What’s in DSM-5

• DSM 5 diagnoses and numbers xiii-xl

• summary of changes from IV -preface
• How the DSM 5 was developed-Intro 5-19
• Further description of major changes-intro
5-19
• How to use the manual 19-24
• Diagnostic codes and diagnostic criteria for
every diagnosis pp31-715
• Dimensional assessment measures 733-748
• Dimensional assessment of personality
disorders 761-783
• Focus on cultural assessment 749-760
• Cultural formulation interviews 749-760
• Conditions for further study 783-808
• Highlight of all changes from DSM-IV to
DSM 5 PP 809 – 816
• Glossary of mental terms 817-832
• Glossary of cultural concepts of distress
833-838
• DSM crosswalks for ICD-9 and ICD 10 863-
897
WHY CHANGE?
• DSM-IV’s organizational structure failed to
reflect shared features or symptoms of related
disorders and diagnostic groups (like psychotic
disorders with bipolar disorders, or
internalizing (depressive, anxiety, somatic) and
externalizing (impulse control, conduct,
substance use) disorders.
• DSM-IV Thin on Culture
• Did not represent or
integrate the latest
findings from
neuroscience, genetics
and cognitive research
• Multi axial structure
was out of line with
the rest of medicine
• Global assessment of
functioning was an
unreliable measure

• Decision trees did not

increase inter-rater
reliability
 Other problems
• Separates diagnoses from treatment
• Diagnosis has become an end in itself! (billability & pressure
for scientific determinism)
• Minimizes TIME as a major factor in making diagnoses
• Minimizes emergent symptoms
• Minimizes lack of symptom clarity as an issue
• Ignores internal unobservables
• Funnels tx focus to symptom negation rather than well-being
• Forces clinician to make immediate diagnoses
• Forces clinician to more severe DX
• There have been no no established "zones of
rarity" between diagnosis (much symptom
overlap)

• Law-like biological markers have not yet been

found

• Categorical measurement (depressed vs NOT

depressed) doesn’t capture clinical variance
DSM III & IV limits
Focus on only what is observable; limits diagnostic
possibilities

Limited number of observable signs & symptoms

(12 to 19 symptoms )

Because law-like biomarkers have not been found,

Elements that cannot be seen directly
are excluded. This is exactly the opposite of
medicine which strives to see below the surface.

Limited number of observable signs/symptoms

But 400 diagnoses in DSM = diagnostic confusion

Simple counting of the number of symptoms in

Order to make a diagnosis DOES NOT WORK
DSM III & IV – problems with measuring
Limited number of observable signs and
Symptoms, Elements that cannot be seen directly
are excluded. This is exactly the opposite of
medicine which strives to see below the surface.

Limited number of observable signs/symptoms

But 400 diagnoses in DSM

# 1 Problem = under- determination of

diagnosis
Consequences = - boundary problems (paris)
- false positives
- rise of comorbidity
- problems of differential dx
- one size fits all diagnoses
- only agreement on most severe
 The relationship between Categorical Dx,
comorbidity and increased reliability
• 1. no major depression; 2. major depression
• 1. No generalized anxiety 2. generalized anxiety
Depression
1 2 3 4 5 6 7 8
None minimal mild minor moderate major severe maximal

General anxiety
1 2 3 4 5 6 7 8
None minimal mild minor moderate major severe maximal
Categorical measurement increases potential for inter-rater Dimensional measure
reliability. 50% chance of inter-rater reliability inter-rater reliability
lower = 12%
Fewer choices = easier= less information = more possibility of
making mistake = inflated comorbidity
More choices = harder=
Categorical measures = No clinical variance & no diagnostic threshold more info
Decreasing variance increases potential for inter rater reliability and Subtle distinctions ; less
increases potential for specious comorbidity Potential for specious
• DSM III & IV turned assessment into yes/no
decision trees
• Inflated comorbidity
• Inflated inter-rater reliability (but did not
increase it)
• Never established true biological markers
• Reduced the rigorousness of good assessment
in the name of clinical utility
 DSM 5
1. Emphasizes dimensional measurement
2. Provides World Health Organization measure
of overall well-being
3. Does away with Axes
4. Focuses more on culture
5. Attempts to “Re-organize” diagnostic
categories according to what we now (think
we)know
6. Attempts to “re-group” individual diagnoses
according to what we now (think we) know
7. Includes crosswalks with ICD-9 and ICD 10
http://www.dsm5.org/Pages/Default.aspx
 1. Dimensional measures
http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures#Level1

• Allows clinician opportunity to “fine tune” diagnosis

• Captures diagnostic complexity
• Should reduce inflated comorbidity. By allowing
inclusion of crosscutting symptoms (such as anxiety)
within other diagnoses
• Focuses assessment on crosscutting symptoms
• Creates "severity specifier" for many diagnoses
• Dimensions make diagnosis congruent with up-to-
date neurocognitive research indicating symptoms
are on a continuum
• DSM 5 adds dimensional
measures WITHOUT
abandoning categorical
measures

• Criteria are basically the same

as they were in the DSM-IV
 Crosscutting symptoms
(symptoms that can occur across many DXs)
• Captures symptom comorbidity without diagnostic comorbidity

• Cross-cutting symptom measures may aid in a comprehensive

mental status assessment by drawing attention to symptoms
that are important across diagnoses. They are intended to help
identify additional areas of inquiry that may guide treatment
and prognosis. The cross-cutting measures have two levels:
Level 1 questions are a brief survey of 13 domains for adult
patients and 12 domains for child and adolescent patients, and
Level 2 questions provide a more in-depth assessment of
certain domains.
http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures#Level1
Table 1: Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure:
domains, thresholds for further inquiry, and associated Level 2 measures for
adults ages 18 and over

Domain Domain Name Threshold to guide DSM-5 Level 2 Cross-Cutting Symptom Measure available online
further inquiry

I. Depression Mild or greater LEVEL 2—Depression—Adult (PROMIS Emotional Distress—Depression—Short

Form)1

II. Anger Mild or greater LEVEL 2—Anger—Adult (PROMIS Emotional Distress—Anger—Short Form)1

III. Mania Mild or greater LEVEL 2—Mania—Adult (Altman Self-Rating Mania Scale)
IV. Anxiety Mild or greater LEVEL 2—Anxiety—Adult (PROMIS Emotional Distress—Anxiety—Short Form)1

V. Somatic Symptoms Mild or greater LEVEL 2—Somatic Symptom—Adult (Patient Health Questionnaire 15 Somatic
Symptom Severity [PHQ-15])

VI. Suicidal Ideation Slight or greater None

VII. Psychosis Slight or greater None
VIII. Sleep Problems Mild or greater LEVEL 2—Sleep Disturbance - Adult (PROMIS—Sleep Disturbance—Short Form)1

IX. Memory Mild or greater None

X. Repetitive Thoughts Mild or greater LEVEL 2—Repetitive Thoughts and Behaviors—Adult (adapted from the Florida
and Behaviors Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])

XI. Dissociation Mild or greater None

XII. Personality Mild or greater None
Functioning
XIII. Substance Use Slight or greater LEVEL 2—Substance Abuse—Adult (adapted from the NIDA-modified ASSIST)
DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure—Adult
   
None Slight Mild Moderate Severe Highest
During the past TWO (2) WEEKS, how much (or how often) have you been bothered by the
following problems? Not at Rare, less Several More than Nearly Domain
all than a day days half the days every day Score
or two
(clinician)

I. 1. Little interest or pleasure in doing things? 0 1 2 3 4  

2. Feeling down, depressed, or hopeless? 0 1 2 3 4

II. 3. Feeling more irritated, grouchy, or angry than usual? 0 1 2 3 4  

III. 4. Sleeping less than usual, but still have a lot of energy? 0 1 2 3 4  

0 1 2 3 4
5. Starting lots more projects than usual or doing more risky things than usual?

