DSM-5. Jon E. Grant, JD, MD, MPH Professor University of Chicago Pritzker School of Medicine Chicago, IL

Transcription

1 DSM-5 Jon E. Grant, JD, MD, MPH Professor University of Chicago Pritzker School of Medicine Chicago, IL

2 Disclosure Information Financial relationships: Grant/Research support from: NIDA, NCRG, Forest Pharmaceuticals and Roche Pharmaceuticals Other relationships: On the ICD-11 committee Collaborator: Donald Black (University of Iowa) 4/21/2014

3 Purpose of DSM DSM provides a common language. Helps ensure consistency in the definition of mental disorders for clinicians in the United States and elsewhere. DSM is widely used beyond the confines of psychiatry - researchers, administrators, civil servants, attorneys, and others. When used as intended, DSM requires clinical expertise and training. One important limitation is that it does not provide treatment information. Because psychiatry lacks specific laboratory diagnostic tests and confirmed etiologies for most disorders, diagnosis relies largely on the patient s symptoms and history. For that reason, it is essential that diagnostic criteria be precise and clear.

4 DSM-I The APA Committee on Nomenclature and Statistics set to work on a single national system of classification of mental illnesses that led to the publication in 1952 of the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I). Relatively compact at 132 pages, DSM-I was the first official manual of mental disorders to focus on clinical utility for classification. Definitions were relatively simple and consisted of brief prototypical descriptions. Most disorders were reactions reflecting the influence of Adolf Meyer and his psychobiological approach to psychiatry, which hypothesized that disorders were types of reaction patterns that are exaggerations or aberrations of, or substitutions for, normal, healthy, and adaptable ways of living.

5 DSM-II APA contributed to ICD-8 and published DSM-II in Among the several changes in DSM-II, the most striking was the omission of the term reaction from diagnoses. Names of several disorders were changed, and the manual encouraged users to record multiple psychiatric diagnoses (listed in order of importance) and associated physical conditions. In 1974 the APA created a task force to produce a revised version of DSM to coincide with ICD-9 (1977).

6 DSM-III Published in 1980, DSM-III was 494 pages and a reflection of the increased emphasis on empirical data in psychiatric practice and research. The first effort by a medical specialty to provide a comprehensive and detailed diagnostic manual in which all disorders were defined by specific criteria so that the methods for making a psychiatric diagnosis were relatively clear. Field tests of over 12,000 patients. DSM-III was published in coordination with ICD-9. In addition to the inclusion of diagnostic criteria, the other major innovation of DSM-III was the introduction of a multiaxial classification system.

7 DSM-IV The goal was to balance historical precedent, new data, and the needs required for compatibility with ICD-10. A major change from previous versions was the inclusion of a clinical significance criterion for almost half of all the categories. Several new disorders were introduced (e.g., acute stress disorder, bipolar II disorder, Asperger s disorder), and others were deleted or subsumed by other categories (e.g., cluttering, transsexualism, passive-aggressive personality disorder).

8 DSM-5 Priority was given to clinical utility; that is, any changes to the criteria or organization of the manual had to be useful to clinicians. Changes had to be guided by research evidence accumulated since the publication of DSM-IV. DSM-5 had to maintain historical continuity with previous editions, particularly DSM-III and DSM-IV. Diagnostic advances would be made through a careful and transparent process involving literature reviews, secondary analyses of existing data sets, and primary analyses of newly collected data.

