Diagnostic groupings in the DSM 5

Diagnostic groupings in IV-TR and

5
In DSM-IV TR, the diagnostic groupings had a separate
category for children and adolescents.
DSM 5 does not make a separate category for children
and adolescents
In DSM-IV TR some of the categories had names that
made no sense-such as somatoform disorders
DSM 5 attempts to simplify diagnostic category names
DSM 5 organizes diagnostic categories into 20
chapters, starting with diagnostic categories that are
seen earlier in life and progressing to those that are
seen later in life

Changes throughout DSM

Attention to severity assessment and specification

of severity for each diagnosis
Inclusion of other specified disorder and
unspecified disorder as a diagnosis for each
group (Replaces that NOS)
"Other specified disorder" permits clinician to
communicate sub threshold diagnoses and specific
reasons why client did not meet criteria for other
diagnoses within that group

DSM 5 changes in classification

DSM 5 has 20 diagnostic groupings plus a group of

other conditions that might be a focus clinically (V
codes)
DSM 5 organizes these categories beginning with
those that might be seen earlier in life and
progressing to those later in life

Neuro
develop
mental

Bipolar

Schizophrenia

Younger

Anxiety

Depr
essiv
e

Somatic
symptom
related

Trauma
related

Obsessi
vecompulsi
ve and
related

Dissocia
tive

Eliminatio
n
disorders

Feeding and
eating
disorders

Sexual
dysfunctio
ns

Sleep wake
disorders

Gender
dysphoria

Disruptive
, impulse
control
disorders

Neurocog
nitive
disorders

Substance
related and
addictive
disorders

Paraphilia
disorders

Personality
disorder

Others

Older

The progression from younger to older in the DSM is general and there are
specific disorders such as some early childhood feeding disorders that
clearly occur later

1. Neurodevelopmental disorders
2. schizophrenia spectrum and other
psychotic disorders
3. bipolar and related disorders
4. depressive disorders
5. anxiety disorders
6. obsessive-compulsive and related
disorders
7. Trauma and related disorders
8. dissociative disorders
9. Somatic symptom and related
disorders
10. feeding and eating disorders
11. elimination disorders
12. sleep wake disorders
13. sexual dysfunctions
14. gender dysphoria
15. disruptive, impulse control, and
conduct disorders
16. neurocognitive disorders
17. paraphilia disorders
Which are your top 7 or 8

Changes in the groupings:

1. Neurodevelopmental disorders
SUMMARY
Neurodevelopmental disorders1. mental retardation is removed intellectual disability
is put in.
2. Autism spectrum disorder is the new DSM 5
diagnosis encompassing autistic disorder.
Aspergers and childhood disintegrative disorder as
well as pervasive developmental disorder.
3. Several changes have been made to ADHDspecifiers = combined; inattententive type;
hyperactive/impulsive type

MENTAL RETARDATION = INTELLECTUAL DISABILITY

Severity level for intellectual disability
Severity
level

Conceptual domain

Social domain

Practical domain

Mild

Preschool = no obvious differences. Schoolaged children and adults = academic skills

involving reading writing math time or money. In
adults abstract thinking planning cognitive
flexibility are somewhat impaired impaired.
Tendency toward concrete thinking

Immaturity and social interactions; some

difficulty picking up social cues
communication conversation in language
more concrete than peers. Possible
difficulties in emotional regulation and ageappropriate behavior. Perhaps impairment
in risk assessment

Personal care may be age-appropriate, but

more complex tasks might require support.
For example grocery shopping, transportation
home and childcare organization food prep
banking and money management

Moderate

Conceptual skills lag markedly language

development and pre-academic skills slow to
develop. School-age children = progress in
reading writing mass understanding of time and
money but slower than peers. Adults =
academic skill development is at an elementary
level. Ongoing assistance needed in conceptual
decision-making

Marked differences in social and

communication from peers. Spoken
language is much less complex than peers.
Capacity for relationships evident in familial
friendship ties. Problems with perceiving
social cues in social situations accurately.
Social judgment and decision-making
limited. Help is needed with life decisions

Personal care is okay in adulthood. Adults

typically can participate in all household tasks
with teaching. Can work with considerable
support in the workplace

Severe

Limited attainment of conceptual skills. Little or

no understanding of written language math,
time and money. Extensive support for problem
solving is needed

Spoken language is limited in terms of

vocabulary and grammar. Communication
is focused on the here and now an
everyday event. Relationships and
relational ability is considerable.

Support needed for all activities of daily living.

Supervision required at all times. We will not
make responsible decisions regarding wellbeing .skill acquisition is very limited

Profound

No concept of symbolic processes, perhaps

some functional use of objects, although this
might be limited by disturbance and motor

Might understand simple instructions and

cues. Social expression is often nonverbal.
Can respond and enjoy relationships with
people who were well known to them. Can
initiate limited social interaction with such
people through gestures. Sensory and
physical impairments may prevent social
activities

Dependent on others for all aspects of daily

physical care. Participation in these activities
is limited.. Some simple concrete tasks such
as carrying dishes to the table might be
accomplished. Co-occurring physical and
sensory impairments are often barriers to
participation

skills

SEVERITY DETERMINED BY ADAPTIVE FUNCTIONING NOT IQ

Includes deficits in language speech and communication

1.
2.
3.
4.

Expressive language disorder

Combined into "language disorder" (315.39) in
Receptive-expressive language disorder DSM 5
Phonological (articulation) disorder= speech sound disorder (315.39) In DSM 5
Stuttering AKA Childhood onset fluency disorder (315.35) In DSM 5

Social pragmatic communication

disorder 315.39
A.

Persistent difficulties in the social use of verbal and nonverbal

communication as manifested by all of the following;
deficits in using communication for searching purposes
A.impairments of the ability to change communications to match the context or needs of the
listener
B.difficulties following rules for conversation and storytelling such as taking turns in
conversation , rephrasing and knowing how to use verbal and nonverbal to regulate interaction
C.Difficulties in understanding what is not explicitly stated

B.

C.

Deficits result in functional limitations and effective communications.

The onset is in the early developmental. (But deficits aren't fully
noticeable until later in life)
Not attributable to another medical condition or neurological condition
and not better explained by other neurodevelopmental disorders

Differential diagnoses should always consider the possibility of autism

spectrum disorder, in particular those with mild severity.
Primary deficits of ADHD can cause some impairments in social communication
social anxiety disorder and social phobia can often appear with similar
symptoms and again mild intellectual developmental disorder might also mask
symptoms

LEARNING DISORDERS
DEFINED INDEPENDENT FROM GENERAL
INTELLIGENCE
DIAGNOSED WHEN AN INDIVIDUALS ACHIEVEMENT
ON INDIVIDUALLY ADMINISTERED STANDARDIZED
TESTS IN READING, MATH OR WRITTEN
EXPRESSION IS SUBSTANTIALLY BELOW THAT FOR
EXPECTED AGE AND INTELLIGENCE
DSM IV
Dyslexia reading disorder
Dyscalculia math disorder
Dysgraphia written expression disorder

DSM 5 criteria no separation

A.

Difficulty learning and using academic skills indicated by the presence of at

least one of the following symptoms for at least 6 months despite interventions.
1.
2.
3.
4.
5.
6.

B.

C.
D.

Inaccurate or slow and effortful word reading

Difficulty understanding the meaning of what is read
Difficulties with spelling
Difficulties with written expression
Difficulties mastering number sense, number facts, or calculation
Difficulty with mathematical reasoning

Affected academic skills are substantially and quantifiably below those

expected for the individual's chronological age causing significant interference
with performance (quantifiable suggest testing)
The learning difficulties begin during school way cheers but might not become
apparent until those faculties require more regular use
Not better accounted for by intellectual disabilities visual or auditory deficits
other mental or neurological disorders etc.

ADHD

In DSM-IV TR, ADHD was grouped in the

diagnostic domain of "disruptive behavior
disorders seen in childhood and adolescence"
DSM 5 has moved it to neurodevelopmental
disorders
DSM-IV TR separated ADHD into 2 subtypes:
predominantly attention deficit
predominantly hyperactivity impulsivity

DSM 5 has moved these two sub-types to

specifiers

Diagnostic Criteria for ADHD

(DSM-IV)

DSM 5
hasoccur
move
d ons
et age
limit to 12!
Must
before
age
7 years
Present for at least 6 months
Causes impairment in at least 2 settings

Now requires SEVERAL SYMPTOMS

across settings

Meets 6 of 9 symptoms of inattention

AND/OR 6 of 9 symptoms of
hyperactivity/impulsivity
Must be developmentally inappropriate levels

DSM 5 criteria

A.

Persistent pattern of inattention and or hyperactivity-impulsivity that

interferes with functioning or development as characterized by
inattention and or hyperactivity/impulsivity
1. Inattention: 6 or more of the following symptoms have persisted
for at least 6 months to a degree that is inconsistent with
developmental level and that negatively impacts directly on social
and academic activities
A.
B.
C.
D.
E.
F.
G.
H.
I.

Often fails to give close attention to details or makes careless mistakes in schoolwork
Has difficulty sustaining attention in tasks or play activitiesAnd remaining focused
Often does notseem to listen when spoken to directly
Does not follow through on instructions and fails to finish schoolwork chores or
duties
Has difficulty organizing tasks and activities
Avoids dislikes or is reluctant to engage in tasks that require sustained mental effort
Loses things necessary for tasks or activities
Is easily distracted
Is forgetful in daily activities

Specifiers

314.01 combined presentation

314.00-predominantly inattentive presentation
314.01 predominantly hyperactive impulsive
In partial remission
Severity level (mild moderate severe)

XOther important changes ADHD

ADHD can now be co-morbid with Autism spectrum

Symptom threshold has been specified for adults
Adults require a minimum of 5 symptoms not 6
Developmentally appropriate example of symptoms
are offered

Autism Spectrum disorder

Represents a new classification of several

disorders that were considered different forms of
autism
Previously, these were separate diagnoses.

Autistic disorder
Retts disorder
Childhood disintegrative disorder
Aspergers
PDD NOS

PDDs in DSM IV TR
Autistic disorder
Retts disorder
Childhood disintegrative disorder
Aspergers
PDD NOS

All characterized by severe deficits and

pervasive impairment in multiple areas of development
Reciprocal social interaction
Communication impaired
Stereotyped behavior, interests and activities

With the new DSM 5. Those separate disorders have now been
consolidated and ASD is evaluated in terms of severity rather than
separate diagnosis
RETTS Disorder removed because it has been established as a
physical disease

major changes for ASD

Three domains from the DSM IV-TR became two:

1Social interaction; 2 communication deficits; 3
repetitive behavior/fixated interest =
1) Social interaction/communication deficits
2) Fixated interests and repetitive behaviors
Deficits in communication and social behaviors are inseparable and
more accurately considered as a single set of symptoms with
contextual and environmental specificities
Delays in language are not unique nor universal in ASD and are more
accurately considered as a factor that influences the clinical
symptoms of ASD, rather than defining the ASD diagnosis
Requiring both criteria to be completely fulfilled improves specificity
of diagnosis without impairing sensitivity
Providing examples for subdomains for a range of chronological ages
and language levels increases sensitivity across severity levels from
mild to more severe, while maintaining specificity with just two
domains
Decision based on literature review, expert consultations, and
workgroup discussions; confirmed by the results of secondary

X
A.