IV. 6. Feeling nervous, anxious, frightened, worried, or on edge? 0 1 2 3 4  

7. Feeling panic or being frightened? 0 1 2 3 4

8. Avoiding situations that make you anxious? 0 1 2 3 4

V. 9. Unexplained aches and pains (e.g., head, back, joints, abdomen, legs)? 0 1 2 3 4  

10. Feeling that your illnesses are not being taken seriously enough? 0 1 2 3 4

VI. 11. Thoughts of actually hurting yourself? 0 1 2 3 4  

VII. 12. Hearing things other people couldn’t hear, such as voices even when no 0 1 2 3 4  

one was around?

13. Feeling that someone could hear your thoughts, or that you could hear what another 0 1 2 3 4
person was thinking?

VIII. 14. Problems with sleep that affected your sleep quality over all? 0 1 2 3 4  

IX. 15. Problems with memory (e.g., learning new information) or with location 0 1 2 3 4  
(e.g., finding your way home)?

X. 16. Unpleasant thoughts, urges, or images that repeatedly enter your mind? 0 1 2 3 4  

17. Feeling driven to perform certain behaviors or mental acts over and over again? 0 1 2 3 4

XI. 18. Feeling detached or distant from yourself, your body, your physical surroundings, or 0 1 2 3 4  
your memories?

XII. 19. Not knowing who you really are or what you want out of life? 0 1 2 3 4  

20. Not feeling close to other people or enjoying your relationships with them? 0 1 2 3 4

XIII. 21. Drinking at least 4 drinks of any kind of alcohol in a single day? 0 1 2 3 4  

22. Smoking any cigarettes, a cigar, or pipe, or using snuff or chewing tobacco? 0 1 2 3 4

23. Using any of the following medicines ON YOUR OWN, that is, without a doctor’s 0 1 2 3 4
prescription, in greater amounts or longer than prescribed [e.g., painkillers (like
Vicodin), stimulants (like Ritalin or Adderall), sedatives or tranquilizers (like sleeping
pills or Valium), or drugs like marijuana, cocaine or crack, club drugs (like ecstasy),
hallucinogens (like LSD), heroin,
inhalants or solvents (like glue), or methamphetamine (like speed)]?
THE CROSS-CUTTING SYMPTOM MEASURES CAN DO THREE THINGS

1.POINT YOU IN THE RIGHT DIRECTION DIAGNOSTICALLY (LEVEL I)

2.GIVE YOU A BASIC SENSE OF THE CLINICAL PROFILE OF EACH
CLINET
3.CAPTURE SYMPTOMS THAT ARE LIKELY TO OCCUR ACROSS
DIAGNOSIS, BUT NOT NECESSARILY QUALIFY FOR ITS OWN DX
DEPRESSION
ANXIETY
SOMATIC SYMPTOMS
SLEEP ISSUES ETC.
 level II measures(Dimensional)
• Level II crosscutting measures
– Focus on one specific domain
– Provides a more varied clinical profile within that
domain
– Allows for follow-up exploration with more than one
domain in order to specify diagnostic boundaries.
(For example, in my dealing with major depression
with a co-occurring anxiety disorder or major
depression, with anxious features
– Provides clinical verification before diagnosis
 Level 2 measures of symptoms
• Level 2 questions provide a more in-depth
assessment of certain domains:
http://www.psychiatry.org/practice/dsm/dsm5/
online-assessment-measures
# Level2

• Level 2 is given as a specific follow up, once the

clinician is ‘oriented’ in a symptomatic direction
they are focused WITHIN a specific symptom
domain
 List of all the level 2 (disorder specific) cross-cutting symptom measures
Level 2 Cross-Cutting Symptom Measures
For Adults
LEVEL 2—Depression—Adult (PROMIS Emotional Distress—Depression—Short Form)
LEVEL 2—Anger—Adult (PROMIS Emotional Distress—Anger—Short Form)
LEVEL 2—Mania—Adult (Altman Self-Rating Mania Scale [ASRM])
LEVEL 2—Anxiety—Adult (PROMIS Emotional Distress—Anxiety—Short Form)
LEVEL 2—Somatic Symptom—Adult (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])
LEVEL 2—Sleep Disturbance—Adult (PROMIS—Sleep Disturbance—Short Form)
LEVEL 2—Repetitive Thoughts and Behaviors—Adult (Adapted from the Florida Obsessive-Compulsive Inventory [FOCI]
Severity Scale [Part B])
LEVEL 2—Substance Use—Adult (Adapted from the NIDA-Modified ASSIST)

For Parents of Children Ages 6–17

LEVEL 2—Somatic Symptom—Parent/Guardian of Child Age 6–17 (Patient Health Questionnaire 15 Somatic Symptom
Severity Scale [PHQ-15])
LEVEL 2—Sleep Disturbance—Parent/Guardian of Child Age 6–17 (PROMIS—Sleep Disturbance—Short Form)
LEVEL 2—Inattention—Parent/Guardian of Child Age 6–17 (Swanson, Nolan, and Pelham, version IV [SNAP-IV])
LEVEL 2—Depression—Parent/Guardian of Child Age 6–17 (PROMIS Emotional Distress—Depression—Parent Item Bank)
LEVEL 2—Anger—Parent/Guardian of Child Age 6–17 (PROMIS Emotional Distress—Calibrated Anger Measure—Parent)
LEVEL 2—Irritability—Parent/Guardian of Child Age 6–17 (Affective Reactivity Index [ARI])
LEVEL 2—Mania—Parent/Guardian of Child Age 6–17 (Adapted from the Altman Self-Rating Mania Scale [ASRM])
LEVEL 2—Anxiety—Parent/Guardian of Child Age 6–17 (Adapted from PROMIS Emotional Distress—Anxiety—Parent Item
Bank)
LEVEL 2—Substance Use—Parent/Guardian of Child Age 6–17 (Adapted from the NIDA-Modified ASSIST)

