DSM5 Powerpoint Supplement to MashWolfe Abnormal Child Psychology

DSM-5 Powerpoint Supplement to Mash/Wolfe Abnormal Child Psychology (2013, 5 th Edition) This material is based on a DSM-5 Powerpoint presentation prepared by Kenneth J. Zucker and on the DSM-5 supplement to Barlow and Durand, Abnormal Psychology, prepared by Jade Qi Wu, Hannah Tavormina, David Barlow and Mark Durand. Adapted with permission. 1

Some Early Proposals for the DSM-5 • A revised meta-structure and harmonization with ICD-11 (~ 2015) • Reduced usage of NOS (Not Otherwise Specified) • Dimensional diagnosis to complement categorical diagnosis • Deletion of the distress/impairment criterion (X) • Greater emphasis on a life-course developmental perspective, culture-related, and gender-related diagnostic issues • Elimination of the multiaxial system (Axes I-V) • Biomarkers 2 • DSM-5 as a “living document” (5. 1, 5. 2, etc. )

General Changes in DSM-5 • Revised definition of a mental disorder and distress/impairment criterion • Some dimensional options described in Section III (Assessment Measures) • Not Otherwise Specified Becomes “Other Specified X Disorder” and “Unspecified X Disorder” • Section III contains a chapter on Cultural Formulation and the Appendix contains a Glossary of Cultural Concepts of Distress (9 examples: Ataque of nervios, Dhat syndrome, 3 Susto, etc. )

Definition of a Mental Disorder DSM-IV-TR “…conceptualized as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress…or disability…or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom…. Whatever its origin, it must currently be considered a manifestation of a behavioral, psychological, or biological dysfunction in the individual. ” DSM-5 “…a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotional regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities. ” 4

The Distress/Impairment Criterion Examples from DSM-5 • Symptoms cause clinically significant impairment in social, occupational, or other important areas of current functioning • The symptoms cause clinically significant impairment in social, occupational, or other important areas of functioning • The symptoms cause clinically significant impairment in social, academic, occupational, or other important areas of functioning • The condition is associated with clinically significant distress or impairment in social, school, or other important areas of functioning • A problematic pattern of X leading to clinically significant impairment or distress… • The symptoms…cause clinically significant distress in the individual • Some diagnoses (e. g. , Encopresis) do not have a distress/impairment criterion or do not require distress or impairment (e. g. , Enuresis) 5

Chapter Organization for DSM-5 A. Neurodevelopmental Disorders B. Schizophrenia Spectrum and Other Psychotic Disorders C. Bipolar and Related Disorders D. Depressive Disorders E. Anxiety Disorders F. Obsessive-Compulsive and Related Disorders

Chapter Organization for DSM-5 (cont’d) G. Trauma- and Stressor-Related Disorders H. Dissociative Disorders I. Somatic Symptom and Related Disorders J. Feeding and Eating Disorders K. Elimination Disorders L. Sleep-Wake Disorders M. Sexual Dysfunctions N. Gender Dysphoria

Chapter Organization for DSM-5 (cont’d) O. Disruptive, Impulse Control, and Conduct Disorders P. Substance-Related and Addictive Disorders Q. Neurocognitive Disorders R. Personality Disorders T. Paraphilic Disorders U. Other Mental Disorders

Changes in Chapter Structure DSM-IV-TR DSM-5 Diagnostic Criteria • Diagnostic Features • Associated Features and Disorders • Associated Features Supporting the Diagnosis • Prevalence • Course • Development and Course • Familial Pattern • Risk and Prognostic Factors • Specific Culture, Age, and Gender Features • Culture-Related Diagnostic Issues • Gender-Related Diagnostic Issues • Diagnostic Markers • Suicide Risk • Functional Consequences • Differential Diagnosis • Comorbidity 9

Overview of Key Changes in DSM-5 Relevant to Children and Adolescents 1. Greater Attention to Developmental Issues in Diagnosis 2. Changes in Organization Related to Childhood Disorders 3. Other Changes in Organization 4. New Categories for Children 5. Changes to Existing Categories for Children 6. Addition of Subtypes and Specifiers 7. Proposed New Disorders and Features (Section III) 10

1. Greater Attention to Developmental Issues in Diagnosis • Subsections of the text of DSM-5 on “Development and Course” describe how presentations of the disorder may change across the lifespan. • Age-related factors in diagnosis such as symptom presentation and differences in prevalence are included. • The DSM-5 manual is organized to reflect a lifespan approach, with disorders typically diagnosed in children (e. g. , neurodevelopmental disorders) at the beginning and those more applicable to older adults (e. g. , neurocognitive disorders) at the end. 11

Greater Attention to Developmental Issues in Diagnosis (cont’d) • Age-related factors have been added to the diagnostic criteria (e. g. , revised criteria for posttraumatic stress disorder in children under age 6; specific criteria to describe how symptoms are expressed in children). • Greater integration of information regarding sex and gender differences and cultural issues into diagnosis as relevant. 12

