A DSM By Any Other Name? 6/18/2013

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1 A DSM By Any Other Name? Disclosures Financial Conflicts PrairieCare Medical Group (co-owner) PrairieCare (CEO & Chief Medical Officer) CATCH, LLC (co-owner) A University of Minnesota Medical School Affiliate Joel V. Oberstar, MD CEO & Chief Medical Officer Disclaimer Outline The contents of his handout are for informational purposes only and are not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified healthcare provider with any questions you may have regarding a medical or psychiatric condition. Never disregard professional/medical advice or delay in seeking it because of something you have read in this handout. Material in this handout may be copyrighted by the author or by third parties; reasonable efforts have been made to give attribution where appropriate. DSMs of Yesteryear DSM-5 Conceptually Changes in DSM-5 (not all inclusive) Why a DSM in the First Place? DSMs of Yesteryear Shared language Fosters accurate diagnosis Seeks to be somewhat a-theoretical (just the facts, ma am) DSM-I: 1952 (132 pages) DSM-II: 1968 (119 pages) DSM-III: 1980 (494 pages) DSM-III-R: 1987 (567 pages) DSM-IV: 1994 (886 pages) DSM-IV-TR: 2000 (943 pages) DSM-5: 2013 (947 pages) Source: Jon Grant, MD, MPH, JD. DSM-5: History, Overview, and Practice Implications. Presented Minnesota Psychiatric Society Spring Scientific Program. St. Paul, MN. Joel V. Oberstar, MD 1

2 19 Diagnostic Classes Organization Neurodevelopment Disorders Schizophrenia Spectrum and Other Psychotic Disorders Bipolar Depressive Disorders Obsessive Compulsive Trauma and Stress-Related Disorders Dissociative Disorders Elimination Disorders Sleep-Wake Disorders Sexual Dysfunctions Gender Dysphasia Disruptive, Impulse-Control, and Conduct Disorders Substance-Related and Addictive Disorders Neurocognative Disorders Personality Disorders Paraphilic Disorders chapter placement developmental life span Moves from child adol adult - Section I - covers historical material and development of DSM-5 - Section II - criteria for the 19 major diagnostic classes - medication-induced movement disorders - other adverse effects of medication - other conditions that may be a focus of clinical attention (V & Z codes) - Section III - includes assessment measures - cultural formulation - alternative DSM-5 model for personality disorders - criteria sets for conditions for further study. - Appendix Source: Jon Grant, MD, MPH, JD. DSM-5: History, Overview, and Practice Implications. Presented Minnesota Psychiatric Society Spring Scientific Program. St. Paul, MN. Source: Jon Grant, MD, MPH, JD. DSM-5: History, Overview, and Practice Implications. Presented Minnesota Psychiatric Society Spring Scientific Program. St. Paul, MN. Multiaxial System Recording DSM-5 Diagnoses Axis I vs. Axis II Axis III inconsistently used Axis V unreliable and arbitrary Multiple diagnoses OK Rank order according to importance Levels the Axis I/II playing field Replace x with subtype or level of severity. Subtypes mutually exclusive (specify type) Specifiers are not mutually exclusive general medical condition changed to another medical condition Source: Jon Grant, MD, MPH, JD. DSM-5: History, Overview, and Practice Implications. Presented Minnesota Psychiatric Society Spring Scientific Program. St. Paul, MN. Diagnostic Certainty Neurodevelopmental Disorders Clinician can utilize: V-codes (deferred) (not psychotic but otherwise unclear) (psychotic but otherwise unclear) Diagnosis (provisional) Intellectual Disability (Intellectual Developmental Disorder) Communication Disorders Autism Spectrum Disorder ADHD Specific Learning Disorder Motor Disorders Source: Jon Grant, MD, MPH, JD. DSM-5: History, Overview, and Practice Implications. Presented Minnesota Psychiatric Society Spring Scientific Program. St. Paul, MN. Joel V. Oberstar, MD 2