DSM 5 criteria for all ASD

Persistent deficits in social communication and social interaction across contexts, not accounted for by general

developmental delays, and manifest by all 3 of the following:

1. Deficits in social-emotional reciprocity; ranging from abnormal social approach and failure of normal
back and forth conversation through reduced sharing of interests, emotions, and affect and response
to total lack of initiation of social interaction,
2. Deficits in nonverbal communicative behaviors used for social interaction; ranging from poorly
integrated- verbal and nonverbal communication, through abnormalities in eye contact and bodylanguage, or deficits in understanding and use of nonverbal communication, to total lack of facial
expression or gestures.
3. Deficits in developing and maintaining relationships, appropriate to developmental level (beyond
those with caregivers); ranging from difficulties adjusting behavior to suit different social contexts
through difficulties in sharing imaginative play and in making friends to an apparent absence of
interest in people
B.
1.
2.
3.
4.
C.
D.

Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the
following:
Stereotyped or repetitive speech, motor movements, or use of objects; (such as simple motor
stereotypies, echolalia, repetitive use of objects, or idiosyncratic phrases).
Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive
resistance to change; (such as motoric rituals, insistence on same route or food, repetitive questioning
or extreme distress at small changes).
Highly restricted, fixated interests that are abnormal in intensity or focus; (such as strong attachment
to or preoccupation with unusual objects, excessively circumscribed or perseverative interests).
Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment;
(such as apparent indifference to pain/heat/cold, adverse response to specific sounds or textures,
excessive smelling or touching of objects, fascination with lights or spinning objects).
Symptoms must be present in early childhood (but may not become fully manifest until social
demands exceed limited capacities)
Symptoms together limit and impair everyday functioning.

Specifiers

With or without accompanying intellectual

impairment
With her without accompanying language
impairment
Associated with a known medical or genetic
condition or environmental factor
With catatonia
Specify severity level

severity

Severity level
ASD

Social communication and

interaction

Restricted interests and repetitive

behaviors

3.Requires very substantial

support

Severe deficits in verbal and

nonverbal social communication
skills cause severe impairments in
functioning; very limited initiation
of social interactions and minimal
response to social overtures from
others.

Preoccupations, fixated rituals

and/or repetitive behaviors
markedly interfere with functioning
in all spheres. Marked distress
when rituals or routines are
interrupted; very difficult to
redirect from fixated interest or
returns to it quickly

2 requires substantial support

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 response to social
overtures from others

RRBs and/or preoccupations or

fixated interests appear frequently
enough to be obvious to the casual
observer and interfere with
functioning in a variety of
contexts. Distress or frustration is
apparent when RRBs are
interrupted; difficult to redirect
from fixated interest

I requires support

Without supports in place, deficits

in social communication cause
noticeable impairments. Has
difficulty initiating social
interactions and demonstrates
clear examples of atypical or
unsuccessful responses to social
overtures of others. May appear to
have decreased interest in social
interactions.

Rituals and repetitive behaviors

(RRBs) cause significant
interference with functioning in
one or more contexts. Resists
attempts by others to interrupt
RRBs or to be redirected from
fixated interest.

ASD CONCERNS

STIGMA - aspergers made autism respectable!

Will it continue to de-stigmatize or re-stigmatize
Will clinicians and insurance companies control
for the intellectual disability bias?
Prior co-morbid estimates with previous classification
= 25-75%
Drops to negligible with PDD and Aspergers

2. Schizophrenia
spectrum

Schizophrenia spectrum and other

X
psychotic disorders
1.
2.

3.
4.
5.
6.

7.

The spectrum seems to emphasize degrees of psychosis

Change in criteria for schizophrenia now requires at least
one criteria to be either a. Delusions, b. Hallucinations or c.
Disorganized speech
Subtypes of schizophrenia were eliminated
Dimensional measures of symptom severity are now
included
Schizoaffective disorder has been reconceptualized
Delusional disorder no longer requires the presence of nonbizarre" in delusions. There is now specifier for bizarre
delusions.
Schizotypal personality disorder is now considered part of
the spectrum

2: schizophrenia and the DSM 5

X Overview of changes from DSMIV TR to the DSM five

Schizophrenia and other disorders related to
schizophrenia are now grouped within a spectrum
Overall definition of schizophrenia has not changed that
much
Requirements that delusions must be bizarre and
hallucinations must be "first rank." (eg. Two or more
voices conversing together) have been eliminated.
The four subtypes of schizophrenia (paranoid,
catatonic, disorganized and chronic undifferentiated)
have been eliminated.
Rating of symptom severity is most important

Spectrums
Spectrum as it applies to mental disorder is a range of
linked conditions, sometimes also extending to include
singular symptoms and traits. The different elements of a
spectrum either have a similar appearance or are thought
to be caused by the same underlying mechanism. In either
case, a spectrum approach is taken because there
appears to be "not a unitary disorder but rather a
syndrome composed of subgroups". The spectrum may
represent a range of severity, comprising relatively
"severe" mental disorders through to relatively "mild and
nonclinical deficits".[1]
In some cases, a spectrum approach joins together
conditions that were previously considered separately.
(wikipedia)

Spectrum suggests a progression

from
Mild or brief
Debilitation
Severity

Attenuated
psychosis
Syndrome
in conditions
for further
study

Major or lengthy
Debilitation
severity

Schizotypal
personality
Disorder
(Found in PD
Section)

delusional
disorder

Brief
psychotic
disorder

Schizophreniform
disorder

Schizophrenia

In the following areas

1.Delusions
2.Hallucinations
3.Disorganized thinking/speech
4.Disorganized or abnormal motor behavior
5.Negative symptoms

Schizoaffective
disorder

Attenuated psychosis
syndrome

CRITERIA
A.

At least one of the following symptoms is present in attenuated form and with
relatively intact reality testing. It is of sufficient severity or frequency to warrant
clinical attention
1. Delusions
2. Hallucinations
3. Disorganized speech
B.
Symptoms must have been present at least once per week for the last month
C.
Symptoms have begun or worsened in the last year
D.
Symptom is sufficiently distressing or disabling to the individual
E.
Symptom is not better explained by another mental disorder including a
depressive or bipolar disorder with psychotic features and is not caused by a
substance
F.
Criteria for any other psychotic disorder have never been met

Symptoms are psychosis like, but below the threshold for a full psychotic disorder.
Typically the symptoms are less severe and more transient than in another
psychotic disorder. Insight is relatively intact this condition might be stress
related. Typically the individual realizes that these changes are taking place and
DIAGNOSTIC
FEATURES
something is wrong.
Usually occurs in late adolescence or early adulthood

Schizotypal personality disorder

(Technically not in the spectrum)
Criteria
A.

A pervasive pattern of social and interpersonal deficits marked by acute discomfort with and reduce
capacity for close relationships as well as by cognitive or perceptual distortions and eccentric cities
of behavior beginning by early adulthood and present in a variety of contexts as Indicated by 5 or
more of the following:
1.
2.
3.
4.
5.
6.
7.
8.
9.

1.

Ideas of reference (excluding delusions of reference)

Odd beliefs or magical thinking that influences behavior; i.e. belief in clairvoyance, astral projection telepathy etc.
Unusual perceptual experiences, including bodily illusions
Odd thinking and speech
Suspicious or paranoid ideation
Inadequate or constricted affect
Behavior or appearance that is odd eccentric or peculiar
Lack of close friends or confidants
Excessive social anxiety that does not diminish

does not occur exclusively within the course of schizophrenia a bipolar disorder or
depressive disorder with psychotic features or another psychotic disorder or autism
spectrum disorder

Pervasive pattern of social and it interpersonal deficits as well as eccentricities of behavior

and cognitive distortions. Such people usually have few close relationships and are
considered odd. They may be fascinated or preoccupied with paranormal phenomena
and/or superstitions they might believe that they have magical powers. They typically
do not fit in and have difficulty matching the norms of consensual social interaction.
Typically these people do not become psychotic and any psychotic symptoms are
often transient and mild

Schizophrenia

DSM-5 Criteria and DSM-IV criteria are same:

CRITERION A.
2 or more characteristic symptoms present
for 1-month period over a 6-month
period:
1.
2.
3.
4.

Delusions
Hallucinations
Disorganized speech
disorganized behavior

Except for

Requirement of bizarre delusionsand/or

schneidnerian 1st rank hallucinations is
changed to
At least 1 of the two below need to be from core
positive symptoms (delusions, hallucinations,
disorganized speech)
1.Delusions
2.
Hallucinations
3.
Disorganized speech
4.
disorganized behavior
5.
Negative symptoms (personality

 B. Level of functioning in one or more areasX work, interpersonal relations, self care,
vocation-is markedly below the level of
functioning prior to the onset; social/
occupational dysfunction cant work or relate
C. Continuous signs of the disturbance for at
least 6 months (at east 1 month with
symptoms from category A. Duration is the
main factor in differentiating schizophrenia
from similar illnesses
D. have successfully ruled out schizoaffective
disorder and mood disorder (with psychotic
symptoms) b/c no evidence of mania or
depression
E. not due to substance abuse

Specifiers

1st episode, currently in acute stage

1st episode currently in partial remission
1st episode in full remission
multiple episodes, currently in acute episode
multiple episodes currently in partial remission
multiple episodes currently in full remission
continuous
with catatonia

Schizophrenia

Diagnostic features

Other symptoms outside the major diagnostic criteria include mood dysphoria,
inappropriate affect sleep disturbance depersonalization, derealization somatic concerns,
vocational impairments

Lack of insight or awareness or even denial about the existence of the illness is also a
symptom that commonly occurs.
Aggression, sometimes associated with delusions is common in males, although not as a
rule
Although there are many brain and genetic abnormalities that have been identified, there
are no absolute biological markers
Schizophrenia is often overdiagnosed in the poor
There is a high rate of suicide among schizophrenics-6%. With a suicide attempt rate of
close to 20%

Schizophreniform disorder

X
Diagnostic features

* At least one third of people who receive this diagnosis

recover. However the other two thirds will eventually be
diagnosed with schizophrenia
Meets all the diagnostic criteria for Schizophrenia, except
duration
Diagnosed when duration is less than six months (Absence
of criterion B) (this includes prodromal, active and residual
phase)_
Make this diagnosis when someone is having an episode
longer than one month, but it has not yet lasted 6 months
(call it provisional)
The 'Tweener' disorder in terms of length. The period of
active psychotic symptoms (delusions, hallucinations,
disorganized thinking, disorganize motor behavior) is longer
than a brief psychotic episode, but not as long as
schizophrenia

Schizophreniform

XDiagnostic criteria 295.40

A. 2 or more of the following present for a significant portion

of time. At least one of these must be one 2 or 3
1.
2.
3.
4.
5.

