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Using the DSM-5: Try It, You'll Like It
by Jason King, Ph.D.

8 CE Hours - $199

Last revised: 01/20/2016

Course content © copyright 2014-2016 by Jason King, Ph.D. All rights reserved.


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Learning Objectives

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 clinicians with a basic understanding of the DSM-5 so as to facilitate their clinical utility. The course content is not assumed to cause any psychological reactions in the reader.

Outline

Introduction
Personal Cognitive Restructuring
Understanding and Using the DSM-5
Nonaxial Format
Neurodevelopmental Disorders
Schizophrenia Spectrum and Other Psychotic Disorders
Bipolar-Related Disorders
Depressive Disorders
Anxiety Disorders
Obsessive-Compulsive and Related Disorders
Trauma- and Stressor-Related Disorders
Dissociative Disorders
Somatic Symptom and Related Disorders
Feeding and Eating Disorders
Elimination Disorders
Sleep-Wake Disorders
Sexual Dysfunctions
Gender Dysphoria
Disruptive, Impulse-Control, and Conduct Disorders
Substance-Related and Addictive Disorders
Neurocognitive Disorders
Personality Disorders
Paraphilic Disorders
Other Mental Disorders
Medication-Induced Movement Disorders and Other Adverse Effects of Medication
Other Conditions that May Be a Focus of Clinical Attention
Conditions for Further Study
Appendix 1: Summary of DSM-5 Changes
Appendix 2: Schizophrenia Spectrum and Other Psychotic Disorders Differential Diagnosis
Appendix 3: Bipolar-Related Disorders Differential Diagnosis
Appendix 4: Disruptive and Depressive Disorders Differential Diagnosis
Appendix 5: Anxiety Disorders Differential Diagnosis
Appendix 6: Obsessive-Compulsive and Related Disorders Differential Diagnosis
Appendix 7: Trauma- and Stressor-Related Disorders Differential Diagnosis
Appendix 8: Dissociative Disorders Differential Diagnosis
Appendix 9: Feeding and Eating Disorders Differential Diagnosis
Appendix 10: Gender Dysphoria Differential Diagnosis
References

Introduction

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013) 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 (APA, 2013). As clinicians use the DSM-5, they 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 (APA, 2013). They 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.

Personal Cognitive Restructuring

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, and chapters are now arranged according to a lifespan or developmental approach (which fits the paradigm of counseling). 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: Clinicians make diagnoses, 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)

Understanding and Using the DSM-5

Clinicians taking this course are encouraged to have their DSM-5 available for reference, in particular the Preface; Section I (i.e., Introduction, Use of the Manual, and Cautionary Statement for Forensic Use of DSM-5); Section III Emerging Measures and Models (i.e., Assessment Measures); and the Appendix (i.e., Highlights of Changes From DSM-IV to DSM-5). To appreciate the rationale for the DSM-5 changes, clinicians 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 clinicians use the manual as intended and avoid diagnostic errors, as well as maintain cultural sensitivity and avoid historical and social prejudices in the diagnosis of pathology.

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. Most importantly, 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, on 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 (APA, 2013, p. 20). This definition links disorders and broadens their conceptualization on the basis of common neurocircuitry, genetic vulnerability, and environmental exposures. With this new definition, the DSM-5 encourages one 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. Clinicians will still list the principal diagnosis first and use provisional diagnosis to indicate diagnostic uncertainty.

I also strongly encourage you to refer to the rich textual description provided for each disorder. This narrative includes the following:

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 abilities. It is also advisable to carefully read each coding note as well as coding and reporting procedures for each disorder. As you shift from using the DSM-IV-TR to the DSM-5, 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 recommend clinicians recognize the limitations of using the DSM-5 in forensic settings. The manual is not designed for nonclinical professionals and does not meet the technical needs of the courts and legal professionals (APA, 2013, p. 25). When using the DSM-5, it is not sufficient to simply check off the symptoms in the diagnostic criteria to make a diagnosis. Proper use of the manual requires clinical training to recognize when signs and symptoms exceed normal ranges.

Nonaxial Format

A new and important change for clinicians is the DSM-5’s use of “dimensional” rather than multiaxial assessment (APA, 2013 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 to third-party payers (APA, 2013 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” (APA, 2013, 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” (APA, 2013, 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 disability across different cultures and settings. This psychometrically established measure covers 6 domains:

Clinicians 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’s website (http://www.who.int/classifications/icf/whodasii/en/), and by visiting the DSM-5 website (http://www.psychiatry.org/File%20Library/Practice/DSM/DSM-5/WHODAS2SelfAdministered.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, Moderate (principal diagnosis)

Z56.82 Problem Related to Current Military Deployment Status

F10.20 Moderate Alcohol Use Disorder

Moderate-mild disability (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

Cross-Cutting Symptom Measures and Disorder-Specific Severity Measures

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 (APA, 2013). The DSM-5 cross-cutting symptom measures aid in a comprehensive assessment by drawing attention to clinical symptoms that manifest, or cut-across diagnoses. 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. 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 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 (APA, 2013; Jones, 2012).

Clinicians can access these no-cost assessment measures at http://www.psychiatry.org/psychiatrists/practice/dsm/dsm-5/online-assessment-measures. The DSM-5 provides clinicians with further information on the background and reasoning for use of these emerging measures in clinical practice (APA, 2013 pp. 733-748). In conclusion, 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.

Coding and Reporting Procedures

The official coding system in use in the United States as of publication of the DSM-5 is the World Health Organization’s (WHO) International Classification of Diseases (ICD) ICD-9-CM. Official adoption of ICD-10-CM is scheduled to take place on October 1, 2015, and the codes, which are shown parenthetically in the DSM-5, should not be used until the official implementation occurs. 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 system.

Neurodevelopmental Disorders

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 International Classification of Diseases (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 clinicians 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” (APA, 2013, pp. 32-33).

Intellectual Disability (Intellectual Developmental Disorder)

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.” (APA, 2013, 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, clinicians 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).

Global Developmental Delay

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.

Language Disorder

In the DSM-5, this disorder combines DSM-IV-TR expressive language disorder and mixed receptive-expressive language disorder, with completely reconceptualized criteria.

Speech Sound Disorder

This is the new name for DSM-IV-TR’s phonological disorder. Clinicians are encouraged to read diagnostic criteria as it is completely reconceptualized.

Childhood-Onset Fluency Disorder (Stuttering)

The DSM-5 changes include:

Social (Pragmatic) Communication Disorder

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:

Greeting and sharing information

Changing communication to match context

Following social rules for conversation and storytelling

Understanding implicit statements

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%).