9 DSM-5 DSM-5 represents a significant departure from its predecessors, as indicated by changes to specific categories and disorders as well as its overall organization. The manual was reorganized in response to whether advances in neuroscience, brain imaging, and genetics might suggest a framework for arranging disorders by more than common symptoms. What emerged from those discussions is reflected by the reorganization of the 19 major diagnostic classes in DSM-5

10 19 Diagnostic Classes Neurodevelopmental Disorders Schizophrenia Spectrum and Other Psychotic Disorders Bipolar and Related Disorders Depressive disorders Anxiety Disorders Obsessive Compulsive and Related Disorders Trauma and Stress-Related Disorders Dissociative Disorders Somatic Symptom and Related Disorders Feeding and Eating Disorders Elimination Disorders Sleep-Wake Disorders Sexual Dysfunctions Gender Dysphoria Disruptive, Impusle-Control, and Conduct Disorders Substance-Related and Addictive Disorders Neurocognitive Disorders Personality Disorders Paraphilic Disorders

11 Controversies Involving DSM-5 The revision process was not without controversy, but it must be placed in perspective: All prior DSM editions were accompanied by considerable public consternation. A steady drumbeat of criticism began early, both within the field as well as among the public at large. The main concerns from various critics were that the DSM-5 process lacked openness and transparency; That decisions were made capriciously and did not follow the evidence; That no independent scientific review was done; That rates of reliability were unacceptably low; That prevalence rates would increase because the thresholds for important categories (e.g., ADHD, mild neurocognitive disorder, disruptive mood dysregulation disorder) were too loose; and That many task force and work group members had conflicts of interest.

12 DSM-5 Coding The official coding system in the United States is not DSM-5 but rather the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), released by the World Health Organization in This is the result of a treaty obligation to report health statistics using the ICD system. DSM-5 and ICD-9-CM use the same codes, which range from 290 to 319. Some DSM-5 disorders are assigned the same ICD code, which is unavoidable because the selection of diagnostic codes in DSM-5 is limited to those already included in ICD-9. It was expected that DSM-5 and its new counterpart, ICD-10, would become available at the same time (May 2013), so that both would employ the same new codes.

13 Indicating Diagnostic Certainty DSM-5 allows various ways for clinicians to specify level of diagnostic certainty V-codes: Information is insufficient to know whether a presenting problem is attributable to a mental disorder (i.e., academic problem, partner-relational problem) Diagnosis or condition deferred: This designation can be used when information is inadequate to make a diagnostic judgment Unspecified mental disorder (nonpsychotic): Information is available to rule out a psychotic disorder, but further specification is not possible Unspecified schizophrenia spectrum and other psychotic disorder: The patient is psychotic, but further diagnostic specification is not possible. Specific diagnosis (provisional): Enough information is available to make a working diagnosis, but the clinician wishes to indicate a significant level of diagnostic uncertainty by recording (provisional) following the diagnosis.

14 Substance-Related and Addictive Disorders In addition to the substance-related disorders, this chapter also includes gambling disorder, Reflects evidence that gambling behaviors activate reward systems similar to those activated by drugs of abuse and produce some behavioral symptoms that appear comparable to those produced by the substance use disorders. Other excessive behavioral patterns, such as Internet gaming, have also been described, but the research on these and other behavioral syndromes is less clear. Thus, groups of repetitive behaviors, which some term behavioral addictions, with such subcategories as sex addiction, exercise addiction, or shopping addiction, are not included because at this time there is insufficient peer-reviewed evidence to establish the diagnostic criteria and course descriptions needed to identify these behaviors as mental disorders.

15 DSM-IV SUBSTANCE ABUSE CRITERIA Failure to fulfill major role obligations at work, school, or home Recurrent use under hazardous conditions Substance-related legal problems Continued use despite problems One or more problems occurring within the same 12-month period

16 CRITERIA FOR SUBSTANCE DEPENDENCE Tolerance Withdrawal Taken in larger amount/over longer time Attempts/desire to limit or abstain from use Over involvement in use Interference with responsibilities Use despite knowledge of problems 3 or more symptoms occurring within the same 12-month period

17 Alcohol Use Disorder A. A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period: 1. Alcohol is often taken in larger amounts or over a longer period than was intended. 2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use. 3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects. 4. Craving, or a strong desire or urge to use alcohol.

18 5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home. 6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol. 7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use. 8. Recurrent alcohol use in situations in which it is physically hazardous. 9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol. 10. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect. b. A markedly diminished effect with continued use of the same amount of alcohol. 11. Withdrawal, as manifested by either of the following: a. The characteristic withdrawal syndrome for alcohol b. Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.

