the situation and represent clinically significant distress. Anxiety disorders differ from transient fear or anxiety and “also differ from developmentally normative fear or anxiety by being excessive or persisting beyond developmentally appropriate periods” (DSM-5, p. 189).
Third, to provide greater accuracy and flexibility in the clinical description of individual symptomatic presentations, there are severity measures that are specific to each anxiety disorder for children and adults (located at psychiatry.org/dsm5 under “Online Assessment Measures” and then “Disorder-Specific Severity Measures”). The severity measures correspond closely to the criteria that constitute each disorder’s definition. You can administer these measures at both an initial interview and over time to track the severity of the client’s disorder and response to treatment.
Fourth, the DSM-5 removed all of the DSM-IV-TR’s age requirements. For example, the criteria for agoraphobia, specific phobia and social anxiety disorder (social phobia) no longer include the requirement that individuals older than 18 recognize that their anxiety is excessive or unreasonable. This change is based on evidence that individuals with such disorders often overestimate the danger in phobic situations, while older individuals often misattribute phobic fears to aging. In addition, the six-month duration, previously limited to individuals younger than 18 in the DSM-IV-TR, is now extended to all ages. This change is intended to minimize the overdiagnosis of transient fears. Also in contrast to the DSM-IV-TR, the diagnostic criteria for separation anxiety disorder no longer specify that onset must be before age 18 because a substantial number of adults report onset after that age.
Fifth, the DSM-5 emphasizes cultural sensitivity among all anxiety disorders, but especially social anxiety disorder and panic disorder (see “Culture-Related Diagnostic Issues” on pp. 205-206, 211-212, and 216). “Since individuals with anxiety disorders typically overestimate the danger in situations they fear or avoid, the primary determinant of whether the fear or anxiety is excessive or out of proportion is made by the clinician, taking contextual cultural factors into account” (p. 189). This means culture-specific symptoms such as tinnitus, neck soreness, headaches, and uncontrollable screaming or crying that manifest in Japanese, Korean, Latino, Vietnamese, Latin American, Cambodian, African American, or Caribbean populations should not count as required symptoms when formulating a diagnosis. For additional discussion on expanded cultural sensitivity for the DSM-5 anxiety disorders, I recommend reading “Cultural Issues” on page 14 and the “Glossary of Cultural Concepts of Distress” on pages 833-837.
According to Bogels, et al. (2013), separation anxiety disorder in adults has been underdiagnosed despite high adulthood prevalence that is often comorbid and debilitating, and notwithstanding a substantial portion of individuals reporting first onset of the disorder in adulthood. Causal factors for underdiagnosis include previous classification of the disorder in the DSM-IV-TR under a chapter titled “Disorders Usually First Diagnosed in Infancy, Childhood or Adolescence,” giving the impression that the disorder was restricted to pediatric populations. This trend concerned the DSM-5 anxiety disorders work group, resulting in separation anxiety disorder being moved to the anxiety disorders chapter and the addition of the following language to its diagnostic criteria:
Criterion A.1. “…or experiencing…”
Criterion A.2. “…such as illness, injury, disasters or death.”
Criterion A.3. “…having an accident, becoming ill.”
Criterion A.4. “…to go out, away from home,…to work…”
Criterion B. “The fear, anxiety, or avoidance is persistent…”
Criterion D. “…worries about ill health or other harm befalling significant others in generalized anxiety disorder; or concerns about having an illness in illness anxiety disorder.”
Characteristic of this disorder, adults typically become overly concerned about the Criterion A events happening to their offspring and spouse, resulting in personal marked discomfort. Adults with separation anxiety disorder may also be uncomfortable when traveling independently. You can determine the severity level of this disorder for children or adults by using the DSM-5 Severity Measure for Separation Anxiety Disorder.
In the DSM-IV-TR, selective mutism was classified in the chapter titled “Disorders Usually First Diagnosed in Infancy, Childhood or Adolescence.” It is now classified as an anxiety disorder, given that a large majority of children with selective mutism are anxious. The diagnostic criteria are largely unchanged from the DSM-IV-TR.
The DSM-5 removed the DSM-IV-TR Criterion B phrase “… which may take the form of a situationally bound or situationally predisposed Panic Attack” because a panic attack is not indicative of specific phobia. DSM-5 added Criterion D: “The fear or anxiety is out of proportion to the actual danger posed by the specific object or situation and to the sociocultural context.” To enhance sensitivity to lifespan developmental factors, the textual description clarifies that in children, the fear or anxiety may be expressed by crying, tantrums, freezing, or clinging. You can determine the severity level of this disorder for children or adults by using the DSM-5 Severity Measure for Specific Phobia.
Social phobia (as it was called in the DSM-IV-TR) receives a name enhancement with “social anxiety disorder” being added to its formal diagnostic title. Similar to what happened with specific phobia, the DSM-5 removed the DSM-IV-TR Criterion B phrase: “Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed Panic Attack.” To more accurately convey the definitive feature of this disorder, the phrase was replaced with the following language: “The individual fears that he or she will act in a way or show anxiety symptoms that will be negatively evaluated.” In addition, the DSM-IV-TR generalized specifier was removed from the DSM-5 and replaced with a performance only specifier (first introduced on p. 455 of the DSM-IV-TR). You can use this specifier for clients whose fear is restricted to speaking or performing in public (for example, dancers, speakers, musicians, or athletes). You can determine the severity level of this disorder for children or adults by using the DSM-5 Severity Measure for Social Anxiety Disorder (Social Phobia).
The DSM-5 collapses the DSM-IV-TR characteristic types “cued, uncued, situational, and situationally predisposed” to “expected and unexpected.” The DSM-IV-TR diagnosis “panic disorder without agoraphobia” is also collapsed into the DSM-5 conceptualization. Removed from the DSM-5 is “panic disorder with agoraphobia” because if agoraphobia is present, a separate diagnosis of agoraphobia is given. You can determine the severity level of this disorder for children or adults by using the DSM-5 Severity Measure for Panic Disorder.
In the DSM-5, the 13 symptoms characteristic of a panic attack become usable as a new specifier. Panic attack “symptoms are presented for the purpose of identifying a panic attack; however, panic attack is not a mental disorder and cannot be coded. Panic attacks can occur in the context of any anxiety disorders as well as other mental disorders (e.g., Depressive Disorder, Posttraumatic Stress Disorder, Substance Use Disorder) and some medical conditions (e.g., cardiac, respiratory, vestibular, gastrointestinal). When the presence of panic attack is identified, it should be noted as a specifier (e.g., ‘Posttraumatic Stress Disorder with Panic Attack’). For panic disorder, the presence of panic attacks is contained within the criteria for the disorder and panic attack is not used as a specifier” (DSM-5, p. 214). For clients who display fewer than four of the required panic attack specifier symptoms, you may use the designation “with limited symptom attacks” in the diagnostic formulation.
In the DSM-IV-TR, agoraphobia was not a codable disorder. In the DSM-5, agoraphobia represents an “upgrade” of the DSM-IV-TR “agoraphobia without history of panic disorder” discussed on pages 441-443. Essentially, agoraphobia is diagnosed irrespective of the presence of panic disorder because a substantial number of individuals with agoraphobia do not experience panic symptoms. It is diagnosed only if the fear, anxiety, or avoidance persists. Endorsement of fears from two or more of the following five agoraphobia situations is now required because this is a robust means for distinguishing agoraphobia from specific phobias:
You can determine the severity level of this disorder for children or adults by using the DSM-5 Severity Measure for Agoraphobia.
May 2013 Publication |
Effective August 2015 |
Differential Diagnosis Depressive, bipolar, and psychotic disorders Generalized anxiety/worry is a common associated feature of depressive, bipolar, and psychotic disorders and should not be diagnosed separately if the excessive worry has occurred only during the course of these conditions.
[see DSM-5, pp. 225-226] |
Differential Diagnosis Depressive, bipolar, and psychotic disorders Although generalized anxiety/worry is a common associated feature of depressive, bipolar, and psychotic disorders, generalized anxiety disorder may [see DSM-5, pp. 225-226] |
The DSM-5 retains the DSM-IV-TR diagnostic symptoms for Generalized Anxiety Disorder. Because of its high comorbidity with depressive disorders and its potential for being over-diagnosed in children, the DSM-5 encourages you to restrict diagnosing by properly assessing manifest symptom “intensity, duration, or frequency” to ensure that symptoms are “pervasive, pronounced, and distressing” and that client “worries are excessive and typically interfere significantly with psychosocial functioning” (DSM-5, pp. 222-223). To further reduce excessive and unfounded use of this disorder, criterion F was expanded to require the rule out for 11 other mental disorders. You can determine the severity level of this disorder for children or adults by using the DSM-5
Severity Measure for Generalized Anxiety Disorder.
May 2013 Publication |
Effective October 2018 |
Diagnostic Criteria Coding note: …Note that the ICD-10-CM code depends on whether or not there is a comorbid substance use disorder present for the same class of substance. [see DSM-5, p. 226] |
Diagnostic Criteria Coding note: …Note that the ICD-10-CM code depends on whether or not there is a comorbid substance use disorder present for the same class of substance. In any case, an additional separate diagnosis of a substance use disorder is not given… [see DSM-5, p. 226] |
No changes from DSM-IV-TR.
No changes from DSM-IV-TR.
May 2013 Publication |
Effective October 2018 |
This category applies to presentations in which symptoms characteristic of an anxiety disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the anxiety disorders diagnostic class.
[see DSM-5, p. 233] |
This category applies to presentations in which symptoms characteristic of an anxiety disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the anxiety disorders diagnostic class, and do not meet criteria for adjustment disorder with anxiety or adjustment disorder with mixed anxiety and depressed mood. [see DSM-5, p. 233] |
Use this category to communicate the specific reason that the presentation does not meet the criteria for any specific anxiety disorder. This is done by recording “other specified anxiety disorder” followed by the specific reason (e.g., “generalized anxiety not occurring more days than not”). Other examples include:
See Appendix 5 for Differential Diagnosis of Anxiety Disorders
May 2013 Publication |
Effective October 2018 |
This category applies to presentations in which symptoms characteristic of an anxiety disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the anxiety disorders diagnostic class.
[see DSM-5, p. 233] |
This category applies to presentations in which symptoms characteristic of an anxiety disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any of the disorders in the anxiety disorders diagnostic class, and do not meet criteria for adjustment disorder with anxiety or adjustment disorder with mixed anxiety and depressed mood. [see DSM-5, p. 233] |
Use this category for situations in which symptoms characteristic of an anxiety disorder cause clinically significant distress or impairment in social, occupational, or other important areas of functioning, but do not meet the full criteria for any of the disorders listed in this diagnostic classification (chapter), and you are not able to specify because there is insufficient information to make a more specific diagnosis.
See Appendix 5 for Differential Diagnosis of Anxiety DisordersIn the DSM-5, the obsessive-compulsive and related disorders chapter is a new addition containing:
This reorganization of previous DSM-IV-TR disorders and integration with new DSM-5 disorders represents a grouping of similar clinical profiles characterized by repetitive or ritualistic behaviors, uncontrollable urges, intrusive mental images, and preoccupation with distressing thoughts.
Anxiety is prominent in the obsessive-compulsive and related disorders. However, the anxiety presentation in these disorders differs from the anxiety presentation in the fear and phobic-based disorders listed in the DSM-5 anxiety disorders chapter. The anxiety manifest from the obsessive-compulsive and related disorders is usually tension building, behavioral activation focused, non-phobic stimulus-driven, and non-physiologically arousing; whereas the anxiety disorders are usually more restlessness in nature, behavioral avoidance focused, phobic stimulus-driven, and physiologically arousing. Finally, obsessive-compulsive and related disorders differ neurobiologically from anxiety disorders in that the basal ganglia tends to be dysregulated. This collection of subcortical nuclei located in the limbic system of the brain controls voluntary motor movements, routine behaviors, cognition, and emotion.
This disorder received some substantial changes in the DSM-5:
First, DSM-IV-TR Criterion A1 language “…thoughts, impulses, or images…” and “intrusive and inappropriate” is changed in the DSM-5 to read “thoughts, urges, or images…” and “intrusive and unwanted.” The rationale for these two word changes is that individuals with OCD do not act impulsively, as manifested by individuals with ADHD or bipolar disorder, but rather they act to get relief from a progressive urge; and the clinical focus needs to address what is subjectively distressing for the individual, rather than what is judgmentally determined inappropriate by the clinician.
Second, the DSM-5 removed DSM-IV-TR Criterion A2 and A4 for obsessions:
A2. “The thoughts, impulses, or images are not simply excessive worries about real-life problems.” This was removed because it is assumed in making a diagnosis of a psychopathological condition, hence it was redundant.
A4. “The person recognizes that the obsessional thoughts, impulses, or images are a product of his or her own mind (not imposed from without as in thought insertion).” This was assumed into an expansion of the DSM-IV-TR insight specifier.
Also, in Criterion B, removed:
B. “At some point during the course of the disorder, the person has recognized that the obsessions or compulsions are excessive or unreasonable (Note: This does not apply to children).” This was assumed into an expansion of the DSM-IV-TR insight specifier.
Third, the DSM-5 expanded the DSM-IV-TR insight specifier for OCD. You can now indicate “with good or fair insight,” in which the individual can entertain that their mental intrusion or catastrophic belief is definitely or probably not true. For example, the individual believes that the house definitely will not, probably will not, or may or may not burn down if the stove is not checked 30 times. The DSM-IV-TR “with poor insight” specifier, in which the individual believes their mental intrusion or catastrophic belief is probably true, is retained in the DSM-5. For example, the individual believes that the house will probably burn down if the stove is not checked 30 times. You can now indicate “with absent insight/delusional beliefs,” in which the individual is completely convinced their mental intrusion or catastrophic belief is true. For example, the individual is convinced that the house will burn down if the stove is not checked 30 times. Research estimates that 4% or less of individuals with OCD will qualify for the with absent insight/delusional beliefs specifier.
Katharine Phillips, M.D., former chair of the DSM-5 Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Work Group, provided helpful context as to why the with absent insight/delusional beliefs specifier was added. In a February 15, 2013 interview with Psychiatric News (doi: 10.1176/appi.pn.2013.2b39), she said, “clinical experience suggests that patients with delusional beliefs as a symptom of one of these [obsessive-compulsive related] disorders are sometimes diagnosed with a psychotic disorder, which may lead to inappropriate treatment with antipsychotic medication only. The specifier will emphasize that patients with delusional beliefs that may occur as a symptom of these disorders do have OCD or body dysmorphic disorder or hoarding disorder. Those with OCD and body dysmorphic disorder should be treated with an SSRI rather than antipsychotic monotherapy.”
Fourth, the DSM-5 added a tic-related specifier to identify individuals with a current or past comorbid tic disorder, because this comorbidity may have important clinical implications related to themes of OCD symptoms, comorbidity, course, and pattern of familial transmission. Research estimates that about 30% of individuals diagnosed with OCD will qualify for this specifier at some point during their lifespan.
Use the DSM-5 Level 2 – Repetitive Thoughts and Behaviors Cross-Cutting Symptom Measure. This measure is an adaptation of the Florida Obsessive Compulsive Inventory Severity Scale and is available for children ages 11-17 and adults ages 18+. Because body dysmorphic disorder, hoarding disorder, trichotillomania (hair-pulling) disorder, and excoriation (skin-picking) disorder are “related” to OCD, this measure can be used for symptom severity determination.
In the DSM-5, Criterion A now includes language to address “flaws…that are not observable or appear slight to others.” Criterion B is new for the DSM-5 and anchors this disorder as OCD related: “At some point during the course of the disorder, the individual has performed repetitive behaviors (e.g., mirror-checking, excessive grooming, skin-picking, reassurance-seeking) or mental acts (e.g., comparing his or her appearance with that of others) in response to the appearance concerns.” Criterion D is changed in the DSM-5 to exclude any eating disorder as opposed to excluding only anorexia nervosa as found in DSM-IV-TR. Body dysmorphic disorder now has two available specifiers:
The same OCD insight specified discussed previously.
“With muscle dysmorphia” to indicate the individual is preoccupied with the idea that his or her body build is too small or insufficiently muscular.
In DSM-IV-TR, hoarding is listed as one of the diagnostic criteria for obsessive-compulsive personality disorder (OCPD), and when hoarding is extreme, the manual encourages you to consider a diagnosis of OCD that may be comorbid with OCPD. Now in the DSM-5, hoarding is a genetically discrete, strongly heritable disorder that includes difficulty discarding, urges to save, clutter, excessive acquisition, indecisiveness, perfectionism, procrastination, disorganization, and avoidance. Neuroimaging and neuropsychological studies from Dr. Sanjaya Saxena, lead author, and director of the Neuropsychiatric Institute's OCD Program at the University of California, San Diego, indicate that hoarding is neurobiologically distinct from OCD and implicate dysfunction of the anterior cingulate cortex and other ventral and medial prefrontal cortical areas that mediate decision-making, attention, spatial orientation, memory, and emotional regulation (Saxena, 2008). The DSM-5 hoarding disorder is characterized by persistent difficulty discarding or parting with possessions, including animals. The intentional clutter or congest of objects or animals must be clinically significant, excessive, cause long-standing difficulty, and result in substantially compromising the intended purpose of active living areas (more peripheral areas, such as garages, attics, or basements are not included). Individuals with hoarding disorder typically experience distress if they are unable to or are prevented from acquiring items. Deleterious consequences of hoarding include emotional, physical, social, financial, legal, or unsanitary conditions. Hoarding disorder contrasts with normative collecting behavior, which is organized and systematic, and normative collecting does not produce the clutter, distress, or impairment typical of hoarding disorder.
Hoarding disorder has two available specifiers:
The same OCD insight specified discussed previously.
“With excessive acquisition” to classify individuals who engage in disproportionate buying, followed by the acquisition of free items (e.g., leaflets, items discarded by others). Research estimates that about 80%-90% of individuals with hoarding disorder will qualify for this specifier.
You are encouraged to watch this video youtu.be/qPtrEJuK6fo to learn about Jessica’s Hoarding Disorder symptoms. |
For the DSM-5, Criterion A is retained as presented in DSM-IV-TR. Criterion B from DSM-IV-TR is changed from “An increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior” to “Repeated attempts to decrease or stop hair pulling” in the DSM-5. DSM-IV-TR Criterion C “Pleasure, gratification, or relief when pulling out the hair” is removed and additional exclusionary criteria distinguishing trichotillomania from other mental disorders (e.g., body dysmorphic disorder) is added.
This diagnosis, new to the DSM-5, is listed in the chapter on obsessive-compulsive and related disorders, which also contains obsessive-compulsive disorder (OCD), body dysmorphic disorder, hoarding disorder and trichotillomania (hair-pulling disorder). Diagnostic features for excoriation include compulsive skin-picking at multiple body sites, including the face, arms and hands, and using objects such as tweezers, pins, scissors, and fingernails. Individuals may be triggered by feelings of anxiety, boredom, distress, or tension and will spend several hours per day for months or even years picking at skin.
To meet the diagnostic criteria for excoriation disorder, individuals must spend a minimum of one hour per day picking, thinking about picking and resisting urges to pick their skin. Some of these individuals may engage in rituals with skin and scabs that cause damage, scarring, and infection. Ironically, pain is not routinely reported in these individuals. According to the DSM-5, excoriation disorder has a high correlation with OCD. The dermatopathological diagnosis is rarely required because skin lesions are clearly identifiable, and most individuals who engage in it admit to skin-picking. Excoriation disorder is not to be diagnosed if it occurs in response to a psychotic disorder, is not tic-like as displayed in Tourette’s disorder, and is not to be confused with nonsuicidal self-injury, which typically has an intentional, noncompulsive, psychopathological expectation resulting from interpersonal difficulties (DSM-5, pp. 803-806).
You are encouraged to watch this video youtu.be/6FUQ2GoBmpY to learn about Celina’s Excoriation (Skin-Picking) Disorder symptoms. |
Lochner and colleagues (2013) found that in individuals with excoriation disorder, their skin-picking persisted despite repeated attempts to decrease or stop, and their recurrent skin-picking resulted in skin lesions. “Urges” or “the need” to pick were not endorsed by all study subjects, but this behavior did correlate with the severity of skin-picking; “resistance” to picking was not universally endorsed either. The researchers found that although most study participants had urges to pick or a sense of relief when picking, such phenomena were not universal and should not be included in the DSM-5 diagnostic criteria set. They suggested that an additional criterion of repeated attempts to decrease or stop skin-picking seemed warranted.
May 2013 Publication |
Effective October 2018 |
Diagnostic Criteria Coding note: …Note that the ICD-10-CM code depends on whether or not there is a comorbid substance use disorder present for the same class of substance. [see DSM-5, p. 257] |
Diagnostic Criteria Coding note: …Note that the ICD-10-CM code depends on whether or not there is a comorbid substance use disorder present for the same class of substance. In any case, an additional separate diagnosis of a substance use disorder is not given… [see DSM-5, p. 257] |
No changes from DSM-IV-TR.
No changes from DSM-IV-TR.
Other Specified Obsessive-Compulsive and Related Disorder
Use this category to communicate the specific reason that the presentation does not meet the criteria for any specific obsessive-compulsive and related disorder. This is done by recording “other specified obsessive-compulsive and related disorder” followed by the specific reason (e.g., “body-focused repetitive behavior disorder”). Other examples include:
- Body dysmorphic-like disorder with actual flaws
- Body dysmorphic-like disorder without repetitive behaviors
- Obsessional jealousy
- Shubo-kyofu
- Koro
- Jikoshu-kyofu
Read more about these culturally sensitive descriptions on pages 263-264 in your DSM-5.
Unspecified Obsessive-Compulsive and Related Disorder
Use this category for situations in which symptoms characteristic of an obsessive-compulsive and related disorder cause clinically significant distress or impairment in social, occupational, or other important areas of functioning, but do not meet the full criteria for any of the disorders listed in this diagnostic classification (chapter), and you are not able to specify because there is insufficient information to make a more specific diagnosis.
JoAnn, a 43-year-old woman who lived alone in her house, presented for counseling after being referred by her daughter. She described her current hoarding behavior as “difficulty throwing things away” and “going on frequent shopping sprees.” JoAnn’s difficulties with organization and discarding of her possessions had resulted in a clutter-filled environment in her home (see DSM-5, p. 248 for a clinical definition of clutter). As a result, her main disability was complete social isolation due to embarrassment about others seeing her home in this state. JoAnn’s symptoms of hoarding had waxed and waned since childhood. Her problems with severe hoarding began to worsen since moving into her home 14 years ago, and continued to worsen in the last six years. Her family history was significant for hoarding behaviors in her mother and maternal grandmother.
JoAnn’s house consisted of four bedrooms, two and one-half baths, and a den. The volume of cluttered possessions took up the majority of the living space with clutter as high as four feet in some areas. No rooms in the house could be used for their intended purpose, especially the kitchen. Getting around the house was only partially possible by using trails, as tables, chairs, couches, and floors were almost completely covered with items. JoAnn’s hoarded possessions included newspapers, magazines, bills, videos, pictures, clothing items, and musical instruments, books, leaflets, and notes. She had not allowed people to visit her home in many years, causing her to lose touch with many friends and relatives.
On the DSM-5 Level 2 – Repetitive Thoughts and Behaviors Cross-Cutting Symptom Measure, JoAnn’s responses produced an average total score of 3.2, indicating a severe rating of symptom intensity. On the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) 36-item version, self-administered, JoAnn’s average domain score was 4.8, indicating a severe-extreme functional impairment rating. Putting it all together, JoAnn’s DSM-5 diagnostic formulation was written in this manner:
Severe-extreme functional impairment per WHODAS
Z60.2 Problem Related to Living Alone (chronic feelings of loneliness, isolation, and lack of structure in carrying out activities of daily living)
F42 Severe Hoarding Disorder, With Excessive Acquisition, With Absent Insight/Delusional Beliefs
Appendix 6: Obsessive-Compulsive and Related Disorders Differential Diagnosis
RAD received a complete reconceptualization and expansion in the DSM-5. The DSM-IV-TR subtype “inhibited” was removed and assumed into the new disorder conceptualization. Also, the DSM-IV-TR subtype “disinhibited” was upgraded into an independent clinical syndrome: disinhibited social engagement disorder. Evidence-derived criteria that defines two statistically and clinically distinct syndromes justified the change. If you who work with children presenting with these disorders, I suggest reading Charles Zeanah and Mary Margaret Gleason’s 2010 article, “Reactive attachment disorder: Review for DSM-V.”
RAD differs from disinhibited social engagement disorder in that “the former is expressed as an internalizing disorder with depressive symptoms and withdrawn behavior, while the latter is marked by disinhibition and externalizing behavior” (DSM-5, p. 265). RAD is characterized by avoidant and disturbed attachment behaviors and a marked absence of seeking comfort from primary caretakers. Disinhibited social engagement disorder is characterized by indiscriminate behaviors that violate the social boundaries of the child’s culture, yet it can be common for the child not to have any signs of disturbed attachment.
RAD requires that a minimum of five out of eight symptoms manifest prior to age five but no sooner than nine months of age (the DSM-IV-TR required only two of five symptoms and did not include the restriction of being at least nine months old). Disinhibited social engagement disorder requires that at least five of seven symptoms manifest after age nine months (unlike with RAD, there is no requirement that symptoms manifest before age five). Developmental psychology research indicates that selective attachments become evident around nine months of age; the presence of this condition becomes important for distinguishing normative from pathological symptoms. RAD and disinhibited social engagement disorder share the common trauma-stressor origin of repeated insufficient care during early childhood development. You may use the DSM-5 Early Development and Home Background Form – Parent/Guardian to screen for early developmental trauma and current trauma-inducing home experiences. If children display symptoms of either disorder for more than 12 months, use the specifier persistent, and use the specifier severe when all possible symptoms are endorsed.
The DSM-5 no longer lists posttraumatic stress disorder (PTSD) under the category of “anxiety disorders” but rather in a new category called “trauma- and stressor-related disorders” (along with reactive attachment disorder, disinhibited social engagement disorder, acute stress disorder and adjustment disorder). The DSM-5 now contains more than 25 potential trauma-causing events, including sexual abuse, natural disasters, vehicle accidents, and medical incidents. An exception to the new DSM-5 diagnostic criteria is trauma caused by non-life-threatening illnesses or debilitating conditions. In the DSM-5, there are now three new exposure sources:
1) Directly experiencing the traumatic event, such as a first responder collecting human remains or a child protective worker repeatedly being exposed to details of sexual abuse
2) Witnessing the traumatic event in person
3) Learning that the traumatic event occurred to a close family member or close friend, with natural death not qualifying as a trauma trigger
4) Exposure to the traumatic event through media such as pictures, television, or movies is not considered to be directly experiencing the traumatic event unless that exposure is related to a person’s work. Personally, I find this exclusion concerning. In a mixed-methods study Pulido (2005) found that indirect exposure to a terrorist attack was particularly relevant and related to PTSD symptoms, while Breslau (2010) and colleagues found that 0.7 percent of 9/11 PTSD cases resulted from indirect media exposure.
The DSM-5 contains new language discussing cultural syndromes and idioms of distress and how these influence PTSD expression. Temperamental, environmental, and physiological factors are also discussed. Suicide risk factors, functional consequences of PTSD, development and course (children, adolescents, younger adults, older adults), and gender-related diagnostic issues are also new to the DSM-5. What I find most helpful are the new risk and prognostic factors that discuss pretraumatic (before), peritraumatic (during), and posttraumatic (after) factors. These factors help to guide the diagnostic process and promote clinical utility for effective treatment planning.