Clinicians are encouraged to watch this video http://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.

Autism Spectrum Disorder

As early as 1993, authors and researchers have referred to the various pervasive developmental disorders as 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). 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” (APA, 2013, p. 53). Consolidating use of these dichotomous autism-based titles into a spectrum designation helps to avoid diagnostic confusion and to minimize fragmented treatment planning.

Major Changes

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 clinicians to properly assess:

This reconceptualization of autism in the DSM-5 provides clinicians with a denser diagnostic cluster to reduce 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 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 use of the specifier associated with a known medical or genetic condition or environmental factor. Clinicians 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, clinicians record that separately as catatonia associated with autism spectrum disorder.

Clinician-Rated Severity of Autism Spectrum and Social Communication Disorders

Severity, or intensity of symptoms, for autism spectrum disorder are now communicated on three levels:

Level 1 mild, requiring support;

Level 2 moderate, requiring substantial support; and

Level 3 severe, requiring very substantial support (APA, 2013).

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 (APA, 2013, 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 clinicians to review Table 2 Severity Levels for Autism Spectrum Disorder displayed in the DSM-5 (p. 52).

Clinicians are reminded 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” (APA, 2013, p. 55). For a helpful visual of the DSM-5 changes to the DSM-IV-TR pervasive developmental disorders, I recommend clinicians download Bec Oakley’s DSM Diagnostic Criteria Graphics at http://www.snagglebox.com/downloads/dsm-graphics. 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.”

Current Research

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.

Clinical Scenario

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:

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” (APA, 2013, 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 APA, 2013 pp. 733-744 or http://www.psychiatry.org/psychiatrists/practice/dsm/dsm-5/online-assessment-measures).The Clinician-Rated Severity of Autism Spectrum and Social Communication Disorders (see APA, 2013, p. 52 or http://www.psychiatry.org/psychiatrists/practice/dsm/dsm-5/online-assessment-measures).

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” (APA, 2013, 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” (APA, 2013, p. 52). The diagnostic formulation offered to clinicians 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.

Attention-Deficit/Hyperactivity Disorder

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.

Additional DSM-5 changes include:

Specific Learning Disorder

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 clinicians are to specify all academic domains and subskills that are impaired. For example, clinicians using the DSM-5 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) and clinicians 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, clinicians are encouraged to read this chapter to become acquainted with these modifications.

Stereotypic Movement Disorder

The DSM-5 changes include:

Tourette’s Disorder

The DSM-5 changes include:

Persistent (Chronic) Motor or Vocal Tic Disorder

The DSM-5 changes include:

Provisional Tic Disorder

The DSM-5 changes include:

Other Specified Neurodevelopmental Disorder

Clinicians may use this category for presentations in which symptoms characteristic of a neurodevelopmental disorder that cause 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 neurodevelopmental disorders diagnostic class. This classification is the replacement for the DSM-IV-TR not otherwise specified (NOS). For example, neurodevelopmental disorder associated with prenatal alcohol exposure (characterized by a range of developmental disabilities following exposure to alcohol in utero).

Schizophrenia Spectrum and Other Psychotic Disorders

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.

Clinician-Rated Assessment of Symptoms and Related Clinical Phenomena in Psychosis

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 the 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). Clinicians can obtain the CRDPSS in the DSM-5, pages 742-744 or http://www.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.

Assessment

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” (APA, 2013, 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 clinicians 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”).

Clinicians are encouraged to watch this video http://youtu.be/zA1hyqA6UTY 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.

Schizotypal (Personality) Disorder

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.”

Delusional Disorder

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.

Shared Psychotic Disorder (Folie a Deux)

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.

Brief Psychotic Disorder

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

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). Clinicians also can communicate these specifiers based on first episode, multiple episodes, continuous episodes, or unspecified. Use of these specifiers assists clinicians to determine the intensity, frequency, and duration of clinical intervention services that are more person-centered.

Schizophrenia

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:

Schizoaffective Disorder

Although the DSM-5 acknowledges that “there is growing evidence that schizoaffective disorder is not a distinct nosological category” (APA, 2013, 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.

Substance/Medication-Induced Psychotic Disorder

No changes from DSM-IV-TR.

Psychotic Disorder Due to Another Medical Condition

No changes from DSM-IV-TR.

Catatonia Associated With Another Mental Disorder (Catatonia Specifier)

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 Mannerism
Catalepsy Stereotypy
Waxy flexibility Agitation
Mutism Grimacing
Negativism Echolalia
Posturing Exhopraxia

Catatonic Disorder Due to Another Medical Condition

Clinicians 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 catatonic disorder due to a general medical condition in DSM-IV-TR.

Other Specified Schizophrenia Spectrum and Other Psychotic Disorder

To enhance diagnostic specificity, the DSM-5 provides example presentations in which symptoms characteristic of a schizophrenia spectrum and other psychotic disorder cause clinically significant distress or impairment but do not meet the full criteria for any of the schizophrenia spectrum and other psychotic disorders. This classification is the replacement for DSM-IV-TR not otherwise specified (NOS). The other specified disorder category is provided to allow clinicians to communicate the specific reason that the presentation does not meet the criteria for any specific category within a diagnostic class. This is done by recording the name of the category, followed by the specific reasons. Examples offered in the DSM-5 include:

Persistent auditory hallucinations

Delusions with significant overlapping mood episodes

Attenuated psychosis syndrome (also see APA, 2013, pp. 783-786)

Delusional symptoms in partner of individual with delusional disorder

Clinical Scenario

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 identity 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.

Appendix 2: Schizophrenia Spectrum and Other Psychotic Disorders Differential Diagnosis

Bipolar-Related Disorders

The DSM-5 retains the fourth edition’s bipolar I, bipolar II and cyclothymic disorders. 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 amount of time 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 conducts research on 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 differing 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.”

Clinicians are encouraged to watch this video http://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.

Mania versus Hypomania

The DSM-5 retains the dichotomous distinction between bipolar I and bipolar II disorders. To recap, bipolar I 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 group.

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.

Clinicians should 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 a 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” (APA, 2013, p. 124).

This condition is considered an indicator of true bipolar disorder, not substance/medication-induced bipolar and related disorder (APA, 2013, 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” (APA, 2013, p. 125).

Bipolar I Disorder

The DSM-5 added the following verbiage to help clinicians 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 "Bipolar II Disorder

To further distinguish irritability as a nonpsychiatric marker for mania and hypomania, the APA, 2013 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,…”

Cyclothymic Disorder

The following verbiage was added to the symptom descriptions in the APA, 2013:

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).