19 Reasons for Changes First, clinicians had trouble distinguishing the syndromes. Whereas studies showed that test-retest reliability of DSM-IV dependence was uniformly very good to excellent, the reliability of DSM-IV abuse was lower and more variable. Many also assumed that abuse was often a prodromal phase of dependence, but several prospective studies showed that this was not the case. In addition, the division between abuse and dependence led to diagnostic orphans, whereby a person could meet two criteria for dependence but none for abuse. Such individuals could have substance use problems with the same severity as others with a diagnosis but were left undiagnosed.

20 Non-Substance-Related Disorders Gambling Disorder

21 Gambling Disorder A. Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting four (or more) of the following in a 12-month period: 1. Needs to gamble with increasing amounts of money in order to achieve the desired excitement. 2. Is restless or irritable when attempting to cut down or stop gambling. 3. Has made repeated unsuccessful efforts to control, cut back, or stop gambling. 4. Is often preoccupied with gambling (e.g., having persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money with which to gamble).

22 Gambling Disorder 5. Often gambles when feeling distressed (e.g., helpless, guilty, anxious, depressed). (former: gambles as a way of escaping from problems ) 6. After losing money gambling, often returns another day to get even ( chasing one s losses). 7. Lies to conceal the extent of involvement with gambling. 8. Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling. 9. Relies on others to provide money to relieve desperate financial situations caused by gambling. B. The gambling behavior is not better explained by a manic episode.

23 Gambling Disorder Specify if: Episodic: Meeting diagnostic criteria at more than one time point, with symptoms subsiding between periods of gambling disorder for at least several months. Persistent: Experiencing continuous symptoms, to meet diagnostic criteria for multiple years. Specify if: In early remission: After full criteria for gambling disorder were previously met, none of the criteria for gambling disorder have been met for at least 3 months but for less than 12 months. In sustained remission: After full criteria for gambling disorder were previously met, none of the criteria for gambling disorder have been met during a period of 12 months or longer.

24 Gambling Disorder Specify current severity: Mild: 4 5 criteria met. Moderate: 6 7 criteria met. Severe: 8 9 criteria met.

25 Specifiers Severity is based on the number of criteria endorsed. Individuals with mild gambling disorder may exhibit only 4 5 of the criteria, with the most frequently endorsed criteria usually related to preoccupation with gambling and chasing losses. Individuals with moderately severe gambling disorder exhibit more of the criteria (i.e., 6 7). Individuals with the most severe form will exhibit all or most of the nine criteria (i.e., 8 9). Jeopardizing relationships or career opportunities due to gambling and relying on others to provide money for gambling losses are typically the least often endorsed criteria and most often occur among those with more severe gambling disorder. Individuals presenting for treatment of gambling disorder typically have moderate to severe forms of the disorder.

26 Differential Diagnosis Nondisordered gambling. In professional gambling, risks are limited and discipline is central. Social gambling typically occurs with friends or colleagues and lasts for a limited period of time, with acceptable losses. Manic episode. Loss of judgment and excessive gambling may occur during a manic episode.in additional diagnosis of gambling disorder should be given only if the gambling behavior is not better explained by manic episodes. Personality disorders. Problems with gambling may occur in individuals with antisocial personality disorder and other personality disorders. If the criteria are met for both disorders, both can be diagnosed. Other medical conditions. Some patients taking dopaminergic medications (e.g., Parkinson s disease) may experience urges to gamble. If such symptoms dissipate when dopaminergic medications are reduced in dosage or ceased, then a diagnosis of gambling disorder would not be indicated.

27 Culture-Related Diagnostic Issues Individuals from specific cultures and races/ethnicities are more likely to participate in some types of gambling activities than others (e.g., pai gow, cockfights, blackjack, horse racing). Prevalence rates of gambling disorder are higher among African Americans than among European Americans, with rates for Hispanic Americans similar to those of European Americans. Indigenous populations have high prevalence rates of gambling disorder.