Delusions
Hallucinations
Disorganized speech
Disorganized motor behavior
Negative symptoms

B. Lasts at least one month but less than 6 months. When

diagnosis is made before recovery, specify "provisional
C. Schizoaffective disorder, depressive disorder or bipolar
disorder with psychotic features have been ruled out
because either no major mood episodes have occurred
with the psychotic symptoms or if they have occurred,
their occurrence was infrequent
D. Not attributable to substances or another medical

Schizoaffective disorder

Diagnostic criteria295.70
A.

An uninterrupted. period which there is a major mood episode con

current with criterion A of schizophrenia
1.
Delusions
2.
Hallucinations
3.
Disorganized thinking
4.
Grossly abnormal motor behavior
5.
Negative symptoms of schizophrenia
B. In addition, Delusions or hallucinations must occur for two or more

C.

D.

weeks with an absence of a major mood episode during the

lifetime duration of the illness
Symptoms that meet criteria for major mood episode be present for
the majority of the duration of the Active, and residual portions of
the illness
Not attributable to the effects of a substance medication or other
medical condition

The requirement that a major mood disorder must be present for the majority
Of the duration of illness AFTER criterion A is met, makes this alongitudinal
Illness or bridge on spectrum

Subtypes

Specify whether:
295.70-bipolar type
295.70-depressive type

Specify if:
with catatonia
1st episode currently in acute episode
1st episode currently in partial remission
1st episode currently in full remission
multiple episodes currently in acute episode
multiple episodes currently in partial remission
multiple episodes currently in full remission
continuous
severity level-use. Clinician related dimensions of
psychotic symptoms

PSYCHOTICISM
HIGH
SCHIZOAFFECTIVE
SCHIZOPHRENIA
ACUTE

A
F
F
E
C
T

NONE

MOOD DISORDERWITH
PSYCHOTIC FEATURES

HIGH
SCHIZOPHRENIA
PARTIAL REMISSION

MOOD DISORDER

NONE

X3. Bipolar and related disorders

summary
Diagnosis must now include both changes in mood and

changes in activity/energy level

Some particular conditions can now be diagnosed under
"other specified bipolar and related disorders
An "anxiety" specifier has now been included
Attempts made to clarify definition of 'hypomania".
However it was not successful
Bipolar I mixed episode no longer requires full criteria
for depressed and mania or hypomania
New specifier is mixed features.

Some particular conditions can now be diagnosed unde

"other specified bipolar and related disorders
These do not meet full criteria for bipolar diagnosis
1. No history of major depression with hypomanic
episode052. Short durations. Cyclothymic (less than 24 months).
3. Multiple episodes of hypomanic symptoms that do
not meet criteria and multiple episodes of
depressive symptoms that you might meet criteria
4. History of major depressive disorder

Hypomanic symptoms present but not of

sufficient duration (less than 4 days)
Insufficient number of hypomanic
symptoms

Problems
Severity Criteria are unclear
"Severity is based on the number of criterion symptoms,
Francis severity of those symptoms and the degree of
functional disability." (Page 154)
Dimensional measures for both mania and depression
exist as level II crosscutting measures. These could be
used to measure severity.

Bipolar I Coding for severity

Bipolar I
disorder

Current or
most recent
episodemanic

Current or
most recent
episodehypomanic

Current or
most recent
episodedepressed

Current or
most recent
episodeunspecified

Mild

296.41

Not applicable

296.51

Not applicable

Moderate

296.42

Not applicable

296.52

Not applicable

Severe

296.43

Not applicable

296.53

Not applicable

Mild = few if any symptoms in excess of those required to meet the diagnostic criteria are
present. The intensity is distressing that manageable. Symptoms resulting minor
impairment of social and occupational functioning
Moderate = number of symptoms and intensity and/or functional impairment are between
those specified for mild and severe
Severe = number of symptoms is substantially in excess of those required to make DX.
Intensity of symptoms is seriously distressing and unmanageable. Symptoms interfere

The dimensional Alternative

assessment
of mania and hypomania
DSM 5 offer some assistance
Suggests 1st using the level I crosscutting
symptoms scale-PP.734 735.
That the answers to question 9 and 10-increased
energy anddecreased need for sleepare positive then

Move to use of the Altman self rating mania scale

(ASRM) - See next slide

Level 2
Dimensional
Measure for
Mania
Level II
measures are
more in-depth
than level I
measures. The
level I measure
shown in week 1
measured a
number of
different
symptoms. Level
II focuses in on
only one
subgroup. In this
case mania

Instructions for the mania scale

Instructions to Clinicians
The DSM-5 Level 2ManiaAdult measure is the Altman Self-Rating Mania Scale. The ASRM is a 5-item se rating mania scale
designed to assess the presence and/or severity of manic symptoms. The measure is completed by the individual prior to a
visit with the clinician. If the individual receiving care is of impaired capacity and unable to complete the form (e.g., an
individual with dementia), a knowledgeable informant complete the measure. Each item asks the individual (or informant) to
rate the severity of the individuals manic symptoms during the past 7 days.

Scoring and Interpretation

Each item on the measure is rated on a 5-point scale (i.e., 1 to 5) with the response categories having differ anchors
depending on the item. The ASRM score range from 5 to 25 with higher scores indicating greater severity of manic symptoms.
The clinician is asked review the score on each item on the measure during th clinical interview and indicate the raw score for
each item in the section provided for Clinician Use. The r scores on the 5 items should be summed to obtain a total raw
score and should be interpreted using the Interpretation Table for the ASRM below:

Interpretation Table for the ASRM

- A score of 6 or higher indicates a high probability of a manic or hypomanic condition
- A score of 6 or higher may indicate a need for treatment and/or further diagnostic workup
- A score of 5 or lower is less likely to be associated with significant symptoms of mania

Instructions: for client

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.
1. Please read each group of statements/question carefully.
2. Choose the one statement in each group that best describes the way you (the individual receiving care) have been feeling for
the past week.
3. Check the box (P or x) next to the number/statement selected.
4. Please note: The word occasionally when used here means once or twice; often means several times o more and
frequently means most of the time.

Coding and recording procedures for

bipolar one disorder
Coding is complicated
Must specify the following in the order presented below
1. Bipolar I disorder
2. Type of current episode (manic or depressive)
3. Severity level
4. Current state of most recent episode (active, in partial
remission, in full remission, unspecified)
5. Psychotic features present
6. Presence of other specifiers (uncoded)

Bipolar I Coding for Current state of episode

& psychosis
Bipolar I
disorder

Current or
most recent
episodemanic

Current or
most recent
episodehypomanic*

Current or
most recent
episodedepressed

Current or
most recent
episodeunspecified**

W/ psychotic
features

296.44

Not applicable

296.54

Not applicable

In Partial
remission

296.45

296.45

296.55

Not applicable

In full remission

296.46

296.46

296.56

Not applicable

Unspecified

296.40

296.40

296.50

Not applicabl

*Do not code severity and psychotic features if current or most recent
episode is hypomanic. **Do not code severity and psychotic features if
current or most recent episode = unspecified.

4. Depressive disorders
SUMMARY
New diagnosis included = "disruptive mood
dysregulation disorder-use for children up to age
18
New diagnosis included = "premenstrual dysphoric
disorder
What used to be called dysthymic disorder is now
"persistent depressive disorder
Bereavement is no longer excluded

MDD: Specifiers

Severity
With anxious distress
With mixed features
Melancholic Features
Atypical Features
Catatonic
Postpartum
Seasonal
With Psychotic Features(Mood congruent or
incongruent)

Depression is mainly coded by

severity and recurrence
Severity/course
specifier

Single episode

Recurrent episode

Mild

296.21

296.31

Moderate

296.22

296.332

Severe

296.23

296.33

With psychotic features

296.24

296.34

In partial remission

296.25

296.35

In full remission

296.26

296.36

Unspecified

296.20

296.30

Mild = few if any symptoms in excess of those required to meet the diagnostic criteria are present.
The intensity is distressing that manageable. Symptoms resulting minor impairment of social and
occupational functioning
Moderate = number of symptoms and intensity and/or functional impairment are between those
specified for mild and severe

Severe = number of symptoms is substantially in excess of those required to make DX. Intensity of
symptoms is seriously distressing and unmanageable. Symptoms interfere markedly with social and

Problems with severity

Severity Criteria are unclear
"Severity is based on the number of criterion symptoms,
Francis severity of those symptoms and the degree of
functional disability." (Page 154)
Dimensional measures for both mania and depression
exist as level II crosscutting measures. These could be
used to measure severity.

LEVEL ii CROSS-CUTTING MEASURE FOR DEPRESSION. The questions below ask about these
feelings in more detail and especially how often you (the individual receiving care) have been bothered
by a list of symptoms during the past 7 days. Please respond to each item by marking ( or x) one
box per row.

Instructions to Clinicians
The DSM-5 Level 2DepressionAdult measure is the 8-item PROMIS
Depression Short Form that assesses the pure domain of depression in
individuals age 18 and older. The measure is completed by the individual prior
to a visit with the clinician. If the individual receiving care is of impaired
capacity and unable to complete the form (e.g., an individual with dementia), a
knowledgeable informant may complete the measure as done in the DSM-5
Field Trials. However, the PROMIS Depression Short Form has not been
validated as an informant report scale by the PROMIS group. Each item asks
the individual receiving care (or informant) to rate the severity of the
individuals depression during the past 7 days.
Scoring and Interpretation
Each item on the measure is rated on a 5-point scale (1=never; 2=rarely;
3=sometimes; 4=often; and 5=always) with a range in score from 8 to 40 with
higher scores indicating greater severity of depression. The clinician is asked
to review the score on each item on the measure during the clinical interview
and indicate the raw score for each item in the section provided for Clinician
Use. The raw scores on the 8 items should be summed to obtain a total raw
score. Next, the T-score table should be used to identify the T-score
associated with the individuals total raw score and the information entered in
the T-score row on the measure.