Substance/Medication-Induced Bipolar and Related Disorder

No changes from DSM-IV-TR.

Bipolar and Related Disorder Due to Another Medical Condition

No changes from DSM-IV-TR.

Other Specified Bipolar-Related Disorders

To enhance diagnostic specificity, the APA, 2013 provides four example presentations in which symptoms characteristic of a bipolar or related disorder cause clinically significant distress or impairment but do not meet the full criteria for any of the bipolar-related disorders. This classification is the replacement for DSM-IV-TR not otherwise specified (NOS). The other specified disorder category is provided to allow clinicians to communicate the specific reason that the presentation does not meet the criteria for any specific category within a diagnostic class. This is done by recording the name of the category, followed by the specific reasons.

Other specified bipolar and related disorders include the following (listed on APA, 2013, p. 148):

Assessment

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 (APA, 2013, 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 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 clinicians to suspend diagnosing a personality disorder during an untreated mood episode (APA, 2013, 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.”

Descriptive and Course Specifiers

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 decreased likelihood of recovery, poorer role functioning and quality of life, less time experiencing euthymia, and 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 in 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 clinicians 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 poor response to lithium or become less stable when taking antidepressants. Additionally, more accurately identifying these concurrent behaviors may allow clinicians 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 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

Depressive Disorders

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” (APA, 2013, p. 155). However, the depressive disorders are a neighboring chapter to bipolar-related disorders because “of symptomatology, family history and genetics” (APA, 2013, 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. Included in the depressive disorders chapter in the DSM-5 are:

Disruptive mood dysregulation disorder

Major depressive disorder

Persistent depressive disorder (dysthymia)

Premenstrual dysphoric disorder

Disruptive Mood Dysregulation Disorder

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 use of antipsychotic medication for 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.

Current Research

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 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.

Clinical Scenario

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 use of the TV and it being 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 responded 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 a 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.

Assessment

In completing the DSM-5 Early Development and Home Background form and Level 1 Cross-Cutting Symptom Measures for children 6-17 (available at http://www.psychiatry.org/psychiatrists/practice/dsm/dsm-5/online-assessment-measures), 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:

F34.8 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.

Major Depressive Disorder

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, clinicians 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 http://www.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:

  1. Many individuals who clearly met criteria for a major depressive episode were deprived of treatment because the diagnosis was restricted.

  2. The DSM-IV-TR bereavement exclusion suggested that grief somehow protected someone from major depression.

  3. The International Classification of Diseases (ICD) does not contain a bereavement exclusion, and the DSM-5 was revised with the overarching goal of harmonizing the two classifications as much as possible.

Essentially, this means clinicians should default to the standard major depressive episode criteria when individuals present with clinical symptoms resulting from 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 clinicians to read the DSM-5 footnote on page 161 to help them distinguish grief from a major depressive episode. In addition, page 289 provides an option for clinicians 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, clinicians 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.

For enhanced diagnostic precision and targeted treatment planning, clinicians can use six descriptive specifiers retained from the DSM-IV-TR and two new descriptive specifiers (APA, 2013, pp. 184-188):

With anxious distress (new)

With mixed features (new for the DSM-5; a “downgrade” from the DSM-IV-TR diagnosis)

With melancholic features (retained from the DSM-IV-TR)

With atypical features (retained)

With psychotic features (retained)

With catatonia (retained)

With peripartum onset (formerly postpartum onset in the DSM-IV-TR)

With seasonal pattern (retained)

Clinicians 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.

Persistent Depressive Disorder (Dysthymia)

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. I would remind clinicians 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):

With pure dysthymic syndrome

With persistent major depressive episode

With intermittent major depressive episodes, with current episode

With intermittent major depressive episodes, without current episode

Clinical Scenario

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. What follows is a letter I drafted for his physician in support of psychotropic medication treatment.

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

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.

Premenstrual Dysphoric Disorder

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:

  1. Evaluate the previous criteria for premenstrual dysphoric disorder.
  2. Assess whether there was sufficient empirical evidence to support its inclusion as a diagnostic category.
  3. Comment on whether the previous diagnostic criteria were consistent with the additional data that had become available.

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 clinicians 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, clinicians 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. Clinicians 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.

Substance/Medication-Induced Depressive Disorder

No changes from DSM-IV-TR.

Depressive Disorder Due to Another Medical Condition

No changes from DSM-IV-TR.

Other Specified Depressive Disorder

To enhance diagnostic specificity, the DSM-5 provides example presentations in which symptoms characteristic of a depressive disorder cause clinically significant distress or impairment but do not meet the full criteria for any of the depressive disorders. This classification is the replacement for DSM-IV-TR not otherwise specified (NOS). The other specified disorder category is provided to allow clinicians to communicate the specific reason that the presentation does not meet the criteria for any specific category within a diagnostic class. This is done by recording the name of the category, followed by the specific reasons. Examples offered in the DSM-5 include:

Recurrent brief depression

Short-duration depressive episode (4-13 days)

Depressive episode with insufficient symptoms

See Appendix 4: Disruptive and Depressive Disorders Differential Diagnosis

Anxiety 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 (APA, 2013, 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” (APA, 2013, 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 a 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” (APA, 2013, 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. Clinicians 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 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 determination of whether the fear or anxiety is excessive or out of proportion is made by the clinician, taking cultural contextual 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.

Separation Anxiety Disorder

According to Bögels, 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 A1 “…or experiencing…”

Criterion A2 “…such as illness, injury, disasters or death.”

Criterion A3 “…having an accident, becoming ill…”

Criterion A4 “…to go out, away from home…”

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. Clinicians can determine the severity level of this disorder for children or adults by using the DSM-5 Severity Measure for Separation Anxiety Disorder.

Selective Mutism

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.

Specific Phobia

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. Clinicians can determine the severity level of this disorder for children or adults by using the DSM-5 Severity Measure for Specific Phobia.

Social Anxiety Disorder (Social 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). Clinicians can use this specifier for clients whose fear is restricted to speaking or performing in public (for example, dancers, speakers, musicians, or athletes). Clinicians 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).

Panic Disorder

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. Clinicians can determine the severity level of this disorder for children or adults by using the DSM-5 Severity Measure for Panic Disorder.

Panic Attack Specifier

In the DSM-5, the 13 symptoms characteristic of 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” (APA, 2013, p. 214). For clients who display fewer than four of the required panic attack specifier symptoms, clinicians may use the designation “with limited symptom attacks” in the diagnostic formulation.