28 Critiques Eliminating committing illegal acts as a symptom for the diagnosis neglects the findings that it appears only at high severity levels of gambling disorder. The effect of lowering the threshold from five out of 10 symptoms to four out of nine symptoms will have an effect of reducing diversity because of the fewer number of combinations that can occur with diagnostic criteria. Although the task force concluded that there was insufficient empirical evidence to warrant including behavioral disorders other than gambling at this time, the creation of such a classification leaves the door open for other non-substance-based disorders.

29 Implications for assessing individuals with a Gambling Disorder. With gambling disorder grouped with substance-use disorders, this could lead to new developments, both in terms of research and in terms of the practical application of that research in prevention, treatment and public policy. For example, while there is plenty of evidence that gambling treatment of various types does help people, there is a lot to be learned about how it works, and for whom. By integrating research in brain imaging, genetics and clinical trials, there is an opportunity to understand the mechanisms of effective behavioral change, and then tailor programs to increase their reach and success rates. Prevention this change reminds clinicians to educate and screen for gambling Treatment clinicians treating addictions may now broaden their area to gambling Insurance how knows yet but policies that cover addiction treatment may now expand to include gambling

30 Other Changes in DSM-5 A key distinction between DSM-5 and previous versions is that this one attempts to help physicians convey the severity of disease. Although dimensional views of disease were present in DSM-IV, the past versions of DSM have given the impression that a psychiatric diagnosis is either present or absent, ie, that one either meets or does not meet the criteria for a particular disorder. To correct that simple dichotomized approach, the DSM-5 includes an expanded approach to dimensional aspects of diagnoses along with categories. (For example, stimulant use disorder can now include the specifier of current severity of mild, moderate or severe whereas this was not included in DSM-IV- TR) With specifiers, subtypes, severity ratings and new tools for assessing symptoms, clinicians should be better able to capture gradients of a disorder

31 Section III Section III, (a new section for DSM), includes a cross-cutting symptom measure that allows the clinician to examine 13 domains across psychiatric disorders and to be aware of symptoms that may not fit neatly into the diagnostic criteria of the presenting symptoms but are still important to the patient s care. Specific domains can be scored and tracked at each follow-up visit. These can serve as a guide for additional inquiry and to assess response to treatment.

32 Level 1 Cross-Cutting Symptom Measure Patient- or informant-rated measure that assesses mental health domains that are important across psychiatric diagnoses. It is intended to help clinicians identify additional areas of inquiry that may have significant impact on the individual s treatment and prognosis. The adult version of the measure consists of 23 questions that assess 13 psychiatric domains, including depression, anger, mania, anxiety, somatic symptoms, suicidal ideation, psychosis, sleep problems, memory, repetitive thoughts and behaviors, dissociation, personality functioning, and substance use (Table 1). Each domain consists of one to three questions. Each item inquires about how much (or how often) the individual has been bothered by the specific symptom during the past 2 weeks.

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34 Scoring and Level 2 On the adult self-rated version of the measure, each item is rated on a 5-point scale (0=none or not at all; 1=slight or rare, less than a day or two; 2=mild or several days; 3=moderate or more than half the days; and 4=severe or nearly every day). Rating of mild (i.e., 2 or greater on any item within a domain, except for substance use, suicidal ideation, and Psychosis) may serve as a guide for additional inquiry and follow-up to determine if a more detailed assessment is necessary Level 2 Cross-Cutting Symptom Measures provide one method of obtaining more in-depth information on potentially significant symptoms to inform diagnosis, treatment planning, and follow-up. They are available online at

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36 Elimination of the Multiaxial System In the DSM-5, personality disorders and intellectual disability are no longer relegated to second-level importance. The psycho-socio stressors previously cited in Axis IV can now be recorded using the appropriate V-code (listed in DSM-5 as Other conditions that may be a focus of clinical attention). For example, instead of listing housing as a problem on Axis IV, the V-codes allow for a detailed understanding of the housing problem (for example, V60.0 homelessness; V60.1 inadequate housing; V60.6 problem related to living in a residential institution).