The DSM-5 eliminated the “subjective fear-based distress” criterion because research indicates that not all individuals with PTSD respond with a fear-based reaction. Some individuals instead respond with anhedonic, dysphoric, aggressive, phobic, or dissociative reactions to the trauma-causing event. This change in the diagnostic criteria helps us to be more sensitive to the diverse PTSD presentations that we may see in our clients. According to Dr. Matthew J. Friedman, a member of the DSM-5 Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic and Dissociative Disorders Work Group: “When PTSD was first proposed in 1980 for DSM-III, the major scientific model was that it was a fear-based anxiety disorder. So, the A2 criteria in DSM-IV called for a fear-based reaction of fear, helplessness or horror. But a lot of research now indicates that for many people who have intense emotional reactions to a traumatic event and go on to develop PTSD, their reaction is not fear-based, but more likely to be dysphoria or anhedonia.”
The DSM-5 now requires four symptom categories to diagnose PTSD (the DSM-IV-TR required only three categories). Those four categories, with the DSM-5 additions in italics, are:
1) Intrusion symptoms: Covers spontaneous memories of the traumatic event, recurrent dreams related to it, flashbacks, or other intense or prolonged psychological distress. Added verbiage includes:
“Involuntary” to recurrent and intrusive distressing memories
…(“may occur on a continuum, with the most extreme expression being a complete loss of awareness of present surroundings”)
2) Persistent avoidance of stimuli: Refers to distressing memories, thoughts, feelings, or external reminders of the event. Added verbiage includes:
“…that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s)”
3) Negative alterations in cognitions and mood: Represents myriad feelings, from a persistent and distorted sense of blame of self or others, to estrangement from others or markedly diminished interest in activities. It also includes an inability to remember key aspects of the event or reconceptualized symptoms and persistent negative emotional states, such as numbing. Added verbiage and two new criteria include:
“…(typically due to dissociative amnesia and not to other factors such as head injury, alcohol, or drugs)”
Persistent and exaggerated negative beliefs or expectations about oneself, others, or the world
Persistent, distorted cognitions about the cause or consequences of the traumatic event(s) that lead the individual to blame himself/herself or others
4) Marked alterations in arousal and reactivity: Includes aggressive, reckless, or self-destructive behavior, sleep disturbances, hypervigilance, or related problems. This criterion emphasizes the “flight” aspect associated with PTSD and also accounts for the “fight” reaction often seen in PTSD. Added new criteria include:
Reckless or self-destructive behavior
New descriptive and course specifiers for PTSD include with dissociative symptoms (depersonalization, feeling a disconnection from one’s body/derealization, feeling disconnected from the surrounding environment) and with delayed expression (in the DSM-IV-TR, this was referred to as “delayed onset”).
The most clinically significant addition to PTSD in the DSM-5 is the creation of independent diagnostic criteria for pediatric PTSD for children age six and younger. These criteria merge the adult Criterion C and Criterion D and lower the symptom threshold from 3 to 1 to be developmentally sensitive. Some of the culturally sensitive pediatric language includes:
Koffel and colleagues (2012) utilized pre- and post-deployment data collected from a sample of 213 National Guard brigade combat team soldiers deployed to Iraq. Koffel and colleagues found that the DSM-5 symptom of anger showed the most increase from pre- to post-deployment in participants diagnosed with PTSD. In addition, anger had the strongest relation to PTSD and showed some evidence of specificity. They concluded that several of the other new and revised DSM-5 PTSD symptoms appear to be nonspecific and that their inclusion in the diagnostic criteria for PTSD is unlikely to improve differential diagnosis.
Elhai and colleagues (2012) surveyed 585 college students on the web using the Stressful Life Events Screening Questionnaire to assess for trauma exposure, but with additions to account for the proposed traumatic stressor changes in the DSM-5 PTSD criteria. Although 67 percent of participants reported at least one traumatic event on the basis of the DSM-IV-TR PTSD trauma classification, 59 percent of participants would meet the DSM-5’s proposed trauma classification for PTSD. They concluded that estimates of PTSD prevalence would be 0.4-1.8 percent higher for the DSM-5 versus the DSM-IV-TR.
May 2013 Publication |
Effective August 2015 |
Differential Diagnosis Adjustment disorders In acute stress disorders, the stressor can be of any severity rather than of the severity and type required by Criterion A of acute stress disorder. [see DSM-5, p. 285] |
Differential Diagnosis Adjustment disorders In |
May 2013 Publication |
Effective October 2018 |
Diagnostic Criteria
[see DSM-5, p. 280] |
Diagnostic Criteria
[see DSM-5, p. 280] |
Acute stress disorder in the DSM-5 is conceptually intact from the DSM-IV-TR. The only changes include the following:
Differentiation between acute stress disorder and PTSD is critical in the diagnostic process:
May 2013 Publication |
Effective March 2014 |
Diagnostic Criteria - after “Specify whether:” section -
[see DSM-5, p. 287] |
Diagnostic Criteria - after “Specify whether:” section - Specify if: Acute: If the disturbance lasts less than 6 months. Persistent chronic): If the disturbance lasts for 6 months or longer. [see DSM-5, p. 287] |
May 2013 Publication |
Effective October 2018 |
Differential Diagnosis Posttraumatic stress disorder and acute stress disorder …With regard to symptom profiles, an adjustment disorder may be diagnosed following a traumatic event when an individual exhibits symptoms of either acute stress disorder or PTSD that do not meet or exceed the diagnostic threshold for either disorder. An adjustment disorder should also be diagnosed for individuals who have not been exposed to a traumatic event [see DSM-5, p.288] |
Differential Diagnosis Posttraumatic stress disorder and acute stress disorder …With regard to symptom profiles, an adjustment disorder may be diagnosed following a traumatic event when an individual exhibits symptoms of either acute stress disorder or PTSD that do not meet or exceed the diagnostic threshold for either disorder. Because adjustment disorder cannot persist for more than 6 months after termination of the stressor or its consequences, cases in which symptoms occurring in response to a traumatic event that fall short of the diagnostic threshold for PTSD and that persist for longer than 6 months should be diagnosed as other specified trauma- and stressor-related disorder. An adjustment disorder should also be diagnosed for individuals who have not been exposed to a traumatic event [see DSM-5, p.288] |
The DSM-IV-TR adjustment disorders, with their associated specifiers, are also conceptually intact in the DSM-5, but they find a new home in the trauma and stressor-related disorders chapter. Added to Criterion B1 is the phrase “taking into account the external context and the cultural factors that might influence symptom severity and presentation.”
Use this category to communicate the specific reason that the presentation does not meet the criteria for any specific trauma- and stressor-related disorder. This is done by recording “other specified trauma- and stressor-related disorder” followed by the specific reason (e.g., “persistent complex bereavement disorder”).
Read more about these culturally sensitive descriptions on page 289 in your DSM-5.
Use this category for situations in which symptoms characteristic of a trauma- and stressor-related disorder cause clinically significant distress or impairment in social, occupational, or other important areas of functioning, but do not meet the full criteria for any of the disorders listed in this diagnostic classification (chapter), and you are not able to specify because there is insufficient information to make a more specific diagnosis.
See Appendix 7: Trauma- and Stressor-Related Disorders Differential Diagnosis
According to the DSM-5, “Dissociative disorders are frequently found in the aftermath of trauma, and many of the symptoms, including embarrassment and confusion about the symptoms or a desire to hide them, are influenced by the proximity to trauma” (p. 291). For this reason, the dissociative disorders are a “neighboring” diagnostic category with the trauma and stressor-related disorders in the new manual chapter sequencing. The DSM-5 dissociative disorders chapter contains dissociative identity disorder, dissociative amnesia, depersonalization/derealization disorder and other specified dissociative disorder.
Significant modifications were made to dissociative identity disorder in the DSM-5. Criterion A focus on two or more distinct personality states being manifest in the client is retained from the DSM-IV-TR. However, the DSM-5 replaces the phrase “each with its own relatively enduring pattern of perceiving, relating to, and thinking about the environment and self” with the phrase “which may be described in some cultures as an experience of possession.” Also new to the diagnostic criteria is identity disruption in the individual, which is evidenced by discontinuity in sense of agency and alterations in sensory-motor functioning, affect, behavior, consciousness, memory, perception, or cognition. This new Criterion A contains elements from the DSM-IV-TR’s Criterion B and Criterion C descriptions. Symptoms of identity disruption may be reported by the client or observed by the clinician.
The new Criterion B addresses recurrent memory gaps in everyday events, important personal information, and trauma events that are independent of common forgetfulness. Criterion D provides an exclusion that the individual’s identity disturbance is not part of a cultural or religious normative practice. The DSM-5 retains the diagnostic note stating that childhood imaginary or fantasy play is not indicative of the disorder. The DSM-5 also contains text modifications that clarify the nature and course of trauma-induced identity disruptions as displayed in children, adolescents, older individuals, females, and males.
Finally, the DSM-5 includes an important suicide risk note for this disorder: “Over 70% of outpatients with dissociative identity disorder have attempted suicide; multiple attempts are common, and other self-injurious behavior is frequent” (p. 295). Although the DSM-5 proposes suicidal behavior disorder and nonsuicidal self-injury as conditions for further study in Section III (pp. 801-806), I advise you to consider suicidal and nonsuicidal self-injurious behaviors as symptoms related to major depressive disorder, posttraumatic stress disorder, dissociative identity disorder, or borderline personality rather than independent clinical syndromes.
For dissociative amnesia, the disorder description is very similar to that found in the DSM-IV-TR. What is new in the DSM-5 is the following diagnostic note: “Dissociative amnesia most often consists of localized or selective amnesia for a specific event or events; or generalized amnesia for identity and life history” (p. 298). The disorder’s descriptive text was updated to include helpful conceptualization and treatment planning components that include trauma, child abuse, and victimization history, as well as self-mutilation, suicide attempts, and other high-risk behaviors. Dissociative fugue disorder, included in the DSM-IV-TR, is “downgraded” to become a specifier for dissociative amnesia in the DSM-5. The independent diagnosis was redundant because dissociative amnesia already accounts for an individual’s inability to recall some or all information from his or her past, along with accompanying confusion about personality identity.
In the DSM-5, depersonalization disorder now includes the word “derealization” in its title. This addition took place to improve clinical conceptualization and to promote recognition that individuals with trauma backgrounds may experience either or both syndromes. The DSM-5 replaces the DSM-IV-TR phrase “mental processes” by using “with respect to one’s thoughts, feelings, sensations, body or actions” in Criterion A1. For Criterion A2, derealization diagnostic criteria require the following: “Experiences of unreality or detachment with respect to surroundings (e.g., individuals or objects are experienced as unreal, dreamlike, foggy, lifeless, or visually distorted).” Regarding differential diagnosis, remember that even though borderline personality disorder may present with transient, stress-related paranoid ideation or severe dissociative symptoms, depersonalization symptoms are generally of insufficient severity or duration to warrant an additional diagnosis.
Use this category to communicate the specific reason that the presentation does not meet the criteria for any specific dissociative disorder. This is done by recording “other specified dissociative disorder” followed by the specific reason (e.g., “dissociative trance”).
Chronic and recurrent syndromes of mixed dissociative symptoms include:
Read more about these culturally sensitive descriptions on pages 306-307 in your DSM-5.
Use this category for situations in which symptoms characteristic of a dissociative disorder cause clinically significant distress or impairment in social, occupational, or other important areas of functioning, but do not meet the full criteria for any of the disorders listed in this diagnostic classification (chapter), and you are not able to specify because there is insufficient information to make a more specific diagnosis.
You can use “An office mental status examination for complex chronic dissociative symptoms and multiple personality disorder” by Loewenstein (1991). His psychopathological symptoms and assessment questions include the following:
Blackouts/time loss
- Do you ever have blackouts, blank spells, or memory lapses?
- Do you lose time?
Disremembered behavior
- Do you find evidence that you have said and done things that you do not recall?
- Do people tell you of behavior you have engaged in that you do not recall?
Fugues
- Do you ever find yourself in a place and not know how you got there?
Unexplained possessions
- Do you find objects in your possession (clothes, groceries, books) that you do not remember acquiring? Out-of-character items? Items a child might have?
- Do you find that objects disappear from you in ways for which you cannot account?
- Do you find writings, drawings, or artistic productions in your possession that you must have created but do not recall creating?
Inexplicable changes in relationships
- Do you find that your relationships with people frequently change in ways that you cannot explain?
Fluctuations in skills/habits/knowledge
- Do you find that sometimes you can do things with amazing ease that seem much more difficult or impossible at other times?
- Does your taste in food, music, or personal habits seem to fluctuate?
- Does your handwriting change frequently? A little? A lot? Is it childlike?
- Are you right-handed or left-handed? Does it fluctuate?
Fragmentary recall of life history
- Do you have gaps in your memory of your life?
- Do you remember your childhood? When do those memories start? What is your first memory? What is your next memory? Next?
Intrusion/overlap/interference (passive influence)
- Do you have thoughts or feelings that come from inside or outside you that don’t feel like yours? Are they outside your control?
- Do you have impulses or engage in behaviors that don’t seem to be coming from you?
- Do you hear voices, sounds, or conversations in your mind?
Negative hallucinations
- Do you ever not see/hear what’s going on around you? Can you block out people or things altogether?
Analgesia
- Are you able to block out physical pain? Wholly? Partly? Always? Sometimes?
Depersonalization/Derealization
- Do you frequently have the experience of feeling as if you are outside yourself or watching yourself as if you were another person?
- Do you ever feel disconnected from yourself or as if you were unreal?
- Do you experience the world as unreal? As if you are in a fog or daze?
- Do you ever look in the mirror and not recognize yourself?
Trauma
- Who made the rules in your family and how were they enforced?
- Did you witness violence between family members?
- Have you ever had unwanted sexual contact with anyone? As a child? Teenager? Adult?
- As a child, what made you feel safe? Was anyone kind to or supportive of you?
- Flashbacks; intrusive symptoms; sight, sound, taste, smell, touch: Do you ever experience events that happened to you before as if they are happening now?
- Nightmares: how often, since when? Do you awaken disoriented? Find yourself somewhere else?
- Are there specific people, situations, or objects that trigger you? Are these associated with time loss?
- Are you a jumpy person? Easily startled?
- Do you avoid people, situations, or things that remind you of traumatic or overwhelming events? Can you block out feelings?
Somatoform symptoms
- Do you ever get physical symptoms/pain that your doctors can’t medically explain?
I recommend reading Brand and Loewenstein’s (2010) article “Dissociative disorders: An overview of assessment, phenomonology and treatment” for a phenomenal discussion about theoretical models and clinical utility of dissociation in trauma (with associated experience, reexperiencing, and avoidance symptoms). I endorse Dalenberg and Carlson’s (2012) article “Dissociation in posttraumatic stress disorder part II: How theoretical models fit the empirical evidence and recommendations for modifying the diagnostic criteria for PTSD,” I also encourage you to review the International Society for the Study of Trauma and Dissociation website at isst-d.org for helpful resources on this topic.
See Appendix 8 for Differential Diagnosis of Dissociative Identity Disorder
May 2013 Publication |
Effective August 2015 |
Differential Diagnosis If the somatic symptoms are consistent with another mental disorder (e.g., panic disorder), and the diagnostic criteria for that disorder are fulfilled, then that mental disorder should be considered as an alternative or additional diagnosis. A separate diagnosis of somatic symptom disorder is not made if the somatic symptoms and related thoughts, feelings, or behaviors occur only during major depressive episodes… [see DSM-5, p. 314] |
Differential Diagnosis If the somatic symptoms are consistent with another mental disorder (e.g., panic disorder), and the diagnostic criteria for that disorder are fulfilled, then that mental disorder should be considered as an alternative or additional diagnosis. [see DSM-5, p. 314] |
In an interview with Psychiatric News, Joel Dimsdale, chair of the DSM-5 Somatic Symptoms Disorders Work Group, commented, “The heart of these disorders is a disproportionate and excessive response to somatic symptoms. We are talking about persistent symptoms lasting six months, including thoughts, feelings and behaviors that are disproportionate to somatic symptoms. Patients may catastrophize about fairly minor somatic symptoms, become very anxious and constantly scan for information about an illness, or avoid situations and behaviors they believe are related to illness.”
According to research by Rosmalen and colleagues (2011), data failed to provide empirical support for the designated DSM-IV-TR somatoform-related disorders symptom cluster. Yet their data underlined the validity of the emerging DSM-5 dimensional approach of diagnosing these disorders. In the DSM-IV-TR, there was a great deal of overlap across the somatoform disorders and a lack of clarity about the boundaries of diagnoses. Hence, the DSM-5 collapses the DSM-IV-TR’s somatization disorder, undifferentiated somatoform disorder, and pain disorder into a new diagnosis: somatic symptom disorder. According to the new manual, this diagnosis encompasses about 75 percent of the DSM-IV-TR hypochondriasis diagnoses. Clinical profiles of this disorder include client symptoms marked by “significant disruption [and] marked impairment” and “disproportionate, persistently excessive” client reactions (DSM-5, p. 311).
To avoid pejorative and demeaning client attributions, the DSM-5 indicates that “it is not appropriate to give an individual a mental disorder diagnosis solely because a medical cause cannot be demonstrated. Somatic symptoms without an evident medical explanation are not sufficient to make this diagnosis. The individual’s suffering is authentic, whether or not it is medically explained” (p. 311). You may use the specifier with predominant pain to indicate this presence in clients. You can also communicate symptom duration of longer than six months with the specifier persistent. Severity of the disorder is indicated by mild (one symptom), moderate (two-plus symptoms), or severe (multiple symptoms) designations. When developing a clinical formulation of somatic symptom disorder, you would do well to consider the DSM-5’s discussion on culture-related diagnostic issues mentioned earlier in this article.
The former hypochondriasis disorder is renamed illness anxiety disorder in the DSM-5 to capture individuals who exhibit high health anxiety without also having somatic symptoms in a manner that is not pejorative (for example, by referring to them as “hypochondriacs”). Clients receiving this diagnosis display incessant worry and preoccupation related to illness. You can use two new specifiers: care seeking type (excessive health-related behaviors) or care avoidant type (maladaptive avoidance).
Criteria for this disorder were modified to strongly recommend neurological examination to ensure clear evidence of incompatibility with neurological disease. In addition to the expansion of the diagnostic name (functional neurological symptom disorder communicates motor and sensory symptoms indicative of central nervous system functioning), conversion disorder has 12 new descriptive and course specifiers for diagnostic precision.
This disorder, previously located in the DSM-IV-TR’s “other conditions that may be a focus of clinical attention,” receives an upgrade in the DSM-5. Criterion B4 from the DSM-IV-TR, which read “stress-related physiological responses precipitate or exacerbate …,” was changed to “the factors influence the underlying pathophysiology, precipitating or exacerbating symptoms …” New specifiers include mild, moderate, severe (requiring hospitalization/emergency department visitation), and extreme (life-threatening risk).
This independent chapter from the DSM-IV-TR merges into the DSM-5 chapter on somatic symptom and related disorders. Also known as Munchausen syndrome, or Munchausen by proxy, this disorder may be imposed on one’s self or on another. The new manual replaces three DSM-IV-TR types with two specifiers: single episode and recurrent episode. You should be diagnostically skilled in differentiating this disorder from the non-mental health condition of malingering by reading the DSM-5 pages 726-727.
You can determine the severity of these somatic symptom and related disorders for children or adults by using the Clinician-Rated Severity of Somatic Symptom Disorder.
Use this category to communicate the specific reason that the presentation does not meet the criteria for any specific somatic symptom and related disorder. This is done by recording “other specified somatic symptom and related disorder” followed by the specific reason (e.g., “pseudocyesis”). Other examples include:
Read more about these culturally sensitive descriptions on page 327 in your DSM-5.
Use this category for situations in which symptoms characteristic of a somatic symptom and related disorder cause clinically significant distress or impairment in social, occupational, or other important areas of functioning, but do not meet the full criteria for any of the disorders listed in this diagnostic classification (chapter), and you are not able to specify because there is insufficient information to make a more specific diagnosis.
Allen and colleagues (2013) published an article on the prevalence, stability, and psychosocial correlates of eating disorders in a population-based sample of male and female adolescents. They discovered that eating disorder prevalence rates were significantly greater when using the DSM-5 criteria versus DSM-IV-TR criteria at all time points for females and age 17 only for males. “Unspecified/other” eating disorder diagnoses were significantly less common when applying the DSM-5 criteria, but they still formed 15-30 percent of the DSM-5 cases. Stice and colleagues (2013) also reported results from an eight-year prospective community study of young women. They found that the new DSM-5 eating disorder criteria capture clinically significant psychopathology and usefully assign individuals with eating disorders to homogeneous diagnostic categories. The DSM-5’s new conceptualization of feeding, eating, and elimination disorders place greater emphasis on observable, recurrent, quantifiable, and persistent client behaviors.
I begin with a discussion of obesity, the condition of being grossly fat or overweight that is calculated as a ratio of a person’s height and weight wherein the body mass index is greater than 30. As I travel the country providing DSM-5 trainings, a common question posed by attendees is “Why was obesity not included in the manual?” I assume some of you taking this course may share similar sentiments, especially considering that the DSM-5 defines a mental disorder as a “syndrome characterized by clinically significant disturbance in an individual’s cognition, emotional regulation or behavior that reflects a dysfunction in the psychological, biological or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational or other important activities” (p. 20).
Multiple mechanisms contribute to individuals’ vulnerability to obesity, including genetic, developmental, and environmental factors that are likely to interact in diverse ways to produce the behavioral phenotype of overeating. A growing body of evidence from epidemiologic and community samples has documented a relationship between obesity and psychiatric disorders, including mood and anxiety disorders, as well as personality disorders. Moreover, developing evidence suggests a relationship between obesity and attention-deficit/hyperactivity disorder and posttraumatic stress disorder. Obesity also has several correlates in common with eating disorders and substance use disorders, including hypothalamic-pituitary-adrenal axis dysregulation and environmental precipitants such as childhood trauma. It further shares many symptomatic features with mood disorders, including increased appetite, decreased activity levels, and sleep disturbance.
Even though obesity is linked to hypothalamic dysregulation, according to the DSM-5, obesity “results from long-term excess of energy intake relative to energy expenditure. A range of genetic, physiological, behavioral and environmental factors that vary across individuals contributes to the development of obesity; thus, obesity is not considered a mental disorder” (p. 329). It is important to understand that obesity’s pathophysiology (functional changes resulting in abnormal states) is not limited to the brain, the main body organ considered for mental disorders. The stomach, intestines, pancreas, liver, muscles, and adipose tissues are involved in the etiology and maintenance of obesity. Most important, many hormonal mechanisms participate in the regulation of appetite and food intake, storage patterns of adipose tissue, rates of metabolism, and development of insulin resistance. Hence, by definition, obesity is a medical condition, not a psychological condition. If you work with clients whose overweight condition or obesity is a focus of clinical attention and who display nonadherence to medical treatment for this condition, you can use the code 278.00 Overweight or Obesity found on page 725 of the DSM-5 under Other Conditions That May Be a Focus of Clinical Attention.
Changes to the phrasing of diagnostic criteria in the DSM-5 guide you in distinguishing eating behaviors that warrant a diagnosis of pica from behaviors that are developmentally normal, culturally supported, or socially normative, or that support a diagnosis of a different mental disorder. Criteria A and B now include the words “nonfood substances,” and the DSM-IV-TR phrase “culturally sanctioned practice” was changed to “culturally supported or socially normative practice” in Criterion C.
Pica eating may be comorbid with a number of mental disorders, including Intellectual Development Disorder (formerly called “mental retardation” in the DSM-IV-TR), autism spectrum disorder, schizophrenia and obsessive-compulsive disorder. In addition, pica eating can co-occur with trichotillomania (hair-pulling) disorder and excoriation (skin-picking) disorder when hair or skin is ingested. When nonnutritive substances are ingested to suppress appetite in the setting of anorexia nervosa, a pica diagnosis is not warranted.
You are encouraged to watch this video youtu.be/0TN1_EgYdfU of Krystin’s Pica symptoms. |
Relatively minor changes occurred in the DSM-5’s phrasing of diagnostic criteria for rumination disorder:
The word “rechewing” was replaced with the phrase “regurgitated food may be re-chewed, re-swallowed, or spit out.”
Criterion B is new: “The repeated regurgitation is not attributable to an associated gastrointestinal or other medical condition (e.g., gastroesophageal reflux, pyloric stenosis).”
Regurgitation and associated rumination may occur in the context of another mental disorder such as intellectual developmental disorder or generalized anxiety disorder. Rumination disorder is now mutually exclusive to binge eating disorder and avoidant/restrictive food intake disorder.
These changes are intended to improve clinical case formulation and comprehensive treatment planning by ensuring applicability across the age range and removing some ambiguity inherent in the prior phrasing. A diagnosis of rumination disorder is made only if the regurgitation and associated behaviors have features or consequences that warrant additional clinical attention.
Be aware that pica eating and rumination can occur in both children and adults. The disorders appear to be more prevalent in some populations yet frequently are not disclosed or detected. Clinical assessment to evaluate the presence of pica is advised when physical symptoms or abnormalities suggest that the consumption of nonfood substances may be a contributing factor or when other clinical factors raise concern. The structured Diagnostic Interview Schedule for Children can be used to assess pica in children. No validated assessments are available for adults. I suggest using an empathic, nonjudgmental tone with child clients to avoid exacerbating their sense of shame or their unwillingness to disclose rumination or pica eating. It is important to provide psychoeducation to parents that include information about the potential medical consequences of these disorders.
This disorder was previously titled “feeding disorder of infancy or early childhood” in DSM-IV-TR. It received a name change in the DSM-5 because avoidant or restrictive food intake symptoms manifest in children and adults. This disorder requires broad clinical assessment that includes dietary intake, a physical examination, and laboratory testing to detect and measure significant weight loss, significant nutritional deficiency, dependence on enteral feeding or oral nutritional supplements, and marked interference with psychosocial functioning.
Unlike clients with anorexia nervosa, clients with avoidant/restrictive food intake disorder do not display a fear of gaining weight or becoming fat and do not manifest specific disturbances related to the perception and experience of their own body weight and shape. Instead, this disorder may represent a conditioned negative response associated with food intake following, or in anticipation of, an aversive experience – for example, choking, traumatic ingestion, or repeated vomiting. It may also be based on the sensory characteristics of food, such as appearance, color, smell, texture, temperature, or taste. The diagnosis should not be applied if the client’s inadequate food intake is related to the insufficient availability of food or to specific cultural practices involving food. Thus, parental underfeeding of infants should be excluded, as should normal dieting and fasting in relation to religious observances.
A 2010 article by Bryant-Waugh (a member of the DSM-5 Clinical and Public Health Committee) and colleagues in the International Journal of Eating Disorders provides nine questions to assess and diagnose avoidant/restrictive food intake disorder:
1) What is the current food intake? This ascertains whether the current intake represents an adequate, age-appropriate amount or range (is the diet sufficient in terms of energy, and does it include major food groups and essential micronutrients).
2) Is the diet supplemented by oral nutritional supplements or enteral feeding? This helps ascertain whether the individual is dependent on these other means of feeding.
3) Is the avoidance or restriction persistent? This helps determine whether the condition is an established rather than transient problem.
4) What are the individual’s weight and height? This allows calculation of body mass index or body mass index percentile, comparison of the individual’s previous weight and height percentiles, assessment of whether growth is faltering, and whether the weight has been lost or is static when it should be increasing.
5) Does the individual present with clinical or laboratory signs and symptoms of nutritional deficiency or malnutrition? For example, is there lethargy secondary to iron deficiency anemia or delayed bone age as a consequence of chronic restricted intake?
6) Is there evidence of any significant distress or impairment to the individual’s social and emotional development or functioning associated with the eating disturbance?
7) Is the avoidance or restriction associated with a lack of interest in food or eating, or a failure to recognize hunger?