Agoraphobia

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 following five agoraphobia situations is now required because this is a robust means for distinguishing agoraphobia from specific phobias:

Clinicians can determine the severity level of this disorder for children or adults by using the DSM-5 Severity Measure for Agoraphobia.

Generalized Anxiety Disorder

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 clinicians 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” (APA, 2013, pp. 222-223). Clinicians can determine the severity level of this disorder for children or adults by using theDSM-5 Severity Measure for Generalized Anxiety Disorder.

Substance/Medication-Induced Anxiety Disorder

No changes from DSM-IV-TR.

Anxiety Disorder Due to Another Medical Condition

No changes from DSM-IV-TR.

Other Specified Anxiety Disorder

To enhance diagnostic specificity, the DSM-5 provides example presentations in which symptoms characteristic of an anxiety disorder cause clinically significant distress or impairment but do not meet the full criteria for any of the anxiety disorders. This classification is the replacement for DSM-IV-TR not otherwise specified (NOS). The other specified disorder category is provided to allow clinicians to communicate the specific reason that the presentation does not meet the criteria for any specific category within a diagnostic class. This is done by recording the name of the category, followed by the specific reasons. Examples offered in the DSM-5 include:

Limited-symptom attacks

Generalized anxiety not occurring more days than not

Khy'l cap (wind attacks)

Ataque de nervios (attack of nerves)

See Appendix 5 for Differential Diagnosis of Anxiety Disorders

Obsessive-Compulsive and Related Disorders

In the DSM-5, the obsessive-compulsive and related disorders chapter is a new addition containing:

Obsessive-compulsive disorder (moved from the DSM-IV-TR anxiety disorders chapter)

Body dysmorphic disorder (moved from the DSM-IV-TR somatoform disorders chapter)

Hoarding disorder (new for the DSM-5)

Trichotillomania (hair-pulling) disorder (moved from the DSM-IV-TR other impulse control disorders chapter)

Excoriation (skin-picking) disorder (new for the DSM-5)

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.

Obsessive-Compulsive Disorder

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.

and 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. Clinicians 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. Clinicians 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.

Clinicians are reminded to 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.

Clinicians are reminded to review the other specified obsessive-compulsive and related disorders in this chapter that present similar OCD syndromes, such as obsessional jealousy.

Body Dysmorphic Disorder

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.

Hoarding Disorder

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 clinicians 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 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.

Clinicians are encouraged to watch this video http://youtu.be/qPtrEJuK6fo to learn about Jessica’s Hoarding Disorder symptoms.

Trichotillomania (Hair-Pulling) Disorder

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.

Excoriation (Skin-Picking) Disorder

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 (APA, 2013, pp. 803-806).

Clinicians are encouraged to watch this video http://youtu.be/6FUQ2GoBmpY to learn about Celina’s Excoriation (Skin-Picking) Disorder symptoms.

Current Research

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 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.

Other Specified Obsessive-Compulsive and Related Disorder

To enhance diagnostic specificity, the DSM-5 provides example presentations in which symptoms characteristic of an obsessive-compulsive and related disorder cause clinically significant distress or impairment but do not meet the full criteria for any of the obsessive-compulsive and related disorders. This classification is the replacement for DSM-IV-TR Not Otherwise Specified (NOS). The “other specified” disorder category is provided to allow clinicians to communicate the specific reason that the presentation does not meet the criteria for any specific category within a diagnostic class. This is done by recording the name of the category, followed by the specific reasons. Examples offered in the DSM-5 include:

Body dysmorphic-like disorder with actual flaws

Body dysmorphic-like disorder without repetitive behaviors

Body-focused repetitive behavior disorder

Obsessional jealousy

Shubo-kyofu

Koro

Jikoshu-kyofu

Substance/Medication-Induced Obsessive-Compulsive and Related Disorder

No changes from DSM-IV-TR.

Obsessive-Compulsive and Related Disorder Due to Another Medical Condition

No changes from DSM-IV-TR.

Clinical Scenario

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 APA, 2013, 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 WHODAS 2.0 (World Health Organization Disability Assessment Schedule 2.0) 36-item version, self-administered, JoAnn’s average domain score was 4.8, indicating a severe-extreme disability rating. Putting it all together, JoAnn’s DSM-5 diagnostic formulation was written in this manner:

Severe-extreme disability 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

Trauma- and Stressor-Related Disorders

Reactive Attachment Disorder and Disinhibited Social Engagement Disorder

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. In addition, 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. Clinicians who work with children presenting with these disorders may want to read 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” (APA, 2013, 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 indiscriminant behaviors that violate 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; 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. Clinicians 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, clinicians use the specifier persistent, and they use the specifier severe when all possible symptoms are endorsed.

Posttraumatic Stress Disorder

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.

Major Changes

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 includes:

“…(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 includes:

Reckless or self-destructive behavior

New descriptive and course specifiers for PTSD include with dissociative symptoms (depersonalization, feeling 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 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 specific pediatric language includes:

“reenactment of events related to trauma, directly or symbolically”

“may appear in play or dissociative states”

“developmental regression”

“frightening dreams without recognizable content”

“may become preoccupied with reminders of the trauma”

“tend to experience primary mood changes”

Current Research

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.

Acute Stress Disorder

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:

Adjustment Disorders

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.”

Other Specified Trauma- and Stressor-Related Disorder

To enhance diagnostic specificity, the DSM-5 provides example presentations in which symptoms characteristic of a trauma- and stressor-related disorder cause clinically significant distress or impairment but do not meet the full criteria for any of the specified trauma- and stressor-related disorders. This classification is the replacement for DSM-IV-TR not otherwise specified (NOS). The other specified disorder category is provided to allow clinicians to communicate the specific reason that the presentation does not meet the criteria for any specific category within a diagnostic class. This is done by recording the name of the category, followed by the specific reasons. Examples offered in the DSM-5 include:

Adjustment-like disorders with delayed onset of symptoms that occur more than three months after the stressor

Adjustment-like disorders with prolonged duration of more than months without prolonged duration of stressor

Ataque de nervios

Persistent complex bereavement disorder

Appendix 7: Trauma- and Stressor-Related Disorders Differential Diagnosis

Dissociative Disorders

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.

Dissociative Identity Disorder

Significant modifications were made to dissociative identity disorder in the DSM-5. The 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 clinicians 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.

Dissociative Amnesia

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.

Depersonalization/Derealization Disorder

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 requires 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, clinicians are reminded 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.