For Children Ages 11–17

LEVEL 2—Somatic Symptom—Child Age 11–17 (Patient Health Questionnaire 15 Somatic Symptom Severity Scale [PHQ-15])
LEVEL 2—Sleep Disturbance—Child Age 11–17 (PROMIS—Sleep Disturbance—Short Form)
LEVEL 2—Depression—Child Age 11–17 (PROMIS Emotional Distress—Depression—Pediatric Item Bank)
LEVEL 2—Anger—Child Age 11–17 (PROMIS Emotional Distress—Calibrated Anger Measure—Pediatric)
LEVEL 2—Irritability—Child Age 11–17 (Affective Reactivity Index [ARI])
LEVEL 2—Mania—Child Age 11–17 (Altman Self-Rating Mania Scale [ASRM])
LEVEL 2—Anxiety—Child Age 11–17 (PROMIS Emotional Distress—Anxiety—Pediatric Item Bank)
LEVEL 2—Repetitive Thoughts and Behaviors—Child Age 11–17 (Adapted from the Children’s Florida Obsessive Compulsive
Inventory [C-FOCI] Severity Scale)
LEVEL 2—Substance Use—Child Age 11–17 (Adapted from the NIDA-Modified ASSIST)
Table 1: Adult DSM-5 Self-Rated Level 1 Cross-Cutting Symptom Measure:
domains, thresholds for further inquiry, and associated Level 2 measures for
adults ages 18 and over

Hypothetically scores on our client using level I crosscutting symptoms indicated

the following areas circled
Domain Domain Name Threshold to guide DSM-5 Level 2 Cross-Cutting Symptom Measure available online
further inquiry

I. Depression b
Mild or greater LEVEL 2—Depression—Adult (PROMIS Emotional Distress—Depression—Short
Form)1

II. Anger Mild or greater LEVEL 2—Anger—Adult (PROMIS Emotional Distress—Anger—Short Form)1

III. Mania Mild or greater LEVEL 2—Mania—Adult (Altman Self-Rating Mania Scale)
IV. Anxiety Mild or greater LEVEL 2—Anxiety—Adult (PROMIS Emotional Distress—Anxiety—Short Form)1
b
V. Somatic Symptoms Mild or greater LEVEL 2—Somatic Symptom—Adult (Patient Health Questionnaire 15 Somatic
b Symptom Severity [PHQ-15])

VI. Suicidal Ideation Slight or greater None

VII. Psychosis Slight or greater None
VIII. Sleep Problems Mild or greater LEVEL 2—Sleep Disturbance - Adult (PROMIS—Sleep Disturbance—Short Form)1
b
IX. Memory Mild or greater None
X. Repetitive Thoughts Mild or greater LEVEL 2—Repetitive Thoughts and Behaviors—Adult (adapted from the Florida
and Behaviors Obsessive-Compulsive Inventory [FOCI] Severity Scale [Part B])

XI. Dissociation Mild or greater None

XII. Personality Mild or greater None
Functioning
XIII. Substance Use Slight or greater LEVEL 2—Substance Abuse—Adult (adapted from the NIDA-modified ASSIST)
b
LEVEL 2—Depression—Adult* *PROMIS Emotional Distress—Depression—Short Form
 Name:
Age:
 Sex: Male Female Date:_
 If the measure is being completed by an informant, what is your relationship with the individual receiving care?
 In a typical week, approximately how much time do you spend with the individual receiving care? hours/week
 
Instructions: On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that during the past 2 weeks you (the
individual receiving care) have been bothered by “no interest or pleasure in doing things” and/or “feeling down, depressed, or hopeless” at a
mild or greater level of severity. The questions below ask about these feelings in more detail and especially how often you (the individual
receiving care) have been bothered by a list of symptoms during the past 7 days. Please respond to each item by marking (P or x) one box per
row.
    Clinician
Use
 
In the past SEVEN (7) DAYS....
Item
  Never Rarely Sometimes Often Always Score
1. I felt worthless. q 1 q2 q3 q4 q5  
 
2. I felt that I had nothing to look forward to. q 1 q2 q3 q4 q5  
 
3. I felt helpless. q 1 q2 q3 q4 q5  
 
4. I felt sad. q 1 q2 q3 q4 q5  
 
5. I felt like a failure. q 1 q2 q3 q4 q5  
 
6. I felt depressed. q 1 q2 q3 q4 q5  
 
7. I felt unhappy. q 1 q2 q3 q4 q5  
 
8. I felt hopeless. q 1 q2 q3 q4 q5  
Total/Partial Raw Score:  
Prorated Total Raw Score:  
T-Score:  
LEVEL 2—Substance Use—Adult* *Adapted from the NIDA-Modified ASSIST
 Name:
 Age:
 Sex: q Male q Female Date:
 
If the measure is being completed by an informant, what is your relationship with the individual receiving care?
 In a typical week, approximately how much time do you spend with the individual receiving care? hours/week
 Instructions: On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that during the past 2 weeks you
(the individual receiving care) have been bothered by “using medicines on your own without a doctor’s prescription, or in greater
amounts or longer than prescribed, and/or using drugs like marijuana, cocaine or crack, and/or other drugs” at a slight or greater level of
severity. The questions below ask how often you (the individual receiving care) have used these medicines and/or substances during the
past 2 weeks. Please respond to each item by marking (P or x) one box per row.
  During the past TWO (2) WEEKS, about how often did you use any of the following  
Clinician
  medicines ON YOUR OWN, that is, without a doctor’s prescription, in greater amounts Use
or longer than prescribed?
    One or Several More than Nearly  
  Not at all two days days half the days every day Item Score
   
a. Painkillers (like Vicodin) q 0 q1 q2 q3 q4  
b. Stimulants (like Ritalin, Adderall) q 0 q1 q2 q3 q4  
c. Sedatives or tranquilizers (like sleeping q 0 q1 q2 q3 q4  
pills or Valium)
Or drugs like:
d. Marijuana q 0 q1 q2 q3 q4  
e. Cocaine or crack q 0 q1 q2 q3 q4  
f. Club drugs (like ecstasy) q 0 q1 q2 q3 q4  
g. Hallucinogens (like LSD) q 0 q1 q2 q3 q4  
h. Heroin q 0 q1 q2 q3 q4  
i. Inhalants or solvents (like glue) q 0 q1 q2 q3 q4  
j. Methamphetamine (like speed) q 0 q1 q2 q3 q4  
Total Score:  

Useless for alcohol. Perhaps ADS

 Level 2 cross-cutting scale for Somatic symptoms - Adult
LEVEL 2—Somatic Symptom—Adult Patient*
*Adapted from the Patient Health Questionnaire Physical Symptoms (PHQ-15)
 
 Name: Age: Sex: q Male q Female Date:
 
If the measure is being completed by an informant, what is your relationship with the individual receiving care?
 