3 Neurodevelopmental Disorders Intellectual Disability (Intellectual Developmental Disorder) Decreased emphasis on IQ Increased emphasis on adaptive fxn Severity rating based thereupon IDD reflects WHO s classification system Neurodevelopmental Disorders Communication Disorders Language disorder Combines DSM-IV s expressive and mixed expressive-receptive disorders Phonological d/o speech sound d/o Stuttering childhood-onset fluency d/o Social (pragmatic) communication d/o Probs w/verbal/nonverbal communication Not used w/asd;? Prev PDD NOS Neurodevelopmental Disorders Neurodevelopmental Disorders Autism Spectrum Disorder Comprises autism, Asperger s, CDD and PDD NOS 1. deficits in social communication/interaction 2. restricted repetitive behaviors/interests/activities ADHD The big 18 largely unchanged examples added to the criterion items to facilitate application across the life span cross-situational requirement has been strengthened to several symptoms in each setting the onset criterion has been changed from symptoms that caused impairment were present before age 7 years to several inattentive or hyperactive-impulsive symptoms were present prior to age 12 subtypes replaced with presentation specifiers that map to subtypes comorbid diagnosis with ASD now allowed a symptom threshold change has been made for adults, to reflect their substantial evidence of clinically significant ADHD impairment, with the cutoff for ADHD of five symptoms, instead of six required for younger persons, both for inattention and for hyperactivity/impulsivity. Neurodevelopmental Disorders Specific Learning Disorder Combines reading d/o, math d/o, d/o of written expression, and LD NOS Specifiers for deficit types Recognition of variety of terms internationally (e.g., dyslexia, dyscalculia) Neurodevelopmental Disorders Motor Disorders Developmental coordination d/o stereotypic movement disorder Differentiated from body-related OCD behaviors Tourette s disorder persistent (chronic) motor or vocal tic disorder provisional tic disorder other specified tic disorder and unspecified tic disorder Joel V. Oberstar, MD 3

4 Schizophrenia Spectrum and other Psychotic Disorders Schizophrenia Schizoaffective Disorder Delusional Disorder Catatonia Schizophrenia Spectrum and other Psychotic Disorders Schizophrenia Two changes to A criterion Elimination of special attribution to bizarre delusions and Schneiderian first-rank auditory hallucinations (e.g., two or more voices conversing). Two Criterion A symptoms are required for any diagnosis of schizophrenia. Must have one of Delusions Hallucinations disorganized speech. Schizophrenia Spectrum and other Psychotic Disorders Schizophrenia Subtypes (i.e., paranoid, disorganized, catatonic, undifferentiated, and residual types) eliminated. A dimensional approach to rating severity for the core symptoms of schizophrenia is included in Section III. Schizophrenia Spectrum and other Psychotic Disorders Schizoaffective Disorder primary change = a major mood episode must be present for a majority of the disorder s total duration after Criterion A has been met. Schizophrenia Spectrum and other Psychotic Disorders Delusional Disorder Criterion A no longer requires delusions must be nonbizarre. A specifier for bizarre type delusions provides continuity with DSM-IV. Better clarifies the d/o from psychotic variants of OCD/BDD. no longer separates delusional disorder from shared delusional disorder Schizophrenia Spectrum and other Psychotic Disorders Catatonia Same criteria are used to diagnose catatonia regardless of context (i.e., a psychotic, bipolar, depressive, or other medical disorder, or an unidentified medical condition) all contexts require three catatonic symptoms (from a total of 12 characteristic symptoms) May use specifier for Depressive, bipolar, and psychotic disorders separate diagnosis in the context of another medical condition an other specified diagnosis. Joel V. Oberstar, MD 4

5 Bipolar Bipolar Bipolar Disorders Other Specified Bipolar and Related Disorder Anxious Distress Modifier Bipolar Disorders Criterion A for manic and hypomanic episodes now includes an emphasis on changes in activity and energy as well as mood. Bipolar I disorder, mixed episode replaced with specifier, with mixed features, instead Bipolar Bipolar Other Specified Bipolar and Related Disorder Relates to NOS type diagnosis h/o MDD + hypomania not lasting 4 consecutive days h/o MDD + hypomania w/o sufficient symptoms but lasting 4+ days Anxious Distress Modifier In both bipolar and depressive chapters intended to identify patients with anxiety symptoms that are not part of the bipolar diagnostic criteria. Depressive Disorders Major Depressive Disorder Bereavement Exclusion Specifiers Depressive Disorders Disruptive Mood Dysregulation Disorder Bipolar diversion Kids up to 18 yoa with persistent irritability and frequent episodes of extreme behavioral dyscontrol Premenstrual Dysphoric Disorder Persistent depressive disorder Prev dysthymia Chronic MDD Joel V. Oberstar, MD 5