8) Is the avoidance or restriction based on sensory aspects of food such as appearance (including color), taste, texture, smell, or temperature?
9) Does the avoidance or restriction follow an aversive experience associated with intense distress, such as a choking incident, an episode of vomiting or diarrhea, or complications from a medical procedure such as an esophagoscopy?
In the DSM-5, Criterion A focuses on behaviors, such as restricting calorie intake, and no longer includes the word “refusal” in terms of weight maintenance because that implies an intention on the part of the client and can be difficult to assess. Removed from the DSM-5 is a previous criterion that made amenorrhea (the absence of at least three menstrual cycles) core to diagnosing anorexia nervosa. Amenorrhea has proved difficult or impossible to apply to several groups that are nonetheless susceptible to anorexia nervosa, including premenarcheal girls, women taking exogenous hormones, postmenopausal women, and males. Additionally, although amenorrhea is commonly described in adolescents and young women who are low in weight, studies have not identified consistent differences in the percentage of expected weight or percentage of body fat among those menstruating regularly and those manifesting amenorrhea. Furthermore, while amenorrhea often occurs following a reduction in body weight and body fat, it precedes weight loss in approximately 20 percent of individuals with anorexia nervosa.
Additional changes to anorexia nervosa in the DSM-5 include wording clarity; guidance for diagnosing children, adolescents, and adults; and the inclusion of new remission specifiers and severity specifiers (i.e., mild, moderate, severe, extreme) based on the World Health Organization’s body mass index for adults and body mass index percentile for children and adolescents (DSM-5, p. 339). The restricting type and binge eating/purging type descriptive specifiers are retained in the DSM-5.
To reduce the excessive use of “Eating Disorder Not Otherwise Specified” (EDNOS), the required frequency and duration of disordered eating and compensatory behaviors in bulimia nervosa were reduced from twice weekly to once per week, and from six months to three months. Partial and full remission specifiers are new, along with new severity specifiers based on the number of disordered eating episodes, ranging from one episode per week (mild) to 14-plus episodes per week (extreme).
In an interview with Psychiatric News in 2013, Timothy Walsh, chair of the American Psychiatric Association’s Eating Disorders Work Group, said, “An enormous amount of research in the last several decades – more than 1,000 published papers – justifies the inclusion of binge eating disorder” in the DSM-5. He added that its inclusion would “help to significantly decrease the use of eating disorder-not otherwise specified.” In the DSM-IV-TR, binge eating – defined as uncontrolled binge eating without emesis or laxative abuse – was not recognized as a disorder. Instead, it was described in Appendix B: Criteria Sets and Axes Provided for Further Study and was diagnosable using only the catch-all category EDNOS. Many factors justify the “upgrading” of binge eating disorder in the DSM-5. Some of these factors include the following:
Binge eating disorder criteria in the DSM-5 are unchanged from the proposed research criteria in DSM-IV-TR. To reduce the excessive use of EDNOS, the required frequency and duration of disordered eating and compensatory behaviors in binge eating disorder were reduced from twice weekly to once per week and from six months to three months. Partial and full remission specifiers are new, along with new severity specifiers based on the number of disordered eating episodes, ranging from one episode per week (mild) to 14-plus episodes per week (extreme).
You are encouraged to watch this video youtu.be/1OQbUZeYAik to learn about important differential diagnostic criteria between Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder. |
Use this category to communicate the specific reason that the presentation does not meet the criteria for any specific feeding and eating disorder. This is done by recording “other specified feeding or eating disorder” followed by the specific reason (e.g., “bulimia nervosa of low frequency”). Other examples include:
Read more about these culturally sensitive descriptions on pages 353-354 in your DSM-5.
Use this category for situations in which symptoms characteristic of a feeding and eating disorder cause clinically significant distress or impairment in social, occupational, or other important areas of functioning, but do not meet the full criteria for any of the disorders listed in this diagnostic classification (chapter), and you are not able to specify because there is insufficient information to make a more specific diagnosis.
Allen and colleagues (2013) found that eating disorder prevalence rates were significantly greater when using the DSM-5 than DSM-IV-TR criteria, at all time points for females and at age 17 only for males. They also discovered that “unspecified”/“other” eating disorder diagnoses were significantly less common when applying the DSM-5 than DSM-IV-TR criteria, but still formed 15% to 30% of the DSM-5 cases. Moreover, cross-over from binge eating disorder to bulimia nervosa was particularly high. Regardless of the diagnostic classification system used, all eating disorder diagnoses were associated with depressive symptoms and poor mental health quality of life. These results provide further support for the clinical utility of the DSM-5 eating disorder criteria, and for the significance of binge eating disorder and purging disorder.
Lawanda, a 52-year-old single woman with morbid obesity presents with complaints of fatigue, difficulty losing weight, and no motivation. She notes a marked decrease in her energy level, particularly in the afternoons. She is tearful and states that she was diagnosed with depression (multiple episodes since age 13, with no suicide ideation) and prescribed an antidepressant that she chose not to take. Lawanda reported gaining an enormous amount of weight during the past six years, and she is presently at the highest weight she has ever been - 243 pounds with a BMI of 41. She states that every time she tries to cut down on her eating she has symptoms of shakiness and increased hunger. She does not follow any specific diet, refuses medical treatment, and has been so fearful of hypoglycemia that she often eats extra snacks.
Lawanda’s health care practitioners have repeatedly advised weight loss and exercise to improve her health status. She complains that the pain in her knees and ankles makes it difficult to do any exercise. Lawanda further annotated that neighborhood children verbally taunt and tease her when she goes outside to get the mail - resulting in elevated depressive mood states, feeling keyed up or tense, and feeling unusually restless.
At intake, Lawanda completed the Minnesota Multiphasic Personality Inventory 2 (MMPI-2), the 36-item version, self-administered World Health Organization Disability Assessment Schedule 2.0, and the DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure – Adult.
Putting together all relevant information obtained from psychological testing, mental status examination, and a biopsychosocial, the following DSM-5 diagnosis is warranted:
F33.1 Moderate Major Depressive Disorder, Recurrent, With Anxious Distress
Mild-moderate functional impairment (score of 87 per self-administered WHODAS 2.0)
E66.9 Overweight or Obesity (nonadherence to medical treatment)
Z60.4 Social Exclusion or Rejection (per teasing and intimidation by others regarding obesity)
Emerging Avoidant Personality Disorder features (per results from MMPI-2)
Appendix 9: Feeding and Eating Disorders Differential Diagnosis
Diagnostic criteria for these disorders are unchanged in the DSM-5. If you work with encopresis, I strongly recommend Shapira and Dahlen’s (2010) article on a treatment protocol for enuresis using an alarm.
As with all other diagnostic classifications, the elimination disorders classification offers diagnostic flexibility and cultural sensitivity by using the categories Other Specified Elimination Disorder or Unspecified Elimination Disorder.
Sleep-wake disorders in the DSM-5 represent a radical revamping of diagnostic syndromes, clinical conceptualization, and specifier annotations. This is because the DSM-IV-TR “was prepared for use by mental health and general medical clinicians who are not experts in sleep medicine” (DSM-5, p. 362). As you read the sleep-wake disorders chapter in the DSM-5, notice an increased emphasis on a multidimensional approach to assessment that includes medical examination, such as the use of polysomnography, quantitative electroencephalographic analysis, and testing for hypocretin (orexin) deficiency (DSM-5). Also notice a greater emphasis on the dynamic relationship between sleep-wake disorders and certain mental or medical conditions and that pediatric, developmental criteria, and the general text are integrated based on existing neurobiological and genetic evidence and biological validators (Kaplan, 2013). The DSM-5 sleep-wake disorders textual descriptors use the terminology "coexisting with" or "comorbidity" instead of the DSM-IV-TR "related to" or "due to.” Sleep-wake disorders in the DSM-5 further provide diagnostic precision by offering use of course specifiers (i.e., episodic, persistent, recurrent, acute, subacute), descriptive specifiers (i.e., with mental disorder, with medical condition, with another sleep disorder), and severity specifiers (i.e., mild, moderate, severe).
According to Arline Kaplan’s (2013) article “Catching up on sleep: From comorbidity to pharmacotherapy” that appeared in Psychiatric Times in August 2013, not only is obstructive sleep apnea (a Sleep-Wake Disorder) linked with coronary artery disease, heart failure, systemic hypertension, stroke, and diabetes, but it is also a significant risk factor for depression. On the flip side, psychiatric disorders are highly comorbid with sleep-wake disorders. This is why the DSM-5 uses the terminology “coexisting with” or “comorbidity” instead of the previous edition’s terminology of “related to” or “due to.” For example, Voinescu and colleagues (2012) published “Sleep disturbance, circadian preference and symptoms of adult attention deficit hyperactivity disorder (ADHD)”. They reported that study “subjects with probable ADHD complained more frequently of sleep disturbance of the insomnia type (more than 50%) and reported shorter sleep duration and longer sleep latencies and more frequent unwanted awakenings. Individuals likely to suffer from ADHD and/or insomnia disorder were significantly more evening-oriented than controls. Inattention was associated with both insomnia and eveningness, while impulsivity was associated with poor sleep. Hyperactivity and sleep timing were associated with poor sleep only in the probable insomnia group.”
Such research results support the DSM-5’s new pediatric, developmental criteria and text that are integrated on the basis of existing neurobiological validators and genetic evidence. They also bolster the DSM-5’s greater emphasis on the dynamic relationship between sleep-wake disorders, certain mental or medical conditions (for example, Alzheimer’s disease and Parkinson’s disease) and substance use disorders. As I review the DSM-5, I find the following mental health disorders have sleep-wake problems embedded in the diagnostic criteria:
A further review of the DSM-5 reveals that the following mental health disorders tend to coexist with and/or exacerbate sleep-wake disorders:
In summary, some form of sleep-wake disorder or sleep disturbance symptom is present in most, if not all, of our counseling clients across the life span. For this reason, I strongly recommend reading Milner and Belicki’s (2010) article “Assessment and treatment of insomnia in adults: A guide for clinicians,” and actively incorporate the associated psychological approaches into their clinical treatment planning. As I read their article, I find Table 2, “Overview of Factors That Contribute to Insomnia,” to be very clinically enlightening. Remember that depression, anxiety, and cognitive changes often accompany sleep-wake disorders that must be addressed in treatment planning and management (DSM-5).
The DSM-5 presents an entirely new conceptualization and organization of 10 sleep-wake disorders.
First, because both arousal (wake) cycles and sleep cycles become dysregulated in these disorders, the word “wake” has been added to the previous DSM title of “sleep disorders.” The “sleep-wake” title also aligns with common language used by sleep-related disorder clinics and in descriptive literature. All of the sleep-wake disorders share resulting daytime distress and impairment as core features.
Second, epidemiological, neurobiological, and intervention research influenced the organization of the DSM-5 sleep-wake disorders chapter. It facilitates client differential diagnosis of sleep-wake complaints (necessitating a multidimensional approach) and clarifies when referral to a sleep specialist for further assessment and treatment planning is indicated. This contrasts with the previous DSM edition’s effort to simplify sleep-wake disorders classification and aggregated diagnoses under broader, less differentiated labels that were not necessarily research-based or clinically informed. Ironically, the sleep disorders chapter in the DSM-IV-TR was not prepared by experts in sleep medicine, but rather by mental health professionals and general medical clinicians.
Third, biological validators are essential in confirming the presence of a sleep-wake disorder independent of a prominent mood, anxiety, psychotic, or substance use disorder. This increased emphasis on medical testing requires all sleep-wake disorders except for insomnia and hypersomnolence to be confirmed by polysomnography (a multiparametric test used in the study of sleep and as a diagnostic tool in sleep medicine), quantitative electroencephalographic analysis (numerical examination of electrical activity along the scalp and associated behavioral correlates), or laboratory results indicating a deficit of orexin (a neurotransmitter that regulates arousal, wakefulness, and appetite).
Fourth, use the DSM-5 child or adult Level 2 Sleep Disturbance Patient-Reported Outcome Measurement Information System (PROMIS) Short Form. This reliable and precise instrument assesses self-reported perceptions of sleep quality, sleep depth, and restoration associated with sleep. This includes perceived difficulties and concerns with getting to sleep or staying asleep, as well as perceptions of the adequacy of and satisfaction with sleep. Please understand that sleep disturbance does not focus on symptoms of specific sleep disorders, nor does it provide subjective estimates of sleep quantities (for example, the total amount of sleep, time to fall asleep, or amount of wakefulness during sleep). The sleep disturbance short form is generic rather than disease-specific, and it assesses sleep disturbance during the past seven days in clients age 18 and older. Charles F. Reynolds III, chair of the DSM-5 Sleep-Wake Disorders Work Group, told Psychiatric News in 2012 that use of dimensional assessment measurements, such as the PROMIS, “speaks to the concept of measurement-based care, a pervasive theme that has informed the entire DSM-5. You will see in the accompanying text a listing of useful dimensional measures of sleep impairment to help you understand how troublesome the symptoms are and to measure improvement as patients go through treatment. The dimensional measures will also help researchers correlate measures of severity with underlying brain dysfunction.”
Fifth, the DSM-5 mirrors sleep-wake disorder conceptualizations contained in the American Academy of Sleep Medicine’s second edition of the ICSD-2. This primary diagnostic, epidemiological, and coding resource for clinicians and researchers in the field of sleep and sleep medicine has historical roots in the European Sleep Research Society, the Japanese Society of Sleep Research, and the Latin American Sleep Society. Because the ICSD-2 was published in 2005, the DSM-5 reflects more recent pathogenic process evidence for parsimonious and credible sleep-wake phenotypes, while the ICSD-2 contains many more sleep-wake disorder types than the DSM-5.
Sixth, you will find an expanded listing of descriptive specifiers (details to inform treatment planning), course specifiers (time frames related to symptom onset or symptom absence), and severity specifiers (rating the intensity, frequency, duration, or symptom count) for each of the sleep-wake disorders. Examples of descriptive specifiers include with mental disorder, with medical condition, and with another sleep disorder. Examples of course specifiers include episodic, persistent, recurrent, acute, and subacute. Examples of severity specifiers include mild, moderate, and severe (based on quantified day-time alertness, cataplexy, apneas, hypoxemia, and hypercarbia). As a whole, these six changes promote clinical judgment and will help you to experience feasibility.
Under insomnias (problems with initiating/maintaining sleep), primary insomnia and insomnia related to another mental disorder (both found in the previous edition of the DSM) have become insomnia disorder. Primary hypersomnia and hypersomnia related to another mental disorder have become hypersomnolence disorder.
Narcolepsy now requires either the presence of cataplexy (sudden loss of muscle tone), hypocretin deficiency as measured using cerebrospinal fluid, or REM sleep latency deficiency as measured using polysomnography. This disorder also has five new descriptive specifiers, each with its own diagnostic code.
Breathing-related sleep disorder, found in the DSM-IV-TR, becomes the classification title for this section of the sleep-wake disorders chapter, and the disorder itself is now designated as obstructive sleep apnea-hypopnea. New for the DSM-5 are obstructive sleep apnea-hypopnea, central sleep apnea (with three specifiers, including comorbid with opioid use), and Sleep-Related Hypoventilation (with comorbid specifier for medication/substance use and neurological/medical disorders).
Circadian rhythm sleep-wake disorders contain six types: delayed sleep phase type, advanced sleep phase type (new for DSM-5), irregular sleep-wake type (new for DSM-5), non-24-hour sleep-wake type (new for the DSM-5 and commonly found in visually impaired individuals), shift work type, and unspecified type. Please note that the jet lag type was removed from the DSM-5.
You are encouraged to watch this video youtu.be/CqBaY8577cQ of Mindy discussing her symptoms from Circadian Rhythm Sleep-Wake Disorder, Non-24-Hour Sleep-Wake Type. |
DSM-IV-TR sleepwalking disorder and sleep terror disorder are merged to become the DSM-5 non-rapid eye movement sleep arousal disorder, with the following specifiers (APA 2013):
Nightmare disorder is retained with changes to Criterion A in which “physical integrity” replaces “self-esteem.” DSM-IV-TR parasomnia not otherwise specified is renamed in the DSM-5 to rapid eye movement sleep behavior disorder for disruptive dream enacting behaviors, and DSM-IV-TR dyssomnia not otherwise specified is renamed in the DSM-5 to restless legs syndrome.
May 2013 Publication |
Effective October 2018 |
Diagnostic Criteria Coding note: …Note that the ICD-10-CM code depends on whether or not there is a comorbid substance use disorder present for the same class of substance. [see DSM-5, p. 414] |
Diagnostic Criteria Coding note: …Note that the ICD-10-CM code depends on whether or not there is a comorbid substance use disorder present for the same class of substance. In any case, an additional separate diagnosis of a substance use disorder is not given… [see DSM-5, p. 414] |
You may use this classification when the symptoms precede the onset of the substance/medication use, the symptoms persist for a substantial period of time (e.g., about one month) after the cessation of acute withdrawal or severe intoxication, or there is other evidence suggesting the existence of an independent non-substance/medication-induced sleep disorder (e.g., a history of recurrent non-substance/medication-related episodes).
Specify whether
Specify if
Read more about these culturally sensitive descriptions on pages 420-421 in your DSM-5.
Use this category for situations in which symptoms characteristic of an insomnia, hypersomnolence, or sleep-wake disorder cause clinically significant distress or impairment in social, occupational, or other important areas of functioning, but do not meet the full criteria for any of the disorders listed in this diagnostic classification (chapter), and you are not able to specify because there is insufficient information to make a more specific diagnosis.
Jasmine, a 36-year-old Caucasian female, is married and has four children. She reported a history of major depression (with two to three episodes of intense suicidal ideation) and Generalized Anxiety Disorder. Results from the World Health Organization’s Adult ADHD Self-Report Scales (Kessler, et al., 2004) indicated possible Attention-Deficit/Hyperactivity Disorder combined presentation. Results from the psychometric Conners’ Continuous Performance Test II confirmed the presence of a mild to moderate ADHD combined presentation profile. Despite pharmacological (both prescription and over the counter) and psychological (sleep hygiene and behavioral-focused) interventions, Jasmine continued to report this produced functional impairment with employment obligations and interpersonal relationships.
In the spirit of the DSM-5 and in collaboration with her general practitioner, I referred Jasmine to a local sleep medicine clinic to receive formal sleep-wake disorder testing (polysomnography). This was done to confirm the presence of an independent sleep-wake disorder not better accounted for by her depression and anxiety disorders. The resulting sleep-wake study report included the following excerpts:
This is a 36-year-old female patient with a past medical history that is remarkable for gastric reflux, allergies, and asthma. Patient is overweight with a BMI (body mass index) of 26.31. There is a longstanding history of: frequent awakenings, use of sleeping pills, frequent difficulty waking up, nonrestorative sleep, excessive daytime sleepiness, nasal congestion, frequent loud snoring, palpitations, night sweats, and waking up with muscle paralysis. Patient complains of excessive daytime sleepiness with an Epworth Sleepiness score that is abnormal at 14 out of 24. Total sleep time is adequate at 8 hours per night. Patient denies smoking and drinking alcohol. Current medications include: Pantoprazole, Simvastatin, Amitriptyline, Loratadine, and Fluticasone. As such, an overnight sleep study was ordered for evaluation of an underlying sleep-related breathing disorder.
Interpretation:
Obstructive apneas (suspension of external breathing) of 17.1/hour associated with oxygen desaturation to as low as 72%. This is consistent with the diagnosis of moderate Obstructive Sleep Apnea.
Sleep-related hypoventilation/hypoxemia due to sleep apnea is present.
Severe initial insomnia.
Recommendations:
Continuous positive airway pressure (CPAP) therapy should be offered to this patient given the risk of stroke and the significant daytime sleepiness. As such, a second overnight sleep study for CPAP titration is strongly recommended. If daytime sleepiness persists despite adequate CPAP therapy, then further evaluation for hypersomnolence should be considered.
Recall that hypersomnolence, excessive sleepiness, is a new disorder for the DSM-5. The addition of this diagnosis conforms to the sleep medicine expert’s recommendation for potential comorbid existence.
Adhering to the DSM-5 dimensional rather than the DSM-IV-TR multiaxial classification (Jones, 2012), Jasmine received the following diagnostic formulation:
G47.33 Moderate Obstructive Sleep Apnea-Hypopnea
Z63.0 Relationship Distress with Spouse or Intimate Partner
F33.1 Moderate Major Depressive Disorder, Recurrent (the DSM-5 Level 2 Depression – Adult PROMIS Emotional Distress – Depression – Short Form and the Severity Measure for Depression – Adult [Patient Health Questionnaire] were administered to determine severity rating (see also Jones, 2012).
G47.34 Mild Idiopathic Sleep-Related Hypoventilation
F90.2 Mild Attention-Deficit/Hyperactivity Disorder, Combined Presentation, In Partial Remission (see DSM-5, p. 60 for discussion on new severity and remission specifier options).
F41.1 Mild Generalized Anxiety Disorder (the DSM-5 Severity Measure for Generalized Anxiety Disorder – Adult was administered to determine severity rating).
The DSM-5 presents a new conceptualization and organization of sexual dysfunctions, gender identity disorder, and the paraphilias. Each of these diagnostic classifications is now carved out as an independent chapter and contains important language changes and symptom descriptions.
According to Boskey’s (2013) article, “Sexuality in the DSM 5,” the new manual does a reasonable job of reflecting changing public and scientific opinions. A number of positive changes in the new manual will please many involved in sexuality counseling, research, and activism. The DSM-5 makes it much clearer that a broad range of sexuality and gender expressions should be considered normal and healthy, while streamlining the diagnosis of sexual dysfunction for both men and women. Furthermore, it includes an expanded sexual abuse section with definitions that give clearer descriptions of the broad range of acts that providers and the legal system should consider problematic.
The DSM-5 retains the lifelong, acquired, generalized, and situational DSM-IV-TR subtypes and now designates them as specifiers for all sexual dysfunction diagnoses. New to the manual is important language indicating that:
The DSM-5 removes language that portrayed sexual dysfunctions as disorders of the sexual response cycle related to desire (fantasies about sexual activity), excitement (subjective sense of sexual pleasure and accompanying psychological changes), orgasm (peaking of sexual pleasure with release of sexual tensions and rhythmic contraction), or resolution (muscular relaxation and general well-being). Sexual dysfunctions are now understood to have requisite biological underpinnings that are influenced by intrapersonal, interpersonal, cultural, and psychological factors. For example, the DSM-5 requires consideration of the following factors during assessment and diagnosis of all sexual dysfunctions:
The DSM-5 also emphasizes that a diagnosis of sexual dysfunction is not to be made if severe relationship distress, partner violence, or significant stressors better explain the sexual difficulties. However, an appropriate V or Z code for the relationship problem or stressor may be listed. Some of these V or Z codes, properly designated as “Other Conditions That May Be a Focus of Clinical Attention,” include the following (DSM-5, pp. 715-727):
May 2013 Publication |
Effective October 2018 |
Diagnostic Criteria Coding note: …Note that the ICD-10-CM code depends on whether or not there is a comorbid substance use disorder present for the same class of substance.
[see DSM-5, p. 446] |
Diagnostic Criteria Coding note: …Note that the ICD-10-CM code depends on whether or not there is a comorbid substance use disorder present for the same class of substance. In any case, an additional separate diagnosis of a substance use disorder is not given…
[see DSM-5, p. 446] |
Changes to the DSM-5 include removal of the following specifiers:
Changes to the DSM-5 include addition of the following specifiers:
Use this category to communicate the specific reason that the presentation does not meet the criteria for any specific sexual dysfunction. This is done by recording “other specified sexual dysfunction” followed by the specific reason (e.g., “sexual aversion”).
Use this category for situations in which symptoms characteristic of a sexual dysfunction cause clinically significant distress or impairment in social, occupational, or other important areas of functioning, but do not meet the full criteria for any of the disorders listed in this diagnostic classification (chapter), and you are not able to specify because there is insufficient information to make a more specific diagnosis.
In the DSM-5, gender identity disorder is changed to gender dysphoria. The use of the word dysphoria properly conveys the intense feelings of depression and discontent that individuals experience when their physical body is incongruent with their manifest gender identification, as opposed to having psychological confusion regarding their gender identification (as suggested by the diagnosis title of gender identity disorder).
In her article “Sexuality in the DSM 5”, Elizabeth Boskey (2013) reported that during the revision process, activists from the transgender community were vocal on both sides of the question of how gender identity should be addressed in the DSM-5. While some advocated for the removal of gender identity disorder from the manual to signal the normalization of nonbinary gender identities within today’s society, others fought to retain it, concerned that securing insurance coverage for gender confirmation surgery (also known as gender reassignment surgery) would be even more difficult if the disorder was no longer diagnosable by mental health professionals. According to Jack Drescher, a member of the Sexual and Gender Identity Disorders Work Group for the DSM-5, a central tension in discussions about the diagnosis was between the possibly stigmatizing effect of retaining a category for gender conflicts among a list of mental disorders and the need to maintain access to care for individuals who experience distress or impairment in function related to gender conflicts. “We decided the access-to-care issue was very important,” Drescher said. “If you take out the diagnosis, you don’t have a code for treatment.”
Boskey further observed that the language used in the gender dysphoria criteria in the DSM-5 reflects both a more modern understanding of gender identity and the input of stakeholders. This can be seen quite clearly in the post-transition specifier, which looks at dysphoria that continues after an individual has transitioned to full-time living in the desired gender and has undergone (or is preparing to have) at least one cross-sex medical procedure or treatment regimen. In particular, the full specifier includes language describing gender reassignment surgery as “confirming the desired gender.” Many transgender individuals and activists prefer the term “gender confirmation surgery” over “sex reassignment surgery.” The term is seen as more accurately reflecting a construct in which gender is internal and inherent (the body can be changed to match it) rather than an external construct determined by the presence of a particular set of genitalia.
The DSM-5 provides a thorough discussion regarding the differences between early-onset gender dysphoria and late-onset gender dysphoria. Additionally, and importantly, the gender dysphoria criteria eliminate the sexual orientation specifiers found in DSM-IV-TR’s definition of gender identity disorder. This reflects a growing understanding that gender identity and sexual orientation are not inherently intertwined. In summary, changes to the previous gender identity disorder in the DSM-5 make the gender dysphoria diagnosis more restrictive and conservative. As Drescher notes, “It takes psychiatrists out of the business of labeling children or others simply because they show gender-atypical behavior.”
Additional highlights of changes to the former gender identity disorder in the DSM-5 include:
The DSM-5 now recognizes separate diagnostic criteria for children (ages 10 and younger), with six of the following eight symptoms required for a diagnosis:
Aversive attitudes
- Desire to be of other gender
- Dislike of anatomy
- Desire to have other sex characteristics
Aversive behaviors
- Cross-dressing
- Cross-gender fantasy
- Cross-gender play
- Cross-gender playmates
- Rejection of toys
- Games and activities typically associated with their gender
In contrast, adolescents (age 11 and older) and adults (age 18 and older) only need to meet two of the following six symptoms for a diagnosis:
Mental fixation
- Incongruence
- Conviction that one possesses feelings of the other gender
Strong desires
- To change
- To have sex characteristics of the other gender
- To be the other gender
- To be treated as the other gender
Use this category to communicate the specific reason that the presentation does not meet the criteria for gender dysphoria. This is done by recording “other specified gender dysphoria” followed by the specific reason (e.g., “brief gender dysphoria”). Another example includes:
The current disturbance meets symptom criteria for gender dysphoria, but the duration is less than 6 months.
Use this category for situations in which symptoms characteristic of gender dysphoria cause clinically significant distress or impairment in social, occupational, or other important areas of functioning, but do not meet the full criteria for any of the disorders listed in this diagnostic classification (chapter), and you are not able to specify because there is insufficient information to make a more specific diagnosis.