In a typical week, approximately how much time do you spend with the individual receiving care? hours/week
 
Instructions: On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that during the past 2 weeks you (the individual receiving care) have been
bothered by “unexplained aches and pains”, and/or “feeling that your illnesses are not being taken seriously enough” at a mild or greater level of severity. The questions below ask
about these feelings in more detail and especially how often you (the individual receiving care) have been bothered by a list of symptoms during the past 7 days. Please respond to
each item by marking (P or x) one box per row.
  Clinician
Use
During the past 7 days, how much have you been bothered by any of the following problems? Item
Score
  Not bothered Bothered Bothered  
at all a little a lot
  1 2  
0
   
1. Stomach pain  
2. Back pain  
3. Pain in your arms, legs, or joints (knees, hips, etc.)  
4. Menstrual cramps or other problems with  
your periods WOMEN ONLY
5. Headaches  
6. Chest pain  
7. Dizziness  
8. Fainting spells  
9. Feeling your heart pound or race  
10. Shortness of breath  
11. Pain or problems during sexual intercourse  
12. Constipation, loose bowels, or diarrhea  
13. Nausea, gas, or indigestion  
14. Feeling tired or having low energy  
15. Trouble sleeping  
Total/Partial Raw Score:  
Prorated Total Raw Score: (if 1-3 items left unanswered)  
LEVEL 2—Anxiety—Adult* *PROMIS Emotional Distress—Anxiety—Short Form
 Name:
 Age:
 Sex: q Male q Female Date:
 If the measure is being completed by an informant, what is your relationship with the individual?
 In a typical week, approximately how much time do you spend with the individual? hours/week
 
Instructions to patient: On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that during the past 2
weeks you (individual receiving care) have been bothered by “feeling nervous, anxious, frightened, worried, or on edge”, “feeling panic
or being frightened”, and/or “avoiding situations that make you anxious” at a mild or greater level of severity. The questions below ask
about these feelings in more detail and especially how often you (individual receiving care) have been bothered by a list of symptoms
during the past 7 days. Please respond to each item by marking (P or x) one box per row.
    Clinician
  In the past SEVEN (7) DAYS....  
Use
Item
  Never Rarely Sometimes Often Always Score

1. I felt fearful. q 1 q2 q3 q4 q5  
 
2. I felt anxious. q 1 q2 q3 q4 q5  
 
3. I felt worried. q 1 q2 q3 q4 q5  
 
4. I found it hard to focus on anything q 1 q2 q3 q4 q5  
other than my anxiety.

 
5. I felt nervous. q 1 q2 q3 q4 q5  
 
6. I felt uneasy. q 1 q2 q3 q4 q5  
 
7. I felt tense. q 1 q2 q3 q4 q5  
Total/Partial Raw Score: 
Prorated Total Raw Score:  
T-Score:  
 Level 2 cross-cutting scale for anxiety in children – parent filled

Instructions to parent/guardian:
On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you
indicated that during the past 2 weeks your child receiving care has been bothered by “feeling nervous, anxious, or
scared”, “not being able to stop worrying”, and/or “couldn’t do things he/she wanted to or should have done because
they made him/her feel nervous” at a mild or greater level of severity. The questions below ask about these feelings in
more detail and especially how often your child receiving care has been bothered by a list of symptoms during the past
7 days. Please respond to each item by marking ( or x) one box per row.

In the past SEVEN (7) DAYS, my           Clinician

child said that he/she … use
 
  Never almost never Sometimes Often Almost always Item
1 2 3 4 5 score
1. Felt like something awful might  
happen
2. Felt nervous  
3. Felt scared  
4. Felt worried  
5. Worried about what could  
happen to him/her.
6. Worried when he/she went to  
bed at night
7. Got scared really easy.  
8. Was afraid of going to school.  
9 Worried when he/she was at  
home
10. Worried when he/she was  
away from home
          Total/partial raw score  
          Prorated total raw score  
          T-score  
LEVEL 2—Sleep Disturbance—Adult* *PROMIS—Sleep Disturbance—Short Form
Name:
 Age:
 Sex: q Male q Female Date:
 If the measure is being completed by an informant, what is your relationship with the individual receiving care?
 In a typical week, approximately how much time do you spend with the individual receiving care? hours/week
 
Instructions to patient: On the DSM-5 Level 1 cross-cutting questionnaire that you just completed, you indicated that during the past
2 weeks you (the individual receiving care) have been bothered by “problems with sleep that affected your sleep quality over all” at a mild or
greater level of severity. The questions below ask about these feelings in more detail and especially how often you (the individual receiving
care) have been bothered by a list of symptoms during the past 7 days. Please respond to each item by marking (P or x) one box per row.
 
  Clinician
Use
In the past SEVEN (7) DAYS....  
  Not at all A little bit Somewhat Quite a bit Very much  
1. My sleep was restless. q 1 q2 q3 q4 q5  
 
2. I was satisfied with my sleep. q 5 q4 q3 q2 q1  
 
3. My sleep was refreshing. q 5 q4 q3 q2 q1  
 
4. I had difficulty falling asleep. q 1 q2 q3 q4 q5  
   
In the past SEVEN (7) DAYS....
  Never Rarely Sometimes Often Always  
5. I had trouble staying asleep. q 1 q2 q3 q4 q5  
 
6. I had trouble sleeping. q 1 q2 q3 q4 q5  
 
7. I got enough sleep. q 5 q4 q3 q2 q1  
   
In the past SEVEN (7) DAYS....
  Very Poor Poor Fair Good Very good  
8. My sleep quality was... q 5 q4 q3 q2 q1  
Total/Partial Raw Score:  
Prorated Total Raw Score:  
T-Score:  
 DIMENSIONAL SEVERITY MEASURES