Other Specified Dissociative Disorder

To enhance diagnostic specificity, the DSM-5 provides example presentations in which symptoms characteristic of a dissociative disorder cause clinically significant distress or impairment but do not meet the full criteria for any of the dissociative disorders. This classification is the replacement for DSM-IV-TR not otherwise specified (NOS). The other specified disorder category is provided to allow clinicians to communicate the specific reason that the presentation does not meet the criteria for any specific category within a diagnostic class. This is done by recording the name of the category, followed by the specific reasons. Examples offered in the DSM-5 include:

Chronic and recurrent syndromes of mixed dissociative symptoms

Identity disturbance due to prolonged and intense coercive persuasion

Acute dissociative reactions to stressful events

Dissociative trance

Assessment

Clinicians 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/derealizations

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 clinicians to review the International Society for the Study of Trauma and Dissociation website at www.isst-d.org for helpful resources on this topic.

See Appendix 8 for Differential Diagnosis of Dissociative Identity Disorder

Somatic Symptom and Related Disorders

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.”

Somatic Symptom Disorder

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 (APA, 2013, 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). Clinicians may use the specifier with predominant pain to indicate this presence in clients. Clinicians 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, clinicians would do well to consider the DSM-5’s discussion on culture-related diagnostic issues mentioned earlier in this article.

Illness Anxiety Disorder

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. Clinicians can use two new specifiers: care seeking type (excessive health-related behaviors) or care avoidant type (maladaptive avoidance).

Conversion Disorder (Functional Neurological Symptom Disorder)

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.

Psychological Factors Affecting Other Medical Conditions

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).

Factitious Disorder

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. Clinicians should be diagnostically skilled in differentiating this disorder from the non-mental health condition of malingering by reading the DSM-5 pages 726-727.

Clinicians 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.

Other Specified Somatic Symptom and Related Disorder

To enhance diagnostic specificity, the DSM-5 provides example presentations in which symptoms characteristic of a somatic symptom and related disorder cause clinically significant distress or impairment but do not meet the full criteria for any of the somatic symptom and related disorders. This classification is the replacement for DSM-IV-TR Not Otherwise Specified (NOS). The “other specified” disorder category is provided to allow clinicians to communicate the specific reason that the presentation does not meet the criteria for any specific category within a diagnostic class. This is done by recording the name of the category, followed by the specific reasons. Examples offered in the DSM-5 include:

Brief somatic symptom disorder

Brief illness anxiety disorder

Illness anxiety disorder without excessive health-related behaviors

Pseudocyesis

Feeding and Eating Disorders

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 at 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 places greater emphasis on observable, recurrent, quantifiable, and persistent client behaviors.

Obesity

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 a number of 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 a number of 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. For clinicians working 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.

Pica

Changes to phrasing of diagnostic criteria in the DSM-5 guide clinicians 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.

Clinicians are encouraged to watch this video http://youtu.be/0TN1_EgYdfU of Krystin’s Pica symptoms.

Rumination Disorder

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.

Clinicians should 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 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 clinicians use an empathic, nonjudgmental tone with child clients to avoid exacerbating their sense of shame or their unwillingness to disclose rumination or pica eating. Clinicians should provide psychoeducation to parents that includes information about the potential medical consequences of these disorders.

Avoidant/Restrictive Food Intake Disorder

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.

Assessment

A 2010 article by Bryant-Waugh (member of the DSM-5 Clinical and Public Health Committee) and colleagues in the International Journal of Eating Disorders provides clinicians with 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 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?

Anorexia Nervosa

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 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 (APA, 2013, p. 339). The restricting type and binge eating/purging type descriptive specifiers are retained in the DSM-5.

Bulimia Nervosa

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).

Binge Eating Disorder

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).

Clinicians are encouraged to watch this video http://youtu.be/1OQbUZeYAik to learn about important differential diagnostic criteria between Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder.

Other Specified Feeding or Eating Disorder

To enhance diagnostic specificity, the DSM-5 provides example presentations in which symptoms characteristic of a feeding or eating disorder cause clinically significant distress or impairment but do not meet the full criteria for any of the feeding or eating disorders. This classification is the replacement for DSM-IV-TR not otherwise specified (NOS). The “other specified” disorder category is provided to allow clinicians to communicate the specific reason that the presentation does not meet the criteria for any specific category within a diagnostic class. This is done by recording the name of the category, followed by the specific reasons. Examples offered in the DSM-5 include:

Current Research

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.

Clinical Scenario

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 the DSM-5 diagnosis is warranted:

F33.1 Moderate Major Depressive Disorder, Recurrent, With Anxious Distress

Mild-moderate disability (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

Elimination Disorders

Enuresis and Encopresis

Diagnostic criteria for these disorders are unchanged in the DSM-5. For clinicians working with encopresis, I strongly recommend Shapira and Dahlen’s (2010) article on a treatment protocol for enuresis using an alarm.

Sleep-Wake Disorders

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” (APA, 2013, p. 362). As clinicians read the sleep-wake disorders chapter in the DSM-5, they will notice an increased emphasis on a multidimensional approach to assessment that includes medical examination, such as the use of a polysomnography, quantitative electroencephalographic analysis, and testing for hypocretin (orexin) deficiency (APA, 2013). They will 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 durations 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.”

Common Comorbidity

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 disorderor sleep disturbance symptom is present in most, if not all, of our counseling clients across the life span. For this reason, all clinicians should carefully read 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. Clinicians are reminded that depression, anxiety and cognitive changes often accompany sleep-wake disorders that must be addressed in treatment planning and management (APA, 2013).

Major Changes

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 interventions research influenced 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, clinicians are to 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. Clinicians should understand that sleep disturbance does not focus on symptoms of specific sleep disorders, nor does it provide subjective estimates of sleep quantities (for example, 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. Clinicians will see in the accompanying text a listing of useful dimensional measures of sleep impairment to help them 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, clinicians 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 clinicians to experience feasibility.

Insomnias

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

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 Disorders

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

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 visual impaired individuals), shift work type, and unspecified type. Please note that jet lag type was removed from the DSM-5.

Clinicians are encouraged to watch this video http://youtu.be/CqBaY8577cQ of Mindy discussing her symptoms from Circadian Rhythm Sleep-Wake Disorder, Non-24-Hour Sleep-Wake Type.

Parasomnias

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):

Sleepwalking type

Sleep-related eating

Sleep-related sexual behavior

Sleep terror type

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.