2. Changes in Organization Related to Childhood Disorders • Consistent with a lifespan emphasis, and in an effort to integrate developmental issues throughout, DSM-5 has eliminated the separate section for “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence” previously included in DSM-IV. For the most part, these disorders (e. g. , ADHD, Autism Spectrum Disorder) now appear in a section on neurodevelopmental disorders, but not entirely. • For example, a number of disorders usually first diagnosed in infancy (e. g. , reactive attachment disorder, pica) and childhood (e. g. , selective mutism, separation anxiety disorder, oppositional defiant disorder, conduct disorder) are now integrated throughout the manual in sections with other disorders that have a later onset. 13

Changes in Organization Related to Childhood Disorders (cont’d) The goal of emphasizing a lifespan approach and greater recognition of the fact that many disorders can and do manifest across the lifespan has merit. While true that boundaries drawn between disorders of childhood and other age groups are arbitrary, and potentially hamper tests of continuity of disorders over time, the long-term implications of this significant change to DSM organization are unclear. The addition of a specific section dedicated to disorders of childhood in DSM-III was widely regarded as having played a critical role in increasing research interest in childhood disorders; whether removing this distinction will result in a decrease in the level of attention being paid to disorders of children remains to be seen (Hayden and Mash, in press). 14

3. Other Changes in Organization • DSM-5 has moved to a nonaxial documentation of diagnosis, eliminating the multiaxial system (Axis I, II, IV, and V) included in DSM-IV-TR. • The melding of Axes I, II, and III reflects the view that different mental disorders are fundamentally conceptualized in a similar way, integrating biological, physical, behavioral, and psychosocial factors and processes. • Separate notations are now made for important psychosocial and contextual factors (formerly Axis 15 IV) and disability (formerly Axis V).

Other Changes in Organization (cont’d) • Obsessive-Compulsive Disorder is no longer included in the section on anxiety disorders, but in a new separate section on Obsessive Compulsive and Related Disorders (e. g. , trichotillomania [hair-pulling disorder]. • Posttraumatic Stress Disorder and Acute Stress Disorder are no longer included in the section on anxiety disorder, but in a new separate section on Trauma- and Stressor-Related 16 Disorders.

4. New Categories for Children • Autism Spectrum Disorder (ASD) is a new DSM-5 disorder that contains the previous DSM-IV autistic disorder (autism), Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (PDD-NOS). 17

New Categories for Children (cont’d) • Disruptive Mood Dysregulation Disorder (DMDD) is a new disorder for children up to age 18 years who exhibit persistent irritability and frequent episodes of extreme behavioral control. • This new category, which is included in DSM 5 as a Depressive Disorder, was added to address concerns about potential overdiagnosis and over-treatment of bipolar 18 disorder in children.

New Categories for Children (cont’d) • Social (pragmatic) Communication Disorder is a new condition involving persistent difficulties in the social uses of verbal and nonverbal communication. • Some individuals previously diagnosed with Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS) in DSM-IV may meet criteria for Social Communication Disorder, provided that they do not also display restricted behaviors, interests, and activities. 19

5. Changes in Existing Categories for Children • The term Intellectual Disability (intellectual developmental disorder) replaces the term Mental Retardation that was used in DSM-IV. • The names of several communication disorders have been changed (e. g. , phonological disorder has been changed to speech sound disorder). • A new category of Specific Learning Disorder combines the diagnoses of Reading Disorder, Mathematics Disorder, and Disorder of Written 20 Expression.

Changes in Existing Categories for Children (continued) • Symptoms of autism spectrum disorder are grouped into two categories, rather than three: 1. Deficits in social communication and social interaction; and 2. Restricted, repetitive patterns of behavior, interests, or activities. Note: Previously, deficits in communication and social interaction were view separately. However, research now indicates that they are best viewed as single factor (Guthrie et al. , 2013). 21

Changes in Existing Categories for Children (cont’d) • Selective Mutism and Separation Anxiety Disorder are now classified as anxiety disorders rather than as Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence. 22

Changes in Existing Categories for Children (cont’d) • Criteria for Oppositional Defiant Disorder are now grouped into three types: angry/irritable mood, argumentative/defiant behavior, and vindictiveness. • Conduct disorder features a specifier to indicate when it occurs with limited prosocial emotions. This specifier is intended to capture children with CD who display: lack of remorse or guilt, callous-lack of empathy, unconcerned about performance, and shallow or deficient affect. 23

6. Addition of Subtypes and Specifiers • DSM-5 provides subtypes and specifiers for increased specificity of diagnoses. • Subtypes define mutually exclusive and jointly exhaustive subgroupings within a diagnosis (e. g. , predominantly inattentive, predominantly hyperactive/impulsive, or combined presentation in the case of ADHD), and are indicated by the instruction: “Specify whether” in the diagnostic criteria set. 24

Addition of Subtypes and Specifiers (cont’d) • Specifiers are used to indicate such things as course (e. g. , in partial remission, in full remission), associated conditions (e. g. , with or without accompanying intellectual impairment), severity level of a disorder (e. g. , mild, moderate, or severe), age of onset (e. g. , onset before age 10 years), and/or others. In contrast to subtypes, specifiers are not intended to be mutually exclusive or jointly exhaustive, which means that more than one specifier may be given. 25