Note:
This look-up table works only if all items on the form are answered. If 75% or more of the
questions have been answered; you are asked to prorate the raw score and then look up the
conversion to T-Score. The formula to prorate the partial raw score to Total Raw Score is:
(Raw sum x number of items on the short form)
Number of items that were actually answered
If the result is a fraction, round to the nearest whole number. For example, if 6 of 8 items were
answered and the sum of those 6 responses was 20, the prorated raw score would be 20 X 8/
6 = 26.67. The T-score in this example would be the T-score associated with the rounded
whole number raw score (in this case 27, for a T-score of 64.4).
The T-scores are interpreted as follows:
Less than 55 = None to slight
55.059.9 = Mild
60.069.9 = Moderate
70 and over = Severe
Note: If more than 25% of the total items on the measure are

Explanation of other specifiers

With anxious distress = 1. Tense, 2. Restless 3. Excessive worry 4. Fear of catastrophe 5. Fear of losing control
If present, Code severity of anxiety
Mild = 2 symptoms
moderate = 3 symptoms
moderate- severe = 4 or 5 symptoms
With mixed features = prominent dysphoria or depressed mood, diminished interest or pleasure, psychomotor retardation and/or
other symptoms found in depressive episodes

With melancholic features = loss of pleasures and all activities, lack of reactivity to pleasurable experiences. 3 or more of the
following; depressed mood that is worse in the morning, early-morning awakening mark psychomotor agitation or retardation,
significant weight loss, excessive guilt

With atypical features = mood improves in response to positive events (mood reactivity) 2 or more of the following; weight gain or
increase in appetite, hypersomnia, heavy feeling in arms or legs heightened sensitivity to interpersonal rejection

Mood congruent psychotic features = with depression, delusions and hallucinations are often punitive, self punishing and rejecting.
Perhaps delusions of persecution or annihilation.

Mood incongruent psychotic features = delusions and hallucinations are not consistent with mood being displayed

With postpartum onset = onset of mood symptoms occurs during pregnancy or in the 4 weeks following delivery. Depressive
episodes are far more common than manic episodes

Seasonal pattern = regular temporal correlation between the onset of manic, hypomanic or depressive episodes and a particular
time of year, usually without the presence of psychosocial stressors

With anxiety
Anxiety is very common with depression

anxious distress =

1. Tense
2. RelentlessRestlessness
3. Excessive worryOr concern that is
unwarranted
4. Excessive concern regarding the
occurrence of a major negative event 5. Fear of losing control
If present, Code severity of anxiety
Mild = 2 symptoms
moderate = 3 symptoms
moderate- severe = 4 or 5 symptoms

Persistent depressive disorder 300.

X Formerly known as dysthymic
disorder

In The DSM-IV TR, dysthymia was considered a

depressive disorder that that was
A. long-lasting (chronic) and
B. did not meet the full criteria for a major depressive
episode- a milder form of depression

Persistent depressive disorder in the DSM

X
5
Combines dysthymia and a chronic form
of major depressive disorder (without
Persistent depressive disorder
certain symptoms

Dysthymia vs MDD
Chronic sense of inadequacy
Depression is not as intense as with MDD
Symptoms are typically not as acute as
with MDD
MDD = depressed mood, most of day, nearly every
day for two weeks
Dys = depressed mood more days than not over a
period of 2 years

Seems more like a personality disorder

dissatisified personality

X
Dysthymic Disorder and Chronic

major depressive disorder

2 or more of the following associated Symptoms
Along with depressed mood
1.
2.
3.
4.
5.
6.

Change in appetite
Change in sleep
Decreased energy
Decreased self worth
Poor concentration
Hopelessness

X
Please note that there are 3 major symptoms missing
from this list that are included in major depressive
disorder;
1. Absence of pleasure (anhedonia)
2. Recurrent thoughts of suicide
3. Psychomotor retardation or agitation
This suggests that only a particular type of major
depressive disorder-1 without suicidal ideation,
anhedonia and lethargy qualify for this diagnosis

PDD: Specifiers

Severity
With anxious distress
With mixed features
Melancholic Features
Atypical Features
Psychosis-mild (mood congruent or incongruent)
Postpartum
Partial remission
Full remission
Late onset-21 or older
Early onset

With pure dysthymic syndrome-criteria for major depression is not been

met
With persistent major depressive episode-full criteria have been met,
excluding anhedonia, psychomotor retardation and suicidal ideation
Intermittent major depressive episodes with or without current episode

The bereavement exclusion is gone

In DSM-IV, there was an exclusion criterion for a major depressive episode

that was applied to depressive symptoms lasting less than 2 months
following the death of a loved one (i.e., the bereavement exclusion). This
exclusion is omitted in DSM-5 for several reasons. The first is to remove the
implication that bereavement typically lasts only 2 months when both
physicians and grief counselors recognize that the duration is more
commonly 12 years. Second, bereavement is recognized as a severe
psychosocial stressor that can precipitate a major depressive episode in a
vulnerable individual, generally beginning soon after the loss. When major
depressive disorder occurs in the context of bereavement, it adds an
additional risk for suffering, feelings of worthlessness, suicidal ideation,
poorer somatic health, worse interpersonal and work functioning, and an
increased risk for persistent complex bereavement disorder, which is now
described with explicit criteria in Conditions for Further Study in DSM-5
Section III. Third, bereavement-related major depression is most likely to
occur in individuals with past personal and family histories of major
depressive episodes. It is genetically influenced and is associated with similar
personality characteristics, patterns of comorbidity, and risks of chronicity
and/or recurrence as nonbereavement-related major depressive episodes.
Finally, the depressive symptoms associated with bereavement-related
depression respond to the same psychosocial and medication treatments as
nonbereavement-related depression.

Disruptive mood dysregulation disord

296.99
The purpose of this diagnosis was to provide a category for
children that created an alternative to the diagnosis of
bipolar disorder
Evidence for such a diagnosis has long been available.
Earlier proposals were "severe mood dysregulation
Evidence suggests that children with this type of mood
dysregulation will not go on to be bipolar, but more likely
suffer from major depression

Diagnostic criteria
A.

B.
C.
D.
E.
F.
G.
H.
I.
J.
K.

Severe recurrent temper outburst manifested verbally or

behaviorally; grossly out of proportion to the situation to the
situation
Outbursts are inconsistent with developmental level
Outbursts occur 3 or more times a week
Mood between temper outburst is persistently irritable or angry
most of the day, nearly every day.
Criterion a through D have been present for 12 or more months
Criteria a through D are present in at least 2 or more settings
Initial Diagnosis can be made between the ages of 6 to 18
Age of onset-established her history or observation-must be before the
age of 10
No presence of manic or hypomanic episode
These behaviors do not occur during an episode of major depression and
are not better explained by another mental disorder
Symptoms are not attributable to the effects of a substance, another
medical or neurological condition

Diagnostic features

Chronic, severe persistent irritability with the

following:
Frequent temper outbursts in response to frustration
over a sustained period of time and are
developmentally inappropriate
Anger and irritability remains constant even after
temper outbursts of stopped

Prevalence estimates range between 2% and 5%

Affects males more than females
such children seem to be extremely temperamental
in prodromal manifestation
sometimes diagnosed as oppositional defiant
disorder

5. Anxiety disorders, 6.
obsessive-compulsive disorder
and 7. trauma-related disorders
SUMMARY

Stress and trauma related disorders

Anxiety disorders
Disinhibited social engagement dis.
Reactive attachment disorder
Adjustment disorders
Panic disorder
PTSD
Agoraphobia
Generalized anxiety disorder Acute stress disorder
Social phobia
Specific phobia
PTSD
Obsessive-compulsive related disorders
Specified
anxiety disorder
Acute Stressanxiety
disorder
Unspecified
disorder
Obsessive compulsive disorder Obsessive compulsive disorder
Separation anxiety disorder
ocd w/ poor insight
selectivemutism
Hoarding disorder
Hair-pulling disorder
Skin-picking disorder
Body dysmorphic disorder
Medication-induced ocd
Other specified/unspecified ocd

5. Anxiety disorders
Obsessive-compulsive disorder has been
moved out of this category
PTSD has been moved out of this category
Acute stress disorder has been moved out of
this category
Panic attacks can now be used as a specifier
within any other disorder in the DSM
Separation anxiety disorder has been moved to
this group
Selective mutism has been moved to this group

Other changes and anxiety

disorders
Criteria for specific phobia, and social anxiety disorder that
requires that individuals over 18 recognize that their anxiety is
excessive or unreasonable has been deleted
I don't know I don't see it in here. I don't know. I had a lot of
awareness requirement is now that anxiety must be out of
proportion to the actual danger or threat in a situation after a
cultural context is considerED
Panic disorder and agoraphobia are unlinked in the DSM 5
THE generalized specifier for social anxiety disorder has
been deleted and replaced with her performance only
specifier

6. Obsessive-compulsive and
related disorders

A completely new diagnostic grouping category

Hoarding disorder-new diagnosis
Excoriation (skin picking) disorder-new diagnosis
Substance induced obsessive-compulsive disorder-new
diagnosis
Tic specifier has been added
Muscle dysphoria is now a specifier within body dysmorphic
disorder
Obsessive-compulsive disorder-refined to allow distinction
between individuals with good to fair poor or absent/delusional

OCD Specifiers
In DSM-IV TR a requirement for the diagnosis was that
the person suffering realized that the worries and
behaviors were excessive
Now insight is a specifier
With good or fair insight-individual recognizes that
beliefs and behaviors are not true and will not work
With poor insight-individual believes that behaviors and
beliefs will help
With absent insight/delusional beliefs-individual is
zealous in thinking that thoughts and behaviors must
happen

Hoarding disorder 300.3

A. Persistent difficulty discarding her, parting with possessions,

regardless of their actual value
B. Difficulty is due to perceived need to save the items and due to
distress associated with discarding them
C. To difficulty discarding results in the accumulation of
possessions that congest and clutter active living areas and
compromise their intended use
D. Causes clinically significant distress or impairment in social,
occupational or other Areas of functioning
E. Not attributable to another medical condition
F. Not better accounted for by.
Specifiers

With excessive acquisition-in addition to keeping things, this

type actively seeks out more(80 to 90% of all hoarders)
With good or fair insight
With poor insight
With absent insight and delusional beliefs this would
trump delusional disorder

Excoriation (skin picking)

disorder 698.4
A. Recurrent skin picking resulting in lesions
B. Repeated attempts to stop or decrease behavior
C. Causes clinically significant distress or
impairment in social, occupational
D. Not attributable to the effects of a substance or
medication
E. Not better explained by

X Substance/medication induced
obsessive-compulsive and related
disorder
A. Obsessions, compulsions, skin picking, hair pulling or
other body focused repetitive behaviors occur
B. Evidence that symptoms began during or soon after
substance use, withdrawal or medication exposure.
Substance or medication is capable of producing
obsessive-compulsive symptoms
C. Not better accounted for by OCD that is not
substance/medication induced
D. Does not occur exclusively during delirium
E. Causes clinically significant distress

OCD due to another medical

condition 294.8
A. Obsessions, compulsions, skin picking, hair
pulling or other body focused repetitive
behaviors occur
B. Evidence that symptoms began during or soon
after Another medical condition that could cause
the symptomsNot better accounted for by OCD
that is not substance/medication induced
C. Does not occur exclusively during delirium
D. Causes clinically significant distress
Specify if
With the possessive compulsive disorder like symptoms
With appearance. Preoccupation
With hoarding symptoms
With hair pulling symptoms
With skin picking symptoms

Other specified obsessivecompulsive and related disorder

300.3
Use when OCD symptoms are there and cause
clinically significant distress, but do not meet full
criteria for an OCD related diagnoses
Specify

Body dysmorphia with actual flaws

Body dysmorphia without repetitive behaviors
Body dysmorphia with repetitive behaviors
obsessional jealousy

Substance-Related Disorders
:

Substance Use Disorders

Substance Dependence
Substance Abuse

The distinction between

Dependence and abuse disorders
has been eliminated in the DSM 5

Substance-Induced Disorders
Substance Intoxication
Substance Withdrawal
Substance induced mental disorder

Substance use disorders maladaptive

pattern leading to clinically significant
mpairment or distress for at least 12 month
Must have at least 2 of the following11:

1. Substance taken in larger amount (need more for

increased effect)
2. Persistent desire or efforts to quit
3. Time spent to obtain, use, recover from effects
4. Cravings Or urges to use
5. Failure to fulfill significant roles
6. Continued use despite persistent and recurrent
problems
7. Important social/occupational activities are
reduced
8. Recurrent use in physically hazardous situations
9. Use continues despite knowledge of impact of
the problem
10. Tolerance, as defined by a. Increased amounts
needed to achieve intoxication or b. Diminished
effect

Substance-related disorders
Substance induced dis.