6 Depressive Disorders Depressive Disorders Major Depressive Disorder No major changes The coexistence within a major depressive episode of at least three manic symptoms (insufficient to satisfy criteria for a manic episode) is now acknowledged by the specifier with mixed features. Increased likelihood that pt is on the bipolar spectrum Bereavement Exclusion Prev DSM-IV exclusion criterion for an MDE 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. eliminates implication bereavement typically lasts only 2 months Bereavement is a severe psychosocial stressor bereavement-related major depression is most likely to occur in individuals with past personal and family histories of major depressive episodes depressive symptoms associated with bereavement-related depression respond to the same psychosocial and medication treatments as non bereavement-related depression. DSM-5 footnote aims to aid clinicians in distinguishing between bereavement and MDD Depressive Disorders Specifiers Clinician guidance re: assessing suicidal ideation, plans, etc. New specifier re: presence of mixed symptoms Specifier re: anxious distress Agoraphobia, Specific Phobia, and Social Anxiety Disorder (Social Phobia) Panic Attack Panic Disorder and Agoraphobia Specific Phobia Social Anxiety Disorder (Social Phobia) Separation Anxiety Disorder Selective Mutism OCD relocated PTSD relocated Acute Stress Disorder relocated Agoraphobia, Specific Phobia, and Social Anxiety Disorder (Social Phobia) Removal of requirement that individuals over age 18 years recognize that their anxiety is excessive or unreasonable. anxiety must be out of proportion to the actual danger or threat in the situation, after taking cultural contextual factors into account the 6-month duration (prev <18 yoa) extended to all ages. Joel V. Oberstar, MD 6

7 Panic Attack essential features of panic attacks remain unchanged terms unexpected and expected panic attacks employed panic attack can be listed as a specifier that is applicable to all DSM-5 disorders. Panic Disorder and Agoraphobia unlinked; now two dx w/separate criteria co-occurrence now coded with two diagnoses. Agoraphobia in 5 requires fears from 2+ situations (differentiates from specific phobias) criteria for agoraphobia extended to be consistent with criteria sets for other anxiety disorders (e.g., clinician judgment of the fears as being out of proportion to the actual danger in the situation, with a typical duration of 6 months or more). Specific Phobia Largely unchanged No longer a requirement that individuals over age 18 years must recognize that their fear and anxiety are excessive or unreasonable duration requirement ( typically lasting for 6 months or more ) now applies to all ages Social Anxiety Disorder (Social Phobia) Largely unchanged deletion of the requirement that individuals over age 18 years must recognize that their fear or anxiety is excessive or unreasonable duration criterion of typically lasting for 6 months or more is now required for all ages. the generalized specifier has been deleted and replaced with a performance only specifier Separation Anxiety Disorder Core features unchanged No longer must have onset prior to 18 yoa Language to reflect separation in adults Duration of 6+ months required Selective Mutism Largely unchanged Moved to anxiety disorder section Joel V. Oberstar, MD 7

8 Specifiers Body Dysmorphic Disorder Hoarding Disorder Trichotillomania (Hair-Pulling Disorder) Excoriation (Skin-Picking) Disorder Substance/Medication-Induced OC and Related D/O and OC and Related D/O due to Another Medical Condition Other Specified and Unspecified OC and Related Disorders New: hoarding disorder, excoriation (skinpicking) disorder, substance-/medicationinduced obsessive-compulsive and related disorder, and obsessive-compulsive and related disorder due to another medical condition. trichotillomania moved from DSM-IV classification of impulse-control disorders not elsewhere classified to obsessivecompulsive and related disorders in DSM-5. Specifiers The with poor insight specifier for OCD refined to allow a distinction between individuals with good or fair insight, poor insight, and absent insight/delusional obsessive-compulsive disorder beliefs Analogous insight specifiers have been included for body dysmorphic disorder and hoarding disorder. change emphasizes that the presence of absent insight/delusional beliefs warrants a diagnosis of the relevant obsessive-compulsive or related disorder, rather than a schizophrenia spectrum and other psychotic disorder. The tic-related specifier for obsessive-compulsive disorder reflects a growing literature on the diagnostic validity and clinical utility of identifying individuals with a current or past comorbid tic disorder, because this comorbidity may have important clinical implications. Body Dysmorphic Disorder diagnostic criterion describing repetitive behaviors or mental acts is added a with muscle dysmorphia specifier added to the delusional variant of body dysmorphic disorder (which identifies individuals who are completely convinced that their perceived defects or flaws are truly abnormal appearing) is no longer coded as both delusional disorder, somatic type, and body dysmorphic disorder; in DSM-5 this presentation is designated only as body dysmorphic disorder with the absent insight/delusional beliefs specifier. Hoarding Disorder new diagnosis Trichotillomania (Hair-Pulling Disorder) Parenthetical name added Joel V. Oberstar, MD 8