• In addition to a diagnosis, DSM MEASURES

SEVERITY OF MANY DIAGNOSIS

• SEVERITY HAS NEVER BEEN CONSISTENTLY

MEASURED IN DSM UNTIL NOW
– ONE EITHER WAS PSYCHOTIC OR ONE WAS NOT
– THERE WERE NO GRADATIONS
Severity - The DSM uses 2 methods of assessing
severity, depending on the diagnosis..
Method 1 involves using a specific dimensional
measure or scale Called “disorder specific severity
measures”. These can be find on the DSM 5 website
under online assessment measures (DIMENSIONAL
SCALE )
Method 2 involves counting the number of symptoms
and rating severity based on number of symptoms.
For example, ‘mild alcohol use Disorder = 2 – 3
symptoms: moderate alcohol use disorder = 4 – 5
symptoms; severe alcohol use Disorder= presence of 6
or more symptoms (Total number of diagnostic
crtieria)
Disorder-Specific Severity Measures For Adults
Severity Measure for Depression—Adult (Patient Health Questionnaire [PHQ-9])
Severity Measure for Separation Anxiety Disorder—AdultSeverity Measure for Specific Phobia—Adult
Severity Measure for Social Anxiety Disorder (Social Phobia)—AdultSeverity Measure for Panic Disorder—Adult
Severity Measure for Agoraphobia—AdultSeverity Measure for Generalized Anxiety Disorder—Adult
Severity of Posttraumatic Stress Symptoms—Adult (National Stressful Events Survey PTSD Short Scale [NSESS])
Severity of Acute Stress Symptoms—Adult (National Stressful Events Survey Acute Stress Disorder Short Scale [NSESS])
Severity of Dissociative Symptoms—Adult (Brief Dissociative Experiences Scale [DES-B])
For Children Ages 11–17
Severity Measure for Depression—Child Age 11–17 (PHQ-9 modified for Adolescents [PHQ-A]—Adapted)
Severity Measure for Separation Anxiety Disorder—Child Age 11–17
Severity Measure for Specific Phobia—Child Age 11–17
Severity Measure for Social Anxiety Disorder (Social Phobia)—Child Age 11–17
Severity Measure for Panic Disorder—Child Age 11–17Severity Measure for Agoraphobia—Child Age 11–17
Severity Measure for Generalized Anxiety Disorder—Child Age 11–17
Severity of Posttraumatic Stress Symptoms—Child Age 11–17 (National Stressful Events Survey PTSD Short Scale [NSESS])
Severity of Acute Stress Symptoms—Child Age 11–17 (National Stressful Events Survey Acute Stress Disorder Short Scale
[NSESS])
Severity of Dissociative Symptoms—Child Age 11–17 (Brief Dissociative Experiences Scale [DES-B])
Clinician-Rated
Clinician-Rated Severity of Autism Spectrum and Social Communication Disorders
Clinician-Rated Dimensions of Psychosis Symptom Severity (also available in print book)
Clinician-Rated Severity of Somatic Symptom DisorderClinician-Rated Severity of Oppositional Defiant Disorder
Clinician-Rated Severity of Conduct DisorderClinician-Rated Severity of Nonsuicidal Self-Injury
This document is
found on page
743 of the DSM.
It allows the
clinician to rate
all of the salient
dimensions
that might be
present in a
disorder on the
schizophrenia
spectrum - IN
TERMS OF
SEVERITY -
using Likert scale
to rate the
dimensions
 Psycho-social HX
DSM 5 criteria for major depression
 MSE
A. Five or more of the following symptoms of been
present during the same two-week period and 1. Lead with level I
represent a change from previous functioning; at
least one of the symptoms is either depressed mood crosscutting symptom
or loss of interest or pleasure
1. Depressed mood most of the day, nearly every day as indicated
measures to assess all
by subjective reporter observation. Yes or no
2. Marked diminished interest or pleasure in all our almost all
activities. Most of the day, nearly every day. Yes or no
symptom domains
3. Significant weight loss when not dieting or weight gain or
decrease in appetite, nearly every day. Yes or no
4. Insomnia or hypersomnia nearly every day. Yes or no
5. Psychomotor agitation or retardation nearly every day. Yes or no
6. Fatigue or loss of energy nearly every day. Yes or no
2. Follow-up with level II
7. Feelings of worthlessness or excessive or inappropriate guilt. Yes
or no
8. Diminished ability to think or concentrate or indecisiveness
crosscutting measures in
nearly every day. Yes or no
9. Recurrent thoughts of death or recurrent suicidal ideation or order to capture clinical
suicide attempt Yes or no

B. The symptoms cause clinically significant distress

nuances and potential
or impairment Yes or no comorbid
C. The episode is not attributable to the physiological
effects of a substance or another medical condition
Yes or no
D. The occurrence of the major depressive disorder is 3. Move to categories and
not better explained by schizoaffective schizophrenia
schizophreniform or anything else on the check off criteria
schizophrenia spectrum Yes or no
E. There has never been a manic episode or
hypomanic episode Yes or no 4. Assess severity
Adapted from the Patient Health Questionnaire–9 (PHQ-9) depression
Name:
Age:
Sex: Male q Female q Date:
 Instructions: Over the last 7 days, how often have you been bothered by any of the following problems?
    Clinician
Use
  Item
score

        More Nearly  
Not at all Several than half every
days the days day

1. Little interest or pleasure in doing things 0 1 2 3  

2. Feeling down, depressed, or hopeless 0 1 2 3  
3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3  
4. Feeling tired or having little energy 0 1 2 3  
5. Poor appetite or overeating 0 1 2 3  
         
6.
Feeling bad about yourself—or that you are a failure or
0 1 2 3  
have let yourself or your family down
  Trouble concentrating on things, such as reading the newspaper        
 
7. or watching television 0 1 2 3

  Moving or speaking so slowly that other people could have          

8. noticed? Or the opposite—being so fidgety or restless that you have 0 1 2 3
been moving around a lot more than usual
  Thoughts that you would be better off dead or of hurting yourself in        
 
9. some way 0 1 2 3

Total/Partial Raw Score:  

Prorated Total Raw Score: (if 1-2 items left unanswered)  
Levels of depressive symptoms severity PHQ-9 Score
None 0-4
Mild depression 5-9
Moderate depression 10-14
Moderately severe depression
Severe depression 15-19
20-27
Method #2 for severity
 Alcohol use disorder
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 taken in larger amount (need more for increased effect)

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

Severity
Mild = presence of 2-3 symptoms
moderate = presence of four – five symptoms
severe = presence of six or more symptoms

Course specifiers
early remission = after full criteria were l previously met none of the criteria met
for at least three months but less than 12 (with the exception of craving)
In sustained remission = after full criteria were previously met none exists except craving
during the period of 12 months or more
 2. NO MORE GAF
WHODAS
• DSM IV-TR- HAD SOMETHING CALLED THE
GLOBAL ASSESSMENT OF FUNCTIONING
– THE ONLY DIMENSIONAL MEASURE IN THE DSM IV TR
– USED BY CLINICIAN; COMPLETELY UNRELIABLE AND
NOT VALID
• REPLACED WITH A SCALE THAT HAS RELIABILITY
AND VALIDITY DATA
– THE WORLD HEALTH ORGANIZATION DISABLITY
ASSESSMENT SCALE (WHODAS PP 745-749)
 DSM 5 recommends the following

1. Assess symptom severity/severity of

diagnosis-use severity scales
2. Use dimensional scales or standardized scales
whenever possible
3. Assess suicidality, capacity for self harm or
harming others- use separate assessment
protocol
4. Use World Health Organization disability
assessment scale to assess social and self-care
functioning
 WHODAS 2.0
• Based on the International Classification of
Functioning, Disability, and Health (ICF)
• Applicable to any health condition
• Reliability and clinical utility established in
DSM 5 Field trials
see pages 745 to 748 in DSM 5

WHODAS Assesses the following six areas

1. Understanding and communicating
2. Getting around
3. Self-care
4. Getting along with people
5. Life activities
6. Participation in society
STANDARDIZED WAY TO MEASURE HEALTH AND DISABILITY ACROSS CULTURES

DOES NOT TARGET SPECIFIC DISEASE, SO CAN BE USED TO ASSESS DISABILITY ACROSS DISEASE
WHODAS 36 ITEM ON NEXT 3 SLIDES (PP745-749 IN DSM)

Domain 1
have in: Cognition None
In the past 30 days, how much difficulty did you Mild Moderate Severe Extreme or
cannot do

D1.1 Concentrating on doing something for ten 1 2 3 4 5

minutes?

D1.2 Remembering to do important things? 1 2 3 4 5

D1.3 Analysing and finding solutions to 1 2 3 4 5

problems in day-to-day life?

D1.4 Learning a new task, for example, 1 2 3 4 5

learning how to get to a new place?

D1.5 Generally understanding what people 1 2 3 4 5

say?

D1.6 Starting and maintaining a 1 2 3 4 5

conversation?