Substance use dis.

Pathological pattern of
behaviors related to use
of the substance
1.Impaired control
2.Social impairment
3.Risky use

=
= does occur also

4. Pharmacological effects
Increased tolerance

Substance
Intoxication
Recent
ingestion.
Reversible
symptoms
related to
ingestion

Substance
Withdrawal
Physiological and
psychological
symptoms due to
decreased use or
cessation

Substance
Induced
Mental
disorder.
Recent
ingestion
followed by
symptoms
of another
M.D.

Delirium; persisting dementia; persisting amnesia;

Psychotic disorder; mood dis; anxiety dis; sexual dys; sleep dis.

11 criteria four areas USE Dx

1.
Impaired 2.
Control 3.
4.
5.
social
Impairment6.
7.
Risky 8.
use 9.
10.
Pharmacological
11.
effects

Substance taken in larger amount (need more for increased e

Persistent desire or efforts to quit
Time spent to obtain, use, recover from effects
Cravings Or urge to use
Failure to fulfill significant roles
Continued use despite persistent and recurrent problems
Important social/occupational activities are reduced
Recurrent use in physically hazardous situations
Use continues despite knowledge of impact of the problem
Tolerance, as defined by a. Increased amounts needed to ach
intoxication or b. Diminished effect
Withdrawal

X1. Criteria for Substance Use disorder

A. A maladaptive pattern of substance use leading to

impairment or distress, as seen in 2 of the following
in the same 12-mo. period:
1. Substance taken in larger amount (need more for
increased effect)
2. Persistent desire or efforts to quit
3. Time spent to obtain, use, recover from effects
4. Cravings Or urges to use
5. Failure to fulfill significant roles
6. Continued use despite persistent and recurrent problems
7. Important social/occupational activities are reduced
8. Recurrent use in physically hazardous situations
9. Use continues despite knowledge of impact of the problem
10.Tolerance, as defined by a. Increased amounts needed to
achieve intoxication or b. Diminished effect
11. Withdrawal

DSM 5 use = 2 or more crit. DSM IV

Abuse = 1 or more

1Failure to fulfill major role obligations at work, school,

home such as repeated absences or poor work performance
related to substance use;
#5 DSM 5
2. Frequent use of substances in situation which iis
physically hazardous
#8 dsm 5
3Frequent legal problems (e.g. arrests, disorderly conduct)
for substance abuse removed
4. Continued use despite having persistent or recurrent
social or interpersonal problems #6 dsm 5

Dependence = 3 or more

5. Tolerance or markedly increased amounts of the

substance to achieve intoxication or desired effect or
markedly diminished effect with continued use of the same
amount of substance #10 DSM 5
6 Withdrawal symptoms or the use of certain substances to
avoid withdrawal symptoms #11 DSM 5
7. Use of a substance in larger amounts or over a longer
period than was intended #1 DSM 5
8.persistent desire or unsuccessful efforts to cut down or
control substance use #2 DSM 5

9. Involvement in chronic behavior to obtain the substance,

use the substance, or recover from its effects #3 DSM 5
10. .Reduction or abandonment of social, occupational or
recreational activities because of substance use #7 DSM 5

Specifiers for use disorders

Severity
Mild = presence of 2-3 symptoms
moderate = presence of four five symptoms
severe = presence of six or more symptoms
Course specifiers
In early remission = after full criteria were previously met
none of the criteria have been met for at least three months but
less than 12 (with the
exception of craving)
In sustained remission = after full criteria were
previously met none exists except craving during the period of 12
months or more

Can also diagnose intoxication, withdrawal and induced mental disor

Simple substance dx

Mental disorders that can be induced by substances

I/W
I/W
I

7. Trauma and stress related

disorders
For diagnosis of acute stress disorder, it must be
specified whether the traumatic events were
experienced directly or indirectly
Adjustment disorders (a separate class in the
DSM-IV) are included here as various types of
responses to stress
Major changes in the criteria for the diagnosis of
PTSD

XDiagnostic criteria has gotten more

detailed and specific = more

complicated diagnosis
The basics

Traumatic
events

Subsequent
reactions

A. Exposure to trauma-direct or indirect

B. Presence of intrusive thoughts, memories,
flashbacks, dreams, triggers that cause distress, or
other external cues that remind one of the trauma
C. Avoidance of stimuli associated with the traumatic
event
D. Changes (usually increased sensitivity) in thought
processes and emotions associated
E. Increased arousal or reactivity associated with the
traumatic event with the traumatic event

PTSD changes

Criterion A - the stressor criterion is more explicit with regard to

how an individual experienced traumatic events.
Criterion A2 (subjective reaction) has been eliminated.
Three major symptom clusters in DSM-IVreexperiencing,
avoidance/numbing, and arousal
Now four symptom clusters in DSM-5, because the
avoidance/numbing cluster is divided into two distinct clusters:
avoidance and persistent negative alterations in cognitions and
mood. This latter category, which retains most of the DSM-IV
numbing symptoms, also includes new or reconceptualized
symptoms, such as persistent negative emotional states. The final
clusteralterations in arousal and reactivityretains most of the

PTSD 309.81

A . Exposure to actual or threatened death, serious injury or sexual violence in one of the following ways
1. Directly experiencing the traumatic events
2. Witnessing in person. The event is it occurred to others
3. Learning that the traumatic events occurred to a close family member or close friend
4. Experiencing repeated or extreme exposure to aversive details of the traumatic events; a form of
Vicarious exposure experienced by police officers or 1st responders
B. Presence ofone or more of the following intrusion symptoms associated with the traumatic events beginning
after the event occurred
1. Recurrent, involuntary and intrusive distressing memories of the event
2. Recurrent distressing dreams in which the content is related to the event
3. Dissociative reactions (flashbacks) where individual feels or acts as if the event were recurring
4 intense-prolonged psychological distress when exposed to internal or external cues
5. Marked physiological reactions to internal or external cues
C. Persistence avoidance of stimuli associated with the traumatic events beginning after the event occurred
1. Avoidance or efforts to avoid distressing memories, thoughts or feelings associated with the event
2. Avoidance or efforts to avoid external reminders-people, places, conversations that might arouse
distressing memory starts her feelings associated with the event
D. Negative alterations in cognitions and mood associated with the events beginning or worsening after
the events
1. Inability to remember an important aspect of the traumatic event. This is not caused by a head injury
help call or drugs, but dissociative amnesia related to the event
2. Persistent exaggerated negative beliefs or expectations about oneself, Others and the world-I am bad,
No one can be trusted, the world sucks
3. Distorted cognitions that lead to self blame where the blame of others.
4. Persistent negative emotional state
5. Diminished interest or participation in significant activities
6. Feelings of detachment or estrangement from others

PTSD 309.81-Continued

E. Significant alterations in arousal and reactivity associated with the traumatic event
1. Irritable behavior in angry outbursts with little or no provocation-started after the event, usually
directed toward people or objects
2. Reckless or self-destructive behavior
3. Hypervigilance
4. Exaggerated startle response
5. Problems with concentration
6. Sleep disturbance
F. Duration of the disturbance is longer than one month
G. Causes clinically significant distress or impairment
H. The disturbance is not attributable to the physiological effects of a substance or another medical condition

Specifiers
Specify whether:
Dissociative symptoms are present
Depersonalization = experience of feeling detached from, and disconnected from one self. Often described as
feeling as if one were outside observing oneself or as though in a dream.A sense or feeling of unreality
regarding oneself-with the knowledge that this is not true
Derealization= Experience of unreality of surroundings-the world feels unreal, dreamlike, distant her
distorted. However, one realizes this is not true

Specify if
more

Expression of symptoms is delayed = the full drive gnostic criteria are not met until at least 6 months or
after the event

Please note the presence of anxiety, fear and avoidance. 3 conditions that we find in generalized

PTSD In children-6 or younger

Avoidance and alterations in cognition collapsed into one criterion
group

A . Exposure to actual or threatened death, serious injury or sexual violence in one of the following ways
1. Directly experiencing the traumatic events
2. Witnessing in person. The event is it occurred to others
3. Learning that the traumatic events occurred to a close family member or close friend
B. Presence ofone or more of the following intrusion symptoms associated with the traumatic events beginning
after the event occurred
1. Recurrent, involuntary and intrusive distressing memories of the event
2. Recurrent distressing dreams in which the content is related to the event
3. Dissociative reactions (flashbacks) where individual feels or acts as if the event were recurring
4 intense-prolonged psychological distress when exposed to internal or external cues
5. Marked physiological reactions to internal or external cues
C. One or more of the following symptoms involving either avoidance or negative alterations in cognition are made
must be Present
1. Avoidance or efforts to avoid distressing memories, thoughts or feelings associated with the event
2. Avoidance or efforts to avoid external reminders-people, places, conversations that might arouse
distressing memory starts her feelings associated with the event
3. Increase of negative emotional states
4. Diminished interest or participation in significant activities
5. Socially withdrawn Behavior
6. Reduction in expression of positive emotions
D. alterations in arousal and reactivity associated with the traumatic event
1. Irritable behavior in angry outbursts with little or no provocation2. Hypervigilance
3. Exaggerated startle response
4. Problems with concentration
5. Sleep disturbance
E.. Duration of the disturbance is longer than one month
F. Causes clinically significant distress or impairment

PTSD 309.81-Children
Specifiers are the same

Specifiers
Specify whether:
Dissociative symptoms are present
Depersonalization = experience of feeling detached from, and disconnected from one self. Often described as
feeling as if one were outside observing oneself or as though in a dream.A sense or feeling of unreality
regarding oneself-with the knowledge that this is not true
Derealization= Experience of unreality of surroundings-the world feels unreal, dreamlike, distant her
distorted. However, one realizes this is not true

Specify if
more

Expression of symptoms is delayed = the full drive gnostic criteria are not met until at least 6 months or
after the event

In DSM-IV RAD was divided

into subtypes
Subtypes = inhibited type and disinhibited type (criterion A),
Inhibited = Persistent failure to initiate or respond in a
developmentally appropriate fashion to most social interactions, as
manifest by excessively inhibited, hypervigilant, or highly ambivalent
and contradictory responses (e.g. the child may respond to
caregivers with a mixture of approach, avoidance, and resistance to
comforting, or may exhibit "frozen watchfulness", hypervigilance
while keeping an impassive and still demeanor). Such infants do not
seek and accept comfort at times of threat, alarm or distress, thus
failing to maintain "proximity", an essential element of attachment
behavior
Disinhibited = Diffuse attachments as manifest by indiscriminate
sociability with marked inability to exhibit appropriate selective
attachments (e.g., excessive familiarity with relative strangers or lack
of selectivity in choice of attachment figures). There is therefore a

Disinhibited = 313.89 disinhibited

social engagement disorder
A.