7. Proposed New Disorders and Features (Section III) • DSM-5 includes a new Section III titled “Emerging Measures and Models. ” It presents new disorders referred to as “Conditions for Further Study. ” • This section was designed to stimulate further research on less well-studied disorders not yet sufficiently established to be part of the official DSM-5 classification system for routine clinical use. • Three proposed conditions relevant to children & adolescents are: “Suicidal Behavior Disorder, ” “Nonsuicidal Self-Injury, ” “Neurobehavioral Disorder 26 Associated with Prenatal Alcohol Exposure. ”

Proposed New Disorders and Features (Section III) cont’d • An alternative DSM-5 model for personality disorders is included in Section III. This proposal is a hybrid model that has both a categorical and dimensional focus. 27

Proposed New Disorders and Features (Section III) cont’d • Section III in DSM-5 includes a number of emerging measures for further research and evaluation that, used over time, are intended to provide more accurate and flexible clinical descriptions of individual symptom presentations and associated disability during diagnostic assessments. 28

Proposed New Disorders and Features (Section III) cont’d • Among these measures are: a. A measure of symptom severity across multiple domains that can be used across all diagnostic groups. b. A standard measure of global disability level (WHO Disability Assessment Scale [WHODAS]; World Health Organization, 2001) that replaces the more limited Global Assessment of Functioning Scale presented in DSM-IV. 29

Proposed New Disorders and Features (Section III) cont’d A variety of tools, techniques, and measures are presented that are designed to enhance clinical decision making with children, adolescents, and adults and to better understand the cultural context in which mental disorders occur. These “emerging measures” appear in Section III of the DSM-5 manual and, along with others, at the following website: http: //www. psychiatry. org/practice/dsm 5/onli 30 ne-assessment-measures.

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER: Changes from DSM-IV to DSM-5 • Attention-deficit/Hyperactivity disorder (ADHD) is now included in the DSM-5’s Neurodevelopmental Disorders chapter instead of the Attention-Deficit and Disruptive Behavior Disorders Section in the Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence chapter (which was eliminated entirely in DSM-5). • Why was this done? 31

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER: Changes from DSM-IV to DSM-5 (cont’d) Two main reasons: 1. ADHD shares with these other disorders an early onset and persistent course. 2. ADHD is often associated with disruptions in neurodevelopment and other developmental problems in language, motor, and social development that overlap with the other neurodevelopmental disorders (Nigg & 32 Barkley, in press).

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER: Changes from DSM-IV to DSM-5 (cont’d) • The DSM-5 diagnostic criteria for Attention Deficit/Hyperactivity Disorder (ADHD) have been revised to better allow the diagnosis of adults with ADHD. Research has shown that although ADHD begins in childhood, it can continue into adulthood for some individuals. • To assist in its application across the life span, DSM-5 includes examples to illustrate the types of behavior children, older adolescents, and adults with ADHD might exhibit. 33

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER: Changes from DSM-IV to DSM-5 (cont’d) • A symptom threshold change for adults has been made with the cutoff for ADHD of five symptoms, instead of six required for younger individuals, for both inattention and for hyperactivity/impulsivity. • Onset of impairing symptoms before age 7 has been changed to onset of symptoms before age 12. Support for this change comes from research showing no clinical differences between children identified prior to 7 years versus later with respect to severity, course, outcome, or response to treatment (Barkley, 2010). 34

ATTENTION-DEFICIT/HYPERACTIVITY DISORDER: Changes from DSM-IV to DSM-5 (cont’d) • A comorbid diagnosis with Autism Spectrum Disorders is now allowed in the DSM-5, since research has found that symptoms of both disorders can and do cooccur. * *Kotte et al. , in press, Pediatrics. 35

Neurodevelopmental Disorder: ADHD DSM-IV-TR DSM-5 Attention-Deficit/Hyperactivity Disordera Attention-Deficit/Hyperactivity Disorder • Inattention (6/9) • Hyperactivity-impulsivity (6/9) • Inattention (6/9) • Hyperactivity and impulsivity (6/9) • Age of onset: before age 7 • Age of onset: before age 12 • Symptoms described so as to better able to diagnose adolescents and adults a. Classified as a disorder Usually First Diagnosed in Infancy, Childhood, or Adolescence 36

DISRUPTIVE, IMPULSE-CONTROL, AND CONDUCT DISORDERS, and ANTISOCIAL PERSONALITY DISORDER: Changes from DSM-IV to DSM-5 • Oppositional defiant disorder • Conduct Disorder • Antisocial Personality Disorder 37

Oppositional Defiant Disorder: Changes from DSM-IV to DSM-5 • DSM-5 groups symptoms of Oppositional Defiant Disorder into three types, in order to reflect that the disorder includes emotional and behavioral components: 1. angry/irritable mood 2. argumentative/defiant behavior 3. vindictiveness (spiteful) 38

Oppositional Defiant Disorder (ODD): Changes from DSM-IV to DSM-5 (cont’d) • DSM-5 has removed the exclusionary criterion of conduct disorder and antisocial personality disorder (in individuals age 18 years or older) from the oppositional defiant disorder diagnosis, since these disorders can and do co-occur. 39

Oppositional Defiant Disorder (ODD): Changes from DSM-IV to DSM-5 (cont’d) • DSM-5 provides additional guidance regarding the frequency typically needed for a behavior to be considered symptomatic of the disorder. • Since many symptoms of ODD occur commonly in normally developing children and adolescents, this information is intended to help differentiate ODD from normal oppositional behavior. 40