Domain 2
have in: MobilityNone
In the past 30 days, how much difficulty did you Mild Moderate Severe Extreme or
cannot do
D2.1 Standing for long periods such as 30 1 2 3 4 5
minutes?
D2.2 Standing up from sitting down? 1 2 3 4 5
D2.3 Moving around inside your home? 1 2 3 4 5
D2.4 Getting out of your home? 1 2 3 4 5
D2.5 Walking a long distance such as a 1 2 3 4 5
kilometre [or equivalent]?
 Domain 3 Self-
In the past 30 days, how much difficulty did you have
None Mild Moderate Severe Extreme or
in:
care cannot do

D3.1 Washing your whole body? 1 2 3 4 5

D3.2 Getting dressed? 1 2 3 4 5

D3.3 Eating? 1 2 3 4 5

D3.4 Staying by yourself for a few days? 1 2 3 4 5

Domain 4 Getting along with

people
In the past 30 days, how much difficulty did you have in: None Mild Moderate Severe Extreme or
cannot do

D4.1 Dealing with people you do not know? 1 2 3 4 5

D4.2 Maintaining a friendship? 1 2 3 4 5
D4.3 Getting along with people who are close to you? 1 2 3 4 5

D4.4 Making new friends? 1 2 3 4 5

D4.5 Sexual activities? 1 2 3 4 5

Domain 5 LIFE
did you have in: ACTIVITIES
Because of your health condition, in the past 30 days, how much difficulty None Mild Moderate Severe Extreme or cannot
do

D5.1 Taking care of your household responsibilities? 1 2 3 4 5

D5.2 Doing your most important household tasks well? 1 2 3 4 5

D5.3 Getting all the household work done that you needed to 1 2 3 4 5
do?
D5.4 Getting your household work done as quickly as needed? 1 2 3 4 5

Domain 5 WORK OR SCHOOL

Because of your health condition, in ACTIVITIES
the past 30 days how much None Mild Moderate Severe Extreme or
difficulty did you have in: cannot do
D5.5 Your day-to-day work/school? 1 2 3 4 5
D5.6 Doing your most important work/school tasks well? 1 2 3 4 5
D5.7 Getting all the work done that you need to do? 1 2 3 4 5
D5.8 Getting your work done as quickly as needed? 1 2 3 4 5
D5.9 Have you had to work at a lower level because of a health condition? No 1
Yes 2
D5.10 Did you earn less money as the result of a health condition? No 1
Yes 2
 Domain 6 Participation
In the past 30 days: None Mild Moderate Severe Extreme or cannot do

D6.1 How much of a problem did you have joining in community 1 2 3 4 5

activities (for example, festivities, religious or other activities)
in the same way as anyone else can?

D6.2 How much of a problem did you have because of barriers or 1 2 3 4 5

hindrances in the world around you?

D6.3 How much of a problem did you have living with dignity 1 2 3 4 5
because of the attitudes and actions of others?

D6.4 How much time did you spend on your health condition or its 1 2 3 4 5
consequences?

D6.5 How much have you been emotionally 1 2 3 4 5

affected by your health condition?

D6.6 How much has your health been a drain on the financial 1 2 3 4 5
resources of you or
your family?

D6.7 How much of a problem did your family have because of your 1 2 3 4 5
health problems?

D6.8 How much of a problem did you have in doing things by yourself 1 2 3 4 5
for relaxation or pleasure?
• If WHODAS is used, place
results at the very end of
assessment, after psychosocial
stressors
 3. How to chart without axes
DSM-5 has moved to a nonaxial documentation of diagnosis (formerly
Axes I, II, and III), with separate notations for important psychosocial
and contextual factors (formerly Axis IV) and disability (formerly Axis V)
Taken from Northstar behavioral health system

http://www.northstarbehavioral.com/Overview%20of%20DSM%205%20changes%20HO
%20Version%20for%20Web%208-13-13.pdf
Axis IV - psychosocial and environmental factors - are now
covered through an expanded set of V codes. V codes allow
clinicians to indicate other conditions that may be a focus
of clinical attention or affect diagnosis, course, prognosis or
treatment of a mental disorder

Axis V - CGAS and GAF - are replaced by separate measures

of symptoms severity and disability for individual disorders.
Change to the World Health Organization Disability
Assessment Schedule (WHO DAS 2.0)
Taken from Northstar behavioral health system

http://www.northstarbehavioral.com/Overview%20of%20DSM%205%20changes%20HO
%20Version%20for%20Web%208-13-13.pdf
 All diagnoses are considered primary diagnosis
• All diagnoses are listed consecutively (no distinction between
diagnosis previously listed on axis I, axis II or axis III)

• List diagnosis that is the reason for visit 1st

Primary-reason for visit, 296.33, major depressive disorder, recurrent, severe.
Primary- Medical condition; Parkinson’s disease, moderate
Primary-305.00 alcohol use disorder, mild.
Primary -v15.81 non-adherence to medical treatment. (Patient continues to drink while on antidepressants and
does not take antidepressants regularly.)

• If the principal diagnosis that is a reason for visit is a mental

disorder caused by a medical condition, the medical
condition is listed 1st
Primary-Parkinson's disease-moderate with tremors and newly developed postural instability
(scored 3 on Hoehn and Yahr)
Primary-Reason for visit, 296.22; major depressive disorder, single episode, moderate
 Case example – for listing of DX
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years. He quit smoking 5 years ago after being
diagnosed with Parkinson's disease. Over the last 5 years, John's ability to perform physical activity, has progressively deteriorated.
Although John reports bouts of depression, beginning in adolescence and continuing throughout his adult life, he was not diagnosed with
major depressive disorder until 4 years ago (one year after the diagnosis of Parkinson’s). Since that time, he has been on several
antidepressant medications, most recently Remeron. John reports that he has been a regular drinker since his days in college. Although he
denies it, his alcohol use, according to his wife, has increased since his diagnosis of Parkinsons. However, upon evaluation both john and
his wife agree that he drinks no more than 3 times per week – usually a six pack. Although John has been advised to discontinue drinking,
he has not done so. According to both John and his wife. He misses his medication anywhere from 1 to 3 times per week.

About 3 months ago john fell while at home. His wife at first thought it was a result of his drinking. According to John he noticed that he
was having more difficulty standing and walking while maintaining his A recent neurological consult indicates that John does NOT have
any neurological deficits that are out of normal range for his age but has developed postural instability consistent with a progression of
Parkinson’s

Despite advice to the contrary, John has become progressively more sedentary and has discontinued all forms of exercise. About 1 month
ago, John's employers required that John start working part-time and consider filing for early Social Security. According to them, John's
ability to work has diminished. They too noted that he was having difficulty walking. For the last 3 weeks, John has met all of the criteria
for a severe episode of major depression.