9 Excoriation (Skin-Picking) Disorder New disorder Substance/Medication-Induced OC and Related D/O and OC and Related D/O due to Another Medical Condition Change reflects recognition that substances, medications, and medical conditions can present with symptoms similar to primary obsessive-compulsive and related disorders. Other Specified and Unspecified OC and Related Disorders can include conditions such as bodyfocused repetitive behavior disorder recurrent behaviors [not hair/skin] Repeated attempts to decrease/stop can include conditions such as obsessional jealousy characterized by nondelusional preoccupation with a partner s perceived infidelity. Trauma and Stress-Related Disorders Acute Stress Disorder Adjustment Disorders PTSD RAD Trauma and Stress-Related Disorders Acute Stress Disorder stressor criterion (Criterion A) requires being explicit as to whether qualifying traumatic events were experienced directly, witnessed, or experienced indirectly. Criterion A2 regarding the subjective reaction to the traumatic event (e.g., the person s response involved intense fear, helplessness, or horror ) has been eliminated. individuals may meet diagnostic criteria in DSM-5 for acute stress disorder if they exhibit any 9 of 14 listed symptoms in: intrusion, negative mood, dissociation, avoidance, and arousal. Trauma and Stress-Related Disorders Adjustment Disorders reconceptualized as a heterogeneous array of stress-response syndromes that occur after exposure to a distressing (traumatic or nontraumatic) event subtypes marked by depressed mood, anxious symptoms, or disturbances in conduct have been retained, unchanged. Joel V. Oberstar, MD 9

10 Trauma and Stress-Related Disorders Trauma and Stress-Related Disorders PTSD Significant changes stressor criterion (Criterion A) is more explicit with regard to how an individual experienced traumatic events. A2 (subjective reaction) has been eliminated. Prev three major symptom clusters in DSM-IV reexperiencing, avoidance/numbing, and arousal there are 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. Latter category retains most of the DSM-IV numbing symptoms and also includes new or reconceptualized symptoms, such as persistent negative emotional states. alterations in arousal and reactivity includes most of the DSM-IV arousal symptoms; also includes irritable or aggressive behavior and reckless or self-destructive behavior. PTSD is now developmentally sensitive diagnostic thresholds have been lowered for children and adolescents separate criteria added for children age 6 years or younger with this disorder. RAD Previously RAD w/subtypes, 5 now has reactive attachment disorder disinhibited social engagement disorder. Both are the result of social neglect or impaired attachments. reactive attachment disorder more closely resembles internalizing disorders disinhibited social engagement disorder more closely resembles ADHD. Dissociative Disorders Dissociative Disorders Dissociative Identity Disorder derealization is included in the name and symptom structure of what previously was called depersonalization disorder and is now called depersonalization/derealization disorder dissociative fugue is now a specifier of dissociative amnesia rather than a separate diagnosis criteria for dissociative identity disorder changed to indicate that symptoms of disruption of identity may be reported as well as observed, and that gaps in the recall of events may occur for everyday and not just traumatic events. experiences of pathological possession in some cultures are included in the description of identity disruption. Dissociative Disorders Dissociative Identity Disorder Criterion A expanded to include certain possession-form phenomena and functional neurological symptoms to account for more diverse presentations of the disorder. Criterion A states that transitions in identity may be observable by others or self-reported. Re: Criterion B, individuals with dissociative identity disorder may have recurrent gaps in recall for everyday events, not just for traumatic experiences. Pica and Rumination Disorder Avoidant/Restrictive Food Intake Disorder Anorexia Nervosa Bulemia Nervosa Binge-Eating Disorder Elimination Disorders Joel V. Oberstar, MD 10