37 Global Assessment of Functioning Information formerly conveyed in the Global Assessment of Functioning score on Axis V can now be reflected in the World Health Organization Disability Assessment Schedule, version 2 (WHODAS 2.0) score. The WHODAS 2.0 is a self-assessment of disability across six domains (for example, understanding and communicating, self-care, getting along with people) that provides a general disability score that can be used to track change over time. Unlike the multi-axial system where Axis V received a number that was provided little in the way of explaining a particular patient s struggles in functioning, the scores on the WHODAS 2.0 reflect degrees of dysfunction in very specific domains (for example, mild problems maintaining a friendship and severe problems making new friends).

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39 Cultural Assessment Outline for Cultural Formulation - can be used for assessing the patient s cultural identity, cultural conceptualization of distress, cultural features of vulnerability and resilience, and cultural features affecting the patient-clinician relationship. Cultural Formulation Interview consists of 16 questions to examine the impact of culture on the patient s clinical presentation.

40 Cultural Formulation Interview The is a set of 16 questions that clinicians may use to obtain information during a mental health assessment about the impact of culture on key aspects of an individual s clinical presentation and care. In the CFI, culture refers to The values, orientations, knowledge, and practices that individuals derive from membership in diverse social groups (e.g., ethnic groups, faith communities, occupational groups, veterans groups). Aspects of an individual s background, developmental experiences, and current social contexts that may affect his or her perspective, such as geographical origin, migration, language, religion, sexual orientation, or race/ethnicity. The influence of family, friends, and other community members (the individual s social network) on the individual s illness experience.

41 QUESTIONS?

42 Other Specific Changes Autism disorder, Asperger's disorder, child disintegrative disorder and pervasive developmental disorder NOS have been combined into a single disorder, autism spectrum disorder. Argument for this change was that there was poor reliability data for diagnosing these as individual disorders. Some have argued that some high-functioning individuals will no longer meet diagnostic criteria for autism spectrum disorders, thereby becoming ineligible for services and treatment. They also question the removal of the subgroup of Asperger syndrome in this new edition of the manual as too extreme a move. On the other side, some have argued that perhaps the changes will improve treatment by helping to clarify a diagnosis.

43 Autism DSM-5 includes specifiers for autism spectrum disorder to reflect the heterogeneity within the disorder. Example: person previously diagnosed with Asperger s disorder could be diagnosed with autism spectrum disorder using the specifiers without accompanying intellectual impairment and without accompanying language impairment. The argument for this spectrum of autism was based on the fact that clinicians often had difficulties differentiating the individual disorders and that a larger umbrella disorder may actually make diagnosis easier and thereby better identify those needing services.

44 Psychotic Disorders DSM-5 has also eliminated subtypes of schizophrenia. Schizophrenia subtypes of paranoid, disorganized, catatonic, undifferentiated, and residual have a lengthy history that predates DSM-I, but there was little evidence to support either their clinical utility or predictive validity. Because the course of schizophrenia is highly variable, the subtypes had little stability so that at various stages of illness it was not unusual for a person to meet criteria for different subtypes. DSM-5 uses course (for example, first episode, currently in acute episode compared to episodic with interepisode residual symptoms from DSM-IV-TR) and severity specifiers (for example, delusions present and moderate compared to no severity specifiers in DSM-IV- TR) to reflect the heterogeneity of the disorder in a manner that is more clinically useful.

45 Personality Disorders Special fire was reserved for the entire personality disorders chapter. Work group recommended that the number of disorders be reduced from 10 to 6 Work Group recommended revamping the diagnostic criteria for the remaining disorders, while incorporating a complex scheme to rate up to five personality trait domains and 25 facets. Critics pointed out that the new criteria were so complex as to be unworkable for busy clinicians, and that an already marginalized group of patients would only be further marginalized. Researchers pointed out that the DSM-IV-TR criteria were reliable and valid, that there was no scientific support for the new criteria, and that their implementation would interfere with ongoing research projects.