Primary diagnosis
Primary-reason for visit, 296.33, major depressive disorder, recurrent, severe.
Primary- Medical condition; Parkinson’s disease-recently upgraded to moderate
Primary-305.00 alcohol use disorder, mild.
Primary -v15.81 non-adherence to medical treatment. Patient continues to drink while on antidepressants take antidepressants irregularly
 V codes -psychosocial stressors
Greatly expanded in the DSM 5
• V codes (codes V01–V91) are used to describe encounters with
circumstances other than formal mental disorder diagnoses disease
or injury.

• V codes are taken from the ICD. Their conditions and problems that
may be the focus of clinical attention or that otherwise might affect
the diagnosis, course, prognosis or treatment of the mental disorder.

• First Incorporated in the DSM-III

• Will become Z codes in ICD 10 -October 2014 (these are listed in DSM
5)
 Use V codes To indicate

V codes (codes V01–V91) are used to describe encounters with

circumstances other than formal mental disorder diagnoses disease or
injury

V codes are taken from the ICD. Their conditions and problems that may
be the focus of clinical attention or that otherwise might affect the
diagnosis, course, prognosis or treatment of the mental disorder.

First Incorporated in the DSM-III

Will become Z codes in ICD 10 -October 2014 (these are listed in DSM 5)
 Code in the following ways
1. As a Focus or need for clinical attention
= Place code as a comorbid diagnosis
or as another primary diagnosis

2. As a Psychosocial/ Environmental
stressor = Place code as A stressor at
the end of all of the diagnoses
John is a 65-year-old white male who is morbidly obese and has been a smoker for 40 years. He quit 5 years ago after being diagnosed with Parkinson's disease. Over
he last 5 years, John's ability to perform physical activity, has progressively deteriorated. Although John reports bouts of depression, beginning in adolescence and
continuing throughout his adult life, he was not diagnosed with major depressive disorder until 4 years ago (one year after the diagnosis of Parkinson’s). Since that
ime, he is been on several antidepressant medications, most recently Remeron. John reports that he has been a regular drinker since his days in college. Although he
denies it, his alcohol use, according to his wife, has increased since his diagnosis of Parkinsons. However, upon evaluation both john and his wife agree that he drinks
no more than 3 times per week – usually a six pack. Although John has been advised to discontinue drinking, he has not done so. And according to both John and his
wife. He misses his medication anywhere from 1 to 3 times per week.
About 3 months ago john fell while at home. His wife at first thought it was a result of his drinking. According to John he noticed that he was having more difficulty
tanding and walking while maintaining his A recent neurological consult indicates that John does NOT have any neurological deficits that are out of normal range for
his age but has developed postural instability consistent with a progression of Parkinson’s
Despite advice to the contrary, John has become progressively more sedentary and has discontinued all forms of exercise. About 1 month ago, John's employers
required that John start working part-time and consider filing for early Social Security. According to them, John's ability to work has diminished. They too noted that
he was having difficulty walking. For the last 3 weeks, John has met all of the criteria for a severe episode of major depression.

Primary diagnosis
Primary-reason for visit, 296.33, major depressive disorder, recurrent, severe.
Primary- Medical condition; Chronic Obstructive Pulmonary Disease, moderate
Primary-305.00 alcohol use disorder, mild.
Primary -v15.81 non-adherence to medical treatment. Patient continues to drink while on antidepressants take antidepressants irregularly
Psychosocial stressors and factors that might affect treatment
278.00 – Obesity
69.9 - Problems related to lifestyle. John's diet and his progressive sedentary behavior, along with his nonadherence and progressive isolation are contributing factors to his primary diagnoses
62.29 - Other problems related to employment. John has recently had his work hours cut in half

WHODAS raw score = 98: domain averages: Cognition = 1none

mobility = 4 severe
self-care = 2 mild
getting along with others = 2 mild
Life activities = 2.5 mild- moderate
work activities = 3, moderate
participation = 3.5moderate- severe
 4. A cultural framework:
The DSM and cultural formulation

• DSM calls for systematic cultural assessment in these areas

1. Cultural identity of the individual-describe reference group that might
influence his or her relationships resources, developmental, and current
challenges
2. Cultural conceptualization of distress-describe constructs that influence how
the individual experiences understands and communicates symptoms or
problems to others
3. Psychosocial stressors and cultural features of vulnerability and resilience-
identify key stressors and supports in the individual social environment, role of
religion, family and other social.
4. Cultural features or influencing factors of the relationship between the
individual and clinician.-Identify differences that may cause difficulties in
communication and may influence diagnosis
5. Overall cultural assessment-summarize the implications of the components of
the cultural formulation, identified earlier. (DSM 5, pp749-750)
DSM and the cultural formulation interview

• 16 questions used to obtain information about the

impact of culture on key aspects of a person's clinical
presentation
• Assesses 4 areas
1. Cultural definition of the problem (Q1 – 3)
2. Cultural perceptions of cause, context and support (Q4 –
10)
3. Culture of factors affecting self coping and past help
seeking (Q 11 – 13
4. Cultural factors affecting current help seeking (Q 14 – 16)
This page and the 3 following are reprinted from the DSM 5
website at psychiatry.org. Please see provisions for copying at
the bottom of the slides
5. Overall organization of disorders
 DSM categories organized over developmental lifespan

Initial occurrence
Younger Older
Disruptive
Neuro , impulse
Somatic Sexual Paraphilia
develop Trauma control Neurocognitive
Bipolar Anxiety symptom Elimination dysfunctions disorders
mental related disorders disorders
related disorders

Schizophrenia Depressive Obsessive- Feeding and Gender Substance Personality

compulsive Dissociative eating Sleep wake dysphoria related and disorder Others
and related disorders disorders addictive
disorders

The progression from younger to older in the DSM is general and there are
specific disorders such as some early childhood feeding disorders that
clearly occur later
 DSM categories organized using
empirically validated common factors

Neural Internalizing Physiological Externalizing

commonalities Symptom Symptom Symptom
factors factors factors

Disruptive
Neuro , impulse
Somatic Elimination Sexual Paraphilia
develop Bipolar Trauma control Neurocognitive
Anxiety symptom disorders dysfunctions disorders
mental related disorders disorders
related

Schizophrenia Depressive Obsessive- Gender Substance Personality

Dissociative Feeding and Sleep wake dysphoria related and disorder Others
compulsive
eating disorders addictive
and related
disorders disorders

Bio-genetic
similar
factors

These distinctions have some strong validation from recent neuro-scientific

and genetic research
6. Highlight of specific changes in diagnosis
Gone
• Disorders usually evident in infancy, childhood and adolescence.
• Factitious disorders and malingering
• adjustment disorders (now included in trauma and stress-related
disorders)
• NOS Diagnosis for all categories

Added
• neurodevelopmental disorders
• obsessive-compulsive and related disorders (moved out of anxiety)
• trauma and stress-related disorders (moved out of anxiety)
• Disruptive, impulse control, and conduct related disorders
• "Specified" and “Unspecified" disorder for all diagnoses
• "Suicide risk" is now specified for 25 diagnosis
 