11 Pica and Rumination Disorder Avoidant/Restrictive Food Intake Disorder Anorexia Nervosa Bulemia Nervosa Binge-Eating Disorder Elimination Disorders Pica and Rumination Disorder Revised for clarity and indicate that dx can be made at any age Avoidant/Restrictive Food Intake Disorder Prev DSM-IV feeding disorder of infancy or early childhood renamed and the criteria have been significantly expanded. a large number of individuals, primarily but not exclusively children and adolescents, substantially restrict their food intake and experience significant associated physiological or psychosocial problems but do not meet criteria for any DSM-IV eating disorder. Avoidant/restrictive food intake disorder is a broad category intended to capture this range of presentations. Anorexia Nervosa Core criteria largely unchanged requirement for amenorrhea has been eliminated. wording of the criterion has been changed for clarity, and guidance regarding how to judge whether an individual is at or below a significantly low weight is now provided in the text. Criterion B is expanded to include not only overtly expressed fear of weight gain but also persistent behavior that interferes with weight gain. Bulemia Nervosa Criteria include a reduction in the required minimum average frequency of binge eating and inappropriate compensatory behavior frequency from twice to once weekly. Binge-Eating Disorder minimum average frequency of binge eating required for diagnosis has been changed from at least twice weekly for 6 months to at least once weekly over the last 3 months, which is identical to the DSM-5 frequency criterion for bulimia nervosa. Joel V. Oberstar, MD 11

12 Elimination Disorders Now a new section No significant changes Disruptive, Impulse-Control and Conduct Disorders Oppositional Defiant Disorder Conduct Disorder Intermittent Explosive Disorder Disruptive, Impulse-Control and Conduct Disorders Collates multiple disorders all characterized by problems in emotional and behavioral self-control. antisocial personality disorder has dual listing in this chapter and in the chapter on personality disorders. ADHD frequently comorbid but listed elsewhere Disruptive, Impulse-Control and Conduct Disorders Oppositional Defiant Disorder symptoms are now grouped into three types angry/irritable mood argumentative/defiant behavior Vindictiveness The exclusion criterion for conduct disorder has been removed Note added on guidance re: frequency needed to rise to dx severity rating has been added to the criteria Disruptive, Impulse-Control and Conduct Disorders Conduct Disorder Criteria largely unchanged descriptive features specifier has been added for individuals who meet full criteria for the disorder + limited prosocial emotions. callous and unemotional interpersonal style tend to have a relatively more severe form of the disorder and a different treatment response. Disruptive, Impulse-Control and Conduct Disorders Intermittent Explosive Disorder Main change: physical aggression AND verbal aggression/nondestructive/noninjurious physical aggression qualify More specific criteria defining frequency specifies that the aggressive outbursts are impulsive and/or anger based in nature, and must cause marked distress, cause impairment in occupational or interpersonal functioning, or be associated with negative financial or legal consequences. a minimum age of 6 years (or equivalent developmental level) is required. the relationship of this disorder to other disorders (e.g., ADHD, disruptive mood dysregulation disorder) has been further clarified. Joel V. Oberstar, MD 12

13 Substance-Related and Addictive Disorders Gambling Disorder Criteria/Terminology Substance-Related and Addictive Disorders Gambling Disorder Gambling now included Reflects understanding of brain reward system Substance-Related and Addictive Disorders Criteria/Terminology Eliminates distinction between abuse and dependence Criteria relate to SUD criteria for intoxication, withdrawal, substance/medication-induced disorders, and unspecified substance-induced disorders, where relevant. Two notable changes recurrent legal problems criterion for substance abuse has been deleted from DSM-5 new criterion, craving or a strong desire or urge to use a substance, has been added. the threshold for substance use disorder diagnosis in DSM-5 is set at two or more criteria, in contrast to a threshold of one or more criteria for a diagnosis of DSM-IV substance abuse and three or more for DSM-IV substance dependence. Cannabis withdrawal is new Caffeine withdrawal is new Substance-Related and Addictive Disorders Criteria/Terminology Severity 2 3 criteria = mild disorder 4 5 criteria = a moderate disorder 6 or more = a severe disorder. DSM-IV specifier for a physiological subtype eliminated DSM-IV diagnosis of polysubstance dependence gone Early remission = at least 3 but less than 12 months without substance use disorder criteria (except craving), and sustained remission = at least 12 months without criteria (except craving). new DSM-5 specifiers include in a controlled environment and on maintenance therapy as the situation warrants. Sleep-Wake Disorders Breathing-Related Sleep Disorders Circadian Rhythm Sleep-Wake Disorders Rapid Eye Movement Sleep Behavior Disorder and Restless Legs Syndrome Disorder Medically Unexplained Symptoms Hypochondriasis and Illness Anxiety Disorder Pain Disorder Psychological Factors Affecting Other Medical Conditions and Factitious Disorder Conversion Disorder (Functional Neurological Symptom Disorder) Joel V. Oberstar, MD 13

