HIGHLIGHTS of CHANGES: DSM-IV-TR to DSM - 5 Venkata Kolli

1. HIGHLIGHTS of CHANGES: DSM-IV-TR to DSM-5 Venkata Kolli Creighton-Nebraska Psychiatry Residency Program

3. DSM- A long road! • Medical 203 (1943) • DSM I : 1952: 130 pages long • DSM II: 1968:1974 (7th printing) homosexuality was removed as a disorder by voting! • DSM III: 1980: “multiaxial” • DSM IIIR: 1987. • DSM IV: 1994. • DSM IV-TR:2000.

4. DSM I-DSM 5

5. Why is the roman numeral discarded? DSM –IV to DSM-5

6. DSM-5, book divided into 3 sections 1. Section I: Basics 2. Section II: Diagnostic Criteria and Codes 3. Section III: Emerging Measures and Models

7. DSM –IV TR DSM -5 Axis –I Psychiatric disorders Diagnosis Axis –II Personality disorder & MR Axis III Medical problems Psychosocial & contextual factors Axis IV World Health Organization Disability Assessment Schedule (WHODAS 2.0) Axis V (GAF)

8. Neurodevelopmental disorders • Autism Spectrum Disorder • ADHD • Intellectual Disability • Communication Disorders • Specific Learning Disorders • Motor Disorders • Other Neurodevelopmental disorders

9. Pervasive Developmental Disorder DSM -5 Autistic Disorder Autism Spectrum Disorder Childhood Disintegrative disorder Asperger's Disorder Pervasive Developmental Disorder NOS Can still be diagnosed as ASD but with specifier ‘with known genetic or medical condition’ Rett’s Disorder

10. Autism Spectrum Disorder DSM –IV TR DSM-5 • Formerly (DSM-IV-TR): Required Deficits in 3 Areas: • Social Interaction • Communication • Restricted, Repetitive and Stereotyped Behavior DSM–V: Characterized by Deficits in 2 CORE Domains: • Social Communication and Interaction • Restricted & Repetitive Behavior, Interests, and Activities Deficits in communication are related to social interaction deficits. DSM-5 fixes this double counting.

11. Autism Spectrum Disorders Social Communication and Interaction • Social-Emotional Reciprocity • Non-verbal Communication • Developing, Maintaining, & Understanding relationships • Level 3 is most severe, Level 1 Mild

12. Autism Spectrum Disorders Restricted & Repetitive Behavior, Interests, and Activities • Stereotyped Movements, Use of Objects, or Speech • Insistence on Sameness, Inflexibility, Ritual Behaviors • Highly Restricted/Fixated Abnormal Interests • Hyper- or Hypo-Reactivity to Sensory Input • Level 3 is most severe

13. Autism Spectrum Disorders • Present in Early Development • Symptoms Cause Significant Impairment in Social, Occupational Functioning • Symptoms Not Better Explained by Intellectual Disability or Developmental Delay

14. Intellectual Disability (Intellectual Developmental Disorder) • Formerly Mental retardation • Previously part of Axis II of DSM- IV TR • DSM-5 focus is on adaptive functioning along with standardized testing • In DSM IV Levels of Retardation based on IQ Scores: • Mild (IQ = 50/55 to 70), • Moderate (IQ=35/40 to 50/55), • Severe (IQ= 20/25 to 35/40), • Profound (IQ= <20/25) • Severity Unspecified (Unmeasurable)

15. Intellectual Disability (Intellectual Developmental Disorder) • Deficits in: a) Intellectual and b) Adaptive Functioning c) Onset in Developmental Period • Specifiers: Severity - Based on Conceptual, Social, Practical Functioning & Supports Needed: • Mild • Moderate • Severe • Profound

16. Changes related to Attention Deficit Hyperactivity Disorder • Symptoms present prior to age 12 (opposed to 7 in DSM –IV TR) • Can now have a diagnosis of ADHD &Autism Spectrum Disorder • Adults with ADHD: Symptom cutoffs for diagnosis is 5 criteria (instead of 6 for those <16 years old)

17. Schizophrenia Spectrum and Other Psychotic Disorders

18. Schizophrenia symptoms Positive symptoms Negative symptoms Hallucinations Eg. Second person, Third person (Schneiderian symptom) Delusions Disorganization Bizzare Eg. Aleins controlling thoughts Nonbizzare Eg. Someone following

19. No special attributes • Elimination of the special attribution of bizarre delusions and Schneiderian first-rank auditory hallucinations (e.g., two or more voices conversing). • No bizzareVs non-bizzare significance

20. Psychotic disorders time framesUnchanged from DSM-IV Duration of disturbance

21. Schizophrenia: Criteria A symptoms Hallucinations At least one of these symptoms should be present Delusions Disorganized speech Grossly disorganized or catatonic behavior At least two symptoms must be present for the majority duration Negative symptoms

22. No more Schizophrenia subtypes Schizophrenia No more subtypes undifferentiated Residual paranoid disorganized catatonic Specifier can be used three catatonic symptoms (out of 12)

23. Other Psychotic disorders • Schizoaffective disorder: • Psychosis + Mood symptoms • Major mood episode should be present for majority of the disorders total duration after criteria A(psychotic symptoms) is met. • Delusional disorder no longer has the requirement that the delusions must be nonbizarre

24. Psychotic disorders Part of Section III • Early intervention improves prognosis in psychotic disorders.

25. Bipolar disorder

26. Bipolar Disorders • Changes inactivity &energy as well as mood needs to be present for a diagnosis of mania or hypomania. • NOS changed to ‘other specified bipolar and related disorder’

27. Mixed features specifier • Full criteria for one mood (depression, mania or hypomania) • Have 3 or more symptoms of the other mood pole. • Distractibility, irritability, insomnia& indecisiveness are not included.