46 Neurodevelopmental Disorders Neurodevelopmental Disorders is a reformulated chapter, formerly called Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence. The mental retardation diagnosis has been replaced by intellectual developmental disorder. The term mental retardation was dropped because it was thought to be stigmatizing. There is no longer a reliance on the IQ as the determinant for inclusion in the category; instead, subtypes are used to classify severity of the individual s disorder as mild, moderate, severe, or profound. Adaptive functioning is given greater emphasis. The arbitrary reliance on IQ was considered limiting because it does not take into account the different domains of functioning (social, conceptual/intellectual, practical) that allow a more nuanced view of the person with an intellectual deficit.

47 Bipolar and Related Disorders The mood disorders of DSM-IV-TR have been divided in DSM-5 into bipolar and related disorders and depressive disorders, each having its own chapter. Greater emphasis has been given to changes in activity and mood in the context of mania/hypomania, with the goal of improving the likelihood of early identification. Increased activity has been added for mania/hypomania so that the criterion now includes changes in both mood and activity. Criteria for bipolar I disorder, most recent episode, mixed have been dropped, and instead the specifier with mixed features has been added. Consistent with dimensionality, clinician-rated measures of severity of cooccurring anxiety and substance abuse are available to better characterize the mood disorder, because such symptoms are known to affect outcome and may require special treatment.

48 Depressive Disorders Disruptive mood dysregulation disorder and premenstrual dysphoric disorder are new diagnoses. The former was added to address concerns about the potential overdiagnosis (and overtreatment) of bipolar disorder in children, whereas the latter was given full disorder status (and moved from DSM-IV-TR Appendix B, Criteria Sets and Axes Provided for Further Study ). The coexistence within a major depressive episode of at least three manic symptoms insufficient to satisfy criteria for manic episode is now acknowledged by the specifier with mixed features. The exclusion applied to depressive symptoms lasting less than 2 months following the death of a loved one in DSM-IV TR (i.e., the so-called bereavement exclusion) has been omitted, and bereavement is now acknowledged as a severe psychosocial stressor that can precipitate a major depressive episode.

49 Anxiety Disorders In DSM-5, obsessive-compulsive disorder, posttraumatic stress disorder, and acute stress disorder have been moved from the Anxiety Disorders chapter to other chapters, and separation anxiety disorder has been moved to Anxiety Disorders from Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence. For specific phobia and social anxiety disorder, common changes include deletion of the requirement that adults recognize their anxiety as excessive or unreasonable. Instead, the anxiety should be out of proportion to the actual danger or threat, after taking sociocultural factors into account. The 6-month duration, which was limited to individuals younger than 18 years, has been extended to all ages. This change is expected to minimize the overdiagnosis of transient fears. The terminology for describing different types of panic attacks has been replaced with the terms unexpected and expected. Panic disorder and agoraphobia have been unlinked; each is now its own diagnosis and their co-occurrence is now coded with two diagnoses. Panic attacks can now be used as a specifier for any mental disorder and some medical conditions.

50 The specific phobia criteria are reworded such that the chance of encountering the phobic stimulus is no longer a determinant of whether an individual receives the diagnosis. For example, people who fear snakes but live in an area where there are none now may receive the diagnosis of specific phobia. The different types of specific phobias (now specifiers ) are mostly unchanged, although more attention is given to the distinction between the situational and agoraphobia specifiers. With social anxiety disorder, the generalized specifier has been dropped and replaced with a performance only specifier. Finally, for separation anxiety disorder, the wording has been changed to more adequately represent the expression of separation anxiety symptoms in adulthood. Selective mutism has been dropped as an independent disorder and is now a specifier for separation anxiety disorder.