Appendix 10: Gender Dysphoria Differential Diagnosis
A new chapter in the DSM-5 covers disruptive, impulse-control, and conduct disorders, which are characterized by externalization of problems with negative emotionality and disinhibition. This new chapter represents a merging of two DSM-IV-TR chapters: “impulse control disorders not elsewhere classified” (which included intermittent explosive disorder, kleptomania, pathological gambling, pyromania, trichotillomania, and impulse-control disorder not otherwise specified) and the disruptive behavior disorders that were listed in the chapter titled “disorders usually first diagnosed in infancy, childhood or adolescence.” These included attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder and conduct disorder.
Not included in this new DSM-5 chapter are pathological gambling (now listed in the “substance-related and addictive disorders” chapter) and trichotillomania (now listed in the “obsessive-compulsive and related disorders” chapter because of its recurrent and repetitive manifestation). Because of its close association with conduct disorder, antisocial personality disorder has dual listing in this chapter and in the DSM-5 chapter on personality disorders. Although ADHD is frequently comorbid with the disorders in this chapter, it is listed with the neurodevelopmental disorders because it stems from biological problems with the brain functions that control emotions and learning and has onset in the developmental period.
When assessing and diagnosing these disorders, remember, “It is critical that the frequency, persistence, pervasiveness across situations and impairment associated with the behaviors indicative of the diagnosis be considered relative to what is normative for a person’s age, gender and culture” (DSM-5, pp. 461-462). This guidance helps you avoid pathologizing normative developmental behaviors.
The DSM-5 retains the prior Criterion A requirement of meeting a minimum of four out of eight possible symptoms to diagnose this disorder. What is new is that the eight symptoms are clustered to reflect both emotional and behavioral symptomatology.
The DSM-5 angry/irritable mood cluster contains the DSM-IV-TR symptoms 1) often loses temper, 6) is often touchy or easily annoyed (the DSM-5 removed the words “by others”) and 7) is often angry and resentful.
The DSM-5 argumentative/defiant behavior cluster contains the DSM-IV-TR symptoms 2) often argues with adults (the DSM-5 added language that this applies to children and adolescents and added the words “with authority figures” for adults), 3) often actively defies or refuses to comply with adults’ requests (the DSM-5 added the words “requests from authority figures”) or with rules, 4) often deliberately annoys people (“others” in the DSM-5) and 5) often blames others for his or her mistakes or misbehavior.
The DSM-5 vindictiveness cluster contains the DSM-IV-TR symptom 8) is often spiteful or vindictive (with added language “at least twice within the past six months”).
Language was added to Criterion A (“… and exhibited during interaction with at least one individual who is not a sibling”) so normative family systems experiences will not be pathologized. Another important note has been added to Criterion A that further restricts the diagnosis by indicating that oppositional and defiant behavior persistence, frequency, and intensity should be used to differentiate normative expressions from symptomatic expressions that are uncharacteristic for the individual’s developmental level, gender, and culture. Additional diagnostic guidelines include the following:
For children younger than age five, the behavior must occur on most days for six months.
For children age five and older, the behavior must occur at least once per week for six months.
Language was added to Criterion B that expands the disturbance in behavior to include “distress in the individual or others in his or her immediate social context (e.g., family, peer group, work colleagues).” Criterion C contains new language excluding the diagnosis of oppositional defiant disorder during the course of a substance use disorder or disruptive mood dysregulation disorder.
The DSM-5 removed the previous Criterion D, which excluded comorbidity with conduct disorder.
Oppositional defiant disorder in the DSM-5 also contains three new severity specifiers that reflect the number of settings in which the symptoms are manifest (for example, at home, at school, at work, or with peers). Mild indicates symptoms are confined to one setting, moderate indicates symptoms are present in at least two settings, and severe indicates symptoms are present in three or more settings. Remember that the most frequent settings are at home and only with family members. The Clinician-Rated Severity of Oppositional Defiant Disorder can be used to rate the severity of oppositional defiant problems as experienced by the individual in the past seven days. This measure is intended to capture meaningful variation in the severity of symptoms that may help with treatment planning and prognostic decision-making.
The DSM-5 presents entirely new language for Criterion A for this disorder, requiring either of the following:
Additional changes include:
A new note in the DSM-5 indicates that intermittent explosive disorder may be comorbid with ADHD (it was mutually exclusive in the DSM-IV-TR), oppositional defiant disorder, conduct disorder, or autism spectrum disorder if the symptoms are in excess and warrant independent clinical attention.
The criteria for conduct disorder in the DSM-5 are largely unchanged from the DSM-IV-TR. You will find the same 15 possible symptoms and associated clusters word for word, the same types (childhood-onset and adolescent-onset, with one new type, unspecified onset, when insufficient information is present to determine the age of onset) and the same severity specifiers. What is new are examples for the severity specifiers: lying, truancy, staying out after dark without permission, and other rule-breaking for mild; stealing without confronting the victim and vandalism for moderate; forced sex, physical cruelty, use of a weapon, stealing while confronting the victim, and breaking and entering for severe). Clinicians can use the Clinician-Rated Severity of Conduct Disorder to assist with capturing meaningful variation in the severity of symptoms.
Also new is a descriptive specifier to convey additional information about treatment planning: with limited prosocial emotions. Originally, the DSM-5 ADHD and Disruptive Behavior Disorders Work Group called the specifier callous and unemotional. This was done to specify traits commonly discussed in the peer-reviewed literature regarding this subset of persistently antisocial and violent youth who show lack of empathy and shallow affect across multiple settings and relationships, and who tend to have a more severe form of the disorder, thus resulting in different treatment response. However, parental advocacy groups voiced concern about the potential for stigmatizing youth with this label. In response, the DSM-5 work group settled on the term with limited prosocial emotions.
According to Dolan’s (2008) article “Neurobiological Disturbances in Callous-Unemotional Youths,” “There is growing evidence from genetic, cognitive and emotional information processing studies that callous-unemotional traits may be associated with a unique neurobiological developmental trajectory toward persistent antisocial behavior.” The author noted that youths with prominent callous-unemotional traits seem to have a unique temperamental style characterized by fearlessness and thrill-seeking. Their behavior is relatively stable and is associated with a more severe and persistent pattern of antisocial behavior, including instrumental aggression.
To qualify for this specifier, youths must display at least two characteristics over 12 months in multiple settings and relationships from the following four options (DSM-5, pp. 470-471):
The DSM-5 further requires you to use multiple information sources and to consider reports by others who have known the individual for extended periods of time, such as parents, teachers, co-workers, extended family members, and peers.
Pardini and colleagues (2012) found that girls with the limited prosocial emotions subtype of CD had higher levels of externalizing disorder symptoms, bullying, relational aggression, and global impairment than girls with CD alone. Girls with CD alone tended to have more anxiety problems than girls manifesting the with limited prosocial emotions subtype of CD. In conclusion, the proposed DSM-5 with limited prosocial emotions subtype of CD identifies young girls who exhibit lower anxiety problems and more severe aggression, CD symptoms, academic problems, and global impairment across time than girls with CD alone.
Latzman and colleagues (2013) found significant unique associations of personality trait/temperament dimensions with limited prosocial emotions total and subscale scores. Furthermore, specific personality dimensions differentially and uniquely predicted various with limited prosocial emotions subscales, indicating marked specificity in association such that these traits should be considered separately rather than as a single unit. Taken together, these results confirm the importance of considering traditional personality trait models to understand “callous and unemotional” traits and risk for psychopathy more fully.
A 16-year-old female, Yolanda, presented for substance abuse and mental health treatment after being ordered into my counseling practice for displaying high levels of externalizing disorder symptoms, bullying, relational aggression, and chronic substance use. Her admission evaluation included a variety of assessment measures, most notably the DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure-Child Age 11-17, the Clinician-Rated Severity of Conduct Disorder and the Millon Adolescent Clinical Inventory (MACI). Results from the MACI indicated the following clinical profile for Yolanda (notice the bold text that highlights key descriptors justifying the use of the new descriptive specifier with limited prosocial emotions).
Most notable is her inclination to act thoughtlessly and irresponsibly in peer and family matters and to be generally careless and imprudent, failing to plan ahead or to consider the consequences of her behavior. She may be prone to taking undue chances and seeking thrills, acting as if she were immune from danger. She tends to jump from one risky and momentarily gratifying escapade to another with little or no care for potentially detrimental consequences. Also salient are her failure to constrain or postpone the expression of offensive thoughts or malevolent actions, a deficit in guilt feelings, and a consequent disinclination to refashion repugnant impulses in sublimated form. She may perceive herself as a victim, a youthful bystander subjected to unjust family persecution and school hostility. Through this psychic maneuver, she not only disowns her malicious impulses but attributes 'acts of evil' to others. As a persecuted victim, she then feels free to counterattack and gain restitution and vindication.
Putting it all together, Yolanda’s DSM-5 diagnostic formulation was written in this manner:
F91.2 Severe Conduct Disorder, Adolescent-onset type, With Limited Prosocial Emotions (unconcerned about performance and lack of remorse or guilt)
F10.20 Severe Alcohol Use Disorder
Z55.9 Academic or Educational Problem (receiving failing marks or grades)
Z65.3 Problems Related to Other Legal Circumstances (failure to comply with prior probation requirements)
Z62.820 Parent-Child Relational Problem (arguments that escalate to physical violence on behalf of client)
Criteria and text for antisocial personality disorder can be found in the chapter “Personality Disorders.” Because this disorder is closely connected to the spectrum of “externalizing” conduct disorders in this chapter, as well as to the disorders in the adjoining chapter “Substance-Related and Addictive Disorders,” it is dual coded here as well as in the chapter “Personality Disorders.”
No changes from DSM-IV-TR.
No changes from DSM-IV-TR.
Use this category to communicate the specific reason that the presentation does not meet the criteria for any specific disruptive, impulse-control, and conduct disorder. This is done by recording “other specified disruptive, impulse-control, and conduct disorder” followed by the specific reason (e.g., “recurrent behavioral outbursts of insufficient frequency”).
Use this category for situations in which symptoms characteristic of disruptive, impulse-control, and conduct disorder cause clinically significant distress or impairment in social, occupational, or other important areas of functioning, but do not meet the full criteria for any of the disorders listed in this diagnostic classification (chapter), and you are not able to specify because there is insufficient information to make a more specific diagnosis.
See Appendix 4: Disruptive and Depressive Disorders Differential Diagnosis
Substance-related and behavioral addictive disorders receive a significant reconceptualization in the DSM-5. In this chapter, you will find detailed diagnostic criteria for 10 substance use disorders (former DSM-IV-TR abuse and dependence classifications), substance-induced disorders (same DSM-IV-TR intoxication, withdrawal, and other substance/medication-induced mental disorders), and non-substance-related disorders (DSM-IV-TR pathological gambling). I recommend reading the chapter introduction for an explanation as to why other behavioral addictions (e.g., sex addiction, exercise addiction, or shopping addiction) are not recognized in the DSM-5.
May 2013 Publication |
Effective October 2017 |
Alcohol; Cannabis; Phencyclidine; Other Hallucinogen; Inhalant; Opioid; Sedative, Hypnotic, or Anxiolytic; Stimulant; Tobacco; & Other (or Unknown) Substance Use Disorder Code based on current severity:
Specify current severity: Mild: Presence of 2-3 symptoms.
Moderate: Presence of 4-5 symptoms.
Severe: Presence of 6 or more symptoms.
[see DSM-5, pp. 491, 510, 521, 524, 534, 542, 552, 562, 572, 576] |
Alcohol; Cannabis; Phencyclidine; Other Hallucinogen; Inhalant; Opioid; Sedative, Hypnotic, or Anxiolytic; Stimulant; Tobacco; & Other (or Unknown) Substance Use Disorder Code based on current severity/remission: Specify current severity/remission: Mild: Presence of 2-3 symptoms. Mild, In early remission Mild, In sustained remission Moderate: Presence of 4-5 symptoms. Moderate, In early remission Moderate, In sustained remissionSevere: Presence of 6 or more symptoms. Severe, In early remission Severe, In sustained remission [see DSM-5, pp. 491, 510, 521, 524, 534, 542, 552, 562, 572, 576] |
The DSM-5 collapsed the DSM-IV-TR classifications of abuse and dependence into one classification: use. There are many limitations to the dichotomous classification used in DSM-IV-TR that the DSM-5 rectifies:
A growing body of scientific evidence favors dimensional concepts in the diagnosis of mental disorders, as opposed to categorical concepts used in prior DSM versions. Excessive comorbidity, boundary disputes, and disproportionate use of the NOS categories undermine the hypothesis that DSM-defined disorders represent distinct entities (see Jones, 2012).
Individuals have made the erroneous assumption that substance abuse is distinctively different from substance dependence, especially with dependence representing a more severe manifestation of problematic substance use behavior; when in actuality there are conditions in which substance abuse is worse than substance dependence.
Individuals, especially adolescents, who present with one or two symptoms of substance dependence do not qualify for that diagnosis because three symptoms minimum are required; yet they do not qualify for a substance abuse diagnosis - even though only one symptom is required – because the symptoms of dependence are mutually exclusive from abuse, thus creating what the literature refers to as “diagnostic orphans.”
Dependence is commonly confused as being synonymous with addiction to describe more extreme presentations. The more neutral term “use” in the DSM-5 describes the wide range of the disorder, from a mild form to a severe state of chronically relapsing and compulsive drug-taking. The word addiction is omitted from the DSM-5 diagnostic terminology because of its uncertain definition and its potentially negative connotation.
In the DSM-5, all 11 diagnostic criteria of DSM-IV-TR substance abuse and substance dependence are carried over - except for the abuse criterion recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct). The rationale for this removal is fourfold:
1. Recurrent legal problems may be a valid criminal justice marker, but it is not a valid clinical marker.
2. Recurrent legal problems was used by some professionals as the sine qua non symptom to diagnose abuse at the exclusion of other symptoms.
3. Embedding legal criteria into psychiatric criteria creates reliability challenges because substance use laws are not consistent between states and nations.
4. Recurrent legal problems are prone to social prejudice and injustice because some individuals may encounter higher rates of arrest or incarceration due to their age, gender, race, or socioeconomic status.
In replacement of the DSM-IV-TR recurrent legal problems criterion, the DSM-5 uses craving (DSM-IV-TR p. 192 mentions that individuals with substance dependence are likely to experience this symptom). According to the new manual “craving (Criterion 4) is manifested by an intense desire or urge for the drug that may occur at any time but is more likely when in an environment where the drug previously was obtained or used. Craving has also been shown to involve classical conditioning and is associated with activation of specific reward structures in the brain. Craving is queried by asking if there has ever been a time when they had such strong urges to take the drug that they could not think of anything else. Current craving is often used as a treatment outcome measure because it may be a signal of impending relapse” (DSM-5, p. 483).
In the DSM-5, a minimum of two of the 11 available criteria - representing various manifestations of impaired control, social impairment, risky use, or pharmacological dysregulation - are required to diagnose an individual with a substance use disorder. An important exception to remember is that “symptoms of tolerance and withdrawal occurring during appropriate medical treatment with prescribed medications (e.g., opioid analgesics, sedatives, stimulants) are specifically not counted when diagnosing a substance use disorder” (DSM-5, p. 483). Individuals need to manifest two of the nine remaining criteria to qualify for a substance use disorder diagnosis.
Severity ratings for the DSM-5 substance use disorders can change across time as reflected by reductions or increases in the frequency and/or the dose of substance use based on:
If the individual manifests two to three symptoms, the specifier mild is used; if the individual manifests four to five symptoms, the specifier moderate is used; if the individual manifests six or more symptoms, the specifier severe is used. I want to clarify that these specifiers are quantitative as opposed to qualitative - meaning they communicate the number of symptoms an individual manifests, not how problematic the substance use behavior is.
Additional changes to substance-related disorders in the DSM-5 include the following:
Use this category for situations in which symptoms characteristic of a substance-related disorder cause clinically significant distress or impairment in social, occupational, or other important areas of functioning, but do not meet the full criteria for any of the disorders listed in this diagnostic classification (chapter), and you are not able to specify because there is insufficient information to make a more specific diagnosis.
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Effective October 2018 |
Cannabis Withdrawal Coding note: The ICD-9-CM code is 292.0. The ICD-10-CM code for cannabis withdrawal
is F12.288. Note that the ICD-10-CM code indicates the comorbid presence of a moderate or severe cannabis use disorder, reflecting the fact that cannabis withdrawal can only occur in the presence of a moderate or severe cannabis use disorder. [see DSM-5, p. 518] |
Cannabis Withdrawal Coding note: The ICD-9-CM code is 292.0. The ICD-10-CM code for cannabis withdrawal occurring in the presence of moderate or severe cannabis use disorder is F12.23. For cannabis withdrawal occurring in the absence of a cannabis use disorder (e.g., in a patient taking cannabis solely under appropriate medical supervision), the ICD-10-CM code is F12.93. [see DSM-5, p. 518] |
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Effective October 2018 |
Opioid Withdrawal Coding note: The ICD-9-CM code is 292.0. The ICD-10-CM code for cannabis withdrawal is F11.23. Note that the ICD-10-CM code indicates the comorbid presence of a moderate or severe opioid use disorder, reflecting the fact that opioid withdrawal can only occur in the presence of a moderate or severe opioid use disorder. [see DSM-5, p. 548] |
Opioid Withdrawal Coding note: The ICD-9-CM code is 292.0. The ICD-10-CM code for cannabis withdrawal occurring in the presence of moderate or severe opioid use disorder is F11.23. For opioid withdrawal occurring in the absence of a cannabis use disorder (e.g., in a patient taking opioids solely under appropriate medical supervision), the ICD-10-CM code is F11.93. [see DSM-5, p. 548] |
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Effective October 2018 |
Sedative, Hypnotic, or Anxiolytic Withdrawal Coding note: The ICD-9-CM code is 292.0. The ICD-10-CM code for sedative, hypnotic, or anxiolytic withdrawal depends on whether or not there is a comorbid moderate or severe sedative, hypnotic, or anxiolytic use disorder and whether or not there are perceptual disturbances. For sedative, hypnotic, or anxiolytic withdrawal without perceptual disturbances, the ICD-10-CM code is F13.239. For sedative, hypnotic, or anxiolytic withdrawal with perceptual disturbances, the ICD-10-CM code is F13.232. Note that the ICD-10-CM codes indicate the comorbid presence of a moderate or severe sedative, hypnotic, or anxiolytic use disorder, reflecting the fact that sedative, hypnotic, or anxiolytic withdrawal can only occur in the presence of a moderate or severe sedative, hypnotic, or anxiolytic use disorder. It is not permissible to code a comorbid mild sedative, hypnotic, or anxiolytic use disorder with sedative, hypnotic, or anxiolytic withdrawal.
[see DSM-5, p. 558] |
Sedative, Hypnotic, or Anxiolytic Withdrawal Coding note: The ICD-9-CM code is 292.0. The ICD-10-CM code For sedative, hypnotic, or anxiolytic withdrawal without perceptual disturbances: If a moderate or severe sedative, hypnotic, or anxiolytic use disorder is comorbid, the ICD-10-CM code is F13.239. If there is no comorbid sedative, hypnotic, or anxiolytic use disorder, then the ICD-10-CM code is F13.939. [see DSM-5, p. 558] |
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Effective October 2018 |
Stimulant Withdrawal Coding note: The ICD-9-CM code is 292.0. The ICD-10-CM code depends on whether the stimulant is an amphetamine, cocaine, or other stimulant. The ICD-10-CM code for amphetamine or other stimulant withdrawal is F15.23, and the ICD-10-CM code for cocaine withdrawal is F14.23. Note that the ICD-10-CM code indicates the comorbid presence of a moderate or severe amphetamine, cocaine, or other stimulant use disorder, reflecting the fact that amphetamine, cocaine, or other stimulant withdrawal can only occur in the presence of a moderate or severe amphetamine, cocaine, or other stimulant use disorder. [see DSM-5, p. 569] |
Stimulant Withdrawal Coding note: The ICD-9-CM code is 292.0. The ICD-10-CM code depends on whether the stimulant is an amphetamine, cocaine, or other stimulant. The ICD-10-CM code for amphetamine or other stimulant withdrawal occurring in the presence of moderate or severe amphetamine or other stimulant use disorder is F15.23, and the ICD-10-CM code for cocaine withdrawal occurring in the presence of moderate or severe cocaine use disorder is F14.23. For amphetamine or other stimulant withdrawal occurring in the absence of an amphetamine or other stimulant use disorder (e.g., in a patient taking amphetamines solely under appropriate medical supervision), the ICD-10-CM code is F15.93. [see DSM-5, p. 569] |
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Effective October 2018 |
Other (or Unknown) Substance Withdrawal Coding note: The ICD-9-CM code is 292.0. The ICD-10-CM code for other (or unknown) substance withdrawal
is F19.239. Note that the ICD-10-CM code indicates the comorbid presence of a moderate or severe other (or unknown) substance use disorder. [see DSM-5, p. 583] |
Other (or Unknown) Substance Withdrawal Coding note: The ICD-9-CM code is 292.0. The ICD-10-CM code for other (or unknown) substance withdrawal occurring in the presence of moderate or severe other (or unknown) substance use disorder is F19.239. For other (or unknown) substance use withdrawal occurring in the absence of an other (or unknown) substance use disorder (e.g., in a patient taking an other (or unknown) substance solely under appropriate medical supervision), the ICD-10 CM code is F19.939. [see DSM-5, p. 583] |
These intoxication and withdrawal syndromes are retained from DSM-IV-TR. Intoxication does not apply to tobacco, yet the DSM-5 acknowledges tobacco-induced sleep disorder discussed in the sleep-wake disorders chapter (see substance/medication-induced sleep disorder). You are strongly encouraged to become familiar with the DSM-5 Table 1: Diagnoses associated with substance class (p. 482). The DSM-5 further retains DSM-IV-TR substance/medication-induced mental disorders (i.e., mood disturbances, anxiety syndromes, psychotic symptoms, suicide attempts, sexual dysfunctions, and disturbed sleep).
Remember that the DSM-5 is not the official coding system (it is a classification system). The official coding system used in the United States at the time of the DSM-5 publication was the ninth revision of the ICD. The tenth revision of the ICD was implemented in the United States on October 1, 2015. After this date, the appropriate ICD-10 code for a substance use disorder depends on whether there is a comorbid substance-induced disorder (including intoxication and withdrawal). Because ICD-10 codes for substance-induced disorders indicate both the presence (or the absence) and severity of the substance use disorder, ICD-10 codes for substance use disorders can be used only in the absence of a substance-induced disorder. You are encouraged to see the substance-specific sections for additional coding information.
Dawson and colleagues (2013) found that the profiles of individuals with DSM-IV-TR dependence and the DSM-5 Severe Alcohol Use Disorder were almost identical. In contrast, the profiles of individuals with the DSM-5 Moderate Alcohol Use Disorder and DSM-IV-TR abuse differed substantially. The former endorsed more alcohol use disorder criteria, had higher rates of physiological dependence, were less likely to be White individuals and men, had lower incomes, were less likely to have private and more likely to have public health insurance, and had higher levels of comorbid anxiety disorders than the latter. In conclusion, similarities between the profiles of DSM-IV-TR and the DSM-5 AUD far outweigh differences; however, you may face some changes with respect to appropriate screening and referral for cases at the milder end of the AUD severity spectrum.
Compton and colleagues (2013) found that for DSM-IV-TR alcohol, cocaine, and opioid dependence, optimal concordance occurred when 4-plus DSM criteria were endorsed, corresponding to the threshold for moderate. Maximal concordance of DSM-IV-TR cannabis dependence and cannabis use disorder occurred when 6-plus criteria were endorsed, corresponding to the threshold for severe. Moreover, sensitivity and specificity generally exceeded 85% (>75% for cannabis). In conclusion, there is an excellent correspondence of DSM-IV-TR dependence with the DSM-5 substance use disorders.
Peer and colleagues (2013) found modestly greater prevalence for the DSM-5 SUDs based largely on the assignment of the DSM-5 diagnoses to DSM-IV-TR “diagnostic orphans.” The vast majority of these diagnostic switches were attributable to the requirement that only two of 11 criteria be met for a DSM-5 SUD diagnosis. They also found evidence to support the omission from the DSM-5 of the legal criterion. The addition of craving as a criterion in the DSM-5 did not substantially affect SUD diagnosis. In conclusion, the greatest advantage of the DSM-5 for the diagnosis of SUDs appears to be its ability to capture diagnostic orphans.
Putting it all together, here is how you communicate substance-related disorders in their clinical formulation using the DSM-5 (sequencing from most severe to least severe):
F11.20 Severe Lortab Use Disorder, On Maintenance Therapy (Suboxone), Early Remission (principal diagnosis)
F12.20 Moderate Spice Use Disorder, Early Remission
F15.10 Mild Adderall Use Disorder, Sustained Remission
DSM-IV-TR pathological gambling found in the impulse-control disorders not elsewhere classified chapter is retained in the DSM-5 but renamed and moved into this chapter so as to reconceptualize it as a behavioral addiction. This change reflects “evidence that gambling behaviors activate reward systems similar to those activated by drugs of abuse and produce some behavioral symptoms that appear comparable to those produced by the substance use disorders” (DSM-5, p. 481). Criteria 1-9 used in the DSM-5 for the substance-related disorders are used for gambling disorder.
See Appendix 11 Substance-Related and Addictive Disorders Differential Diagnosis
In contrast to the DSM-IV-TR, the DSM-5 no longer uses the classification title “delirium, dementia, and amnestic and other cognitive disorders.” The preferred term is neurocognitive. Ganguli and her colleagues on the DSM-5 Neurocognitive Disorders (NCD) Work Group discussed in an article (2010) how they initially considered labeling this group of disorders “cognitive disorders.” Cognitive impairments are present in most mental disorders, including schizophrenia, bipolar disorder, depression, attention-deficit/hyperactivity disorder, and autism. But the NCD work group focused on those disorders for which the cognitive deficit is the primary one and is attributable to known structural or metabolic brain disease. Hence the designation neurocognitive. The addition of the prefix neuro provides further specificity because the term cognitive has a broad meaning in psychiatry and psychology, covering all mental representations of information processing, including all conscious activity. The term neurocognitive describes cognitive functions closely linked to particular brain regions, neural pathways, or cortical/subcortical networks in the brain.
Distinct features of NCDs include:
Additional associated features include:
The DSM-5 retains DSM-IV-TR delirium (a disturbance in attention, awareness, and cognition) as a diagnosis that can result from substance intoxication, substance withdrawal, medication, another medical condition, or multiple etiologies. Delirium can now be course specified as acute (lasting a few hours or days) or persistent (lasting weeks or months) and descriptive specified as hyperactive, hypoactive, or mixed level of activity.
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Effective October 2018 |
Diagnostic Criteria
[see DSM-5, p. 597] |
Diagnostic Criteria [see DSM-5, p. 597] |
Use this category to communicate the specific reason that the presentation does not meet the criteria for delirium or any specific neurocognitive disorder. This is done by recording “other specified delirium” followed by the specific reason (e.g., “attenuated delirium syndrome”).
Use this category for situations in which symptoms characteristic of delirium cause clinically significant distress or impairment in social, occupational, or other important areas of functioning, but do not meet the full criteria for any of the disorders listed in this diagnostic classification (chapter), and you are not able to specify because there is insufficient information to make a more specific diagnosis.
An additional change in the DSM-5 is the use of “mild” and “major” to represent the spectrum, or dimension, of neurocognitive disorder (NCD) presentations – particularly the prodromal symptom manifestations that persist beyond normal aging and that are of concern to family members and close friends of affected individuals. This is similar to what we see in psychotic and schizophrenia spectrum disorders.