Substance/Medication-Induced Sleep Disorder

Clinicians 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

Insomnia type

Daytime sleepiness type

Parasomnia type

Mixed type

Specify if

With onset during intoxication

With onset during discontinuation/withdrawal

Other Specified Sleep-Wake Disorder

To enhance diagnostic specificity, the DSM-5 provides example presentations in which symptoms characteristic of a Sleep-Wake Disorder cause clinically significant distress or impairment but do not meet the full criteria for any of the sleep-wake disorders. This classification is the replacement for DSM-IV-TR not otherwise specified (NOS). The “other specified” disorder category is provided to allow clinicians to communicate the specific reason that the presentation does not meet the criteria for any specific category within a diagnostic class. This is done by recording the name of the category, followed by the specific reasons. Examples offered in the DSM-5 include:

Repeated arousals during rapid eye movement sleep without polysomnography

History of Parkinson’s disease or other synucleinopathy

Brief insomnia disorder

Restricted to nonrestorative sleep

Brief-duration hypersomnolence

Clinical Scenario

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. 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 APA, 2013 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).

Sexual Dysfunctions

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.

Major Changes

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:

Role of Psychosocial Factors

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 (APA, 2013, pp. 715-727):

Substance/Medication-Induced Sexual Dysfunction

Changes to the DSM-5 include removal of the following specifiers:

With impaired desire

With impaired arousal

With impaired orgasm

With sexual pain

Changes to the DSM-5 include addition of the following specifiers:

With onset during intoxication

With onset during withdrawal

With onset after medication use

Mild: Occurs on 25%-50% of occasions of sexual activity

Moderate: Occurs on 50%-75% of occasions of sexual activity

Severe: Occurs on 75% or more of occasions of sexual activity

Gender Dysphoria

In the DSM-5, gender identity disorder is changed to gender dysphoria. 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.

Major Changes

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 the 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

Appendix 10: Gender Dysphoria Differential Diagnosis

Disruptive, Impulse-Control, and Conduct Disorders

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, clinicians must 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” (APA, 2013, pp. 461-462). This guidance helps clinicians avoid pathologizing normative developmental behaviors.

Oppositional Defiant Disorder

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 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 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. Clinicians should 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.

Intermittent Explosive Disorder

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.

Conduct Disorder

The criteria for conduct disorder in the DSM-5 are largely unchanged from the DSM-IV-TR. Clinicians 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 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.

New Descriptive Specifier

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 a 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 (APA, 2013, pp. 470-471):

Lack of remorse or guilt

Callous-lack of empathy

Unconcerned about performance

Shallow or deficient affect

The DSM-5 further requires clinicians 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.

Current Research

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 with 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.

Clinical Scenario

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)

Antisocial Personality Disorder

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.”

Pyromania

No changes from DSM-IV-TR.

Kleptomania

No changes from DSM-IV-TR.

See Appendix 4: Disruptive and Depressive Disorders Differential Diagnosis

Substance-Related and Addictive Disorders

Substance-related and behavioral addictive disorders receive a significant reconceptualization in the DSM-5. In this chapter, clinicians 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.

Substance Use Disorders

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.

Diagnostic Criteria

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 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” (APA, 2013, 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 for clinicians 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” (APA, 2013, p. 483). Individuals need to manifest two of the nine remaining criteria to qualify for a substance use disorder diagnosis.

Severity Specifiers

Severity ratings for the DSM-5 substance use disorders can change across time as reflected by reductions or increases in the frequency and/or dose of substance use based on:

Individual’s own report

Report of knowledgeable others

Clinician’s observations

Biological testing

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.

Major Changes

Additional changes to substance-related disorders in the DSM-5 include the following:

Substance-Induced Disorders

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). Clinicians 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).

Recording Procedures for Substance-Related Disorders

Clinicians are reminded 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. Clinicians are encouraged to see the substance-specific sections for additional coding information.

Current Research

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, clinicians 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 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.

Sample DSM-5 Diagnosis

Putting it all together, here is how clinicians 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

Non-Substance-Related Disorders

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” (APA, 2013, p. 481). Criteria 1-9 used in the DSM-5 for the substance-related disorders are used for gambling disorder.

Neurocognitive Disorders

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:

Psychosis

Paranoia and other delusions (disorganized speech and disorganized behavior are not characteristic of psychosis in NCDs)

Mood disturbances

Depression

Anxiety and elation

Additional associated features include:

Agitation

Confusion

Frustration

Sleep disturbances

Apathy (marked declines in motivation, goal-directed behavior, and emotional responsiveness)

Wandering

Disinhibition

Hyperphagia

Hoarding

Delirium

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.

Other Specified Delirium

To enhance diagnostic specificity, the DSM-5 provides example presentations in which symptoms characteristic of delirium cause clinically significant distress or impairment but do not meet the full criteria for any of the delirium disorders. This classification is the replacement for DSM-IV-TR not otherwise specified (NOS). The “other specified” disorder category is provided to allow clinicians to communicate the specific reason that the presentation does not meet the criteria for any specific category within a diagnostic class. This is done by recording the name of the category, followed by the specific reasons. Examples offered in the DSM-5 include:

Attenuated delirium syndrome

Mild and Major Neurocognitive Disorders

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.

Mild NCD

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

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 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 clinicians 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, clinicians should specify current severity:

Mild (difficulties with instrumental activities of daily living such as housework or managing money)

Moderate (difficulties with basic activities of daily living such as feeding and dressing)

Severe (fully dependent)

Descriptive and Severity Specifiers

The DSM-5 requires use of descriptive and severity specifiers to more precisely indicate the client’s symptom level and to promote clinical utility. For example, clinicians 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 (APA, 2013). Clinicians 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):

Clinical Scenario

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 (APA, 2013):

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 APA, 2013, p. 181; coding rules require that a mental disorder due to another medical condition be listed first; see APA, 2013, pp. 22-23).

Moderate-mild disability (87 per self-administered World Health Organization Disability Assessment Schedule [WHODAS] 2.0; see APA, 2013, pp. 745-748).

G31.84 Probable Mild Neurocognitive Disorder (NCD) Due to TBI (APA, 2013, 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 APA, 2013, p. 723).

Z63.0 Relationship Distress with Spouse or Intimate Partner (due to TBI; see APA, 2013, p. 716).

Important NCD Updates

Clinicians 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.

Personality Disorders

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:

personality 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 antisocial personality disorder, which cannot be diagnosed in individuals younger than 18 years (APA, 2013, p. 647).

Other Specified Personality Disorder and Unspecified Personality Disorder

These classifications are the replacement for the DSM-IV-TR not otherwise specified (NOS). They are used for two situations:

1. The individual’s personality pattern meets the general criteria for a personality disorder, and traits of several different personality disorders are present, but the criteria for any specific personality disorder are not met.