Oppositional Defiant Disorder (ODD): Changes from DSM-IV to DSM-5 (cont’d) • DSM-5 adds a severity rating to the criteria for oppositional defiant disorder to reflect research showing that the extent of pervasiveness of symptoms across settings is a significant indicator of severity. 41

Conduct Disorder (CD): Changes from DSM-IV to DSM-5 • The diagnostic criteria for conduct disorder in DSM-5 are mostly unchanged from DSM-IV. • DSM-5 adds a descriptive features specifier for individuals meeting full criteria for conduct disorder and also presenting “with limited prosocial emotions. ” 42

Conduct Disorder (CD): Changes from DSM-IV to DSM-5 (cont’d) • To qualify for the “limited prosocial emotions” (LPE) specifier the individual must persistently display at least two of the following four characteristics: 1. lack of remorse or guilt 2. callous-lack of empathy 3. unconcerned about performance 4. shallow or deficient affect • Limited prosocial emotions applies to individuals with CD who show a callous and unemotional interpersonal style persistently and across multiple settings and relationships. • This specifier is based on research showing that individuals with CD who meet criteria for LPE tend to have a relatively more severe form of the disorder and a different treatment response 43 (Frick, Ray, Thornton, & Kahn, 2013).

Disruptive, Impulse Control, and Conduct Disorders DSM-IV-TR DSM-5 Oppositional Defiant Disorder (4/8)a Oppositional Defiant Disorder (4/8) • Angry/Irritable Mood • Argumentative/Defiant Behavior • Vindictiveness Conduct Disorder (3/15)a • Aggression to people and animals • Destruction of property • Deceitfulness or theft • Serious violation of rules Conduct Disorder (3/15) • Aggression to people and animals • Destruction of property • Deceitfulness or Theft • Serious violation of rules Specifiers • Childhood-onset type • Adolescent-onset type Specifiers (with limited prosocial emotions) • Lack of remorse or guilt • Callous—lack of empathy • Unconcerned about performance • Shallow or deficient affect a. Classified as a disorder Usually First Diagnosed in Infancy, Childhood, or Adolescence 44

Antisocial Personality Disorder (APD): Changes from DSM-IV to DSM-5 • DSM-5 diagnostic criteria for all personality disorders, including Antisocial Personality Disorder are identical to those found in DSM-IV. • During the development of the DSM-5, some professionals working on the DSM-5 personality disorders criteria proposed an alternative model for conceptualizing personality disorders. • Following this model, all personality disorders, including Antisocial Personality Disorder, would be described using standardized criteria that described impaired personality functioning related to self and others, and pathological personality traits. 45

Antisocial Personality Disorder (APD): Changes from DSM-IV to DSM-5 (cont’d) • In the case of Antisocial Personality Disorder, the proposed pathological personality traits include Antagonism (manipulativeness, callousness, deceitfulness, hostility), and Disinhibition (risk taking, impulsivity, and irresponsibility). • Although the alternative model was not officially adopted, it is included in the DSM-5 (Section III), separate from diagnostic criteria. The table immediately after the Diagnostic Criteria for Antisocial Personality Disorder presented below, outlines the proposed diagnostic structure of personality disorders. This structure provides a useful way of thinking about personality functioning, because it highlights areas that are problematic 46 across all personality disorders.

Personality Disorders DSM-IV-TR Paranoid Schizotypal Antisocial Borderline Histrionic Narcissistic Avoidant Dependent Obsessive-Compulsive NOS DSM-5 Unchanged 47

Personality Disorders DSM-IV Personality Disorders Paranoid Schizotypal Antisocial Borderline Histrionic Narcissistic Avoidant Dependent Obsessive-Compulsive NOS Section III: Alternative DSM-5 Model for Personality Disorders ----Schizotypal Antisocial Borderline --Narcissistic Avoidant --Obsessive-Compulsive 48

Personality Disorders Section III: Alternative DSM-5 Model for Personality Disorders • General Criteria for Personality Disorder • Criterion A: Level of Personality Functioning • Criterion B: Pathological Personality Traits • Personality Disorder-Trait Specified 7 features Self (Identity, Self-direction) and Interpersonal (Empathy, Intimacy) 2 of 4 of Criterion A 1 of 4 trait domains: Negative affectivity, detachment, antagonism, disinhibition, psychoticism (30+ facets) 49

Anxiety Disorders: Changes from DSM-IV to DSM-5 • Note: In DSM-5, the DSM-IV category Anxiety Disorders has been subdivided into three categories: anxiety disorders, trauma- and stressor-related disorders, and obsessivecompulsive and related disorders. • General changes to DSM-5 anxiety disorders: • Selective Mutism and Separation Anxiety Disorder are newly classified as anxiety disorders. They were previously classified as Disorders Usually First Diagnosed in Infancy, Childhood or Adolescence. • In DSM-5, Separation Anxiety Disorder may be diagnosed 50 in adults.