The concept of mild NCD is not of recent origin. The DSM-IV-TR (published in 2000) presented mild NCD in Appendix B: Criteria Sets and Axes Provided for Further Study. According to Dan Blazer, who co-chaired the DSM-5 Neurocognitive Disorders Work Group after Dilip V. Jeste was elected American Psychiatric Association president-elect in early 2011, “The movement to diagnose NCDs upstream reflects an emerging literature that confirms both the improvement in early diagnostic determinations and the recognition that the neuropathology underlying these disorders emerges well before the onset of clinical symptoms.” Blazer further commented in the American Journal of Psychiatry that “In the Alzheimer’s field, where it goes by the name of ‘mild cognitive impairment,’ this is a train that has already left the station. Our work group included a neurologist (Ronald Peterson) who informed us that if we did not have this category, we would be very much behind what is going on in the mainstream of Alzheimer’s treatment and research.” Mild NCD is characterized by modest cognitive decline. The disorder does not interfere with an individual’s complex activities of daily living such as paying bills or managing medications, although greater effort, compensatory strategies, or accommodation may be required). Neuropsychological testing results for mild NCD are one to two standard deviations from the mean.
Major NCD syndrome provides consistency with the rest of medicine and with prior DSM editions and necessarily remains distinct to capture the care needs for this group. In contrast to mild NCD, major NCD is characterized by a significant cognitive decline that interferes with an individual’s activities of daily living and impairs independence. Results of neuropsychological testing on these individuals fall two or more standard deviations from the mean. However, the DSM-5 advises that “the distinction between major and mild NCD is inherently arbitrary, and the disorders exist along a continuum.” Major NCD replaces the term dementia in the DSM-5 and conveys a somewhat broader syndrome and underlying pathology compared with dementia. Differential diagnosis between mild and major NCD requires that you use the Table 1 Neurocognitive Domains in the DSM-5 to determine cognitive decline in 32 neuropsychological domains manifest in complex attention, executive function, learning and memory, language, perceptual-motor abilities, and social cognition. According to the manual, this table “provides for each of these key domains a working definition, examples of symptoms or observations regarding impairments in everyday activities, and examples of assessments. The domains thus defined, along with guidelines for clinical thresholds, form the basis on which the neurocognitive disorders, their levels and their subtypes may be diagnosed.” When diagnosing major NCD, you should specify current severity:
The DSM-5 requires the use of descriptive and severity specifiers to more precisely indicate the client’s symptom level and to promote clinical utility. For example, you should descriptively specify NCD without behavioral disturbance or with behavioral disturbance (psychotic symptoms, mood disturbance, agitation, apathy, or other behavioral symptoms). For mild NCD, behavioral disturbance cannot be coded but should still be indicated in writing.
The DSM-5 offers two new NCD designations: Probable and possible. Probable is added to the diagnostic title if there is evidence of a causative disease genetic mutation from either genetic testing, evidence of family history, evidence from laboratory blood testing, or evidence from neuroimaging. Possible is used if there is no evidence resulting from the previously mentioned probable objective factors (DSM-5). You also may use the retained DSM-IV-TR descriptive specifier, without or with behavioral disturbance to indicate the presence of psychotic symptoms, mood disturbance, agitation, apathy, or other behavioral symptoms.
The DSM-5 contains 10 etiological specifiers (formally referred to as subtypes in the DSM-IV-TR):
May 2013 Publication |
Effective October 2018 |
Coding note: …Note that the ICD-10-CM code depends on whether or not there is a comorbid substance use disorder present for the same class of substance.
[see DSM-5, p. 628] |
Coding note: …Note that the ICD-10-CM code depends on whether or not there is a comorbid substance use disorder present for the same class of substance. In any case, an additional separate diagnosis of a substance use disorder is not given… [see DSM-5, p. 628] |
Several other medical conditions can cause neurocognitive disorders (NCDs). These conditions include structural lesions, hypoxia-related to hypoperfusion from heart failure, endocrine conditions, nutritional conditions, other infectious conditions, immune disorders, hepatic or renal failure, metabolic conditions, and other neurological conditions.
This category is included to cover the clinical presentation of a neurocognitive disorder (NCD) for which there is evidence that multiple medical conditions have played a probable role in the development of the NCD.
Use this category for situations in which symptoms characteristic of delirium cause clinically significant distress or impairment in social, occupational, or other important areas of functioning, but do not meet the full criteria for any of the disorders listed in this diagnostic classification (chapter), and you are not able to specify because the precise etiology cannot be determined with sufficient certainty to make an etiological attribution.
Jaxson, a male client in his mid-40s who suffered three TBIs, each resulting from independent automobile accidents, presented for counseling. He presented with post-concussion syndromes reflected in physical symptoms (headaches, dizziness, fatigue, noise/light intolerance, insomnia, nausea, physical weakness), cognitive symptoms (memory complaints, poor concentration), and emotional symptoms (depression, anxiety, irritability, increased aggression, mood lability). Textual additions to the DSM-5 further helped me to understand the causal relationship between TBIs and major depressive episodes, facilitating a more accurate clinical formulation. The most salient DSM-5 diagnostic guidelines included the following (DSM-5):
With moderate and severe TBI, in addition to persistence of neurocognitive deficits, there may be associated neurophysiological, emotional and behavioral complications. These may include depression, sleep disturbance, fatigue, apathy, inability to resume occupational and social functioning at pre-injury level, and deterioration of interpersonal relationships.
Moderate and severe TBI have been associated with increased risk for depression.
Individuals with TBI histories report more depressive symptoms, and these can amplify cognitive complaints and worsen functional outcome.
There are clear associations, as well as some neuroanatomical correlates, of depression with…Traumatic Brain Injury.
Using the DSM-5’s Severity Ratings for TBI, three previously administered clinical neuropsychological tests, and the DSM-5’s Table 1 Neurocognitive Domains, Jaxson received the following dimensional diagnostic formulation:
F06.32 Moderate-Severe Depressive Disorder Due to TBI, with Major Depressive-Like Episode (see DSM-5, p. 181; coding rules require that a mental disorder due to another medical condition be listed first; see DSM-5, pp. 22-23).
Moderate-mild functional impairment (87 per self-administered World Health Organization Disability Assessment Schedule [WHODAS] 2.0; see DSM-5, pp. 745-748).
G31.84 Probable Mild Neurocognitive Disorder (NCD) Due to TBI (DSM-5, pp. 624-627).
Z56.9 Other Problem Related to Employment (recent change of job, underemployment and psychosocial stressors related to work due to TBI; see DSM-5, p. 723).
Z63.0 Relationship Distress with Spouse or Intimate Partner (due to TBI; see DSM-5, p. 716).
You should be aware of several changes that took effect in October 2013 concerning the NCD codes in the DSM-5. The World Health Organization’s International Classification of Diseases (ICD) coding system is subject to revisions at conferences held twice per year. The ICD is the official system of assigning codes to diagnoses in the United States, whereas the DSM-5 is a “user’s manual” on how to properly diagnose mental disorders and report coding as required by the ICD. According to this update, the coding changes ensure that insurance reimbursement can be obtained when the specifier with behavioral disturbance is used for the possible major NCDs. These changes require that etiological medical codes be coded first in major NCDs due to either probable or possible etiologies. The published codes for all major NCDs with possible medical etiologies should be replaced by the same codes used for their respective major NCDs with probable etiologies. The specific changes and updates to NCDs can be accessed at the APA’s DSM-5 website.
The DSM-5 retains all 10 DSM-IV-TR personality disorders, including Cluster A odd and eccentric, Cluster B dramatic and erratic, and Cluster C anxious and avoidant disorders with no changes to diagnostic criteria. The DSM-5 uses the DSM-IV-TR description of a General Personality Disorder that requires an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture - with two symptoms minimum manifest in cognition, affectivity, interpersonal relationships, or impulsivity.
Contrary to common understanding:
[P]ersonality disorder categories may be applied with children or adolescents in those relatively unusual instances in which the individual’s particular maladaptive personality traits appear to be pervasive, persistent, and unlikely to be limited to a particular developmental stage or another mental disorder. It should be recognized that the traits of a personality disorder that appear in childhood will often not persist unchanged into adult life. For a personality disorder to be diagnosed in an individual younger than 18 years, the features must have been present for at least one year. The one exception to this is an antisocial personality disorder, which cannot be diagnosed in individuals younger than 18 years (DSM-5, p. 647).
The essential feature of a personality change due to another medical condition is a persistent personality disturbance that is judged to be due to the direct pathophysiological effects of a medical condition. The particular personality change can be specified by indicating the symptom presentation that predominates in the clinical presentation – such as labile, disinhibited, aggressive, apathetic, paranoid, other, combined, or unspecified type.
The other specified personality disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific personality disorder. This is done by recording “other specified personality disorder” followed by the specific reason (e.g., “mixed personality features”).
Use this category for situations in which symptoms characteristic of a personality disorder cause clinically significant distress or impairment in social, occupational, or other important areas of functioning, but do not meet the full criteria for any of the disorders listed in this diagnostic classification (chapter), and you are not able to specify because there is insufficient information to make a more specific diagnosis.
The diagnostic approach used in the DSM-5 represents the categorical perspective that personality disorders are qualitatively distinct clinical syndromes. An alternative to the categorical approach is the dimensional perspective that personality disorders represent maladaptive variants of personality traits that merge imperceptibly into normality and into one another. See Alternative DSM-5 Model for Personality Disorders in Section III Emerging Measures and Models for a full description of a dimensional model for personality disorders. Remember that the proposed dimensional model for personality disorders is not required for clinical use but introduces a new approach that aims to address numerous shortcomings of the current approach to personality disorder by stimulating further research in this area. It is my personal opinion that the dimensional model will be implemented in DSM-6. As such, you are encouraged to not be concerned with this dimensional model at present and to continue assessing and diagnosing personality disorders as conducted with DSM-IV-TR.
In the DSM-5, paraphilias are now called paraphilic disorders. A paraphilia is necessary but not a sufficient condition in and of itself for having a paraphilic disorder. The DSM-5 requires subjective distress manifest in either of the following: The paraphilia involves another person’s psychological distress, injury or death, or it involves a desire for sexual behaviors with unwilling persons or persons unable to give legal consent. This two-pronged nature of diagnosing requires clinician-rated or self-rated measures and severity assessments that address the strength of the paraphilia itself or the seriousness of its consequences. Keep in mind that it is not rare for an individual to manifest two or more paraphilias.
The paraphilias also receive new classification schemas, or groupings, based on common expressions:
Anomalous Activity Preferences
- Courtship Disorders
- Voyeuristic Disorder (age 18+)
- Exhibitionistic Disorder
- Frotteuristic Disorder
Algolagnic Disorders
- Sexual Masochism Disorder
- Sexual Sadism Disorder
Anomalous Target Preferences
- Pedophilic Disorder
- Fetishistic Disorder
- Transvestic Disorder
The DSM-IV-TR limited transvestic disorder behavior to heterosexual males; the DSM-5 has no such restrictions. To enhance the specification of the respective diagnosis, all paraphilic disorders can be coded as “in a controlled environment” (institutional or other setting) and “in full remission” (being symptom-free for a minimum of five years). Pedophilic disorder is excluded from the use of these new specifiers.
The other specified paraphilic disorder category is used in situations in which the clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific paraphilic disorder. This is done by recording “other specified paraphilic disorder” followed by the specific reason (e.g., “zoophilia”). Other examples include:
Read more about these culturally sensitive descriptions on page 705 in your DSM-5.
Not included in the final publication of the DSM-5, but tested in the clinical field trials, was hypersexual disorder (sexual addiction). It included the following proposed symptomology:
A. Over a period of at least six months, recurrent and intense sexual fantasies, sexual urges or sexual behaviors in association with three or more of the following criteria:
- Time consumed by sexual fantasies, urges or behaviors repetitively interferes with other important (nonsexual) goals, activities, and obligations
- Repetitively engaging in sexual fantasies, urges, or behaviors in response to dysphoric mood states (e.g., anxiety, depression, boredom, irritability)
- Repetitively engaging in sexual fantasies, urges, or behaviors in response to stressful life events
- Repetitive but unsuccessful efforts to control or significantly reduce these sexual fantasies, urges, or behaviors
- Repetitively engaging in sexual behaviors while disregarding the risk for physical or emotional harm to self or others
B. There is clinically significant personal distress or impairment in social, occupational, or other important areas of functioning associated with the frequency and intensity of these sexual fantasies, urges, or behaviors.
C. These sexual fantasies, urges, or behaviors are not due to the direct physiological effect of an exogenous substance (e.g., a drug of abuse or a medication).
Specify if:
- Masturbation
- Pornography
- Sexual behavior with consenting adults
- Cybersex
- Telephone sex
- Strip clubs
- Other
In Kafka’s (2009) paper, “Hypersexual Disorder: A Proposed Diagnosis for DSM-V,” he stated, the “sexual addiction literature, while rich in description of individual sex addicts and possible treatments, has lacked a coherent codification for the specific hypersexual behaviors that are reliably or consistently reported in clinical or research reports.” Hence, the disorder is not included as a formal diagnosis in the DSM-5.
If you need a diagnosis to account for sexually addictive behavior in clients, I suggest ruling out borderline personality disorder and histrionic personality disorder even though hypersexuality is characteristic of both disorders. Remember that hypersexuality is core to manic and hypomanic episodes, so proficient ruling out for bipolar I or II disorders is strongly encouraged. For example, as detailed in the DSM-5, manic/hypomanic episodes are characterized by:
excessive involvement, high potential for painful consequences; sexuality and sexual indiscretions, increased sexual drive, fantasies, and behavior are often present; often disregarding the risk of sexually transmitted disease or interpersonal consequences; sexual promiscuity, infidelity or indiscriminate sexual encounters; haphazard enthusiasm for sexual interactions; poor judgment, loss of insight, and hyperactivity (pp. 128-129).
This residual category applies to presentations in which symptoms characteristic of a mental disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet the full criteria for any other mental disorder in the DSM-5. Classifications include:
For example, dissociative symptoms due to complex partial seizures would be coded and recorded as 345.40 (G40.209) complex partial seizures, 294.8 (F06.8) other specified mental disorder due to complex partial seizures, dissociative symptoms.
For example, dissociative symptoms due to complex partial seizures would be coded and recorded as 345.40 (G40.209) complex partial seizures, 294.9 (F06.9) unspecified mental disorder due to complex partial seizures.
Use this category to communicate the specific reason that the presentation does not meet the criteria for any specific mental disorder. This is done by recording “other specified mental disorder” followed by the specific reason.
Use this category for situations in which symptoms characteristic of a mental disorder cause clinically significant distress or impairment in social, occupational, or other important areas of functioning, but do not meet the full criteria for any of the disorders listed in this diagnostic classification (chapter), and you are not able to specify because there is insufficient information to make a more specific diagnosis (e.g., in emergency room settings).
V71.09 (Z03.89) No Diagnosis or Condition
Although the conditions and problems listed in this chapter are not mental disorders, they warrant your awareness because of their frequent importance in 1) the management by medication of mental disorders or other medical conditions and 2) the differential diagnosis of mental disorders (e.g., anxiety disorder versus neuroleptic-induced akathisia; malignant catatonia versus neuroleptic malignant syndrome). This section contains all syndromes listed in DSM-IV-TR Appendix B: Criteria Sets and Axes Provided for Further Study (pp. 735-751). These include:
Neuroleptic-Induced Parkinsonism
Other Medication-Induced Parkinsonism
Neuroleptic Malignant Syndrome
Medication-Induced Acute Dystonia
Medication-Induced Acute Akathisia
Tardive Dyskinesia
Tardive Dystonia
Tardive Akathisia
Medication-Induced Postural Tremor
Other Medication-Induced Movement Disorder
Antidepressant Discontinuation Syndrome
This is the only new classification in this section. To learn more about characteristic differences between unanticipated initial reactions, unexpected reactions, discontinuation reactions, unsuccessful discontinuation reactions, and sensitization reactions, I recommend reading the following article:
H. Gray Otis and Jason H. King (2006) Unanticipated Psychotropic Medication Reactions. Journal of Mental Health Counseling: July 2006, Vol. 28, No. 3, pp. 218-240.
This article also reviews collaborative treatment, ethical scope of practice, cautionary perspectives, and psychopharmacology resources – all within the context of an illustrative client example.
Use this category to code side effects of medication (other than movement symptoms) when these adverse effects become a main focus of clinical attention. Examples include severe hypotension, cardiac arrhythmias, and priapism.
This DSM-5 chapter covers psychosocial factors that may otherwise affect the diagnosis, course, prognosis, or treatment of a client’s mental disorder. These conditions are presented with their corresponding codes from ICD-9-CM (usually V codes) and ICD-10-CM (usually Z codes). A condition or problem in this chapter may be coded if it is a reason for the current visit or helps to explain the need for a test, procedure, or treatment. Conditions and problems in this chapter may also be included in the medical record as useful information on circumstances that may affect the patient’s care, regardless of their relevance to the current visit. The conditions and problems listed in this chapter are not mental disorders. Their inclusion in the DSM-5 is meant to draw attention to the scope of additional issues that may be encountered in routine clinical practice and to provide a systematic listing that may be useful to you in documenting these issues.
The DSM-5 added more than 100 new V/Z codes and you are encouraged to read pages 715-727 to become familiar with all of the conditions that may be a focus of clinical attention. They are presented in the following major categories (with a sample of new conditions bullet-pointed):
Relational Problems
Abuse and Neglect
Housing and Economic Problems
Other Problems Related to the Social Environment
Problems Related to Crime or Interaction with the Legal System
Other Health Service Encounters for Counseling and Medical Advice
Problems Related to Other Psychological, Personal, and Environmental Circumstances
Other Circumstances of Personal History
Problems Related to Access to Medical and Other Health Care
This section contains tools and techniques to enhance your clinical decision-making process, understand the cultural context of mental disorders, and recognize emerging diagnoses for further study.
A growing body of scientific evidence favors dimensional concepts in the diagnosis of mental disorders.
These are patient or informant-rated measures that assess mental health domains that are important across psychiatric diagnoses. They help you identify additional areas of inquiry that may have a significant impact on your client’s treatment and prognosis. In addition, these measures may be used to track changes in your client’s symptom presentation over time – thus serving as process and outcome measures as part of evidence-based clinical practice.
Dimensional assessments capture meaningful variation in the severity of symptoms, which may help with your treatment planning, prognostic decision-making, and research on pathophysiological mechanisms.
Each item on the self-administered version of the WHODAS 2.0 asks the individual to rate how much difficulty he or she has had in specific areas of functioning during the past 30 days.
Understanding the cultural context of your client’s experience is essential for effective diagnostic assessment and clinical management. DSM-5 not only includes an updated version of the Outline for Cultural Formulation introduced in DSM-IV-TR, but also presents an approach to assessment, using the Cultural Formulation Interview (CFI), which has been field-tested for diagnostic usefulness among clinicians and for acceptability among patients. Assessment categories include:
The Cultural Formulation Interview (CFI) is a set of 16 questions that clinicians may use to obtain information during a mental health assessment about the impact of culture on key aspects of an individual’s clinical presentation and care.
The CFI–Informant Version collects collateral information from an informant who is knowledgeable about the clinical problems and life circumstances of your client(s).
Cultural concepts of distress refers to ways that cultural groups experience, understand, and communicate suffering, behavioral problems, or troubling thoughts and emotions. These concepts replace the limiting DSM-IV-TR terminology culture-bound syndrome, and include:
May 2013 Publication |
Effective August 2015 |
Obsessive-Compulsive Personality Disorder Proposed Diagnostic Criteria B. [see DSM-5, p. 768] |
Obsessive-Compulsive Personality Disorder Proposed Diagnostic Criteria B. [see DSM-5, p. 768] |
In the alternative DSM-5 model, personality disorders are characterized by impairments in personality functioning and pathological personality traits that include:
These proposed criteria sets are not intended for clinical use; only the criteria sets and disorders in Section II of the DSM-5 are officially recognized and can be used for clinical purposes. Proposed criteria sets are presented for conditions on which future research is encouraged.
One of the goals of this proposal was to identify for the purpose of early identification and treatment individuals likely to progress to a full psychotic disorder.
May 2013 Publication |
Effective August 2015 |
Depressive Episodes With Short Duration Hypomania Proposed Diagnostic Criteria A. [see DSM-5, p. 787] |
Depressive Episodes With Short Duration Hypomania Proposed Diagnostic Criteria A. [see DSM-5, p. 787] |
Experienced at least one major depressive episode and at least two episodes of hypomania that meet all criteria other than the four-day duration.
Lasting at least 12 months for adults and six months for children.
Proposed in large part to stimulate much-needed research on the prevalence and consequences of significantly problematic caffeine use.
Already established as a significant problem in China and other Asian countries, but its inclusion here will hopefully lead to more research in Western populations.
Developed to capture impairments in cognition, self-regulation, and adaptive functioning that arise from exposure to alcohol in utero.
Describes individuals who have attempted suicide within the past two years and applies only to actual attempts, not suicidal ideation or preparatory behaviors.
Applied to individuals who display intentional self-harm behaviors unlikely to result in death, such as non-lethal cutting, burning, or stabbing oneself.
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The 10th chapter of the DSM-5, on elimination disorders, contains no changes from DSM-IV-TR.
The 18th chapter on personality disorders includes no changes to DSM-IV-TR criteria.
The 19th chapter on paraphilic disorders contains no alterations to criteria, although it does entail some important conceptual reformulations.
Regarding disruptive behavior diagnoses (conduct disorder and oppositional defiant disorder), APA Work Group Chair Dr. David Shaffer said changes to the criteria are designed to make the criteria considerably more specific than are DSM-IV-TR criteria. He also said the changes are expected to decrease the prevalence of the diagnosis. Specifically, the criteria for oppositional defiant disorder indicate that symptoms must be present more than once a week to distinguish the diagnosis from symptoms common to normally developing children and adolescents.
To improve precision regarding duration and severity and to reduce the likelihood of overdiagnosis, all of the DSM-5 sexual dysfunctions, except substance- or medication-induced sexual dysfunction, now require a minimum duration of approximately six months.
Regarding the new diagnosis of gender dysphoria for children, Criterion A1 (“a strong desire to be of the other gender or an insistence that he or she is the other gender”) is now necessary but not sufficient to meet the diagnosis, which makes the diagnosis more restrictive and conservative. According to Jack Drescher, a member of the DSM-5 Work Group On Sexual and Gender Identity Disorders, “It’s really a narrowing of the criteria because you have to want the diagnosis. It takes psychiatrists out of the business of labeling children or others simply because they show gender-atypical behavior.” Moreover, criteria for the new category emphasize the phenomenon of “gender incongruence” rather than cross-gender identification, as was the case in DSM-IV-TR. By separating gender dysphoria from sexual dysfunctions and paraphilias (with which it had previously been included in DSM-IV-TR in a chapter titled “Sex and Gender Identity Disorders”), work group members said they hope to diminish stigma attached to a unique diagnosis that is used by mental health professionals but for which treatment often involves endocrinologists, surgeons, and other professionals.
In a discussion about the new diagnosis of avoidant/restrictive food intake disorder, Timothy Walsh, Chair of the DSM-5 Eating Disorders Work Group, commented: “We have good data to indicate that if the criteria are rigorously applied by people familiar with the syndrome, only a relatively small number of people will meet the criteria. The lifetime prevalence of the disorder, we believe, is less than five percent, and we have good data that individuals who meet the criteria have a significantly higher frequency of anxiety and depression.”
Two new diagnoses – REM sleep behavior disorder and restless legs syndrome – have been added, which should significantly reduce the use of “Sleep Disorder-Not Otherwise Specified.” The criteria for insomnia include a frequency threshold of three nights per week and a duration of at least three months. The text also includes dimensional measures of severity.
For post-traumatic stress disorder (PTSD), there are now four symptom clusters in the DSM-5 (as opposed to three in DSM-IV-TR): re-experiencing, avoidance, persistent negative alterations in mood and cognition, and arousal. In the DSM-5, PTSD is now developmentally sensitive. Diagnostic thresholds have been lowered and criteria modified for children six and younger. Criteria for both acute stress disorder and PTSD are now more explicit concerning how the distressing or traumatic event was experienced: directly, witnessed or indirectly. The DSM-5 work group members believe the changes to the PTSD criteria are unlikely to affect the epidemiology of the disorder, but if there is any effect, it will be to lower the prevalence slightly.
To diagnose a substance abuse disorder in the DSM-IV-TR, individuals only needed to present with one criterion, whereas to diagnose a substance-related disorder in the DSM-5, individuals must present with a minimum of two criteria. And to avoid overdiagnosing substance abuse solely on legal involvement (as happened with the DSM-IV-TR), the DSM-5 replaced this criterion with craving.
In diagnosing schizophrenia, you will notice an important conceptual change from DSM-IV-TR. An individual can no longer meet Criterion A for psychosis with a single bizarre delusion, but must have a minimum of two symptoms – one of which must be one of the core psychotic symptoms of “delusions, hallucinations or disorganized thinking.”
Regarding the diagnosis of intellectual disability (formerly “mental retardation” in the DSM-IV-TR), the DSM-5 criteria mark a move away from relying exclusively on IQ scores and toward using additional measures of adaptive functioning. DSM-IV-TR criteria had required an IQ score of 70 as the cutoff for diagnosis. The new criteria recommend IQ testing and describe “deficits in adaptive functioning that result in failure to meet developmental and sociocultural standards for personal independence and social responsibility.”
The ninth chapter of the DSM-5 eliminates several diagnoses (somatization disorder, hypochondriasis, pain disorder and undifferentiated somatoform disorder), removes some redundancies and extraneous features in previous criteria, and more clearly delineates the separate diagnoses that make up this chapter. To diagnose an individual with somatic symptom disorder, the individual must be persistently symptomatic for at least six months, ruling out random or intermittent symptom presentations.
To diagnose bipolar-related disorders in the DSM-5, you must properly assess for and actively include an individual’s activity and energy level, in addition to the classic heightened and elevated mood symptom used in DSM-IV-TR. This diagnostic modification will lead to a reduction in the misdiagnosis of Bipolar Disorder in adolescents and adults, and challenges you to be more systematic in their diagnostic formulation.
The new diagnosis of disruptive mood dysregulation disorder should significantly reduce the overdiagnosis of bipolar disorder in children that occurred with DSM-IV-TR.
Chapter 2 of the DSM-5 contains the newly modified autism spectrum disorder (considered a neurodevelopmental disorder). The diagnostic criteria have been collapsed into two core symptoms, with one of the two containing two symptoms that must be met: deficits in social communication and social interaction (so, essentially, still three symptoms). The DSM-5 criteria were tested in real-life clinical settings as part of the field trials, and analysis from that testing indicated there will be no significant changes in the prevalence of autism spectrum disorder. More recently, the largest and most up-to-date study, published by Marisela Huerta et al. in the October 2012 issue of The American Journal of Psychiatry, provided the most comprehensive assessment of the DSM-5 criteria for autism spectrum disorder based on symptom extraction from previously collected data. The study found that DSM-5 criteria identified 91 percent of children with clinical DSM-IV-TR pervasive developmental disorder diagnoses. The remaining nine percent will be properly diagnosed as having a communication disorder, reducing the misdiagnosis of autism spectrum disorder.
With the DSM-5, several of an individual’s attention-deficit/hyperactivity disorder symptoms must be present prior to age 12, as compared to age seven in the DSM-IV-TR. However, this change is supported by substantial research published since 1994 that found no clinical differences between children identified by age seven versus later in life in terms of course, severity, outcome, or treatment response.