Changed
• Delirium, dementia and cognitive disorders = neurocognitive
disorders
• psychotic disorders = schizophrenia spectrum and other psychotic
disorders
• mood disorders = bipolar and related disorders & depressive
disorders
• somatoform disorders = somatic symptom and related disorders
 Neuro developmental disorders
1. The term "mental retardation" has been changed to intellectual disability
2. The term "phonological disorders" has been changed to "communication disorders".
1. A new diagnosis of social/pragmatic communication disorder has been added here
2. childhood onset fluency disorder new name for stuttering
3. Speech sound disorder is new name for phonological disorder
3. Autism spectrum disorder is the new term and DSM 5 which consolidates Aspergers
disorder, autism, and pervasive developmental disorder. Severity measures are
included
4. Several changes have been made to the diagnostic criteria for attention deficit
hyperactive disorder
5. Specific learning disorder combines DSM-IV diagnosis of reading disorder mathematics
disorder disorder of written expression and learning disorder NOS
6. Language disorder combines expressive and mixed receptive expressive into one
7. Symptom onset for ADHD was extended to before age 12; Subtypes eliminated and
replaced by specifiers; now allowed to make a comorbid diagnosis with ASD; Symptom
criteria for adults reduced to 5 instead of 6
Schizophrenia spectrum and other psychotic
disorders
1. The spectrum seems to emphasize degrees of psychosis
2. Change in criteria for schizophrenia now requires at least one
criteria to be either a. Delusions, b. Hallucinations or c.
Disorganized speech
3. Subtypes of schizophrenia were eliminated
4. Dimensional measures of symptom severity are now included
5. Schizoaffective disorder has been reconceptualized
6. Delusional disorder no longer requires the presence of “non-
bizarre" in delusions. There is now specifier for bizarre delusions.
7. Schizotypal personality disorder is now considered part of the
spectrum
 Bipolar and related disorders
• Diagnosis must now include both changes in
mood and changes in activity/energy level
• Some particular conditions can now be
diagnosed under "other specified bipolar and
related disorders“
• An "anxiety" specifier has now been included
• Attempts made to clarify definition of
'hypomania". However it was not successful
 Depressive disorders
• New diagnosis included = "disruptive mood
dysregulation disorder”-use for children up to age 18
• New diagnosis included = "premenstrual dysphoric
disorder“
• What used to be called dysthymic disorder is now
"persistent depressive disorder“
• Bereavement is no longer excluded – used to be an
exclusion for 2 months
• New specifiers such as mixed features. And anxious
distress
Obsessive-compulsive and related disorders

• A completely new diagnostic grouping category

• Hoarding disorder-new diagnosis
• Excoriation (skin picking) disorder-new diagnosis
• Substance induced obsessive-compulsive disorder-
new diagnosis
• Trichotillomania now called hair pulling disorder
• Tic specifier has been added
• Muscle dysphoria is now a specifier within body
dysmorphic disorder
 Trauma and stress related disorders

• For diagnosis of acute stress disorder, it must

be specified whether the traumatic events
were experienced directly or indirectly
• Adjustment disorders (a separate class in the
DSM-IV) are included here as various types of
responses to stress
• Major changes in the criteria for the diagnosis
of PTSD
 Anxiety disorders
• Obsessive-compulsive disorder has been moved out of
this category
• PTSD has been moved out of this category
• Acute stress disorder has been moved out of this category
• Changes in criteria for specific phobia and social anxiety
have been made
• Panic attacks can now be used as a specifier within any
other disorder in the DSM
• Separation anxiety disorder has been moved to this group
• Selective mutism has been moved to this group
 Dissociative disorders
• Depersonalization disorder has been relabeled
“Depersonalization/Derealization disorder“
• Dissociative fugue is no longer a separate
diagnosis but is now specifier within the
diagnosis of "dissociative amnesia“
• Changes in criteria for the diagnosis of
"dissociative identity disorder"
Somatic symptom and related disorders
• This is a new name for what was previously called
"somatoform disorders“
• The number of diagnoses in this category has been
reduced. The diagnoses of somatization disorder,
hypochondriasis, pain disorder and undifferentiated
somatoform disorder have all been removed
• "Illness anxiety disorder" has been an added
diagnosis and replaces hypochondriasis
• Factitious disorder is now included in this group
 Feeding and eating disorders
• "Binge eating disorder' is now included as a
separate diagnosis
• also includes a number of diagnosis that were
previously included in a DSM-IV TR in the
chapter "disorders usually 1st diagnosed
during infancy childhood and adolescence“.
– Pica and rumination disorder are 2 examples
 Elimination disorders
• Originally classified in chapters on childhood and
infancy. Now have separate classification
Sleep wake disorders
• Primary insomnia renamed "insomnia disorder«
• Narcolepsy now distinguished from other forms of
hypersomnia
• Breathing related sleep disorders have been broken into
3 separate diagnoses
• Rapid eye movement disorder and restless leg syndrome
are now independent diagnoses within this category
 Sexual dysfunctions
• Some gender related sexual dysfunctions have been
outed
• Now only 2 subtypes-acquired versus lifelong and
generalized versus situational
Gender dysphoria
• New diagnostic class and the DSM 5
• Include separate classifications for children adolescents
and adults
• The construct of gender has replaced the construct of
sex
 Disruptive, impulse control and conduct
disorders
• New diagnostic grouping and DSM 5
• Combines a group of disorders previously included in
disorders of infancy and childhood such as conduct
disorder oppositional defiant disorder with a group
previously known as impulse control disorders not
otherwise classified
• Oppositional defiant disorder now has 3 subtypes
• Intermittent explosive disorder no longer requires
physical violence but can include verbal aggression
Substance related and addictive disorders

• The distinctions between substance abuse and

substance dependence are no longer made
– Now includes criteria for intoxication, withdrawal
and substance induced disorders
• Now includes gambling disorder
• Cannabis and caffeine withdrawal are now
new disorders
 Neuro-cognitive disorders
• New diagnostic group
• Dementia and amnestic disorder are included
in this new group
• Mild NCD is a new diagnosis
Personality disorders

Nothing changes
DSM 5 promised major changes in criteria

• Promised dimensional focus

• Promised reduction in number of personaliity
disorders to five
• Changes did not occur
• Dimensional focus for personality disorders
was moved to section 3
 Primary Criteria in DSM 5
(Unchanged from DSM-IV TR)
A. Enduring pattern of inner experience & behavior that
deviates markedly from expectations of the culture. This
pattern is manifested in 2 or more of the following areas
A. Cognition;
B. Affect;
C. Interpersonal;
D. Impulse control

B. Inflexible & pervasive across situation

C. Distress or impairment in social, occupational
interpersonal..…
D. Long-standing (back to adolescence or early adulthood)
 Dimensional classification of personality
disorders
• Authors of DSM 5 had planned to use
dimensional measures to diagnose personality
disorders
• They plan to reduce personality disorders
from 10 to 5
• This changed in a closed-door meeting
• Dimensional measures are now in section 3
 Proposed changes in assessment of PDs Two
broad dimensions

Overall 5 Broad
personality Pathological
functioning Trait Domains
Negative Detachment Antagonism Psychoticism
self Interpersonal affectivity
Disinhibition

Self Empathy
Identity Intimacy
direction