A pattern of behavior in which a child actively approaches and interacts with unfamiliar
adults and exhibits at least 2 of the following
1.
Reduced or absent reticence in approaching and interacting with unfamiliar adults
2.
Overly familiar verbal or physical behavior that is not consistent with ageappropriate social boundaries
3.
Diminished or absent "checking back" behaviors
4.
Willingness to go with an unfamiliar adult with minimal or no hesitation
B.
Behaviors in criterion a are not limited to impulsivity such as that seen in ADHD
C.
The child has experienced a pattern of extremes of insufficient care, as evidenced by
at least one of the following
1.
Social neglect or deprivation in the form of persistent lack of having basic
emotional needs for comfort stimulation and affectation met by caregivers
2.
Repeated changes of primary caregivers that limit opportunities for stable
attachment
3.
Rearing in unusual settings
D.
The criterion C is presumed to be responsible for the disturbed behavior in criterion A
E.
The child has a developmental age of at least 9 months

A.

313.89 RAD

A consistent pattern of inhibited, emotionally withdrawn behavior toward adult

caregivers manifested by both of the following
1.
The child rarely or minimally seeks comfort when distressed
2.
The child rarely or minimally responds to comfort. When distressed
B.
A persistent social and emotional disturbance characterized by at least 2 of the
following
1.
Minimal social and emotional responsiveness to others
2.
Limited positive affect
3.
Episodes of unexplained irritability, sadness or fearfulness that are evident
even during nonthreatening interactions with caregivers
C.
The child has experienced the pattern of extremes or insufficient care, as evidenced
by at least one of the following
1.
Social neglect or deprivation in the form of persistent lack of having basic
emotional needs for comfort stimulation and affection met by caregiving adults
2.
Repeated changes a primary caregivers that limit opportunities to form stable
attachment
3.
Rearing in unusual settings that severely limit opportunities to form
attachments
D.
To carry in criterion C is presumed to be responsible for the disturbed behavior in
criterion a
E.
Criterion are not met for autism spectrum disorder
F.
Disturbance is evident before age 5

Adjustment Disorders
In DSM-5, adjustment disorders are reconceptualized as a
heterogeneous array of stress-response syndromes that occur
after exposure to a distressing (traumatic or nontraumatic) event,
rather than as a residual category for individuals who exhibit
clinically significant distress without meeting criteria for a more
discrete disorder (as in DSM-IV ). DSM-IV subtypes marked by
depressed mood, anxious symptoms, or disturbances in conduct
have been retained, unchanged.
Stressor can be of any severity or type (unlike PTSD Criterion A)
Much more flexible diagnosis then PTSD or acute stress disorder
Diagnose adjustment disorder when:
PTSD criteria are not met
Criterion A for PTSD stressors not met
Subthreshold for acute stress disorder & PTSD
Symptoms do not last longer than 6 months after stressor.A transitional state that is longer than acute stress disorder,
but typically not as intense

8. Dissociative disorders
SUMMARY
Depersonalization disorder has been relabeled
Depersonalization/Derealization disorder
Dissociative fugue is no longer a separate
diagnosis but is now specifier within the diagnosis
of "dissociative amnesia
Changes in criteria for the diagnosis of
"dissociative identity disorder"

DID
Criterion A has been expanded to include certain
possession-form phenomena and functional
neurological symptoms to account for more
diverse presentations of the disorder.
Criterion A now specifically states that transitions
in identity may be observable by others or selfreported.
Criterion B, individuals with dissociative identity
disorder may have recurrent gaps in recall for
everyday events, not just for traumatic
experiences. Other text modifications clarify the
nature and course of identity disruptions.

Diagnostic criteria DSM 5

300.14

A. Presence of two or more distinct Personality states, which

may be described in some cultures as an experience of
possession. This disruption and identity involves marked
discontinuity in sense of self and personal agency. This is
accompanied by alterations (often sudden) in affect,
behavior, consciousness, memory, perception and/or
sensorimotor functioning. These signs and symptoms may
be observed by others or reported by the individual
B. Inability to recall important personal information Or gaps in
recall of everyday events. Important personal information or
traumatic events. AKA dissociative amnesia
C. Cause clinically significant distress , And/or impairment
D. Not a part of broadly accepted cultural or religious practice
E. Not due to a substance or general medical condition

Note the difference in the

Diagnostic criteria IV TR
A. Presence of two or more distinct identities,
each with its own relatively stable pattern of
personality traits
B. At least two of these alters take control of
the persons behavior
C. Inability to recall important personal
information that is too extensive to be
explained by ordinary forgetfulness
D. Not due to a substance or general medical
condition

9. Somatic symptom and related

disorders
This is a new name for what was previously called
"somatoform disorders
The number of diagnoses in this category has been
reduced. The diagnoses of somatization disorder,
hypochondriasis, pain disorder and undifferentiated
somatoform disorder have all been removed
"Illness anxiety disorder" has been an added
diagnosis and replaces hypochondriasis
Factitious disorder is now included in this group

Some definitions
Factitious disorder: conscious and intentional feigning or production of
symptoms, because of a psychological need to assume the sick role to
obtain emotional gain
Malingering: conscious and intentional production or exaggeration of
symptoms for material gain, such as money, lodging, food, drugs,
avoidance of military service, or escape from punishment
Somatization: recurrent and multiple symptoms (eg, pain, GI, sexual,
pseudoneurological) with no organic basis, believed to be due to
unconscious expressions of suppressed emotional conflict or stress;
unlike factitious disorders, the symptoms are not created by voluntary,
conscious behavior
Hypochondriasis: obsession with fears that one has a serious,
undiagnosed disease, presumably based on misinterpretation of bodily
sensations - See more at:
http://www.psychiatrictimes.com/articles/factitious-disorder-detectiondiagnosis-and-forensic-implications#sthash.trRTuLQM.dpuf

X Somatic Symptom Disorder

Individuals with somatic symptoms plus abnormal thoughts, feelings, and behaviors
may or may not have a diagnosed medical condition.
The relationship between somatic symptoms and psychopathology exists along a
spectrum.
high symptom count required for DSM-IV somatization disorder did not accommodate
this spectrum.
The diagnosis of somatization disorder was essentially based on a long and complex
symptom count of medically unexplained symptoms.

Individuals previously diagnosed with somatization disorder will usually meet DSM-5
criteria for somatic symptom disorder, but only if they have the maladaptive
thoughts, feelings, and behaviors that define the disorder, in addition to their
somatic symptoms.
In DSM-IV, the distinction between undifferentiated somatoform disorder had been
created in recognition that somatization disorder would only describe a small
minority of somatizing individuals, but this disorder did not prove to be a useful
clinical diagnosis.
They are merged in DSM-5 under somatic symptom disorder, and no specific
number of somatic symptoms is required.

Somatic Symptom
Disorder300.82

Diagnostic Criteria:
A.One or more somatic symptoms that are distressing and result
in significant disruption of daily life
B.Excessive thoughts, feelings or behaviors related to the
symptoms or associated health concerns, as manifested by at
least one of the following:
1.
2.
3.

Disproportionate and persistent thoughts about the seriousness

of symptoms
Persistently high level of anxiety about health or symptoms
Excessive time and energy devoted to the symptoms or health
concerns

C.The state of being symptomatic is persistent (typically more

than 6 months)

Specifiers

Specify if:
with predominant pain (previously classified as pain disorder and DSM-IV)

Specify if:
persistent: severe symptoms lasting longer than 6 months

Specify current severity:

mild = only one of the symptoms specified in criterion B is the filled
moderate = 2 or more of the symptoms in criterion beer for filled
Severe = 2 or more of the symptoms are fulfilled. Plus, there are multiple
other somatic complaints

X 300. 7 Illness anxiety disorder

criteria
Previously
A. Preoccupation
withhypochondriasis
having or acquiring a serious
B.
C.
D.
E.
F.

illness
No evidence of somatic symptoms or extremely
mild symptoms present
High anxiety about health and health status
Excessive health related behaviors or avoidant
health related behaviors
Illness preoccupation present for at least 6
months
not better explained by another disorder

XPain Disorder removed from

DSM 5
DSM-IVpain disorder diagnoses assume that some pains
are associated solely with psychological factors, some with
medical diseases or injuries, and some with both.
lack of evidence that such distinctions can be made with
reliability and validity, and a large body of research has
demonstrated that psychological factors influence all forms of
pain.

individuals with chronic pain attribute pain to a

combination of factors, including somatic, psychological,
and environmental influences-not either/or
DSM-5 some individuals with chronic pain could be DXd
having somatic symptom disorder, with predominant pain
316.0psychological factors affecting other medical
conditions
adjustment disorder

Psychological Factors
Affecting Other Medical
Conditions
Psychological factors affecting other medical
conditions is a new mental disorder in DSM-5, having
formerly been included in the DSM-IV chapter Other
Conditions That May Be a Focus of Clinical
Attention. This disorder and factitious disorder are
placed among the somatic symptom and related
disorders because somatic symptoms are
predominant in both disorders, and both are most
often encountered in medical settings. The variants
of psychological factors affecting other medical
conditions are removed in favor of the stem

Psychological Factors
Affecting Other Medical
A. Medical symptomConditions
or condition is present
B. psychological or behavioral factors adversely affect the
medical condition in one of the following ways
The factors that influence the course of the medical condition as
shown by a close temporal association between a psychological
factors and the development or exacerbation of medical
condition
The factors interfere with the treatment of the medical condition
The factors constitute additional well-established health risk for
the individual
The factors influence the underlying psychopathology
precipitating or exacerbating symptoms or necessitating medical
attention