Anxiety Disorders: Changes from DSM-IV to DSM-5 (cont’d) • For several disorders, the individual no longer needs to recognize that his or her anxiety is excessive. • Agoraphobia is now a disorder in its own right, instead of being classified in the context of other disorders. In addition, it is now diagnosed separately from panic disorder. • Social anxiety disorder is no longer conceptualized as generalized versus non-generalized; instead, a new specifier performance-only has been added. 51

Anxiety Disorders DSM-IV-TR DSM-5 Separation Anxiety Disordera Separation Anxiety Disorder Selective Mutisma Selective Mutism Specific Phobia Social Phobia (Social Anxiety Disorder) Social Anxiety Disorder (Social Phobia) Panic Disorder Without Agoraphobia Panic Disorder With Agoraphobia Generalized Anxiety Disorder a. Classified as a disorder Usually First Diagnosed in Infancy, Childhood, or Adolescence 52

Obsessive Compulsive and Related Disorders: Changes from DSM-IV to DSM-5 • In DSM-IV, these disorders were classified as anxiety disorders. The new DSM-5 category Obsessive-Compulsive and Related Disorders highlights the importance of obsessive thoughts and compulsive behavior in these disorders. • Body dysmorphic disorder is newly classified among obsessive-compulsive and related disorders, having been classified as a somatic 53 symptom disorder in DSM-IV.

Obsessive Compulsive and Related Disorders: Changes from DSM-IV to DSM-5 (cont’d) • Trichotillomania (hair-pulling disorder) is newly classified among obsessive-compulsive and related disorders, having been classified as an impulse control disorder in DSM-IV. • There are two new disorders in this category: – Excoriation (skin-picking disorder), previously classified as an example of impulse control disorders. – Hoarding disorder, previously described as one manifestation of obsessive-compulsive disorder. 54

Obsessive-Compulsive and Related Disorders DSM-IV-TR DSM-5 Obsessive-Compulsive Disordera Obsessive-Compulsive Disorder Body Dysmorphic Disorderb Body Dysmorphic Disorder Hoarding Disorder Trichotillomaniac Trichotillomania (Hair-Pulling) Disorder Excoriation (Skin-Picking) Disorder a. Classified as an Anxiety Disorder b. Classified as a Somatoform Disorder c. Classified as an Impulsive-Control Disorder NEC 55

Trauma and Stressor Related Disorders: Changes from DSM-IV to DSM-5 • In DSM-IV, these disorders were classified as anxiety disorders. The new category of Trauma- and Stressor. Related disorders emphasizes that these disorders follow exposure to an acute or chronic stressor (e. g. , assault, combat, abuse during childhood). • There are two new disorders in this category: Reactive Attachment Disorder and Disinhibited Social Engagement Disorder. These respectively reflect the inhibited and disinhibited subtypes of DSM-IV Reactive Attachment Disorder. 56

Trauma and Stressor Related Disorders: Changes from DSM-IV to DSM-5 (cont’d) • Separate criteria are provided for diagnosing Posttraumatic Stress Disorder in children age 6 years and younger, reflecting the differential presentation of the disorder in young children. • Diagnostic criteria for the nature of “traumatic event(s)” have become slightly more inclusive. • Trauma exposure is now conceptualized as possibly involving multiple traumatic events. 57

Trauma- and Stressor-Related Disorders DSM-IV-TR DSM-5 Reactive Attachment Disorder of Infancy or Early Childhooda • Inhibited type • Disinhibited type Reactive Attachment Disorder Disinhibited Social Engagement Disorder Posttraumatic Stress Disorderb Posttraumatic Stress Disorder (separate criteria for children 6 and younger) Acute Stress Disorderb Acute Stress Disorder (9/14) • experienced directly • witnessed • experienced indirectly • subjective reaction to the event eliminated in Criterion A in DSM-IV Adjustment Disorders a. Classified as a disorder Usually First Diagnosed in Infancy, Childhood, or Adolescence b. Classified as an Anxiety Disorder 58

Depressive Disorders: Changes from DSM-IV to DSM-5 • The DSM-IV chapter on Mood Disorders, which included both depressive and bipolar diagnoses, has been replaced by two separate chapters, one on Depressive Disorders and the second on Bipolar and Related Disorders. • DSM-IV diagnoses of “Dysthymia and Major Depressive Disorder – Chronic” have been combined in the DSM-5 diagnosis “Persistent 59 Depressive Disorder. ”

Depressive Disorders: Changes from DSM-IV to DSM-5 (cont’d) • There is a new depressive disorder in DSM-5 with special relevance for diagnosing children. • Disruptive Mood Dysregulation Disorder is a new disorder that reflects persistent irritability and frequent episodes of extreme behavioral dyscontrol in the form of temper tantrums in children, who in the past would have been (often erroneously) diagnosed with bipolar disorder. 60

DISRUPTIVE MOOD DYSREGULATION DISORDER Criterion A - Temper outbursts • Severe recurrent temper outburst manifested verbally (e. g. , verbal rages) and/or behaviorally (e. g. , physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocation. Criterion B - Inconsistency with developmental level • The temper outbursts are inconsistent with developmental level. Criterion C - Frequency of outbursts • The temper outbursts occur, on average, three or more 61 times per week.

DISRUPTIVE MOOD DYSREGULATION DISORDER (cont’d) Criterion D - Mood between outbursts • The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others (e. g. , parents, teachers, peers). Criterion E - Duration and chronicity • Criteria A-D have been present for 12 or more months. Throughout that time, the individual has not ahd a period lasting 3 or more consecutive months without all of the symptoms in Criteria 62 A-D.