Regarding depressive disorders, the DSM-5 aims to provide an accurate diagnosis for people who need professional help and no diagnosis for those who do not. Therefore, several strategies are provided to help you in using the DSM-5 to differentiate major depression, “normal” bereavement, and pathological bereavement, including changes in diagnostic criteria as well as in the text.
It is true that diagnostic criteria for binge eating disorder in the DSM-5 reduce from twice per week to once per week for recurring episodes of eating significantly more food in a short period of time than most people would eat under similar circumstances. These episodes should also be marked by a feeling of lack of control.
The new DSM-5 diagnosis of mild or moderate neurocognitive disorder (dementia) reflects an attempt to move upstream toward identifying and diagnosing Alzheimer’s and other neurocognitive disorders earlier.
For acute stress disorder, previous DSM-IV-TR criteria requiring dissociative symptoms were too restrictive. Individuals can meet the DSM-5 diagnostic criteria for acute stress disorder if they exhibit any nine of 14 listed symptoms in these categories: intrusion, negative mood, dissociation, avoidance, and arousal. Yet these criteria reductions do not necessarily mean that rates of individuals qualifying for these diagnoses will increase as long as you balance this out with a focus on the entire person.
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SCHIZOPHRENIA SPECTRUM & OTHER PSYCHOTIC DISORDERS |
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DELUSIONAL DISORDER |
BRIEF PSYCHOTIC DISORDER |
SCHIZOPHRENIFORM DISORDER |
SCHIZOPHRENIA |
SCHIZOAFFECTIVE DISORDER |
PROFILE |
Fixed beliefs do not change, even when a person is presented with conflicting evidence. |
Emotional turmoil or overwhelming confusion. |
Identical to schizophrenia; however, lack of a criterion requiring impaired social and occupational functioning. |
A range of cognitive, behavioral, and emotional dysfunctions, but no single symptom is pathognomonic of the disorder; schizophrenia is a heterogeneous clinical syndrome. |
An uninterrupted period of illness during which the individual continues to display active or residual symptoms of psychotic illness. |
PRODROME |
Usually without. |
Usually without. |
Includes prodromal, active, and residual phases. |
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Usually without. |
ONSET |
Sudden (i.e., change from a nonpsychotic state to a clearly psychotic state within 2 weeks). |
Sudden (i.e., change from a nonpsychotic state to a clearly psychotic state within 2 weeks). |
Similar to that of schizophrenia. |
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DURATION |
> 1 month. |
< 1 month. |
> 1 month AND < 6 months; if the disturbance persists beyond 6 months, the diagnosis should be changed to schizophrenia. |
Continuous signs of the disturbance persist for at least 6 months. |
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CHRONICITY |
1 month. |
1 month. |
One-third of individuals recover within 6 months, the remaining two thirds eventually receive a diagnosis of schizophrenia or schizoaffective disorder. |
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DIAGNOSTIC CRITERIA |
5. |
3 (with 1 of 3 symptoms minimum - one must be either delusions, hallucinations, or disorganized speech). |
4 (with 2 of 5 symptoms minimum - one must be either delusions, hallucinations, or disorganized speech). |
6 (with 2 of 5 symptoms minimum - one must be either delusions, hallucinations, or disorganized speech). |
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DELUSIONS |
1 or more w/duration > 1 month. |
If present, at least 1 day but < than 1 month. |
If present, must be for a significant portion of time during a 1-month period. |
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Must be present for at least 2 weeks in the absence of a major mood episode (depressive or manic). |
HALLUCINATIONS |
If present, are not prominent and are related to the delusional theme. |
At least 1 day but < than 1 month. |
If present, must be for a significant portion of time during a 1-month period. |
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Must be present for at least 2 weeks in the absence of a major mood episode (depressive or manic). |
DISORGANIZED THINKING (SPEECH) |
None. |
At least 1 day but < than 1 month. |
If present, must be for a significant portion of time during a 1-month period. |
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Usually without. |
GROSSLY DISORGANIZED OR ABNORMAL MOTOR BEHAVIOR (INCLUDING CATATONIA) |
None. |
Not required but may be present. |
If present, must be for a significant portion of time during a 1-month period. |
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Usually without. |
NEGATIVE SYMPTOMS |
None. |
None. |
If present, must be for a significant portion of time during a 1-month period. |
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May be less severe and less persistent than those seen in schizophrenia. |
FUNCTIONAL IMPAIRMENT |
Is not markedly impaired, but can result in social isolation, marital instability, or occupational problems. |
Although brief, may be severe, but has eventual full return to premorbid level of functioning - outcome is excellent in terms of symptomatology. |
Impaired social and occupational functioning present but not required criterion. |
A constellation of signs and symptoms associated with significant impaired occupational and social functioning. |
Occupational functioning is frequently impaired, but this is not a defining criterion (in contrast to schizophrenia). |
COGNITIVE DEFICITS |
None. |
If present, brief (e.g., poor judgment). |
Confusion or perplexity. |
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Poor insight (i.e., anosognosia is also common in schizoaffective disorder, but the deficits in insight may be less severe and pervasive than those in schizophrenia. |
BEHAVIOR |
Is not obviously bizarre or odd; may be angry or violent and litigious or antagonistic. |
Increased risk of suicidal behavior. |
Dysfunction in several areas of daily functioning, such as school or work, interpersonal relationships, and self-care. |
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MANIC EPISODES |
Brief relative to the duration of the delusional periods. |
May have rapid shifts from one intense affect to another. |
No manic episodes have occurred concurrently with the active-phase symptoms. |
Mood symptoms and full mood episodes are common in schizophrenia and may be concurrent with active-phase symptomatology; however, a schizophrenia diagnosis requires the presence of delusions or hallucinations in the absence of mood episodes. |
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MAJOR DEPRESSIVE EPISODES |
Brief relative to the duration of the delusional periods; many develop irritable or dysphoric mood. |
None. |
No major depressive episodes have occurred concurrently with the active-phase symptoms. |
Mood symptoms and full mood episodes are common in schizophrenia and may be concurrent with active-phase symptomatology; however, a schizophrenia diagnosis requires the presence of delusions or hallucinations in the absence of mood episodes. |
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ASSOCIATED FEATURES |
There may be factual insight but no true insight. |
Poor judgment, cognitive impairment, or nutritional and hygienic deficiencies. |
If mood episodes have occurred during active-phase symptoms, they have been present for a minority of the total duration of the active and residual periods of the illness. |
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MUTUAL EXCLUSIVITY |
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KEY FEATURES THAT DEFINE THE PSYCHOTIC DISORDERS |
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Delusions |
Fixed beliefs that are not amenable to change in light of conflicting evidence. |
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Belief that one is going to be harmed, harassed, and so forth by an individual, organization, or other group. |
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Belief that certain gestures, comments, environmental cues, and so forth are directed at oneself. |
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When an individual believes that he or she has exceptional abilities, wealth, or fame. |
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When an individual believes falsely that another person is in love with him or her. |
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Involves the conviction that a major catastrophe will occur. |
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Focus on preoccupations regarding health and organ function. |
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Central theme is that of an unfaithful partner. |
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Clearly implausible and not understandable to same-culture peers and do not derive from ordinary life experiences. |
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Belief that one’s thoughts have been removed by some outside force. |
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Foreign thoughts have been put into one’s mind by some outside force. |
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Body or actions are being acted on or manipulated by some outside force. |
Hallucinations |
Perception-like experiences that occur without an external stimulus. They are vivid and clear, with the full force and impact of normal perceptions, and not under voluntary control. They may occur in any sensory modality. |
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Involving the perception of sound, most commonly of voices. |
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Involving the perception of taste (usually unpleasant). |
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Involving the perception of odor, such as of burning rubber or decaying fish. |
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Involving the perception of physical experience localized within the body (e.g., a feeling of electricity). |
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Involving the perception of being touched or of something being under one’s skin (e.g., something creeping or crawling on or under the skin). |
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Involving sight, which may consist of formed images, such as of people, or of unformed images, such as flashes of light. |
| Disorganized Thinking/Speech (formal thought disorder) | A persistent underlying disturbance to conscious thought and is classified largely by its effects on speech and writing. |
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The individual may switch from one topic to another. |
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Answers to questions may be obliquely related or completely unrelated. |
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Speech may be so severely disorganized that it is nearly incomprehensible and resembles receptive aphasia in its linguistic disorganization. |
| Grossly Disorganized or Abnormal Motor Behavior | May manifest itself in a variety of ways, ranging from childlike “silliness” to unpredictable agitation. Problems may be noted in any form of goal-directed behavior, leading to difficulties in performing activities of daily living. |
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Is a marked decrease in reactivity to the environment; resistance to instructions; maintaining a rigid, inappropriate or bizarre posture; complete lack of verbal and motor responses (mutism and stupor). It can also include purposeless and excessive motor activity without obvious cause (catatonic excitement). Other features are repeated stereotyped movements, staring, grimacing, mutism, and the echoing of speech. |
| Negative Symptoms | Reflect a diminution or loss of normal functions. Negative symptoms account for a substantial portion of the morbidity associated with schizophrenia but are less prominent in other psychotic disorders. |
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Reductions in the expression of emotions in the face, eye contact, intonation of speech (prosody), and movements of the hand, head, and face that normally give an emotional emphasis to speech. |
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Decreased self-initiated purposeful activities. When severe enough to be considered pathological, avolition is pervasive and prevents the person from completing many different types of activities (e.g., work, intellectual pursuits, or self-care). |
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Diminished speech output. There may be brief and concrete replies to questions and restriction in the amount of spontaneous speech (poverty of speech). Sometimes the speech is adequate in amount but conveys little information because it is overconcrete, overabstract, repetitive, or stereotyped (poverty of content). |
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Lack of interest in social interactions or a preference for solitary activities. |
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Loss of interest or pleasure from activities usually found enjoyable (e.g. exercise, hobbies, music, sexual activities, or social interactions). |
SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDERS DIFFERENTIAL DIAGNOSIS |
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If the client … |
Then the diagnosis may be … |
Reports a pattern of social AND interpersonal deficits marked by acute discomfort with, and reduced capacity for, close relationships as well as by cognitive or perceptual distortions AND eccentricities of behavior. |
Schizotypal (Personality) Disorder |
Reports the presence of 1 delusion with a duration of 1 month; AND HAS NEVER MANIFEST prominent hallucinations, disorganized speech, or negative symptoms; and functioning is NOT markedly impaired; AND behavior is NOT grossly bizarre, odd, disorganized, or catatonic behavior. |
Delusional Disorder |
Reports the presence of delusions, hallucinations, or disorganized speech; WITH a duration of 1 day to 1 month; WITH eventual full return to premorbid level of functioning. |
Brief Psychotic Disorder, without/ with marked stressors (brief reactive psychosis) |
Reports the presence of delusions, hallucinations, or disorganized speech; WITH a duration of 1 day to 1 month; WITH grossly bizarre, odd, disorganized, or catatonic behavior; WITH eventual full return to premorbid level of functioning. |
Brief Psychotic Disorder, with catatonia |
Reports the presence of delusions, hallucinations, or disorganized speech; WITH onset during pregnancy or within 4 weeks postpartum; WITH a duration of 1 day to 1 month; WITH eventual full return to premorbid level of functioning. |
Brief Psychotic Disorder, with peripartum onset |
Reports the presence of delusions, and/or hallucinations, and/or disorganized speech for a SIGNIFICANT PORTION of time during 1 month BUT LESS than 6 months; AND equivocal or no major depressive or manic episodes have occurred concurrently with the active-phase symptoms; BUT DOES NOT report marked functional impairment. |
Schizophreniform Disorder, with good prognostic features |
Reports the presence of delusions, and/or hallucinations, and/or disorganized speech, AND negative grossly bizarre, odd, disorganized, or catatonic behavior; AND mild-moderate negative symptoms for a SIGNIFICANT PORTION of time during 1 month BUT LESS than 6 months; AND equivocal or no major depressive or manic episodes have occurred concurrently with the active-phase symptoms:
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Schizophreniform Disorder, without good prognostic features |
Reports cognitive, emotional, and behavioral dysfunctions IN THE PRESENCE of delusions, and/or hallucinations, and/or disorganized speech; AND negative grossly bizarre, odd, disorganized, or catatonic behavior; AND moderate-severe negative symptoms for at least 6 months; AND equivocal or no major depressive or manic episodes have occurred concurrently with the active-phase symptoms; AND marked functional impairment. |
Schizophrenia |
Reports an uninterrupted period of illness AND the presence of delusions, and/or hallucinations, and/or disorganized speech, and/or negative grossly bizarre, odd, disorganized, or catatonic behavior; and/or negative symptoms; AND delusions or hallucinations for 2 or more weeks IN THE ABSENCE of a major depressive episode BUT WITH a manic episode present for the majority of the total duration of the active and residual portions of the illness. |
Schizoaffective Disorder, Bipolar Type |
| Reports an uninterrupted period of illness AND the presence of delusions, and/or hallucinations, and/or disorganized speech, and/or negative grossly bizarre, odd, disorganized, or catatonic behavior; and/or negative symptoms; AND delusions or hallucinations for 2 or more weeks IN THE ABSENCE of a manic episode BUT WITH a major depressive episode present for the majority of the total duration of the active and residual portions of the illness. | Schizoaffective Disorder, Depressive Type |
| Reports MANIC episode (3+ symptoms; 4 if the mood is only irritable) lasting at least 7 consecutive days AND present most of the day, nearly every day; AND delusions or hallucinations are present at any time in the episode. | Bipolar I Disorder, with psychotic features |
| Reports major depressive episode (5+ symptoms) lasting at least 14 consecutive days AND present most of the day, nearly every day; AND delusions or hallucinations are present at any time in the episode. | Major Depressive Disorder, with psychotic features |
| Reports INTRUSIVE hallucinations (visual or auditory) or NON-BIZARRE delusions (persecutory or nihilistic) IN THE CONTEXT of flashbacks AND/OR dissociative symptoms (depersonalization/ derealization) WITH a trauma-stressor theme IN THE PRESENCE OF intact reality testing. | Posttraumatic Stress Disorder, Acute Stress Disorder, Dissociative Identity Disorder, or Depersonalization/Derealization Disorder |
| Reports ONSET IN LATER LIFE of non-bizarre delusions (usually persecutory) or simple hallucinations (usually visual) WITHOUT disorganized speech and disorganized behavior IN THE CONTEXT of an acquired etiological syndrome (e.g., Alzheimer’s disease or Parkinson’s disease) RESULTING in a primary clinical deficit in cognitive function (e.g., complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) CAUSING decline from a previously attained level of functioning. | Major or Mild Neurocognitive Disorder, with behavioral disturbance |
| Reports TRANSIENT paranoid ideation MOST FREQUENTLY IN RESPONSE to real or imagined abandonment with the real or perceived return of the attachment figure RESULTING in symptom remission. | Borderline Personality Disorder |
BIPOLAR DISORDERS DIFFERENTIAL DIAGNOSIS |
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If the client … |
Then the diagnosis may be … |
Reports delusions or hallucinations for 2 or more weeks IN THE ABSENCE OF a major mood episode (depressive or manic) during the lifetime duration of the illness. |
Schizoaffective Disorder, Bipolar Type |
Reports MANIC episode (3+ symptoms; 4 if the mood is only irritable) lasting at least 7 consecutive days AND present most of the day, nearly every day. |
Bipolar I Disorder |
Reports the mood disturbance IS sufficiently severe to cause marked IMPAIRMENT in social or occupational functioning, or to necessitate HOSPITALIZATION to prevent harm to self or others, or there are PSYCHOTIC features. |
Bipolar I Disorder |
Reports HYPOMANIC episode (3+ symptoms; 4 if the mood is only irritable), lasting at least 4 consecutive days and present most of the day, nearly every day. |
Bipolar II Disorder |
Reports the mood disturbance is NOT severe enough to cause marked IMPAIRMENT in social or occupational functioning, or to necessitate HOSPITALIZATION, or there is an absence of PSYCHOTIC features. |
Bipolar II Disorder |
Reports a mood episode that is associated with an UNEQUIVOCAL change in functioning that is UNCHARACTERISTIC of the individual when not symptomatic. |
Bipolar II Disorder |
Reports for at least 2 years (at least 1 years for children and adolescents) criteria for a major depressive episode (5+ symptoms), a manic episode (3+ symptoms), or hypomanic episode (3+ symptoms) have NEVER BEEN MET. |
Cyclothymic Disorder |
DISRUPTIVE DISORDERS AND DEPRESSIVE DISORDERS DIFFERENTIAL DIAGNOSIS |
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DISRUPTIVE MOOD DYSREGULATION DISORDER |
PERSISTENT DEPRESSIVE DISORDER |
OPPOSITIONAL DEFIANT DISORDER |
INTERMITTENT EXPLOSIVE DISORDER |
PROFILE |
Presence of sad, empty, or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual’s capacity to function. |
Presence of sad, empty, or irritable mood, accompanied by somatic and cognitive changes that significantly affect the individual’s capacity to function. |
Problems in the self-control of emotions and behaviors that violate the rights of others (e.g., aggression, destruction of property) and/or that bring the individual into significant conflict with societal norms or authority figures. |
Problems in the self-control of emotions and behaviors that violate the rights of others (e.g., aggression, destruction of property) and/or that bring the individual into significant conflict with societal norms or authority figures. |
ONSET |
Prior to age 10 years. Common among children presenting to pediatric mental health clinics. |
Often early and insidious (i.e., in childhood, adolescence, or early adult life). |
The first symptoms usually appear during the preschool years and rarely later than early adolescence. |
Late childhood or adolescence and rarely begins for the first time after age 40 years. |
AGE LIMITS |
Restricted prior to age 6 years and after age 18 years. |
None. |
None. |
Restricted prior age 6 years. |
IRRITABLE MOOD |
Very severe persistent, chronic, non-episodic irritability and anger. |
Persistent irritability. |
Persistent irritability/anger (e.g., loses temper, is touchy or easily annoyed, and is angry and resentful). However, common for individuals to show behavioral features without negative mood. |
None. |
| TEMPER OUTBURSTS | Severe recurrent behavioral temper outbursts that are grossly out of proportion and are inconsistent with developmental level. | None. | None. | Severe damage or destruction of property and/or physical assault involving physical injury against animals or other individuals. |
| VERBAL OUTBURSTS | Severe recurrent verbal outbursts that are grossly out of proportion and are inconsistent with developmental level. | None. | Argumentative/defiant behavior (e.g., argues with adults, actively defies or refuses to comply with requests from authority figures or with rules, deliberately annoys others, blames others for his or her mistakes or misbehavior). | Less severe verbal aggression (e.g., temper tantrums, tirades, verbal arguments or fights). Outbursts typically last for less than 30 minutes. |
| PHYSICAL AGGRESSION | Consistently against property, self, or others. | None. | None. | Impulsive/anger-based toward property, animals, or other individuals. |
| SETTINGS | 2 minimum. |
1 minimum. | 1 minimum. |
1 minimum. |
| FREQUENCY |
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Irritable mood most of the day, for more days than not. |
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| DURATION | 12 months minimum. | 12 months minimum. | 6 months minimum. |
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| CHRONICITY | Characteristic of the child, being present most of the day, nearly every day, and noticeable by others in the child’s environment. Approximately half of children continue to meet criteria for the condition 1 year later. Symptoms are likely to change as children mature (i.e., unipolar major depression w/comorbid anxiety). | Symptoms have become a part of the individual’s day-to-day experience and have a chronic course. | Commonly show symptoms only at home and only with family members; often are part of a pattern of problematic interactions with others. | May be episodic or chronic and persistent over many years. |
| DIAGNOSTIC CRITERIA | 11 (with 0 of 0 symptoms minimum). | 8 (with 2 of 6 symptoms minimum). | 3 (with 4 of 8 symptoms minimum). | 6 (with 1 of 2 symptoms minimum). |
| MUTUAL EXCLUSIVITY | Autism spectrum disorder, bipolar disorder, persistent depressive disorder (dysthymia), posttraumatic stress disorder, separation anxiety disorder, oppositional defiant disorder, intermittent explosive disorder. | Schizoaffective disorder, schizophrenia, delusional disorder, other specified or unspecified schizophrenia spectrum and other psychotic disorder, bipolar-related disorders. | Psychotic disorder, bipolar disorder, disruptive mood dysregulation disorder and other depressive disorders, substance use disorders. | Psychotic disorder, bipolar disorder, major depressive disorder, disruptive mood dysregulation disorder, antisocial personality disorder, borderline personality disorder; not attributable to another medical condition (e.g., head trauma, Alzheimer’s disease) or to the physiological effects of a substance (e.g., a drug of abuse, a medication). |
DISRUPTIVE MOOD DYSREGULATION DISORDER (DMDD) DIFFERENTIAL DIAGNOSIS |
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If the client … |
Then the diagnosis may be … |
Reports non-severe/non-chronic irritability or mood elevation that is EPISODIC AND DISTINCTLY DIFFERENT from the 'normal' mood. |
Bipolar Disorder I or II |
Reports temper outbursts WITHOUT the presence of an irritable mood most of the day, every day. |
Oppositional Defiant Disorder |
Reports irritability EXCLUSIVELY during a major depressive episode or during persistent depressive disorder. |
Major Depressive Disorder or Persistent Depressive Disorder |
Reports irritability EXCLUSIVELY during the presence of an anxiety disorder. |
Specific Anxiety Disorder (e.g., Generalized Anxiety Disorder) |
Reports symptoms of Autism Spectrum Disorder and irritability or temper outbursts DUE TO their routine being disturbed or changed. |
Autism Spectrum Disorder |
Reports three behavioral outbursts, over 12 months, involving damage or destruction but DOES NOT report consistent irritable mood between behavioral outbursts. |
Intermittent Explosive Disorder |
MAJOR DEPRESSIVE DISORDER (MDD) DIFFERENTIAL DIAGNOSIS |
|
If the client … |
Then the diagnosis may be … |
Reports abnormally AND persistently elevated/expansive mood and abnormally and persistently increased activity or energy AND significant noticeable change from usual behavior. |
Bipolar I or Bipolar II |
Reports depressive symptoms which ONLY OCCUR as a direct consequence of a medical condition. |
Depressive Disorder Due to Another Medical Condition |
Reports depressive symptoms or changes in mood which ONLY OCCUR as a direct consequence of a substance such as alcohol or prescription or recreational drugs. |
Substance/Medication-Induced depressive or bipolar disorder |
Reports distractibility AND low frustration tolerance AND mood disturbance attributed PRIMARILY to irritability rather than sadness or loss of interest. |
Attention-Deficit/Hyperactivity Disorder, Inattentive Presentation |
Reports depressed mood SPECIFICALLY ATTRIBUTED to a psychosocial stressor (i.e. parents' divorce); however all criteria for MDD are not met. |
Adjustment Disorder with Depressed Mood |
Reports sadness or low mood; however all criteria for MDD or any other mental disorder is not met. |
Sadness |
Reports symptoms of MDD and symptoms of a co-existing personality disorder. |
Both diagnosis are given |
PERSISTENT DEPRESSIVE DISORDER (PDD) DIFFERENTIAL DIAGNOSIS |
|
If the client … |
Then the diagnosis may be … |
Has been diagnosed with PDD but reports symptoms that meet the full criteria for major depressive disorder but there have been periods of AT LEAST 8 WEEKS in at least the preceding 2 years with symptoms BELOW the threshold for a full major depressive episode. |
Persistent Depressive Disorder with intermittent major depressive episodes, with current episode |
Was diagnosed with PDD and reports symptoms that meet the full criteria for a major depressive disorder that has persisted for at least 2 years. |
Persistent Depressive Disorder with persistent major depressive episode |
Is diagnosed with PDD and DOES NOT CURRENTLY report symptoms that meet the full criteria for major depressive disorder BUT has experienced a major depressive episode within the past 2 years. |
Persistent Depressive Disorder with intermittent major depressive episodes, without current episode |
Is diagnosed with PDD and HAS NOT reported symptoms that meet the full criteria for major depressive disorder over the past 2 years. |
Persistent Depressive Disorder with pure dysthymic syndrome |
Reports symptoms of PDD that occur ONLY during a psychotic episode. |
Psychotic Disorder |
Reports symptoms of PDD that can be directly connected to a time period in which the client can report experiencing the physiological effects of a specific and/or chronic illness (through self-report or physician or laboratory reports. |
Depressive or Bipolar and Related Disorder Due to Another Medical Condition |
Reports symptoms of PDD that were experienced during their use of a substance (i.e. prescription or recreational drugs, alcohol). |
Substance/medication-induced depressive or bipolar disorder |
Reports symptoms of PDD and symptoms of a co-existing personality disorder. |
Both diagnoses are given |
PREMENSTRUAL DYSPHORIC DISORDER (PMDD) DIFFERENTIAL DIAGNOSIS |
|
If the client … |
Then the diagnosis may be … |
Does not report at least five of the symptoms of PMDD. Does not report the affective symptoms of PMDD. Does report the physical and/or behavioral symptoms of PMDD. |
Premenstrual Syndrome |
Reports painful periods WITHOUT emotional changes. Reports pain that only begins on the first day of their period. |
Dysmenorrhea |
Reports premenstrual symptoms AND are currently on hormonal treatments symptoms subside when hormonal treatment is discontinued. |
Due to Hormonal Treatments |
ANXIETY DISORDERS DIFFERENTIAL DIAGNOSIS |
|
If the client … |
Then the diagnosis may be … |
Reports excessive fear or anxiety (e.g., concerning getting lost, being kidnapped, having an accident, acquiring an illness, being injured, or dying) separation from HOME OR ATTACHMENT FIGURES is anticipated or occurs. |
Separation Anxiety Disorder |
Reports high social anxiety AND CONSISTENTLY DOES NOT SPEAK IN SPECIFIC SOCIAL SITUATIONS in which there is an expectation for speaking (e.g., at school) DESPITE SPEAKING IN OTHER SITUATIONS (e.g., in their home in the presence of immediate family members). |
Selective Mutism |
Reports marked fear or anxiety, nearly every time (NOT OCCASIONALLY), about a specific object (e.g., spiders, insects, dogs, heights, storms, water, needles, invasive medical procedures, airplanes, elevators, enclosed places, or costumed characters) or situation (e.g., choking, vomiting, or loud sounds). |
Specific Phobia |