28. Depressive disorder • Bereavementspecifier removed from major depressive episode • Previously categorical exclusion 2 months following bereavement

29. Disruptive Mood Dysregulation Disorder (DMDD) • Exhibiting persistent irritability and severe behavioral outbursts 3 or more times per week for more than 1 year. • The mood in between temper outbursts is persistently negative (irritable, angry, or sad), are present in at least 2 settings. • Onset of illness has to be before age 10 years • Chronological or developmental age of at least 6 years

30. Premenstrual dysphoric disorder again a mood diagnosis! • Symptoms are present in the final week before onset of menses • Improves with menses • Minimal in the week following menses

31. Anxiety disorders DSM changes • Anxiety disorders: Agoraphobia, Specific Phobia, and Social Anxiety Disorder (Social Phobia) • Obsessive-Compulsive and Related Disorders • Trauma- and Stressor-Related Disorders

32. Other changes • Previous versions: requirement that individuals over age 18 years recognize that their anxiety is excessive or unreasonable • Anxiety must be out of proportion to the actual danger or threat in the situation, after taking cultural contextual factors into account

33. Panic disorder & Agoraphobia Panic disorder and agoraphobia are unlinked in DSM-5.

34. New OCD disorders Trichotillomania

35. New disorders -OCD’s • Hoarding disorder • Excoriation (skin-picking) disorder • Substance-/medication-induced obsessive-compulsive and related disorder • Obsessive-compulsive and related disorder due to another medical condition • Trichotillomania (Hair-Pulling Disorder): From impulse control disorder

36. Trauma- and Stressor-Related Disorders

37. Post Traumatic Stress Disorder-DSM –IV TR Trauma >3 months chronic ‘reaction with horror, helplessness or fear’ intrusive recollection avoidant/numbing hyper-arousal

38. Post Traumatic Stress Disorder-DSM –5 Trauma Is better defined e.g. sexual assault, recurrent exposure in police officers Removed >3 months chronic ‘reaction with horror, helplessness or fear’ 4 symptom clusters Intrusive recollection Avoidance Numbing Hyper-arousal

39. Trauma- and Stressor-Related Disorders • PTSD will have 2 new sub types 1. PTSD in children less than 6 years 2. PTSD with Prominent dissociative symptoms PTSD Debate in the military: Should PTSD be called Post Traumatic Stress injury?

40. Somatic Symptom and Related Disorders • Somatic symptom disorder covers previous somatization disorder DSM-IV disorder • DSM-IV disorder diagnosis required large collection of symptoms (4 pain, 2 GI, 1 sexual symptoms, 1 pseudo-neurological symptoms) • DSM-V diagnosis: Maladaptive thoughts, feelings, and behaviors are required. • Illness Anxiety disorder (Hypochondriasis):high health anxiety without somatic symptoms

41. Feeding & Eating disorders • Binge eating disorder: Binging but no compensatory purging 1.Eat more food in a short period 2. Once a week for 3 months 3. Guilt, embarrassment, or disgust

42. Eating disorders • Bulimia nervosa: Binge/Purge behavior once a week, was twice a week in DSM-IV • Anorexia Nervosa: • Reduction in energy intake leading to significantly low weight • Fear of gaining weight • Body Image distortions • Amenorrhea for 3 months removed as a criteria

43. Substance-Related and Addictive Disorders Gambling Disorder: Gambling, activates the same brain reward system as other substance use disorders.

44. Substance Use Disorders • Not separate the diagnoses of substance abuse and dependence • Cannabis withdrawal, Caffeine withdrawal are new • 2-3 criteria: mild, 4-5 :moderate, 6 or more: severe

45. Substance Use Disorder

46. Personality disorders • No major changes • 6 categories were proposed • Finally 10 categories were retained • Borderline personality disorder had the highest reliability

47. Conditions of Further Study Relevant for younger populations • Attenuated psychosis syndrome • Internet gaming disorder • Neurobehavioral disorder with prenatal alcohol exposure • Suicidal behavior Disorder • Non suicidal self injury

48. References • American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing;2013. • American Psychiatric Association. Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Arlington, VA: American Psychiatric Publishing; 2000. • http://www.dsm5.org/Documents/PTSD%20Fact%20Sheet.pdf • Stetka BS, Correll, CU. A Guide to DSM-5. Medscape Psychiatry. May 21, 2013. Retrived: 27thMarchhttp://www.medscape.com/viewarticle/803884_15

49. Images • Dailymail.co.uk • www.dutyfreeaddict.com • www.brightsideofnews.com  • www.glogster.com • kidshealth.org  • ssgtleslie.wordpress.com • ssgtleslie.wordpress.com • school.discoveryeducation.com  • http://www.koemba.com/forum/stressed-out-with-an-adhd-child-what-helps/#sthash.981eD4Ns.dpuf • http://emilysrosenlcsw.com/wp-content/uploads/2014/01/Distracted-Student-in-the-Classroom.jpg • ww.trekdek.com  • http://www.lastlashblog.com/2010/11/friday-eye-day.html • ‪www.dermatillomaniatreatment.com • www.trekdek.com  • ‪www.pjvoice.com  • www.uccs.edu - • http://6foot4.net/articles/2013/03/05/utilizing-change/

50. Communication disorders • DSM-5 communication disorders include language disorder (which combines DSM-IV expressive and mixed receptive-expressive language disorders): • Speech sound disorder (a new name for phonological disorder) • Childhood-onset fluency disorder (a new name for stuttering) • Social (pragmatic) communication disorder, a new condition for persistent difficulties in the social uses of verbal and nonverbal communication.