DISRUPTIVE MOOD DYSREGULATION DISORDER (cont’d) Criterion F - Context and severity • Criteria A and D are present in at least two of three settings (i. e. , at home, at school, with peers) and are severe in at least one of these. Criterion G - Age of diagnosis • The diagnosis should not be made for the first time before age 6 years or after age 18 years. Criterion H - Age of onset • By history or observation, the age at onset of 63 Criteria A-E is before 10 years.

DISRUPTIVE MOOD DYSREGULATION DISORDER (con’t) Criterion I - Absence of mania • There has never been a distinct period lasting more than 1 day during which the full symptom criteria, except duration, for a manic or hypomanic episode have been met. • Note: Developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation, should not be considered as a symptom of mania or hypomania. 64

DISRUPTIVE MOOD DYSREGULATION DISORDER (con’t) Criterion J - Distinction from other mental disorders • The behaviors do not occur exclusively during an episode of major depressive disorder and are not better explained by another mental disorder (e. g. , autism spectrum disorder, posttraumatic stress disorder, separation anxiety disorder, persistent depressive disorder [dysthymia]). Criterion K - Distinction from other conditions • The symptoms are not attributable to the physiological effects of a substance or to another 65 medical or neurological condition.

Depressive Disorders: Changes from DSM-IV to DSM-5 (cont’d) • The DSM-IV Bereavement Exclusion, which suggested that depressive symptoms cannot be diagnosed as a depressive disorder in the context of bereavement lasting less than two months after a major loss (e. g. , death of a loved one), has been removed. This highlights the fact that grief and major depression are related yet independent conditions. 66

Depressive Disorders: Changes from DSM-IV to DSM-5 (cont’d) • With mixed features is a new specifier that reflects experiencing depressive symptoms during a manic or hypomanic episode, or manic symptoms during a depressive episode. • With anxious distress is a new specifier that reflects experiencing anxiety during a depressive, manic or hypomanic episode. 67

Depressive Disorders: Changes from DSM-IV to DSM-5 (cont’d) • Note: Athough they are not designated as disorders in DSM-5, “Suicidal Behavior Disorder” and “Non-Suicidal Self-Injury” have been added to the “Conditions for Further Study” section of DSM-5. Suicidal behavior and non-suicidal selfinjury are related to mood disorders in young people. 68

Depressive Disorders DSM-IV-TR DSM-5 Disruptive Mood Dysregulation Disorder (11 criteria) Major Depressive Episode (5/9) Major Depressive Disorder (Single, Recurrent) Major Depressive Disorder (5/9) • Bereavement as an exclusion criterion deleted Dysthymic Disorder (2/6) Persistent Depressive Disorder (Dysthymia) (2/6) Premenstrual Dysphoric Disordera Premenstrual Dysphoric Disorder (5/11) Mood Disorder NOS Other Specified Depressive Disorder Unspecified Depressive Disorder a. Classified in Appendix B (Criteria Sets and Axes Provided for Further Study) 69

Neurodevelopmental Disorders: Intellectual Disability • DSM-5 substitutes the category Intellectual Disability (intellectual developmental disorder) for the category previously referred to as Mental Retardation in DSM-IV. 70

Neurodevelopmental Disorders: Intellectual Disability (cont’d) • Intellectual Disability is the term formally adopted by the American Association on Intellectual and Developmental Disabilities and is the term most commonly used in research journals, and by medical, educational, other professionals, and the lay public. 71

Neurodevelopmental Disorders: Intellectual Disability (cont’d) • DSM-5 replaces the DSM-IV category of “Mental Retardation, Severity Unspecified” with the diagnosis of Global Developmental Delay. • The Global Developmental Delay diagnosis is reserved for children under the age of 5 when clinical severity level cannot be reliably assessed during early childhood. • The diagnosis applies to children who fail to meet developmental milestones in several areas of intellectual functioning but who are unable or too young to participate in systematic/standardized assessments of intellectual functioning. • This diagnosis requires reassessment following a period of time. 72

Neurodevelopmental Disorders: Intellectual Disability (cont’d) • The DSM-5 defines the various levels of severity for Intellectual Disability (using the Mild, Moderate, Severe, and Profound specifiers) on the basis of adaptive functioning, and not IQ scores. • This change was made since it is adaptive functioning that determines what levels of support are required. Also, IQ scores are less 73 valid in the lower end of the IQ range.

Neurodevelopmental Disorders: Autism Spectrum Disorder • The DSM-5 combines four previous diagnoses into Autism Spectrum Disorder, reflecting a general consensus among scientists that Autistic Disorder, Asperger’s Disorder, Childhood Disintegrative Disorder, and Pervasive Developmental Disorder Not Otherwise Specified are actually one condition with different levels of severity. 74

Neurodevelopmental Disorders: Autism Spectrum Disorder (cont’d) • DSM-5 no longer includes the overarching category of Pervasive Developmental Disorders. • The genetic syndrome of Rett’s disorder has been removed from DSM-5 but, when present, can be specified as an associated known genetic disorder when a diagnosis of autism spectrum disorder has been made. 75

Neurodevelopmental Disorders: Autism Spectrum Disorder (cont’d) • The DSM-5 specifies three levels of severity for Autism Spectrum Disorder symptoms in relation to the amount of required support in each the two component areas of Social Communication and Restricted, Repetitive Behaviors. This change was made to provide a compact and precise description of the severity of the individual’s current symptoms while recognizing that symptom severity and required support may vary across situations and 76 over time.