14 somatoform disorders somatic symptom and related disorders. In IV, significant overlap across the somatoform disorders; lack of clarity about their boundaries. primarily seen in medical settings; nonpsychiatrists found IV problematic to use. 5 classification reduces the number of these disorders and subcategories to avoid problematic overlap. Diagnoses of somatization disorder, hypochondriasis, pain disorder, and undifferentiated somatoform disorder removed. Disorder Interface between psychiatry and medicine is complex Somatic symptoms and psychopathology lie on a spectrum the diagnosis of somatization disorder in IV 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. undifferentiated somatoform disorder is subsumed in SSD and no specific number of somatic symptoms is required. Medically Unexplained Symptoms IV overemphasized importance of an absence of a medical explanation for the somatic symptoms. The reliability of medically unexplained symptoms is limited; grounding a diagnosis on the absence of an explanation is problematic and reinforces mind-body dualism. 5 defines disorders on the basis of positive symptoms (i.e., distressing somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to these symptoms). Medically unexplained symptoms do remain a key feature in conversion disorder and pseudocyesis because it is possible to demonstrate definitively in such disorders that the symptoms are not consistent with medical pathophysiology. Hypochondriasis and Illness Anxiety Disorder Hypochondriasis eliminated as a disorder Most individuals w/prev hypochondriasis + somatic sx will now have somatic symptom disorder. individuals with high health anxiety without somatic symptoms would receive a diagnosis of illness anxiety disorder Pain Disorder Most individuals with chronic pain attribute their pain to a combination of factors, including somatic, psychological, and environmental influences. In 5, some individuals with chronic pain would be appropriately diagnosed as having somatic symptom disorder, with predominant pain. For others, psychological factors affecting other medical conditions or an adjustment disorder would be more appropriate. Psychological Factors Affecting Other Medical Conditions and Factitious Disorder New mental illness 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 diagnosis. Joel V. Oberstar, MD 14

15 Conversion Disorder (Functional Neurological Symptom Disorder) Criteria modified to emphasize the essential importance of the neurological examination, and in recognition that relevant psychological factors may not be demonstrable at the time of diagnosis. Sleep-Wake Disorders greater specification of coexisting conditions is provided acknowledges the bidirectional and interactive effects between sleep disorders and coexisting medical and mental disorders primary insomnia has been renamed insomnia disorder to avoid the differentiation of primary and secondary insomnia. DSM-5 also distinguishes narcolepsy, which is now known to be associated with hypocretin deficiency, from other forms of hypersomnolence. pediatric and developmental criteria and text are integrated where existing science and considerations of clinical utility support such integration Sleep-Wake Disorders Sleep-Wake Disorders Breathing-Related Sleep Disorders obstructive sleep apnea hypopnea central sleep apnea sleep-related hypoventilation Circadian Rhythm Sleep-Wake Disorders subtypes expanded advanced sleep phase syndrome irregular sleep-wake type non-24-hour sleep-wake type jet lag type has been removed. Sleep-Wake Disorders Conclusions Rapid Eye Movement Sleep Behavior Disorder and Restless Legs Syndrome recognized as independent disorders DSMs of Yesteryear DSM s evolution has been striking since DSM-I DSM-5 Conceptually Increased emphasis on developmental aspects of psychopathology Changes in DSM-5 Seek to increase validity and reliability of diagnoses Joel V. Oberstar, MD 15