2. The individual’s personality pattern meets the general criteria for a personality disorder, but the individual is considered to have a personality disorder that is not included in the DSM-5 classification (e.g., Passive-Aggressive Personality Disorder).

Dimensional Models for Personality Disorders

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. Clinicians are reminded 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, clinicians 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.

Paraphilic Disorders

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. Clinicians should 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 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). Pedaphillic disorder is excluded from use of these new specifiers.

Hypersexual Disorder

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:

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.

For those clinicians needing 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. Clinicians must also 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).

Other Mental Disorders

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:

Other Specified Mental Disorder Due to Another Medical Condition (e.g., dissociative symptoms due to complex partial seizures)

Unspecified Mental Disorder Due to Another Medical Condition

Other Specified Mental Disorder

Unspecified Mental Disorder (e.g., in emergency room settings).

Medication-Induced Movement Disorders and Other Adverse Effects of Medication

This section contains all syndromes listed in DSM-IV-TR Appendix B: Criteria Sets and Axes Provided for Further Study (pp. 735-751). The only new classification is antidepressant discontinuation syndrome; hence I recommend reading “Unanticipated psychotropic medication reactions” by Otis and King (2006) to learn about discontinuation reactions that happen when use of a medication is reduced or terminated and unsuccessful discontinuation reactions that occur when the client experiences disturbing side effects during termination and, therefore, feels compelled to resume taking the drug.

Other Conditions That May Be a Focus of Clinical Attention

This chapter of the DSM-5 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 clinicians in documenting these issues.

The DSM-5 adds more than 100 new V/Z codes and clinicians are encouraged to read pages 715-727 to become familiar with all of conditions that may be a focus of clinical attention. They are contained in the following major categories:

Relational Problems

Problems related to family upbringing

Other problems related to primary support group

Abuse and Neglect

Child maltreatment and neglect problems

Child physical abuse

Child sexual abuse

Child neglect

Child psychological abuse

Adult maltreatment and neglect problems

Spouse or partner violence, physical

Spouse or partner violence, sexual

Spouse or partner neglect

Spouse or partner abuse, psychological

Adult abuse by nonspouse or nonpartner

Educational and Occupational Problems

Educational Problems

Occupational Problems

Housing and Economic Problems

Housing Problems

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

Nonadherence to Medical Treatment

Conditions for Further Study

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.

Attenuated Psychosis Syndrome

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.

Depressive Episodes With Short-Duration Hypomania

Experienced at least one major depressive episode and at least two episodes of hypomania that meet all criteria other than the four-day duration.

Persistent Complex Bereavement Disorder

Lasting at least 12 months for adults and six months for children.

Caffeine Use Disorder

Proposed in large part to stimulate much-needed research on the prevalence and consequences of significantly problematic caffeine use.

Internet Gaming Disorder

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.

Neurobehavioral Disorder Associated With Prenatal Alcohol Exposure

Developed to capture impairments in cognition, self-regulation, and adaptive functioning that arise from exposure to alcohol in utero.

Suicidal Behavior Disorder

Describes individuals who have attempted suicide within the past two years and applies only to actual attempts, not suicidal ideation or preparatory behaviors.

Nonsuicidal Self-Injury

Applied to individuals who display intentional self-harm behaviors unlikely to result in death, such as non-lethal cutting, burning, or stabbing oneself.

Appendix 1: Summary of DSM-5 Changes

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 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 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 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, clinicians 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, clinicians 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 clinicians 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 clinicians 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 clinicians balance this out with a focus on the entire person.

Appendix 2: Schizophrenia Spectrum and Other Psychotic Disorders Differential Diagnosis

KEY FEATURES THAT DEFINE THE PSYCHOTIC DISORDERS

Delusions

Fixed beliefs that are not amenable to change in light of conflicting evidence.

Persecutory

Belief that one is going to be harmed, harassed, and so forth by an individual, organization, or other group.

Referential

Belief that certain gestures, comments, environmental cues, and so forth are directed at oneself.

Grandiose

When an individual believes that he or she has exceptional abilities, wealth, or fame.

Erotomanic

When an individual believes falsely that another person is in love with him or her.

Nihilistic

Involves the conviction that a major catastrophe will occur.

Somatic

Focus on preoccupations regarding health and organ function.

Jealous

Central theme is that of an unfaithful partner.

Bizarre

Clearly implausible and not understandable to same-culture peers and do not derive from ordinary life experiences.

Thought withdrawal

Belief that one’s thoughts have been removed by some outside force.

Thought insertion

Foreign thoughts have been put into one’s mind by some outside force.

Delusions of control

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.

Auditory

Involving the perception of sound, most commonly of voices.

Gustatory

Involving the perception of taste (usually unpleasant).

Olfactory

Involving the perception of odor, such as of burning rubber or decaying fish.

Somatic

Involving the perception of physical experience localized within the body (e.g., a feeling of electricity).

Tactile

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).

Visual

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.

Derailment or loose associations

The individual may switch from one topic to another.

Tangentiality

Answers to questions may be obliquely related or completely unrelated.

Incoherence or word salad

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.

Catatonia

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.

Affective flattening

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.

Avolition

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).

Alogia

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).

Asociality

Lack of interest in social interactions or a preference for solitary activities.

Anhedonia

Loss of interest or pleasure from activities usually found enjoyable (e.g. exercise, hobbies, music, sexual activities, or social interactions).

 

SCHIOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDERS DIFFERENTIAL DIAGNOSIS

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:

  • and/or manifests onset of prominent psychotic symptoms within 4 weeks of the first noticeable change in usual behavior or functioning; and/or confusion or perplexity;
  • and/or good premorbid social and occupational functioning;
  • and/or absence of blunted/flat affect.

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

Appendix 3: Bipolar Related Disorders Differential Diagnosis

BIPOLAR DISORDERS DIFFERENTIAL DIAGNOSIS

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

Appendix 4: Disruptive and Depressive Disorders Differential Diagnosis

DISRUPTIVE DISORDERS AND DEPRESSIVE DISORDERS DIFFERENTIAL DIAGNOSIS

 

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 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 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
  • Irritable mood most of the day, nearly every day.
  • Temper outbursts three + times per week.
Irritable mood most of the day, for more days than not.
  • Children < 5 years most days.
  • Children > 5 years once per week.
  • Twice weekly for verbal aggression or non-damaging/non-destructive/non-injurious physical aggression.
  • Three damaging/ destructive/injurious behavioral outbursts within a 12-month period.