C. psychological and behavioral factors in criterion B are not

300.19 Factitious disorder criteria

Self-imposed
A. Falsification of physical or psychological signs or symptoms or induction of
injury or disease. In order to deceive
B.Individual present self to others, as if impaired or injured
C.No apparent or obvious external rewards
D., Not better accounted for by
Imposed on others
A. Falsification of physical or psychological signs or symptoms or induction of
injury or disease. In order to deceive
B.Individual presents another individual to others as you know, impaired or
injured
C.No apparent external rewards
D.Not better accounted for by
E.When imposed on others. Diagnosis is given to the perp
Specify if
single episode

Somatic symptoms major focus on symptoms experienced

as well as anxiety- symptoms can have a physical cause, but
the pt. experiences no relief
Illness anxiety major focus on anxiety and what might
happen. Symptoms might or might not be present- but are
mild if there.
Conversion disorder symptoms present. Of a neuroperceptual type; blindness paralysis
Factitious symptoms intentionally produced no apparent
gain-assess motivation
Malingering (v code) intentional gain can be documentedassess motivation

Somatic symptoms
Inauthentic authentic illnesses

Psychogenic illness the mind causes symptoms that

are experienced by the patient but have no real
presence
Unconscious
Diagnosed in part by LACK of evidence
Somatic symptom
Illness anxiety
conversion

Conscious
Factitious
malingering

Diagnosed by evidence

When to suspect factitious

disorder
The person's medical history doesn't make sense
No believable reason exists for the presence of an
illness or injury
The illness does not follow the usual course
There is a lack of healing for no apparent reason,
despite appropriate treatment
There are contradictory or inconsistent symptoms
or lab test results
The person is caught in the act of lying or causing
his or her injury

http://www.psychiatrictimes.com)
The Case of Factitious Disorder Versus Malingering
(2009] Courtney B. Worley,
MPH ; Marc D. Feldman, MD and James C. Hamilton, PhD

Without detailing the full DSM diagnostic criteria sets for these
disorders and their relations, the
following is a summary of how DSM instructs psychiatrists to
diagnose cases of inauthentic illness
behavior:
1. In the absence of overwhelming affirmative evidence of
intentional medical deception (eg, caught
on video, evidence from a room search), diagnose a somatoform
disorder.
2. If there is traditional forensic evidence of overt medical
deception, diagnose malingering or
factitious disorder.
3. If there is any significant material or instrumental benefit from
the intentional medical deception
(eg, financial settlement, disability determination, access to
narcotic medicine), diagnose malingering.
http://www.psychiatrictimes.com)
The Case of Factitious Disorder Versus Malingering
(2009] Courtney B. Worley,
MPH ; Marc D. Feldman, MD and James C. Hamilton, PhD

10. Feeding and eating

disorders
"Binge eating disorder' is now included as a
separate diagnosis
also includes a number of diagnosis that were
previously included in a DSM-IV TR in the chapter
"disorders usually 1st diagnosed during infancy
childhood and adolescence.
Pica and rumination disorder are 2 examples

11. Elimination disorders

Originally classified in chapters on childhood and infancy.
Now have separate classification

12. Sleep wake disorders

Primary insomnia renamed "insomnia disorder

Narcolepsy now distinguished from other forms of
hypersomnia
Breathing related sleep disorders have been broken into
3 separate diagnoses
Rapid eye movement disorder and restless leg syndrome
are now independent diagnoses within this category

13. Sexual dysfunctions

Some gender related sexual dysfunctions have been
outed
Now only 2 subtypes-acquired versus lifelong and
generalized versus situational
New diagnostic class and the DSM 5
Include separate classifications for children adolescents
and adults
The construct of gender has replaced the construct of
sex

14. GENDER DYSPHORIA

DSM 5
Attempted to eliminate the stigma involved in the
previous diagnosis of gender identity disorder
Likely that more research is needed. Prevalence is
remarkably low

Gender Dysphoria in
Adolescents and adults
A. Mark incongruence between one's
experienced/expressed gender and assigned gender.
At least 6 months duration, as manifested by at least
2 of the following
1.
2.
3.
4.
5.
6.

Marked incongruence between one's experienced/expressed gender and primary

and/orsecondary sex characteristics
Strong desire to be rid of one's primary and/or secondary sex characteristics because of
marked incongruence with one's experienced/expressed gender
Strong desire for the primary and/or secondary sex characteristics of the other gender
Strong desire to be of the other gender
Strong desire to be treated as the other gender
Strong conviction that one has the typical feelings and reactions of the other gender

B. Condition is associated with clinically significant

distress or impairment
Specify if "post-transition = the individual has transition to full-time living in the desired
gender (with or without legalization of gender change), and has undergone or is
preparing to have at least one cross-section medical procedure or treatment regimen

Disruptive, impulse control and

conduct disorders

New diagnostic grouping and DSM 5

Combines a group of disorders previously included in disorders
of infancy and childhood such as conduct disorder oppositional
defiant disorder with a group previously known as impulse
control disorders not otherwise classified
Oppositional defiant disorder now has 3 subtypes
Intermittent explosive disorder no longer requires physical
violence but can include verbal aggression

X15. Disruptive, impulse control,

and conduct disorders

Disruptive ones
oppositional defiant disorder
conduct disorder
Intermittent explosive disorder

Impulsive ones
Intermittent explosive disorder
pyromania
kleptomania
Gambling disorder

Major dynamic in all ICDs

Impulsive
act

Spike (steep rise)

In tension immediately
Before the act

Tension and stress

Begins to build

Immediate release in tension,

Experience of pleasure
or gratification

X
A.

ODD

313.81

Pattern of angry/irritable mood, argumentative/defiant behavior, Vindictiveness, lasting at

least 6 months; evidenced by at least 4 symptoms for many of the following categories and
exhibited during interaction with at least one individual, not a sibling.
Angry, irritable mood
1. Often loses temper
2. Is often touchy or easily annoyed.
3. Often angry and resentful

Argumentative, defiant behavior

4. Often argues with authority figures.
5. Actively defies or refuses to comply with requests from authority figures.
6. Deliberately annoys others.
7. Blames others for his or her mistakes
Vindictive behavior
8. Has been spiteful or vindictive at least twice within the past 6 months
B.

Causes distress in person, and others

Does not occur during the course of another disorder

Changes from DSM IV

ODD & conduct disorder are not mutually exclusive
3 symptom type groupings
guidance re: how to distinguish from developmental norms
severity measure included

Specifiers

Mild
Moderate
Severe
Severity can be measured through intensity,
frequency, or pervasiveness. For example, if the
behavior occurs in more than one setting, it is more
pervasive and thus more severe. Usually occurs
in the home and not across settings

X
Dimensional severity assessment
for ODD
Instructions to clinicians for ODD
The Clinician-Rated Severity of Oppositional Defiant Disorder assesses the severity of the OPPOSITIONAL
DEFIANT symptoms for the individual based on their pervasiveness across settings. The measure is intended to
capture meaningful variation in the severity of symptoms, which may help with treatment planning and prognostic
decision-making. The measure is completed by the clinician at the time of the clinical assessment. The clinician is
asked to rate the severity of oppositional defiant problems as experienced by the individual in the past seven days.

Scoring and interpretation for ODD scale

The Clinician-Rated Severity of Oppositional Defiant Disorder is rated on a 4-point scale (Level 0=None;
1=Mild; 2=Moderate; and 3=Severe). The clinician is asked to review all available information for the
individual and, based on his or her clinical judgment, select ( ) the level that most accurately describes the
severity of the individuals condition.

Frequency of use for ODD scale

To track changes in the individuals symptom severity over time, the measure may be completed at regular intervals
as clinically indicated, depending on the stability of the individuals symptoms and treatment status. Consistently high
scores on a particular domain may indicate significant and problematic areas for the individual that might warrant
further assessment, treatment, and follow-up. Your clinical judgment should guide your decision.

ODD dimensional assessment

Problems with diagnosis

Differentiating this from developmental and/or
environmental stress related behavior
Differentiating from other diagnoses such as
bipolar 2
Biased reporting or reporting based on reputation
Expectation induced disruptive behaviors
Behavior is often confined to one way one setting
(for example, the home)
Little or no insight is present on the part of the
suffer. See self is victim

X
A.

Conduct disorder
unchanged
Diagnostic criteria

Repetitive and persistent pattern of behavior in which the basic rights of others or
major age-appropriate societal norms and rules are violated, as manifested by the
presence of at least 3 of the following 15 criteria in the past 12 months. For many of
the categories below, with at least one criteria present in the last 6 months
Aggression to people or animals

1 bullies, threatens or intimidates

2 often initiates physical fights
3 used weapons that can cause serious physical harm
4. been physically cruel to people
5. Been physically cruel to animals
6. Has stolen while confronting a victim
7. Forced someone into sexual activity
destruction of property
8. Has deliberately engaged in fire setting with intent of causing damage
9. Deliberately destroyed others property
deceitfulness or theft
10. Broken into someone else's home building car
11. lies or deceives to obtain goods or favors
12. Has stolen nontrivial items without confronting victim shoplifting etc.
serious violation of rules
13. Stays out at night. Despite parental prohibitions. Begins before 13
14. Has run away from home at least twice
15. Often truant, beginning before age 13

B.
C.

Causes clinically significant impairment

If age 18 or over, not attributable to antisocial personality disorder

16. Neuro-cognitive disorders

New diagnostic group

Dementia and amnestic disorder are included in
this new group
Mild NCD is a new diagnosis

X
Term "dementia" has been deemphasized
done to lessen stigma
Deemphasize irreversibility
Broadens category in a more neutral way (see The following
points below)

Mild neurocognitive disorder has been added

Distinguished from Major (severe) neurocognitive disorder

X Diagnostic criteria for delirium

unchanged
A. disturbance Inattention (reduced ability to direct, focused,

sustain and shift attention and awareness); reduced

orientation to environment
B. . develops over a short period of time and fluctuates during
the day
C. Add a disturbance in cognition (usually marked) such as
memory deficit, disorientation, agitation, language or
perceptual disturbance
D. The criteria from A&C are Not better explained by a
preestablished neurocognitive disorder or evolving
neurocognitive disorder
E. evidence from the history, physical examination or lab
findings thate disturbances are direct consequence of another
medical condition, substance, intox or w/drawal

Specifiers

Substance intoxication delirium = when criteria in A and C

predominate during a period of intoxication
Substance withdrawal delirium = should be made it instead of
substance withdrawal when the symptoms in criterion a and C
predominate in the clinical picture
Medication induced delirium = should be made when the
symptoms in criteria a and C arises a side effect of the
medication taken as prescribed
Delirium due to another medical condition = evidence that the
disturbance is attributable to the physiological consequences of
another medical condition
Delirium due to multiple etiologies = evidence that the delirium
has more than one cause or causal condition
Course =
acute: lasting a few hours or days
persistent: lasting weeks or months

X Diagnostic criteria for Major NCD

AKA DEMENTIA
A. Evidence of significant decline from her
previous level of performance in one or more
cognitive domains.: (Cognitive attention, Memory impairment,
Learning, attention, recognition (Aphasia, agnosia), apraxia , Language,
perceptual/motor problems , Social cognition and/or other disturbance of
executive functions)

B. cause significant impairment in social,

vocational functioning; is a marked decline from
previous functioning And require assistance, and
activities. If daily living, because they interfere with
independence in every day activities
C. Are not caused or related to by delirium
D. Not better explained by

Mild neurocognitive disorder

A.