Neurodevelopmental Disorders: Autism Spectrum Disorder DSM-IV-TR Autistic Disordera Rett’s Disordera Childhood Disintegrative Disordera Asperger’s Disordera Pervasive Developmental Disorder NOSa DSM-5 Autism Spectrum Disorder Social (Pragmatic) Communication Disorder a. Classified as a disorder Usually First Diagnosed in Infancy, Childhood, or Adolescence 77

Neurodevelopmental Disorders: Communication Disorders • The DSM-5 combines two previous diagnoses into Language Disorder, integrating the often cooccurring Expressive Language Disorder and Mixed Receptive-Expressive Language Disorder. • DSM-IV’s Phonological Disorder was renamed Speech Sound Disorder in DSM-5. • DSM-IV’s Stuttering was renamed Childhood. Onset Fluency Disorder (Stuttering) in DSM-5. 78

Neurodevelopmental Disorders: Communication Disorders (cont’d) • The DSM-5 adds a new communication disorder, Social (Pragmatic) Communication Disorder, which involves persistent difficulties in using verbal and nonverbal communication socially. • Some individuals previously diagnosed with PDDNOS (Pervasive Developmental Disorder-Not Otherwise Specified in DSM-IV may meet criteria for Social Communication Disorder, provided that they do not also display restricted behaviors, 79 interests, and activities.

Diagnostic Criteria for Social (Pragmatic) Communication Disorder Criterion A - Persistent difficulties in the social use of verbal and nonverbal communication as manifested by all of the following: • Deficits in using communication for social purposes, such as greeting and sharing information, in a manner that is appropriate for the social context. • Impairment of the ability to change communication to match context or the needs of the listener, such as speaking differently in a classroom than on a playground, talking differently to a child than to an adult, and avoiding 80 use of overly formal language.

Diagnostic Criteria for Social (Pragmatic) Communication Disorder (cont’d) • Difficulties following rules for language and storytelling, such as taking turns in conversation, rephrasing when misunderstood, and knowing how to use verbal and nonverbal signals to regulate interaction. • Difficulties understanding what is not explicitly stated (e. g. , making inferences) and nonliteral or ambiguous meanings of language (e. g. , idioms, humor, metaphors, multiple meanings that depend 81 on the context for interpretation).

Diagnostic Criteria for Social (Pragmatic) Communication Disorder (cont’d) Criterion B - Impairment • The deficits result in functional limitations in effective communication, social participation, social relationships, academic achievement, or occupational performance, individually or in combination. Criterion C - Onset • The onset of the symptoms is early in the developmental period (but deficits may not become fully manifest until social communication demands 82 exceed limited capacities).

Diagnostic Criteria for Social (Pragmatic) Communication Disorder (cont’d) Criterion D - Exclusionary conditions and diagnoses • The symptoms are not attributable to another medical or neurological condition or to low abilities in the domains of word structure and grammar, and are not better explained by autism spectrum disorder, intellectual disability (intellectual developmental disorder), global 83 developmental delay, or another mental disorder.

Neurodevelopmental Disorders: Specific Learning Disorder • The DSM-5 combines four DSM-IV diagnoses (Reading Disorder, Mathematics Disorder, Disorder Of Written Expression, and Learning Disorder Not Otherwise Specified diagnoses) in a single Specific Learning Disorder category. By doing so, the DSM-5 integrates DSM-IV’s frequently co-occurring Reading Disorder, Mathematics Disorder, and Disorder Of Written 84 Expression.

Neurodevelopmental Disorders: Specific Learning Disorder (con’t) • However, within the Specific Learning Disorder diagnosis, DSM-5 uses specifiers to designate whether the impairments are in reading, written expression, mathematics or more than one of these areas, and provides examples of types of deficits for each area. 85

Neurodevelopmental Disorders: Motor Disorders • Stereotypic movement disorder has been more clearly differentiated from body-focused repetitive behavior disorders that are in the DSM -5 obsessive-compulsive disorder chapter. • The DSM-5 Tic Disorders category was changed to include Tourette’s Disorder, Persistent (Chronic) Motor or Vocal Tic Disorder, and Provisional Tic Disorder. The tic criteria have 86 been standardized across all of these disorders.