 

DURATION 12 months minimum. 12 months minimum. 6 months minimum.
  • 3 months for either verbal aggression or non-damaging/non-destructive/non-injurious physical aggression.
  • 12 months for damaging/ destructive/injurious behavioral outbursts.
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

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 major depressive disorder that have 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 with 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 diagnosis 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

Appendix 5: Anxiety Disorders Differential Diagnosis

ANXIETY DISORDERS DIFFERENTIAL DIAGNOSIS

If the client ...

Then the diagnosis may be ...

Reports excessive fear or anxiety (e.g., getting lost, being kidnapped, having an accident, acquiring an illness, being injured, or dying) concerning 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

Appendix 6: Obsessive-Compulsive and Related Disorders Differential Diagnosis

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 urges 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

Appendix 7: Trauma- and Stressor-Related Disorders Differential Diagnosis

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
  • Diminished or absent expression of positive emotions.
  • Emotion regulation capacity is compromised; display episodes of negative emotions of fear, sadness, or irritability that are not readily explained.
None.
DISTURBED BEHAVIOR

Threshold: 2 of 2

  • Rarely or minimally seeks comfort when distressed.
  • Rarely or minimally responds to comfort when distressed.

Threshold: 2 of 4

  • Reduced or absent reticence in approaching and interacting with unfamiliar adults.
  • Overly familiar verbal or physical behavior.
  • Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings.
  • Willingness to go off with an unfamiliar adult with minimal or no hesitation.
SOCIAL AND EMOTIONAL DISTURBANCE

Threshold: 2 of 3

  • Minimal social and emotional responsiveness to others.
  • Limited positive affect.
  • Episodes of unexplained irritability, sadness, or fearfulness that are evident even during nonthreatening interactions with adult caregivers.
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

  • Direct recipient.
  • Witnessing to others, especially primary caregivers (excludes electronic media, television, movies, or pictures).
  • Learning of events to a parent or caregiving figure.
  • Direct recipient.
  • Witnessing to others.
  • Learning of events, violent or accidental, to a family member or friend.
  • Exposure, repeated or extreme, to aversive details (excludes non work-related electronic media, television, movies, or pictures).
  • Direct recipient.
  • Witnessing to others.
  • Learning of events, violent or accidental, to a family member or friend.
  • Exposure, repeated or extreme, to aversive details (excludes non work-related electronic media, television, movies, or pictures).

Identifiable stressor (e.g., single, multiple, recurrent, continuous, acute, or developmental).

INTRUSION SYMPTOMS

Threshold: 1 of 4

  • Psychological distress.
  • Distressing memories.
  • Distressing dreams.
  • Dissociative reactions.
  • Physiological reactions.

Threshold: 1 of 4

  • Psychological distress
  • Distressing memories (repetitive play with traumatic themes).
  • Distressing dreams (may be frightening without recognizable content).
  • Dissociative reactions (trauma-specific reenactment in play).
  • Physiological reactions (…to internal or external cues that symbolize or resemble an aspect…)

Threshold: 0 of 4

  • Psychological distress or physiological reactions
  • Distressing memories (repetitive play with traumatic themes).
  • Distressing dreams (may be frightening without recognizable content).
  • Dissociative reactions (trauma-specific reenactment in play).
  • Physiological reactions (…to internal or external cues that symbolize or resemble an aspect…)

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

  • Significantly increased frequency of negative emotional states.
  • Socially withdrawn behavior.
  • Markedly diminished interest or participation in significant activities, including constriction of play.
  • Persistent reduction in expression of positive emotions.

Threshold: 2 of 7

  • Persistent negative emotional state.
  • Feelings of detachment or estrangement from others.
  • Markedly diminished interest or participation in significant activities.
  • Persistent inability to experience positive emotions.
  • Inability to remember an important aspect of the traumatic event(s)
  • 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.

Threshold: 0 of 1

  • Persistent inability to experience positive emotions.

None.

ALTERATIONS IN AROUSAL AND REACTIVITY

Threshold: 2 of 5

  • Hypervigilance.
  • Exaggerated startle response.
  • Problems with concentration.
  • Sleep disturbance.
  • Irritable behavior and angry outbursts (including extreme temper tantrums).

Threshold: 1 of 6

  • Hypervigilance.
  • Exaggerated startle response.
  • Problems with concentration.
  • Sleep disturbance.
  • Irritable behavior and angry outbursts.
  • Reckless or self-destructive behavior.

Threshold: 0 of 5

  • Hypervigilance.
  • Exaggerated startle response.
  • Problems with concentration.
  • Sleep disturbance.
  • Irritable behavior and angry outbursts.

None.

DISSOCIATIVE SYMPTOMS

None. Specify PTSD as depersonalization/ derealization.

None. Specify PTSD as depersonalization/ derealization.

Threshold: 0 of 2

  • Altered sense of the reality of one’s surroundings or oneself (depersonalization/ derealization).
  • Inability to remember an important aspect of the trauma (amnesia).

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.

Appendix 8: Dissociative Disorders Differential Diagnosis

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 – 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 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

Appendix 9: Feeding and Eating Disorders Differential Diagnosis

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 BEHAVIORS

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/ANTECEDENTS

  • 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 DISTURBANCES

  • 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 OR SHAPE CONCERNS

  • 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 DEFICIENCY

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 DISTURBANCES

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 FEEDING

  • Nasogastric tube feeding.

  • Nutritionally complete supplements.

  • Gastrostomy tube feeding.

  • Hospitalization may be required to restore weight and to address medical complications.

None.

None.

COMPENSATORY BEHAVIORS

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 FEATURES

  • 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 IMPAIRMENT

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. s

  • 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 CRITERIA

4 (with 1 of 4 symptoms minimum).

3.

5 (with 2 of 2 symptoms minimum).

5 (with 3 of 5 symptoms minimum).

MUTUAL EXCLUSIVITY

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.

Appendix 10: Gender Dysphoria Differential Diagnosis

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…

A.1. To be of the other gender.
A.8. For the sex characteristics that match one’s experienced gender.

Strong Preference For…

A.2. Cross-dressing/clothing.
A.3. Cross-gender roles in play.
A.4. Cross-gender activities.
A.5. Cross-gender playmates.

Strong Rejection Of…

A.6. Stereotypical toys, games, and activities.

Strong Dislike Of…

A.7. One’s sexual anatomy.

Marked Incongruence…

A.1. Between gender and sex characteristics.

Strong Desire…

A.2. To be rid of one’s sex characteristics.
A.3. For sex characteristics of the other gender.
A.4. To be of the other gender.
A.5. To be treated as the other gender.

Strong Conviction…

A.6. That one has the typical feelings and reactions of the other gender.

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