Evidence of modest cognitive decline for previous data

performance in one or more cognitive domains-cognitive
attention, executive function, learning and memory,
language, perceptual motor or social cognition. Evidence
based on
1.
2.

B.

C.
D.

Concern of individual, a knowledgeable informant or the clinician that

there is been a mild decline in cognitive function and
Modest impairment in cognitive performance preferably documented by
standardized neuropsychological testing or another quantified clinical
assessment

The cognitive deficits do not interfere for capacity with

independence in every day activities, but greater effort
compensatory strategies or accommodations may be
required
The cognitive deficits do not occur exclusively in the
context of a delirium
Not better accounted for by another mental disorder (major

XSpecifiers whether (Sub-types) of Mild

NCD (dementia) are classified by etiology

in DSM

Alzheimers type
Frontotemporal deterioration
Lewy body disease
Vascular (multi-infarct) dementia
Related to HIV
Head trauma Or TBI
Substance medication induced
Huntingtons disease
Parkinsons diseases
Picks disease
Prions disease
Multiple etiologies
Unspecified

17. Difference between

paraphilia's and paraphilia
disorders
Paraphilia describes
the experience of intense
Sexual arousal to atypical objects, situations, or
individuals.
Paraphilic behavior (such as Pedophilia, zoophilia,
voyeurism and exhibitionism and may be illegal in
some jurisdictions, but may also be tolerated.
A paraphilia is NOT a paraphilic disorder
Paraphilia disorder requires the generation of
clinically significant distress, impairment or acting
them out with the nonconsenting person. (Criterion
B)

Personality disorders
Nothing changes

X
DSM 5 promised major changes in
criteria
Promised dimensional focus
Promised reduction in number of personaliity
disorders to five
Changes did not occur
Dimensional focus for personality disorders was
moved to section 3

Primary Criteria in DSM 5

(Unchanged from DSM-IV TR)
A.

Enduring pattern of inner experience & behavior

that deviates markedly from expectations of the
culture. This pattern is manifested in 2 or more
of the following areas
A.
B.
C.
D.

Cognition;
Affect;
Interpersonal;
Impulse control

B. Inflexible & pervasive across situation

C. Distress or impairment in social, occupational
interpersonal..
D. Long-standing (back to adolescence or early

DSM IV & 5 and personality

clusters
Cluster A
Odd/eccentric
Paranoid
Schizoid
schizotypal

Cluster B
Dramatic, erratic
Self-involved
Anti-social
Histrionic
Narcissistic
Borderline

Cluster C
Anxious/fearful
Dependent
Avoidant
Obsessive-compulsive

Dimensional classification of
personality disorders
Authors of DSM 5 had planned to use dimensional
measures to diagnose personality disorders
They plan to reduce personality disorders from 10
to 5
This changed in a closed-door meeting
Dimensional measures are now in section 3

ANTI_SOCIAL
A) There is a pervasive pattern of disregard for and violation of the rights
of others occurring since age 15 years, as indicated by three or more of
the following:
1. failure to conform to social norms with respect to lawful behaviors as indicated by
repeatedly performing acts that are grounds for arrest;
2. deception, as indicated by repeatedly lying, use of aliases, or conning others for personal
profit or pleasure;
3. impulsiveness or failure to plan ahead;
4. irritability and aggressiveness, as indicated by repeated physical fights or assaults;
5. reckless disregard for safety of self or others;
6. consistent irresponsibility, as indicated by repeated failure to sustain consistent work
behavior or honor financial obligations;
7. lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated,
or stolen from another;

B) The individual is at least age 18 years.

C) There is evidence of conduct disorder with onset before age 15 years.
D) The occurrence of antisocial behavior is not exclusively during the
course of schizophrenia or a manic episode.

OR Mnemonic: CALLOUS MAN

Diagnostic Criteria for Antisocial PD

Conduct disorder before age 15; current age at least 18

Antisocial activities; commits acts that are grounds for arrest
Lies frequently
Lacunaelacks a superego
Obligations not honored (financial, occupational etc.)
Unstablecant plan ahead
Safety of self and others is ignored

Money recklessness with money; spouse and children are

not supported because he bought a motorcycle
Aggressive, Assaultive
Not occurring during schizophrenia or mania

Antisocial signs

Glibness, shallow emotion

Requires constant stimulation
Criminal versatility
Promiscuity
Poor impulse control
Avoids responsibility for actions

Millon identified five subtypes of Anti-Social

Personality Disorder
covetous antisocial variant of the pure
pattern where individuals feel that life has not
given them their due including paranoid
features.
reputation-defending antisocial including
narcissistic features
risk-taking antisocial including histrionic
features
nomadic antisocial including schizoid,
avoidant features
malevolent antisocial including sadistic,
paranoid features.

BORDERLINE PD

A. A pervasive pattern of instability of interpersonal relationships, self-image

and affects, as well as marked impulsivity, beginning by early adulthood
and present in a variety of contexts, as indicated by five (or more) of the
following:
1. Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or
self-injuring behavior covered in Criterion 5
2. A pattern of unstable and intense interpersonal relationships characterized by alternating
between extremes of idealization and devaluation.
3. Identity disturbance: markedly and persistently unstable self-image or sense of self.
4. Impulsivity in at least two areas that are potentially self-damaging (e.g., promiscuous sex,
excessive spending, eating disorders, binge eating, substance abuse, reckless driving).
Note: Do not include suicidal or self-injuring behavior covered in Criterion 5
5. Recurrent suicidal behavior, gestures, threats or self-injuring behavior such as cutting,
interfering with the healing of scars or picking at oneself (excoriation) .
6. Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria,
irritability or anxiety usually lasting a few hours and only rarely more than a few days).
7. Chronic feelings of emptiness
8. Inappropriate anger or difficulty controlling anger (e.g., frequent displays of temper,
constant anger, recurrent physical fights).
9. Transient, stress-related paranoid ideation, delusions or severe dissociative symptoms

OR Mnemonic for Diagnostic

Criteria: I RAISED A PAIN
Identity disturbance

Relationships are unstable

Abandonment is frantically avoided
Impulsive
Self-mutilation, suicidal threats/attempts; splitting - as a predominant
defense mechanism is used
Emptiness is a description of their inner selves
Dissociative symptoms
Affective instability
Paranoid instability
Anger is poorly controlled
Idealization of others, followed by devaluation (splitting person is either all
good or all bad)
Negativisticundermine their own efforts and those of others

First called as if personality because or

changes in direction or interest
Term borderline is unfortunate. Originally
referred to being on the border between
psychotic and neurotic
Label is often used pejoratively among
mental health professionals
Misunderstood and mis-labeled as
manipulative

Borderline Themes

Parental neglect and abuse

Impulsivity
Fears of abandonment
Frequent suicide ideation or gestures
Substance abuse or dependence
Legal difficulties
Disrupted education relationships, vocations,
vacations

X Propose general criteria for

personality disorder
A. Moderate or greater impairment in personality (self
interpersonal functioning)
B. One or more pathological personality traits
C. The impairments in personality functioning are inflexible and
pervasive across a broad range of personal and social
situations
D. The impairments in personality functioning are relatively stable
across time
E. The impairments in personality function are not better
explained by another medical condition or substance
F. Impairments in personality functioning are not better
understood as normal for individuals developmental stage, or
sociocultural environment

Dimensional classification of
personality disorders
Authors of DSM 5 had planned to use dimensional
measures to diagnose personality disorders
They plan to reduce personality disorders from 10
to 5
This changed in a closed-door meeting
Dimensional measures are now in section 3

X
Proposed changes in assessment
Two

broad

Overall
personality
functioning
self

Identity

Interpersonal
Self
direction

Empathy

dimensions

5 Broad
Pathological
Trait Domains
Negative
affectivity

Intimacy

Detachment

Antagonism

Disinhibition

Psychoticism

How to deal with uncertainty

2 dimensions required for all DSM

diagnosis
1. Clarity of symptoms
2. Specified length of time for symptoms

4 basic levels of diagnostic

warrant
High
Symptom
clarity

Diagnostic plausibility
symptom
Uncleartime
unstable

pattern

Diagnostic uncertainty or
Diagnostic confusion

low

Diagnostic certainty
over

Clear
stable

Diagnostic possibility

Diagnostic certainty

The likelihood that a plausible diagnosis is

probable
Clinicians often diagnoses based on clinical
hunches, which are a form of bias
They select one or 2 salient characteristics rather
than the complete 7 to 9- and make assumptions
(Paris, 2013)
This is a form of fast thinking or quick judgment that
leads to framing effects (Kahneman, 2011)
sometimes called the clinicians illusion.

Easy for clinicians to conflate

probability with plausibility

Plausibility = the likelihood that an event or

events are representative of
something more; clinicians tend
to focus on this
Probability = the statistical likelihood of an
event; researchers focus on this
Kahneman, 2011

2 conditions necessary for

Diagnostic certainty
When symptoms are clear and stable over time
When the relationship between plausibility and
probability has been considered
Plausibility- these symptoms represent X
Probability the likelihood of X occurring

High
Symptom
clarity

Diagnostic plausibility
probability
Unclear
unstable

symptom

Diagnostic certainty

pattern

Diagnostic uncertainty or
Diagnostic confusion

low

over time

Clear
stable

Diagnostic possibility

Progression of domains of diagnostic

certainty over time

Diagnostic
uncertainty

Diagnostic
possibilities

Diagnostic
plausibility

Diagnostic
probabilities

Ethical issues arise here when:

Diagnostic
certainty

Clinician unknowingly or unwittingly is in the

wrong domain (incompetence)
Clinician knowingly chooses the wrong domain

Progression of diagnostic certainty over time

Documentation can help

Diagnostic
uncertainty

What leads
me to be
unsure?
Do I know
What dont
I
Know?

Diagnostic
possibilities

Why are
these
The
possibilities
?
How do I
know that
other DXs

Diagnostic
plausibility

What am I
seeing that
is so
compelling?
What am I
missing?
Why am I
missing?

Diagnostic
probabilities

What
makes this
a
probability
and others
not?
Where is
my

Diagnostic
certainty

Why am I
certain?
How do I
know that I
know?

Progression of diagnostic certainty over time

Diagnostic
uncertainty

Diagnostic
possibilities

Diagnostic
plausibility

Diagnostic Diagnostic
probabilitiescertainty

The more uncommon or

unusual a diagnosis is, the
more time
and care one must take in
differentiating or excluding
other more common (statistically) diagnoses