Reports almost always having marked fear or anxiety about one or more social situations in which the individual is exposed to possible SCRUTINY BY OTHERS (e.g., having a conversation, meeting unfamiliar people, eating or drinking, or giving a speech. |
Social Anxiety Disorder |
Reports recurrent unexpected panic attacks (an abrupt surge of intense fear or intense discomfort that reaches a peak within minutes) resulting in PHYSICAL AND COGNITIVE SYMPTOMS. |
Panic Disorder |
Reports persistent marked, or intense, fear or anxiety triggered by the real or anticipated exposure to a wide range of situations AND believes that ESCAPE from such situations might be difficult, or that HELP might be unavailable when panic-like symptoms, or other INCAPACITATING or embarrassing symptoms occur. |
Agoraphobia |
| Reports excessive anxiety and worry (apprehensive expectation) about a NUMBER OF EVENTS OR ACTIVITIES (e.g., every day, routine life circumstances such as possible job responsibilities, health and finances, the health of family members, misfortune to children, doing household chores or being late for appointments). | Generalized Anxiety Disorder |
OBSESSIVE-COMPULSIVE AND RELATED DISORDERS DIFFERENTIAL DIAGNOSIS |
|
If the client … |
Then the diagnosis may be … |
Reports intrusive, unwanted, recurrent, and persistent THOUGHTS, URGES, OR IMAGES typically related to CLEANING, SYMMETRY, FORBIDDEN OR TABOO THOUGHTS, AND HARM; and engages in REPETITIVE BEHAVIORS OR MENTAL ACTS intended to reduce the distress triggered by obsessions or to prevent a feared event. |
Obsessive-Compulsive Disorder |
Reports difficulty controlling excessive anxiety and worry ABOUT A NUMBER OF EVENTS OR ACTIVITIES and finds it difficult to control the worry and to keep WORRISOME THOUGHTS from interfering with attention to tasks at hand. |
Generalized Anxiety Disorder |
Reports preoccupation with DEFECTS OR FLAWS IN PHYSICAL APPEARANCE and performs repetitive behaviors or mental acts in response to the appearance concerns. |
Body Dysmorphic Disorder |
Reports persistent difficulty and distress DISCARDING OR PARTING WITH POSSESSIONS because of a perceived need to save the items. |
Hoarding Disorder |
Reports recurrent HAIR PULLING resulting in loss and repeated attempts to decrease or stop hair pulling. |
Trichotillomania (Hair-Pulling Disorder) |
Reports recurrent SKIN PICKING resulting in skin lesions and repeated attempts to decrease or stop skin picking. |
Excoriation (Skin-Picking) Disorder |
Reports stereotypies – repetitive, seemingly driven, and apparently PURPOSELESS MOTOR BEHAVIOR (e.g., hand shaking or waving, body rocking, head banging, self-biting, hitting own body). |
Stereotypic Movement Disorder |
Reports preoccupation with THOUGHTS OF FOOD, BODY SHAPE, OR WEIGHT resulting in persistent and ritualized behavior that interferes with weight gain. |
Anorexia Nervosa |
Reports preoccupation with having or acquiring a SERIOUS ILLNESS, has a high level of ANXIETY ABOUT PERSONAL HEALTH STATUS, and performs excessive health-related behaviors (e.g., repeatedly checks his or her body for signs of illness). |
Illness Anxiety Disorder |
| Reports urge to use substances or preoccupation with gambling and recurrent substance use or repetitive gambling behaviors. | Substance-Related and Addictive Disorders |
| Reports recurrent and intense SEXUAL URGES, OR SEXUAL FANTASIES, OR SEXUAL BEHAVIORS that either violate the autonomy of another individual, psychologically or physically harm another individual, violate major social norms, or cause significant personal distress (e.g., anxiety, obsessions, and guilt or shame about the sexual impulses). | Paraphilic Disorders |
| Reports tension, affective arousal, and recurrent failure to resist AGGRESSIVE impulses that VIOLATE THE RIGHTS OF OTHERS or that bring the individual into significant CONFLICT WITH SOCIETAL NORMS or authority figures – and results in PLEASURE, GRATIFICATION, OR RELIEF. | Pyromania or Kleptomania |
| Reports guilty preoccupations or ruminations OVER MINOR PAST FAILINGS – that can be delusional or near-delusional; but are usually mood-congruent and NOT necessarily experienced as INTRUSIVE and are NOT associated with COMPULSIONS. | Major Depressive Disorder |
| Reports THOUGHT INSERTION AND DOES NOT manifest prominent obsessions, compulsions, preoccupations with appearance or body odor, hoarding, or body-focused repetitive behaviors. | Schizophrenia Spectrum and Other Psychotic Disorders |
| Reports restricted patterns of behavior, interests, or activities characterized by STEREOTYPED or repetitive motor movements, insistence on sameness, inflexible adherence to routines, or ritualized patterns of behavior (e.g., rigid thinking patterns, greeting rituals, need to take same route or eat same food every day) and PERSISTENT DEFICITS IN SOCIAL COMMUNICATION AND SOCIAL INTERACTION across multiple contexts. | Autism Spectrum Disorder |
REACTIVE ATTACHMENT DISORDER AND DISINHIBITED SOCIAL ENGAGEMENT DISORDER DIFFERENTIAL DIAGNOSIS |
||
|
RAD |
DSED |
PROFILE |
Inhibited - a pattern of markedly disturbed and developmentally inappropriate behavior, in which a child rarely or minimally turns preferentially to an attachment figure for comfort, support, protection, and nurturance. |
Disinhibited - a pattern of markedly disturbed and developmentally inappropriate behavior, in which the child displays overly familiar attachment that actively violates the social and cultural boundaries with relative strangers. |
EXPRESSION |
Internalizing disorder with depressive symptoms and withdrawn/avoidant behavior. |
Externalizing disorder with impulsive symptoms and approaching/attention-seeking behavior. |
| ETIOLOGY | Persistent social neglect – a pattern of extremes of insufficient care or deprivation by caregiving adults. | Persistent social neglect – a pattern of extremes of insufficient care or deprivation by caregiving adults. |
ONSET |
> age 9 months and < age 5 years |
> age 9 months |
DEVELOPMENTAL DELAYS |
Cognition and language. |
Cognition and language. |
| ASSOCIATED FEATURES | Stereotypies and other signs of severe neglect (e.g., malnutrition or signs of poor care). | Stereotypies and other signs of severe neglect (e.g., malnutrition or signs of poor care). |
| EMOTIONAL ABERRANCE |
|
None. |
| DISTURBED BEHAVIOR | Threshold: 2 of 2
|
Threshold: 2 of 4
|
| SOCIAL AND EMOTIONAL DISTURBANCE | Threshold: 2 of 3
|
None. |
| CHRONICITY | Evident in young children; may persist for several years – yet rarely evident in older children. | Early childhood through adolescence; has not been described in adults. |
| DIAGNOSITIC CRITERIA | 7 (with 5 of 8 symptoms minimum). | 5 (with 3 of 7 symptoms minimum). |
| MUTUAL EXCLUSIVITY | Autism spectrum disorder. | None. Cautiously co-diagnose attention-deficit/hyperactivity disorder. |
TRAUMA- STRESSOR-RELATED DISORDERS DIFFERENTIAL DIAGNOSIS |
||||
|
PTSD: < AGE 7 |
PTSD: > AGE 6 |
ACUTE STRESS DISORDER |
ADJUSTMENT DISORDERS |
PROFILE |
Development of characteristic symptoms (e.g., fear-based re-experiencing, emotional, behavioral, anhedonic or dysphoric mood states, negative cognitions, arousal and reactive-externalizing, or dissociative) following exposure to one or more traumatic events. |
Development of characteristic symptoms (e.g., fear-based re-experiencing, emotional, behavioral, anhedonic or dysphoric mood states, negative cognitions, arousal and reactive-externalizing, or dissociative) following exposure to one or more traumatic events. |
Development of characteristic symptoms (e.g., reactive anxiety, dissociative or detached presentation, strong emotional or physiological reactivity, strong anger response/irritable or aggressive response). |
Presence of marked emotional (e.g., depressed mood and/or anxiety) or behavioral symptoms (e.g., suicide attempts or disturbance of conduct) exceeding what would normally be expected in response to an identifiable stressor. |
ONSET |
Exposure to actual or threatened death, serious injury, or sexual violence. |
Exposure to actual or threatened death, serious injury, or sexual violence. |
Exposure to actual or threatened death, serious injury, or sexual violation. |
Identifiable stressor. |
SOURCES |
|
|
|
Identifiable stressor (e.g., single, multiple, recurrent, continuous, acute, or developmental). |
INTRUSION SYMPTOMS |
Threshold: 1 of 4
|
Threshold: 1 of 4
|
Threshold: 0 of 4
|
None. |
PERSISTENT AVOIDANCE |
Threshold: 0 or 1 of 2 Activities, places, or physical reminders that arouse recollections of the traumatic event(s). |
Threshold: 1 of 2 Memories, thoughts, or feelings about or closely associated with the traumatic event(s). |
Threshold: 0 of 2 Memories, thoughts, or feelings about or closely associated with the traumatic event(s). |
None. |
ALTERATIONS IN COGNITIONS AND MOOD |
Threshold: 0 or 1 of 4
|
Threshold: 2 of 7
|
Threshold: 0 of 1
|
None. |
ALTERATIONS IN AROUSAL AND REACTIVITY |
Threshold: 2 of 5
|
Threshold: 1 of 6
|
Threshold: 0 of 5
|
None. |
DISSOCIATIVE SYMPTOMS |
None. Specify PTSD as depersonalization/ derealization. |
None. Specify PTSD as depersonalization/ derealization. |
Threshold: 0 of 2
|
None. |
DURATION |
> 1 month after trauma exposure. |
> 1 month after trauma exposure. |
> 3 days and < 1 month after trauma exposure. |
< 3 months of the stressor onset and < 6 months after the stressor cessation. |
DISTRESS OR IMPAIRMENT |
Relationships with parents, siblings, peers, or other caregivers or with school behavior. |
Social, occupational, or other important areas of functioning. |
Social, occupational, or other important areas of functioning. |
Social, occupational, or other important areas of functioning. |
DIAGNOSTIC CRITERIA |
7 (with 3 symptom clusters requiring 4 of 18 symptoms minimum). |
8 (with 4 symptom clusters requiring 6 of 20 symptoms minimum). |
5 (with 5 symptom clusters requiring 9 of 14 symptoms minimum). |
5 (with 1 of 2 symptoms minimum). |
MUTUAL EXCLUSIVITY |
Acute stress disorder, physiological effects of a substance, and another medical condition. |
Acute stress disorder, physiological effects of a substance, and another medical condition. |
Posttraumatic stress disorder, brief psychotic disorder, physiological effects of a substance, and another medical condition. |
Normative stress reactions, another mental disorder, exacerbation of a preexisting mental disorder, and normal bereavement. |
DISSOCIATIVE IDENTITY DISORDER DIFFERENTIAL DIAGNOSIS |
|
If the client … |
Then the diagnosis may be … |
Reports the presence of chronic or recurrent mixed dissociative symptoms that DO NOT meet Criterion A for dissociative identity disorder or ARE NOT accompanied by recurrent amnesia. |
Other Specified Dissociative Disorder |
Reports the depressed mood and cognitions FLUCTUATE because they are experienced in some identity states but not others. |
Other Specified Depressive Disorder |
DOES NOT report relatively RAPID SHIFTS in mood – typically within minutes or hours. |
Bipolar Disorders |
Reports amnesia for some aspects of trauma, dissociative flashbacks (i.e., reliving of the trauma, with reduced awareness of one’s current orientation), and symptoms of intrusion and avoidance, negative alterations in cognition and mood, and hyper arousal that are focused around the traumatic event. |
Posttraumatic Stress Disorder |
DOES report chaotic identity change and acute intrusions that disrupt thought processes, BUT DOES NOT report predominance of dissociative symptoms and amnesia for the episode. |
Psychotic Disorders |
DOES NOT report longitudinal variability in personality style (due to inconsistency among identities), BUT DOES report pervasive and persistent dysfunction in affect management and interpersonal relationships. |
Personality Disorders |
Reports the ABSENCE OF AN IDENTITY DISRUTION characterized by two or more distinct personality states or an experience of possession. |
Conversion Disorder (Functional Neurological Symptom Disorder) |
DOES NOT obtain very high dissociation scores. |
Seizure Disorders |
DOES NOT report the subtle symptoms of intrusion and depression, BUT DOES over report dissociative amnesia, is relatively undisturbed by or may even seem to enjoy “having” identity disruption characterized by two or more distinct personality states or an experience of possession, or has stereotyped alternate identities, with feigned amnesia, related to the events for which gain is sought. |
Factitious Disorder and Malingering |
DISSOCIATIVE AMNESIA TERMINOLOGY |
|
Generalized amnesia |
Complete loss of memory for one’s life history (personal identity) – more common among combat veterans, sexual assault victims, individuals experiencing extreme emotional stress or conflict. |
Localized amnesia |
Failure to recall events during a circumscribed period of time – the most common form of dissociative amnesia. |
Selective amnesia |
Recall some, but not all, of the events during a circumscribed period of time. |
Systematized amnesia |
Loses memory for a specific category of information. |
| Continuous amnesia | Forgets each new event as it occurs. |
DISSOCIATIVE AMNESIA DIFFERENTIAL DIAGNOSIS |
|
If the client … |
Then the diagnosis may be … |
Reports pervasive discontinuities in sense of self and agency, ACCOMPANIED BY amnesia for everyday events, finding of unexplained possessions, sudden fluctuations in skills and knowledge, major gaps in the recall of life history, and brief amnesic gaps in interpersonal interactions. |
Dissociative Identity Disorder |
DOES NOT report amnesia extending beyond the immediate time of the trauma. |
Posttraumatic Stress Disorder |
Reports memory loss for personal information that is usually embedded in cognitive, linguistic, affective, attentional, and behavioral disturbances; AND INTELLECTUAL AND COGNITIVE DECLINE. |
Neurocognitive Disorders |
Reports episodes of “black outs” or periods of no memory that OCCUR ONLY in the context of intoxication and do not occur in other situations. |
Substance-Related Disorders |
Reports difficulties in the domains of complex attention, executive function, learning and memory, AS WELL as slowed speed of information processing, AND disturbances in social cognition. |
Posttraumatic Amnesia Due To Brain Injury |
DOES NOT display behavior that is PURPOSEFUL, COMPLEX, AND GOAL-DIRECTED lasting for days, weeks, or longer. |
Seizure Disorders |
Reports acute, florid dissociative amnesia; FINANCIAL, SEXUAL, OR LEGAL PROBLEMS; or a wish to escape stressful circumstances. |
Factitious Disorder and Malingering |
DOES NOT report memory decrements associated with stressful events, and that are more specific, extensive, and/or complex. |
Normal and Age-Related Changes in Memory |
DEPERSONALIZATION/DEREALIZATION DISORDER DIFFERENTIAL DIAGNOSIS |
|
If the client … |
Then the diagnosis may be … |
Reports vague somatic complaints as well as fears of permanent brain damage, but DOES NOT report a constellation of typical depersonalization/derealization symptoms. |
Illness Anxiety Disorder |
DOES NOT report that depersonalization/derealization clearly precedes the onset of a major depressive episode or clearly continues after its resolution. |
Major Depressive Disorder |
Reports the symptoms OCCUR ONLY during panic attacks that are part of panic disorder, social anxiety disorder, or specific phobia; OR symptoms are very prominent from the start, clearly exceeding in duration and intensity of the manifest anxiety. |
Anxiety Disorders |
DOES NOT display the presence of intact reality testing (e.g., attention, perception, memory, and judgment). |
Psychotic Disorders |
Reports symptoms during acute INTOXICATION OR WITHDRAWAL of marijuana, hallucinogens, ketamine, ecstasy, and salvia. |
Substance/Medication-Induced Disorders |
Reports symptom onset after age 40 years or the presence of ATYPICAL SYMPTOMS AND COURSE. |
Mental Disorders Due to Another Medical Condition |
FEEDING AND EATING DISORDERS DIFFERENTIAL DIAGNOSIS |
||||
|
AVOIDANT/RESTRICTIVE FOOD INTAKE DISORDER |
ANOREXIA NERVOSA |
BULIMIA NERVOSA |
BINGE-EATING DISORDER |
PROFILE |
An eating or feeding disturbance as manifested by persistent failure to meet appropriate nutritional and/or energy needs. |
Restriction of energy intake relative to requirements, leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. |
Occurrence of excessive food consumption accompanied by a sense of lack of control and inappropriate compensatory behaviors in normal-weight and overweight individuals. |
Occurrence of excessive food consumption accompanied by a sense of lack of control and inappropriate compensatory behaviors in normal-weight, overweight, and obese individuals. |
ONSET |
Commonly develops in infancy or early childhood. |
Commonly begins during adolescence or young adulthood; rarely begins before puberty or after age 40. |
Commonly begins during adolescence or young adulthood; rarely begins before puberty or after age 40. |
Typically begins in adolescence or young adulthood but can begin in later adulthood. |
EATING |
Avoidance or restriction. |
Persistent restriction; may include recurrent episodes of binge eating. |
Recurrent episodes of binge eating characterized by a sense of lack of control over eating during the episodes. |
Recurrent episodes of binge eating characterized by a sense of lack of control over eating during the episodes Threshold: 3 of 5 Marked distress from binge-eating more rapidly than normal, feeling uncomfortably full, not feeling physically hungry, feeling embarrassed, or feeling disgusted with oneself, depressed, or very guilty afterward. |
MOTIVATION/ |
Apparent lack of interest in eating or food. Sensory characteristics of food. Concern about aversive consequences of eating |
Intense fear of gaining weight or of becoming fat. Stressful life events. |
Negative affect. Interpersonal stressors. Dietary restraint. Negative feelings related to body weight, body shape, and food. Boredom. |
Negative affect. Interpersonal stressors. Dietary restraint. Negative feelings related to body weight, body shape, and food. Boredom. |
PSYCHOLOGICAL |
Irritable mood. Generalized emotional difficulties that do not meet diagnostic criteria for an anxiety, depressive, or bipolar disorder, sometimes called “food avoidance emotional disorder.” |
Suicide risk. Preoccupied with thoughts of food. Depressed mood, social withdrawal, irritability, insomnia, and diminished interest in sex. Concerns about eating in public, feelings of ineffectiveness, a strong desire to control one’s environment, inflexible thinking, limited social spontaneity, and overly restrained emotional expression. |
Suicide risk. Ashamed of eating problems. Negative self-evaluation and dysphoria.
|
Suicide risk. Ashamed of eating problems. Negative self-evaluation and dysphoria.
|
BODY WEIGHT |
None. |
Disturbed experiences. Unduly influences self-evaluation.
|
Excessive emphasis on body shape or weight in self-evaluation, and these factors are typically extremely important in determining self-esteem. |
Individuals typically do not show marked or sustained dietary restriction designed to influence body weight and shape between binge-eating episodes. |
WEIGHT LOSS |
Significant, resulting in faltering growth. |
Significant, less than minimally normal or minimally expected. Persistent lack of recognition of the seriousness of the current low body weight. Often viewed as an impressive achievement and a sign of extraordinary self-discipline. Accomplished primarily through dieting, fasting, and/or excessive exercise (Restricting type). |
None. |
None. |
WEIGHT GAIN |
None. |
Perceived as an unacceptable failure of self-control. Persistent behavior that interferes with. May manipulate medication dosage to avoid. |
May take thyroid hormone in an attempt to avoid. May fast for a day or more or exercise excessively in an attempt to prevent. |
None. |
NUTRITIONAL |
Significant; assessed by dietary intake, physical examination, or laboratory testing. |
Significant; assessed by dietary intake, physical examination, or laboratory testing. |
Moderate; fluid and electrolyte disturbances. |
None. Consume more calories. |
PHYSIOLOGICAL |
Hypothermia, bradycardia, or anemia. |
Hypotension, hypothermia, bradycardia, amenorrhea, vital sign abnormalities, loss of bone mineral density, constipation, abdominal pain, cold intolerance, lethargy, or excess energy. |
Menstrual irregularity or amenorrhea; gastrointestinal symptoms. |
Increased medical morbidity and mortality. Associated increased health care utilization. |
SUPPLEMENTARY |
Nasogastric tube feeding. Nutritionally complete supplements. Gastrostomy tube feeding. |
Hospitalization may be required to restore weight and to address medical complications. |
None. |
None. |
COMPENSATORY |
None. |
Self-induced vomiting or the misuse of laxatives, diuretics, or enemas (Purging type). |
Recurrent self-induced vomiting; misuse of laxatives, diuretics, or other medications; fasting; or excessive exercise. |
None. |
ASSOCIATED |
Difficult to console during feeding, apathetic and withdrawn, or developmental lags. Refusal to eat particular brands of foods or to tolerate the smell of food being eaten by others. |
Frequent weighing, obsessive measuring of body parts, and persistent use of a mirror to check for perceived areas of “fat.” Distress over the somatic and psychological sequelae of starvation. Frequently either lack insight into or deny the problem. |
Usually occurs in secrecy or as inconspicuously as possible. Typically are within the normal weight or overweight range. |
Usually occurs in secrecy or as inconspicuously as possible. Greater functional impairment, lower quality of life, more subjective distress, and greater psychiatric comorbidity. |
FUNCTIONAL |
Inability to participate in normal social activities, such as eating with others, or to sustain relationships. |
Significant social isolation and/or failure to fulfill academic or career potential. Serious medical implications from malnourished state. |
Range of limitations associated with the disorder. Severe role impairment, with the social-life domain. |
Social role adjustment problems. Impaired health-related quality of life and life satisfaction. |
DURATION |
None. |
3 months minimum. |
1 episode per week/3 months minimum. |
1 episode per week/3 months minimum. |
CHRONICITY |
May persist in adulthood. |
Some individuals recover fully after a single episode, with some exhibiting a fluctuating pattern of weight gain followed by relapse, and others experiencing a chronic course over many years. |
May be chronic or intermittent, with periods of remission alternating with recurrences of binge eating. |
Common in adolescent and college-age samples; relatively persistent. |
DIAGNOSTIC |
4 (with 1 of 4 symptoms minimum). |
3 |
5 (with 2 of 2 symptoms minimum). |
5 (with 3 of 5 symptoms minimum). |
MUTUAL |
Absence of an underlying medical condition; lack of availability of food or to cultural practices; rumination disorder, anorexia nervosa, bulimia nervosa, and binge-eating disorder. |
Rumination disorder, avoidant/restrictive food intake disorder, bulimia nervosa, and binge-eating disorder. |
Rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, and binge-eating disorder. |
Rumination disorder, avoidant/restrictive food intake disorder, anorexia nervosa, and bulimia nervosa. |
GENDER DYSPHORIA-RELATED TERMINOLOGY |
||
| LIFE-SPAN TRAJECTORY | Disorder of sex development |
Refers to a congenital condition in which development of chromosomal, gonadal, or anatomical sex is atypical. |
Gender assignment/natal gender |
Refers to the initial assignment as male or female usually at birth. |
|
Gender identity |
Refers to an individual’s identification as male, female, or, occasionally, some category other than male or female. |
|
Gender role |
Refers to the public (and usually legally recognized) lived role as boy or girl, man or woman. |
|
Gender dysphoria |
Refers to the affective/cognitive discontent/distress that may accompany the incongruence between one’s experienced or expressed gender and one’s assigned gender. |
|
Gender-atypical/Gender-nonconforming |
Refers to somatic features or behaviors that are not typical (in a statistical sense) of individuals with the same assigned gender in a given society and historical era. |
|
Transgender |
Refers to the broad spectrum of individuals who transiently or persistently identify with a gender different from their natal gender. |
|
Sex reassignment/confirmation surgery |
Refers to somatic transition by cross-sex hormone treatment and genital surgery. |
|
Transsexual |
Refers to an individual who seeks, or has undergone, a social transition from male to female or female to male. |
|
GENDER DYSPHORIA DIAGNOSTIC CRITERIA |
|
Early-onset: Children (ages 2-10~) – Requires 6 of 8 symptoms |
Late-onset: Adolescents (ages ~11-17) and Adults (age 18+) – Requires 2 of 6 symptoms |
Strong Desire…
Strong Preference for…
Strong Rejection of…
Strong Dislike of…
|
Marked Incongruence…
Strong Desire…
Strong Conviction…
|
SUBSTANCE-RELATED & ADDICTIVE DISORDERS |
||||
PROFILE |
A cluster of cognitive, behavioral, and physiological symptoms resulting from a problematic pattern of excessive substance use that directly and intensively activates the brain reward system and the individual continues using the substance despite significant substance-related problems. |
Risking something of value in the hopes of obtaining something of greater value. |
A pattern of excessive and prolonged compulsive playing of nongambling Internet games, often with other players, that results in a cluster of cognitive and behavioral symptoms. |
Recurrent and intense sexual fantasies, sexual urges, and sexual behavior, causing clinically significant personal distress or impairment. |
RISK FACTORS
|
|
|
More likely to be “avoiding boredom” rather than communicating or searching for information. |
Unknown. |
ONSET |
Most commonly during adolescence or young adulthood. |
During adolescence or young adulthood, or during middle or even older adulthood. |
During the preschool years and rarely later than early adolescence. |
Late childhood or adolescence and rarely begins for the first time after age 40 years. |
AGE LIMITS |
None. |
None. |
None. |
At least 18 years of age. |
FREQUENCY |
Gradually increases in both frequency and amount; may use throughout the day or multiple times per day. |
Regular or episodic. |
~8-10+ hours per day > 30 hours per week. |
Unknown. |
DURATION |
Within a 12-month period. |
In a 12-month period. |
In a 12-month period. |
At least 6 months. |
CHRONICITY |
From a mild form to a severe state of chronically relapsing, compulsive drug-taking over a period of months or years. |
Persistent or in remission (including spontaneous, long-term remissions). |
Unknown. |
Unknown. |
DIAGNOSTIC CRITERIA |
11 (with 2 of 11 symptoms minimum). |
9 (with 4 of 9 symptoms minimum). |
9 (with 5 of 9 symptoms minimum). |
5 (with 4 of 5 symptoms minimum). |
SEVERITY |
|
|
None. |
None. |
IMPAIRED CONTROL |
Use more than intended:
or
|
Not required. |
Not required. |
Not required. |
Cut down or control use:
or
|
Control, cut back, or stop gambling:
|
Control participation:
|
Control or significantly reduce sexual fantasies, urges, and behavior:
|
|
Great deal of time is spent in activities necessary to:
or
|
Often preoccupied with gambling:
|
Preoccupation with Internet games:
|
Excessive time is consumed:
and
|
|
Craving, or a strong desire or urge. |
Not required. |
Not required. |
Not required. |
|
SOCIAL IMPAIRMENT |
Recurrent use resulting in a failure to fulfill major role obligations:
|
Has jeopardized or lost a significant: |
Has jeopardized or lost a significant: |
Social, occupational or other important areas of functioning:
|
Continued use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance. |
Not required. |
Continued excessive use despite knowledge of psychosocial problems. |
Continues to engage in repetitive sexual behavior despite adverse consequences:
|
|
Given up or reduced because of use: |
Not required. |
Loss of interests in previous hobbies and entertainment as an exclusive result of Internet games. |
Neglecting health and personal care or other interests, activities and responsibilities. *[ICD-11] |
|
RISKY USE |
Recurrent use in situations in which it is physically hazardous. |
Not required. |
Not required. |
Repetitively engaging in sexual behavior while disregarding the risk for physical or emotional harm to self or others. |
Use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. |
Not required. |
Not required. |
Not required. |
|
PHARMACOLOGY |
Tolerance, as defined by either of the following: |
|||
A need for distinctly increased amounts of the substance to achieve intoxication or desired effect. |
Needs to gamble with increasing amounts of money in order to achieve the desired excitement. |
Need to spend increasing amounts of time engaged in Internet games. |
Not required. |
|
A distinctly diminished effect with continued use of the same amount of substance. |
Not required. |
Not required. |
Continues to engage in repetitive sexual behavior even with little or no satisfaction derived from it. *[ICD-11] |
|
Withdrawal, as manifested by either of the following: |
||||
The characteristic withdrawal syndrome (symptoms) for the substance. |
Is restless or irritable when attempting to cut down or stop gambling. |
Withdrawal symptoms when Internet gaming is taken away.
|
Not required. |
|
Substance (or a closely related substance) is taken to relieve or avoid withdrawal symptoms. |
“Bailout” behavior:
|
Not required. |
Not required. |
|
DISTRESS RESOLUTION |
Not required (however, may use to cope with mood, sleep, pain, or other physiological or psychological problems). |
Often gambles when feeling distressed:
|
Use of Internet games to escape or relieve a negative mood:
|
Repetitively engaging in these sexual fantasies, urges, and behaviors in response to dysphoric mood states (e.g., anxiety, depression, boredom, irritability). |
Not required. |
Not required. |
Not required. |
Repetitively engaging in these sexual fantasies, urges, and behaviors in response to stressful life events. |
|
DECEPTION |
Not required. |
Lies to conceal the extent of involvement with gambling. |
Deceived family members, therapists, or others regarding the amount of Internet gaming. |
Not required. |
COMPENSATORY BEHAVIORS |
Not required. |
“Chasing one’s losses”:
|
Not required. |
Not required. |
ASSOCIATED FEATURES |
|
|
|
|
MUTUAL EXCLUSIVITY |
|
Not better explained by a manic episode.
|
Use of the Internet for required activities in a business or profession, recreational or social Internet use, sexual Internet sites. |
|
Agrawal, A., Heath, A. C., & Lynskey, M. T. (2011). DSM-IV to DSM-5: The impact of proposed revisions on diagnosis of alcohol use disorders. Addiction, 106(11), 1935-1943. doi:10.1111/ j.1360-0443.2011.03517.x
Allen, K. L., Byrne, S. M., Oddy, W. H., & Crosby, R. D. (2013). DSM-IV-TR and DSM-5 eating disorders in adolescents: Prevalence, stability, and psychosocial correlates in a population-based sample of male and female adolescents. Journal of Abnormal Psychology, 122(3), 720-732. doi:http:// dx.doi.org/10.1037/ a0034004
Ambrosini, P., Bennett, D., & Elia, J. (2013). Attention deficit hyperactivity disorder characteristics: II. Clinical correlates of irritable mood. Journal of Affective Disorders, 145(1), 70-76. doi:10.1016/ j.jad.2012.07.014
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Washington, DC: Author.