51 Obsessive-Compulsive and Related Disorders Body dysmorphic disorder was moved from the somatoform disorders. Hoarding was listed as a symptom of obsessive-compulsive personality disorder in DSM-IV- TR (Criterion 5), but research evidence shows that hoarding is a distinct condition. Trichotillomania was moved from the disorders of impulse control Excoriation disorder was given full disorder status. A new insight specifier for obsessive-compulsive disorder allows clinicians to be more precise about the person s level of insight: good, fair, poor, or no insight. An analogous specifier applies to body dysmorphic disorder and hoarding disorder. A tic-related specifier reflects the importance and utility of acknowledging the importance of this symptom for obsessive-compulsive disorder. A muscle dysmorphia specifier reflects the importance of making this distinction in individuals with body dysmorphic disorder.

52 Trauma and Stress-Related Disorders Trauma- and Stressor-Related Disorders, groups all disorders resulting from exposure to a stressor Criteria for acute stress disorder have been collapsed into 14 possible symptoms, 9 are necessary to indicate a diagnosis, and dissociative symptoms are included but not required as they were in DSM-IV-TR. With PTSD, there is no longer a requirement that the person have the subjective experience at the time of the traumatic event of fear, helplessness, and/or horror, because this requirement was not useful in predicting who developed the disorder. A cluster of symptoms related to negative alterations in mood is new to the diagnosis, in addition to the three symptom clusters of reexperiencing the trauma, avoidance and numbing, and hyperarousal. This cluster replaces the numbing symptoms of DSM-IV-TR. Two subtypes are included: posttraumatic stress disorder in preschool children and a dissociative subtype. Adjustment disorders have two new subtypes: a bereavement-related subtype and an acute stress disorder/posttraumatic stress disorder subtype.

53 Neurocognitive Disorders Dementia has been subsumed under the new diagnosis neurocognitive disorder, although the word dementia is not precluded for use in the subtypes where it is standard. DSM-5 recognizes two levels of cognitive impairment: major and mild neurocognitive disorders. Mild neurocognitive disorder permits the diagnosis of less disabling syndromes that may be a focus of concern. The major neurocognitive disorders syndrome provides consistency with the rest of medicine and was included in prior DSM editions, and remains distinct to capture the important care needs of this group. The mild neurocognitive disorders syndrome is consistent with other fields of medicine where it is a significant focus of care and research.

54 Conditions for Further Study Placing Conditions for Further Study in Section III of DSM-5 ensures that interested investigators are discussing and researching the same condition for possible inclusion in future DSM editions. Proposed criteria sets for conditions for further study were first included in DSM-III-R as a way to promote the collection of new data that could be used to validate new disorders. To achieve full disorder status, the condition should be unrepresented (or inappropriately represented); have clinical value; have the potential to improve accurate identification and/or treatment; and be prevalent, impairing, and distinctive.

55 Conditions for Further Study Attenuated Psychosis Syndrome Depressive Episodes With Short-Duration Hypomania Persistent Complex Bereavement Disorder Caffeine Use Disorder Internet Gaming Disorder Neurobehavioral Disorder Associated With Prenatal Alcohol Exposure Suicidal Behavior Disorder Nonsuicidal Self-Injury

56 Useful information in DSM-5 regarding each diagnosis Recording procedures (where applicable) Subtypes and/or specifiers (where applicable) Diagnostic features Associated features supporting diagnosis Prevalence Development and course Risk and prognostic factors Culture-related diagnostic issues Gender-related diagnostic issues Diagnostic markers Functional consequences Differential diagnosis Comorbidity

57 Conclusion The changes to the DSM-5 are too numerous to describe in a single article. They include coding changes, new assessment measures, new disorders (for example, hoarding disorder, excoriation disorder), and new conditions included for further study (attenuated psychosis syndrome, caffeine use disorder, for example). Although readers may have strong views regarding the DSM-5 based on the years of controversy, for better or worse, this is our new diagnostic manual Clinicians would be well-advised to become familiar with it.