Schizophrenia Spectrum and Other Psychotic Disorders DSM-IV-TR DSM-5 Delusional Disorder Shared Psychotic Disorder (Folie a Deux) Delusional Disorder • requirement that the delusions be “nonbizarre” has been eliminated Brief Psychotic Disorder Schizophreniform Disorder Schizophrenia (2/5) • Requirements for Criterion A modified • subtypes eliminated Schizoaffective Disorder 87

Substance Related and Addictive Disorders • The distinction between Substance Abuse Disorder and Substance Dependence Disorder has been eliminated in DSM-5. Now, these two previously separate disorders are replaced by a combined Substance Use Disorder, which includes symptoms of both Substance Abuse and Substance Dependence • Diagnostic criteria for substance intoxication are now specified for each group of substances, and there is no longer a general Substance Intoxication diagnosis in the DSM-5. 88

Substance Related and Addictive Disorders (cont’d) • Additional diagnoses have been added, including, notably Gambling Disorder and Tobacco Use Disorder • There is a move to characterize substance-related disorders by severity instead of only by diagnostic cut-off. For the general diagnosis of Substance Use Disorder, there is a severity rating in DSM-5 based on the number of symptoms endorsed: mild (2 to 3), moderate (4 to 5), severe (6 or more) 89

Substance-Related and Addictive Disorders DSM-IV-TR Substance Dependence (3/7) Substance Abuse (1/4) DSM-5 Substance Use Disorders • • Alcohol Use Disorder (2/11) Cannabis Use Disorder (2/11) Opioid Use Disorder (2/11) Stimulant Use Disorder (2/11) • Tobacco Use Disorder (2/11) Substance-Induced Disorders Impulse-Control Disorders NEC Non-Substance-Related • Pathological Gambling (5/10) Disorders • Gambling Disorder (4/9) 90

Sleep-Wake Disorders • Generally, sleep disorders’ diagnoses have been revised to better reflect scientific understanding of their pathophysiology. • To reflect better biological understanding of breathing-related sleep disorders, they are divided into three separate diagnoses in the DSM -5: obstructive sleep apnea hypopnea, central sleep apnea, and sleep-related hypoventilation. 91

Sleep-Wake Disorders (cont’d) • Evidence has supported Restless Leg Syndrome and REM Sleep Behavior Disorder to have full disorder status in DSM-5. This will reduce the use of the “not otherwise specified” diagnosis used in DSM-IV. • Sleep disorder related to another mental disorder or medical condition has been removed as a diagnosis. Instead, coexisting conditions/substances can be better specified within each diagnosis. This change is meant to emphasize that diagnosed sleep disorders warrant clinical attention beyond that given to coexisting conditions, and to acknowledge the interactive effects between sleep and comorbid disorders. 92

Somatic Symptom and Health Related Disorders • In DSM-IV, somatic symptom disorders were called somatoform disorders. • DSM-5 reflects efforts to consolidate and rearrange DSM-IV diagnoses that were overlapping and poorly defined. • The following DSM-IV Diagnoses are not present in DSM-5: Hypochondriasis, Somatization Disorder, Pain Disorder, Undifferentiated Somatoform Disorder. However, some have been altered to become one or 93 more new DSM-5 diagnoses.

Somatic Symptom and Health Related Disorders (cont’d) • There a number of new disorders in DSM-5. These include Illness Anxiety Disorder and Somatic Symptom Disorder. • Psychological Factors Affecting Other Medical Conditions is another new disorder in DSM-5, although the DSM-IV noted that concerns of this nature may be important to identify. This disorder occurs when there is both a diagnosed medical condition and a psychological or behavioral factor that is making that condition worse (e. g. , the anxiety in panic disorder might worsen a 94 person’s asthma).

Somatic Symptom and Health Related Disorders (cont’d) • Pain Disorder is now classified as “Somatic Symptom Disorder with predominant pain. ” • Conversion Disorder is now known as “Conversion Disorder (Functional Neurological Symptom Disorder). ” This term is more acceptable to patients and doctors, and it reflects the importance of taking neurological data into account when making a diagnosis. 95

Somatic Symptom and Health Related Disorders (cont’d) • Factitious Disorder has been retained in DSM-5, although its subtypes (e. g. , distinguishing between psychological vs. physical symptoms) have been removed. • Body Dysmorphic Disorder is now classified among Obsessive-Compulsive and Related Disorders. While this disorder does involve significant somatic concerns, the new classification reflects the important role played by obsessive and compulsive 96 symptoms.

Somatic Symptom and Related Disorders DSM-IV-TR (Somatoform Disorders) DSM-5 Somatization Disorder Undifferentiated Somatoform Disorder Pain Disorder Somatic Symptom Disorder • Requirement that the symptoms “cannot be fully explained by a known general medical condition” has been removed Hypochondriasis Illness Anxiety Disorder Conversion Disorder (Functional Neurological Symptom Disorder) Factitious Disordera Factitious Disorder a. Classified in a separate chapter in DSM-IV 97

Feeding and Eating Disorders • In DSM-5, this diagnostic category includes several disorders previously included in DSM-IV as feeding and eating disorders of infancy or early childhood (i. e. , pica, rumination disorder, avoidant/restrictive food intake disorder). • Binge-eating disorder became an official diagnosis in the DSM-5. • Overall, eating disorders’ definitions have not changed conceptually from the DSM-IV to DSM-5. 98

Feeding and Eating Disorders DSM-IV-TR DSM-5 Picaa Pica Rumination Disorder Feeding Disorder of Infancy or Early Childhooda Avoidant/Restrictive Food Intake Disorder (extended criteria) Anorexia Nervosa • Amenorrhea deleted for postmenarcheal females • <85% of expected body weight criterion deleted • Severity criteria based on BMI Bulimia Nervosa Binge-Eating Disorderb Binge-Eating Disorder a. Classified as a disorder Usually First Diagnosed in Infancy, Childhood, or Adolescence b. Classified in Appendix B (Criteria Sets and Axes Provided for Further Study)