American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders ,4th Edition, Text Revision, Washington, DC: Author.
Axelson, D., et al. (2012). Examining the proposed disruptive mood dysregulation disorder diagnosis in children in the Longitudinal Assessment of Manic Symptoms study. The Journal of Clinical Psychiatry, 73(10), 1342-1350. doi:10.4088/ JCP.12m07674
Baird, G. (2013). Classification of diseases and the neurodevelopmental disorders: The challenge for DSM-5 and ICD-11. Developmental Medicine & Child Neurology, 55(3), 200-201. doi:10.1111/ dmcn.12087Batstra, L., & Frances, A. (2012). DSM-5 further inflates attention deficit hyperactivity disorder. Journal of Nervous and Mental Disease, 200(6), 486-488.
Baron-Cohen, S., Wheelwright, S., Skinner, R., Martin, J., & Clubley, E. (2001). The autism-spectrum quotient (AQ): Evidence from Asperger Syndrome/high-functioning autism, males and females, scientists and mathematicians. Journal of Autism and Developmental Disorders, 31(1), 5-17. doi:10.1023/ A:1005653411471
Black, D. W. (2013). DSM-5 is approved, but personality disorders criteria have not changed. Annals of Clinical Psychiatry, 25(1).
Bogels, S. M., Knappe, S., & Clark, L. E. (2013). Adult separation anxiety disorder in DSM-5. Clinical Psychology Review, 33, 663-674.
Boskey, E. (2013). Sexuality in the DSM 5. Contemporary Sexuality, 47(7). 1-5.
Brand, B., & Loewenstein, R. J. (2010, October). Dissociative disorders: An overview of assessment, phenomenology, and treatment. Psychiatric Times, 62-29.
Breslau, N., Bohnert, K. M., & Koenen, K. C. (2010). The 9/11 terrorist attack and posttraumatic stress disorder revisited. Journal of Nervous and Mental Disease, 198(8):539-43. doi:10.1097/NMD.0b013e3181ea1e2f.
Bruijnzeel, D., & Tandon, R. (2011). The concept of schizophrenia: from the 1850s to the DSM-5. Psychiatric Annals, 41, 289-295.
Bryant-Waugh, R., Markham, L. Kreipe, R. E. & Walsh, T. (2010). Feeding and eating disorders in childhood. International Journal of Eating Disorders, (43)2, 98-111. doi: 10.1002/ eat.20795
Cavendish, W. (2013). Identification of learning disabilities: Implications of proposed DSM-5 criteria for school-based assessment. Journal of Learning Disabilities, 46(1), 52-57. doi:10.1177/ 0022219412464352
Chung, T., Martin, C. S., Maisto, S. A., Cornelius, J. R., & Clark, D. B. (2012). Greater prevalence of proposed DSM-5 nicotine use disorder compared to DSM-IV nicotine dependence in treated adolescents and young adults. Addiction, 107(4), 810-818. doi:10.1111/ j.1360-0443.2011.03722.x
Compton, W. M., Dawson, D. A., Goldstein, R. B., & Grant, B. F. (2013). Crosswalk between DSM-IV-TR dependence and DSM-5 substance use disorders for opioids, cannabis, cocaine and alcohol. Drug and Alcohol Dependence, doi:http://dx.doi.org/ 10.1016/j.drugalcdep. 2013.02.036
Copeland, W. E., Angold, A., Costello, E., & Egger, H. (2013). Prevalence, comorbidity, and correlates of DSM-5 proposed disruptive mood dysregulation disorder. The American Journal of Psychiatry, 170(2), 173-179.
Cosgrove, L., & Wheeler, E. E. (2013). Industry’s colonization of psychiatry: Ethical and practical implications of financial conflicts of interest in the DSM-5. Feminism & Psychology, 23(1), 93-106. doi:10.1177/ 0959353 512467972
Cosgrove, V. E., & Suppes, T. (2013). Informing DSM-5: biological boundaries between bipolar I disorder, schizoaffective disorder, and schizophrenia. BMC Medicine, 11(127), doi:10.1186/1741-7015-11-127
Dalenberg, C., & Carlson, E. B. (2012). Dissociation in posttraumatic stress disorder part II: How theoretical models fit the empirical evidence and recommendations for modifying the diagnostic criteria for PTSD. Psychological Trauma: Theory, Research, Practice, and Policy, 4(6), 551-559. doi: 10.1037/ a0027900
Dawson, D. A., Goldstein, R. B., & Grant, B. F. (2013). Differences in the profiles of DSM-IV and DSM-5 alcohol use disorders: Implications for clinicians. Alcoholism: Clinical And Experimental Research, 37(Suppl 1), E305-E313. doi:10.1111/j.1530-0277.2012.01930.x
Dolan, M. (2008). Neurobiological disturbances in callous-unemotional youths. American Journal of Psychiatry, 165, 668-670. doi:10.1176/ appi.ajp. 2008.08030393
DuPaul, G. J., Gormley, M. J., & Laracy, S. D. (2013). Comorbidity of LD and ADHD: Implications of DSM-5 for assessment and treatment. Journal of Learning Disabilities, 46(1), 43-51. doi:10.1177/ 0022219 412464351
Duschinsky, R., & Chachamu, N. (2013). Sexual dysfunction and paraphilias in the DSM-5: Pathology, heterogeneity, and gender. Feminism & Psychology, 23(1), 49-55. doi:10.1177/ 095935 3512467966
Elhai, J.D., Miller, M.E., Ford, J.D., Biehn, T.L., Palmieri, P.A., and Frueh, B.C. (2012). Posttraumatic stress disorder in DSM-5: Estimates of prevalence and symptom structure in a nonclinical sample of college students. Journal of Anxiety Disorders, 26, 58-64. doi:10.1016/ j.janxdis.2011.08.013
Epperson, C., Steiner, M., Hartlage, S., Eriksson, E., Schmidt, P. J., Jones, I., & Yonkers, K. A. (2012). Premenstrual dysphoric disorder: Evidence for a new category for DSM-5. The American Journal of Psychiatry, 169(5), 465-475.
Fava, M., Hwang, I., Rush, A. J., Sampson, N., Walters, E. E., & Kessler, R.C. (2010). The importance of irritability as a symptom of major depressive disorder: results from the National Comorbidity Survey Replication. Molecular Psychiatry, 15(8), 856-67. doi: 10.1038/ mp.2009.20
Flanagan, E. H., Solomon, L., Johnson, A., Ridgway, P., Strauss, J. S., & Davidson, L. (2012). Considering DSM-5: The personal experience of schizophrenia in relation to the DSM-IV-TR criteria. Psychiatry: Interpersonal And Biological Processes, 75(4), 375-386. doi:10.1521/ psyc.2012.75.4.375
Foussias, G., & Remington, G. (2010). Negative symptoms in schizophrenia: Avolition and Occam’s razor. Schizophrenia Bulletin, 36(2), 359-369. doi:10.1093/ schbul/sbn094
Fox, J., & Jones, K. (2013). DSM-5 and bereavement: The loss of normal grief? Journal of Counseling & Development, 91(1), 113-119. doi:10.1002/ j.1556-6676.2013.00079.x
Frank, E. (2005). Treating Bipolar Disorder: A Clinician’s Guide to Interpersonal and Social Rhythm Therapy. New York: Guilford Press.
Ganguli, M. (2010). Classification of neurocognitive disorders in DSM-5: A work in progress. American Journal of Geriatric Psychiatry, 19, 205-210. doi:10.1097/ JGP.0b013e 3182051ab4
Gleason, M., et al. (2011). Validity of evidence-derived criteria for reactive attachment disorder: Indiscriminately social/disinhibited and emotionally withdrawn/inhibited types. Journal of The American Academy of Child and Adolescent Psychiatry, 50(3), 216-231.e3. doi:10.1016/ j.jaac.2010.12.012
Good, E. M. (2012). Personality disorders in the DSM-5: Proposed revisions and critiques. Journal of Mental Health Counseling, 34(1), 1-13.
Guthrie, W., Swineford, L. B., Wetherby, A. M., & Lord C. (2013). Comparison of DSM-IV and DSM-5 factor structure models for toddlers with autism spectrum disorder. Journal of American Academy of Child and Adolescent Psychiatry, 52(8), 797-805. doi: 10.1016/ j.jaac.2013.05.004
Heckers, S., et al., (2013). Structure of the psychotic disorders classification in DSM 5, Schizophrenia Research, http://dx.doi.org/10.1016/ j.schres.2013.04.039
Huerta, M., Bishop, S. L., Duncan, A., Hus, V., & Lord, C. (2012). Application of DSM-5 criteria for autism spectrum disorder to three samples of children with DSM-IV diagnoses of pervasive developmental disorders. The American Journal of Psychiatry, 169(10), 1056-1064. doi:10.1176/ appi.ajp. 2012.12020276
Jones, K. (2012). A critique of the DSM-5 field trials. Journal of Nervous And Mental Disease, 200(6), 517-519.
Jones, K. (2012). Dimensional and cross-cutting assessment in the DSM-5. Journal of Counseling & Development, 90(4), 481-487. doi:10.1002/ j.1556-6676. 2012.00059.x
Jones, K., Gill, C., & Ray, S. (2012). Review of the proposed DSM-5 substance use disorder. Journal of Addictions & Offender Counseling, 33(2), 115-123. doi:10.1002/ j.2161-1874.2012. 00009.x
Jones, K. D., Tabitha, Y., & Leppma, M. (2010). Mild traumatic brain injury and posttraumatic stress disorder in returning Iraq and Afghanistan war veterans: Implications for assessment and diagnosis. doi: 10.1002/ j.1556-6678.2010. tb00036.x
Kafka, M. P. (2009). Hypersexual disorder: A proposed diagnosis for DSM-V. Archives of Sex Behavior, 39, 377-400. doi: 10.1007 /s10508-009-9574-7
Kaplan, A. (2013). Catching up on sleep: From comorbidity to pharmacotherapy, Psychiatric Times, 30(8), 417-423.
Kendler, K. S., Neale, M. C., & Walsh, D. (1995). Evaluating the spectrum concept of schizophrenia in the Roscommon family study. The American Journal of Psychiatry, 152(5), 749-54.
King, J. H. (December, 2014). Deconstructing the DSM-5: Assessment and diagnosis of neurodevelopmental disorders. Counseling Today, 57(6), 12-15.
King, J. H. (November, 2014). Deconstructing the DSM-5: Assessment and diagnosis of substance-related and addictive disorders. Counseling Today, 57(5), 12-15.
King, J. H. (October, 2014). Deconstructing the DSM-5: Assessment and diagnosis of obsessive-compulsive and related disorders. Counseling Today, 57(4), 12-15.
King, J. H. (September, 2014). Deconstructing the DSM-5: Assessment and diagnosis of disruptive, impulse-control and conduct disorders. Counseling Today, 57(3), 12-15.
King, J. H. (August, 2014). Deconstructing the DSM-5: Assessment and diagnosis of depressive disorders and bereavement reactions. Counseling Today, 57(2), 12-15.
King, J. H. (July, 2014). Clinical application of the DSM-5 in private counseling practice. The Professional Counselor, 4(3), 202-215. doi:10.15241/jhk.4.3.202
King, J. H. (July, 2014). Deconstructing the DSM-5: Assessment and diagnosis of dissociative and trauma and stressor-related disorders. Counseling Today, 57(1), 12-15.
King, J. H. (June, 2014). Deconstructing the DSM-5: Assessment and diagnosis of anxiety and somatic symptom and related disorders. Counseling Today, 56(12), 12-15.
King, J. H. (May, 2014). Deconstructing the DSM-5: Assessment and diagnosis of bipolar and psychotic-related related disorders. Counseling Today, 56(11), 12-15.
King, J. H. (April, 2014). Deconstructing the DSM-5: Assessment and diagnosis of feeding, eating and elimination disorders. Counseling Today, 56(10), 12-15.
King, J. H. (March, 2014). Deconstructing the DSM-5: Assessment and diagnosis of sleep-wake disorder disorders. Counseling Today, 56(9), 12-15.
King, J. H. (February 2014). Deconstructing the DSM-5: Assessment and diagnosis of sexual and gender-related disorders. Counseling Today, 56(8), 12-15.
King, J. H. (January 2014). Deconstructing the DSM-5: Assessment and diagnosis of schizophrenia spectrum disorders. Counseling Today, 56(7), 18-20.
King, J. H. (December 2013). Deconstructing the DSM-5: Assessment and diagnosis of neurocognitive disorders. Counseling Today, 56(6), 18-20.
King, J. H. (November 2013). Deconstructing the DSM-5: Assessment and diagnosis of disruptive mood dysregulation disorder. Counseling Today, 56(5), 18-20.
King, J. H. (October 2013). Deconstructing the DSM-5: Assessment and diagnosis of posttraumatic stress disorder and excoriation (skin-picking) disorder. Counseling Today, 56(4), 20-22.
King, J. H. (September 2013). Deconstructing the DSM-5: Assessment and diagnosis of autism spectrum disorder. Counseling Today, 56(3), 18-20.
King, J. H. (August 2013). Deconstructing the DSM-5: Understanding and using the DSM-5. Counseling Today, 56(2), 18-20
King, J. H. (July 2013). Deconstructing the DSM-5: The DSM-5 does not make diagnoses. Counseling Today, 56(1), 18-21.
Koffel, E., Polusny, M.A., Arbisi, P.A., and Erbes, C.R. (2012). A preliminary investigation of the new and revised symptoms of posttraumatic stress disorder in DSM-5. Depression and Anxiety, 29, 731-738. doi:10.1002/ da.21965
Kraemer, H., Kupfer, D. J., Clarke, D. E., Narrow, W. E., & Regier, D. A. (2012). DSM-5: How reliable is reliable enough? The American Journal of Psychiatry, 169(1), 13-15.
Latzman, R. D., Lilienfeld, S. O., Latzman, N. E., & Clark, L. A. (2013). Exploring callous and unemotional traits in youth via general personality traits: An eye toward DSM-5. Personality Disorders: Theory, Research, and Treatment, 4(3), 191-202. doi:http://dx.doi.org/ 10.1037/a0000001
Leibenluft, E. (2011). Severe mood dysregulation, irritability, and the diagnostic boundaries of bipolar disorder in youths. American Journal of Psychiatry, 168(2), 129-42. doi: 10.1176/ appi.ajp.2010.10050766
Leigh, H. (2009). A proposal for a new multiaxial model of psychiatric diagnosis: A continuum-based patient model derived from evolutionary developmental gene-environment interaction. Psychopathology, 42(1), 1-10. DOI: 10.1159/ 000173698
Lochner, C., Grant, J. E., Odlaug, B. L., & Stein, D. J. (2012). DSM-5 field survey: Skin picking disorder. Annals of Clinical Psychiatry, 24(4), 300-304.
Loewenstein, R. (1991). An office mental status examination for complex chronic dissociative symptoms and multiple personality disorder. Psychiatric Clinics of North America, 14(3), 567-604.
Lustyk, M. Kathleen, & Gerrish, W. G. (2010). Premenstrual syndrome and premenstrual dysphoric disorder: Issues of quality of life, stress and exercise. Handbook of Disease Burdens and Quality of Life Measures, 1951-1975, 10.1007/978-0-387-78665-0_115(pu.edu/depts/spfc/happenings/documents/chap115.pdf).
Maenner, M. J., Rice, C. E., Arneson, C. L., et al. (2014). Potential impact of DSM-5 criteria on Autism Spectrum Disorder prevalence estimates. JAMA Psychiatry, 71(3), 292-300. doi:10.1001/ jamapsychiatry.2013.3893
Mandy, W. L., Charman, T., & Skuse, D. H. (2012). Testing the construct validity of proposed criteria for DSM-5 autism spectrum disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 51(1), 41-50. doi:10.1016/ j.jaac.2011.10.013
Mann Layne, C. (2007). Early Identification of Autism: Implications for Clinicians. Journal of Counseling & Development, 85, pp. 110-114.
Marecek, J., & Gavey, N. (2013). DSM-5 and beyond: A critical feminist engagement with psychodiagnosis. Feminism & Psychology, 23(1), 3-9. doi:10.1177/ 09593535 12467962
Margulies, D., Weintraub, S., Basile, J., Grover, P., & Carlson, G. (2012). Will disruptive mood dysregulation disorder reduce false diagnosis of bipolar disorder in children? Bipolar Disorders, 14(5), 488-496. doi:10.1111/j.1399-5618. 2012.01029.x
Mazefsky, C., McPartland, J., Gastgeb, H., & Minshew, N. (2013). Brief report: Comparability of DSM-IV-TR and DSM-5 ASD research samples. Journal of Autism and Developmental Disorders, 43(5), 1236-1242. doi:10.1007/ s10803-012-1665-y
McPartland, J. C., Reichow, B., & Volkmar, F. R. (2012). Sensitivity and specificity of proposed DSM-5 diagnostic criteria for autism spectrum disorder. Journal of The American Academy of Child & Adolescent Psychiatry, 51(4), 368-383. doi:10.1016/ j.jaac.2012.01.007
Messinger, J.W., Trémeau, F., Antonius, D., Mendelsohn, E., Prudent, V., Stanford, A.D., & Malaspina, D. (2011). Avolition and expressive deficits capture negative symptom phenomenology: implications for DSM-5 and schizophrenia research. Clinical Psychology Review, 31(1):161-8. doi: 10.1016/ j.cpr.2010.09.002
Mewton, L., Slade, T., Memedovic, S., & Teesson, M. (2013). Alcohol use in hazardous situations: Implications for DSM-IV and DSM-5 alcohol use disorders. Alcoholism: Clinical And Experimental Research, 37(Suppl 1), E228-E236. doi:10.1111/ j.1530-0277.2012.01881.x
Milner, C. E., & Belicki, K. (2011). Assessment and treatment of insomnia in adults: A guide for clinicians. Journal of Counseling & Development, 88(2), 236-244.
Mullins-Sweatt, S. N., Bernstein, D. P., & Widiger, T. A. (2012). Retention or deletion of personality disorder diagnoses for DSM-5: An expert consensus approach. Journal of Personality Disorders, 26(5), 689-703. doi:10.1521/ pedi.2012.26.5.689
Otis, H. G. & King, J. H. (2006). Unanticipated psychotropic medication reactions. Journal of Mental Health Counseling, 28(3), 218-240
Panasetis, P., & Bryant, R. A. (2003). Peritraumatic versus persistent dissociation in acute stress disorder. Journal of Traumatic Stress, 16, 563-566. doi: 10.1023/B:JOTS.000000 4079.74606.ba.
Pardini, D., Stepp, S., Hipwell, A., Stouthamer-Loeber, M., & Loeber, R. (2012). The clinical utility of the proposed DSM-5 callous-unemotional subtype of conduct disorder in young girls. Journal of The American Academy of Child & Adolescent Psychiatry, 51(1), 62-73. doi:10.1016/ j.jaac.2011.10.005
Peer, K., et al. (2013). Prevalence of DSM-IV-TR and DSM-5 alcohol, cocaine, opioid, and cannabis use disorders in a largely substance dependent sample. Drug and Alcohol Dependence, 127(1-3), 215-219. doi: http://dx.doi.org/10.1016/ j.drugalcdep. 2012.07.009
Petry, N. M., Blanco, C., Stinchfield, R., & Volberg, R. (2013). An empirical evaluation of proposed changes for gambling diagnosis in the DSM-5. Addiction, 108(3), 575-581.
Pollak, J., Levy, S., & Breitholtz, T. (1999). Screening for medical and neurodevelopmental disorders for the professional counselor. Journal of Counseling and Development, 77(3), 350-358.
Pomarol-Clotet, S., Murray, T., & McKenna, P. J. (2010). Are there valid subtypes of schizophrenia? A grade of membership analysis. Psychopathology, 43(1):53-62. doi: 10.1159/ 000260044
Pulido, M. L. (2005). The terrorist attacks on the world trade center on 9/11: The dimensions of indirect exposure levels in relation to the development of post traumatic stress symptoms -The ‘‘ripple effect.’’ The City University of New York; UMI–ProQuest Company: Ann Arbor, Michigan.
Pull, C. B. (2013). Too few or too many? Reactions to removing versus retaining specific personality disorders in DSM-5. Current Opinion in Psychiatry, 26(1), 73-78. doi:10.1097/ YCO.0b013e 32835b2cb5
Raven, M., & Parry, P. (2012). Psychotropic marketing practices and problems: Implications for DSM-5. Journal of Nervous and Mental Disease, 200(6), 512-516.
Reid, R. C., Carpenter, B. N., Hook, J. N., Garos, S., Manning, J. C., Gilliland, R., Cooper, E. B., McKittrick, H., Davtian, M. and Fong, T. (2012), Report of findings in a DSM-5 field trial for hypersexual disorder. Journal of Sexual Medicine, 9: 2868-2877. doi: 10.1111/ j.1743-6109. 2012.02936.x
Reisinger, L. M., Cornish, K. M., & Fombonne, É. (2011). Diagnostic differentiation of autism spectrum disorders and pragmatic language impairment. Journal of Autism and Developmental Disorders, 41(12), 1694-704.
Reszka, S. S., Boyd, B. A., McBee, M., Hume, K. A., & Odom, S. L. (2013). Brief report: Concurrent validity of autism symptom severity measures. Journal of Autism and Developmental Disorders, doi:http://dx.doi.org/ 10.1007/s10803-013-1879-7
Rosmalen, J. G. M., Tak, L. M., & de Jonge, P. (2011). Empirical foundations for the diagnosis of somatization: implications for DSM-5. Psychological Medicine, 41, 1133-1142. doi:10.1017/ S0033291 710001625
Saxena, S. (2008) Neurobiology and Treatment of Compulsive Hoarding, CNS Spectrums, pp. 29-36).
Severus, E., & Bauer, M. (2013). Diagnosing bipolar disorders in DSM-5. International Journal of Bipolar Disorders, 1:14, doi:10.1186/ 2194-7511-1-14
Shapira, B. E., & Dahlen, P. (2010). Therapeutic Treatment Protocol for Enuresis Using an Enuresis Alarm. Journal of Counseling & Development, 88(2), 246-252. doi: 10.1002/ j.1556-6678.2010. tb00017.x
Sorrell, J. M. (2013). Diagnostic and Statistical Manual of Mental Disorders-5: Implications for older adults and their families. Journal of Psychosocial Nursing and Mental Health Services, 51(3), 19-22. doi:10.3928/ 02793695-20130207-01
Steiner, M., Haskett, R. F., Carroll, B. J. (1980). Premenstrual tension syndrome: the development of research diagnostic criteria and new rating scales. Acta Psychiatrica Scandinavica, 62(2), 177-90.
Steiner, M., & Streiner, D. L. Validation of a revised visual analog scale for premenstrual mood symptoms: Results from Prospective and retrospective trials. Canadian Journal of Psychiatry, 50(6), 327-322.
Stice, E., Marti, C. N. Rohde, P. (2013). Prevalence, incidence, impairment, and course of the proposed DSM-5 eating disorder diagnoses in an 8-year prospective community study of young women.
Journal of Abnormal Psychology, 122(2), 445-457. doi: 10.1037/ a0030679
Sweanor, D. (2000). Is it the nicotine or the tobacco? Bulletin of the World Health Organization, 78(7), 943.
Swedo, S. E., Baird, G., Cook, E. R., Happe, F. G., Harris, J. C., Kaufmann, W. E., & … Wright, H. H. (2012). Commentary from the DSM-5 workgroup on neurodevelopmental disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 51(4), 347-349. doi:10.1016/ j.jaac.2012.02.013
Sykes, R. (2012). The DSM 5 website proposals for somatic symptom disorder: Three central problems. Psychosomatics: Journal of Consultation Liaison Psychiatry, 53(6), 524-531. doi:10.1016/ j.psym.2012.06.004
Tandon, R., & Gaebel, W., Barch, D., Bustillo, J., Gur, R., Heckers, S., Malaspina, D. et al.,(2013). Definition and description of schizophrenia in the DSM-5. Schizophrenia Research. ccpweb.wustl.edu/pdfs/ 2013_defdes.pdf
Tandon, R., & Carpenter, W. r. (2012). DSM-5 status of psychotic disorders: 1 Year prepublication. Schizophrenia Bulletin, 38(3), 369-370. doi:10.1093/ schbul/sbs048
Tanguay, P. E., Robertson, J., & Derrick, A. (1998). A dimensional classification of autism spectrum disorder by social communication domains. Journal of the American Academy of Child & Adolescent Psychiatry, 37(3), 271-277.
Tannock, R. (2013). Rethinking ADHD and LD in DSM-5: Proposed changes in diagnostic criteria. Journal of Learning Disabilities, 46(1), 5-25. doi:10.1177/ 002221941 2464341
Tsai, L. Y. (2012). Sensitivity and specificity: DSM-IV versus DSM-5 criteria for autism spectrum disorder. The American Journal of Psychiatry, 169(10), 1009-1011. doi:10.1176/ appi.ajp.2012. 12070922
Turygin, N. C., Matson, J. L., Adams, H., & Belva, B. (2013). The effect of DSM-5 criteria on externalizing, internalizing, behavioral and adaptive symptoms in children diagnosed with autism. Developmental Neurorehabilitation, 16(4), 277-282. doi:http://dx.doi.org/10.3109/ 17518423.2013.769281
Voinescu; B. L., Szentagotai; A., & David, D. (2012). Sleep disturbance, circadian preference and symptoms of adult attention deficit hyperactivity disorder (ADHD). Journal of Neural Transmission. 119(10):1195-204. doi: 10.1007/ s00702-012-0862-3
Wakefield, J. C. (2012). DSM-5: Proposed changes to depressive disorders. Current Medical Research And Opinion, 28(3), 335-343. doi:10.1185/ 03007995. 2011.653436
Wakefield, J. C. (2012). The DSM-5’s proposed new categories of sexual disorder: The problem of false positives in sexual diagnosis. Clinical Social Work Journal, 40(2), 213-223. doi:10.1007/ s10615-011-0353-2
Wygant, D. B., & Sellbom, M. (2012). Viewing psychopathy from the perspective of the personality psychopathology five model: Implications for DSM-5. Journal of Personality Disorders, 26(5), 717-726. doi:10.1521/ pedi.2012.26.5.717
Zeanah, C. & Gleason, M. M. (2010). Reactive attachment disorder: Review for DSM-V. Retrieved August 17, 2014 from http://www.nrvcs.org/nrvattachmentresources/documents/APA%20DSM-5%20Reactive %20 Attachment%20Disorder%20 Review%5B1%5D.pdf
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