Nicole M.

Lanouette, MD
Council Member, San Diego Psychiatric Society
Staff Psychiatrist/Faculty, Naval Medical Center San Diego
Voluntary Assistant Professor of Psychiatry, UCSD
January 24, 2014
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ANXIETY DISORDERS
OBSESSIVE-COMPULSIVE AND RELATED DISORDERS
TRAUMA- AND STRESSOR-RELATED DISORDERS
DISSOCIATIVE DISORDERS
The Scream Edvard Munch
! CATEGORICAL
Increasing understanding that:
- OCD more related to other OC-Related Disorders than Anxiety Disorders
- Some disorders t better with other disorders than DSM-IV
categories (e.g., Body Dysmorphic Disorder and OCD)
- Range of responses to traumas/stressors and rationale for grouping resultant
disorders together
! WITHIN CATEGORIES
- Need for new disorders (e.g, Hoarding, Disinhibited Social Engagement Disorder)
- Some DSM-IV criteria less clinically relevant while other criteria not included in
DSM-IV proving more valid (e.g, PTSD)
- Inconsistent terminology (e.g., fear, anxiety, dread, distress) and time criteria
across disorders
- Some symptoms such as panic attacks occur across a wide variety of disorders
- Some coupled disorders less related (e.g., Panic Disorder and Agoraphobia) than
previously thought
- Some distinct disorders work better linked to each other (e.g. Dissociative
Amnesia and Dissociative Fugue)
PROBLEMS WITH DSM-IV
! NEW CATEGORIES
- Obsessive-Compulsive and Related Disorders
- Trauma- and Stressor-Related Disorders
! Childhood disorders no longer separate
CATEGORICAL CHANGES IN DSM-5
! Panic Disorder With or Without
Agoraphobia
! Agoraphobia Without History of
Panic Disorder
! Specic Phobia
! Social Phobia
! Generalized Anxiety Disorder
! Obsessive-Compulsive Disorder
! Posttraumatic Stress Disorder
! Acute Stress Disorder
! Anxiety Disorder Due to General
Medical Condition
! Substance-Induced Anxiety
Disorder
! Anxiety Disorder Not Otherwise
Specied
DSM-IV Anxiety Disorders
! Separation Anxiety Disorder (from childhood disorders)
! Selective Mutism (from childhood disorders)
! Specic Phobia
! Social Anxiety Disorder (Social Phobia)
! Panic Disorder
! Panic Attack Specier
! Agoraphobia (no longer linked to panic disorder)
! Generalized Anxiety Disorder
! Substance/Medication-Induced Anxiety Disorder
! Anxiety Disorder Due to Another Medical Condition
! Other Specied Anxiety Disorder
! Unspecied Anxiety Disorder
Now in separate categories:
! Obsessive-Compulsive Disorder
! Posttraumatic Stress Disorder
! Acute traumatic stress disorder
DSM-5 Anxiety Disorders
ANXIETY DISORDERS
! CHANGES (that made it into DSM-5)
- Use of standardized terms: fear, anxiety and avoidance
- More uniform time criteria (many now 6 months)
- Somewhat less precise time criteria typically lasting..
- Adults no longer have to recognize fear as excessive or
unreasonable " changed to clinician judgment that is
out of proportion to actual threat and sociocultural
situation
- Panic attack specier
! CONSIDERED CHANGES (that are NOT part of DSM-5)
- Less precise time criteria (e.g., several months instead of 3
months)
- Moving Illness Anxiety Disorder (Hypochondriasis) into
Anxiety Disorders
ANXIETY DISORDERS
ANXIETY DISORDERS
! Panic attack is still not a disorder and not codable
! Now it is a specier that can be added to any other DSM-5 disorder (except Panic
Disorder)
! Wording changes
- discrete period " abrupt surge of intense fear or discomfort
- peaks within 10 mins " peaks within minutes
- chills and hot ashes " chills and heat sensations
! Notes added
- Can occur from a calm state or an anxious state
- Culture-specic symptoms (e.g., tinnitus, neck soreness, headache,
uncontrollable screaming or crying) may be seen.
(But do NOT count towards 4 required symptoms)
! Types simplied situationally bound/cued, situationally predisposed, and
unexpected/uncued " Expected or unexpected
ANXIETY DISORDERS
PANIC ATTACK
! Now an Anxiety Disorder (moved from Disorders First Diagnosed in
Infancy, Childhood, or Adolescence)
! Wording and age onset criteria changed to better represent expression
in adulthood:
- possible avoided places now include work (as well as school)
- occupational impairment added (in addition to academic)
- onset before age 18 criterion cut
- duration criterion added for adults (typically 6 months) (still 4 weeks in
children and adolescents)
- early onset (before age 6) specier removed
ANXIETY DISORDERS
SEPARATION ANXIETY DISORDER
! Now an Anxiety Disorder (moved from Disorders First
Diagnosed in Infancy, Childhood, or Adolescence)
- Most children with selective mutism are anxious
- Responds to SSRIs
! Criteria essentially unchanged
ANXIETY DISORDERS
SELECTIVE MUTISM
! CORE FEATURES UNCHANGED
! Standardized language
marked and persistent fear, anxiety response anxious anticipation
distress " " fear, anxiety, avoidance
! Removed that anxiety could manifest as panic attack
(use panic attack specier instead)
! Added: D. The fear or anxiety is out of proportion to the actual danger posed by
the specic object or situation and to the sociocultural context.
- (CUT: [fear that is excessive or unreasonable])
- CUT: requirement for adults to recognize fear as excessive or unreasonable
! Time criterion now applies to all ages (not just <18 years)
persistent, typically lasting for 6 months or more
! Subtypes now referred to as Speciers (but remain basically unchanged)
- more specic options for Blood-injection-Injury (e.g., fear of blood, of injury)
- coding is done by specier (and code all that apply)
ANXIETY DISORDERS
SPECIFIC PHOBIA
! Core features are unchanged, but many minor changes
! Language standardized " fear or anxiety and fear, anxiety or avoidance
! Criterion A (examples added):
- social interactions (e.g., having a conversation, meeting unfamiliar people),
- being observed (e.g., eating or drinking)
- performing in front of others (e.g., giving a speech)
! Criterion B (expanded from A, more detail added):
Fears will act in a way or show anxiety symptoms that will be negatively evaluated (i.e., will
be humiliating or embarrassing; will lead to rejection or offend others)
! Removed may take the form of a panic attack (use panic attack specier instead)
! Added: D. The fear or anxiety is out of proportion to the actual threat posed by the
social situation and to the sociocultural context.
- CUT: requirement for adults to recognize fear as excessive or unreasonable
! Time criterion now applies to all ages (not just <18 years)
persistent, typically lasting for 6 months or more
(Continued)
ANXIETY DISORDERS
SOCIAL ANXIETY DISORDER (SOCIAL PHOBIA)
! Core features are unchanged, but many minor changes (continued):
! Criterion J. Less strict exclusion if co-morbid medical condition present:
If another medical condition (e.g., Parkinsons disease, obesity,
disgurement from burns or injury) is present, the fear, anxiety or
avoidance is clearly unrelated or is excessive
! Generalized specier replaced by Performance only specier
ANXIETY DISORDERS
SOCIAL ANXIETY DISORDER (SOCIAL PHOBIA)
! Panic Disorder and Agoraphobia now unlinked
! Otherwise Panic Disorder is essentially the same with some minor changes:
A. Recurrent unexpected panic attacks. (Panic attack criteria now included)
B. At least one of the attacks has been followed by 1 month (or more) of one or both of
the following:
1. Persistent concern or worry about additional panic attacks or their
consequences (e.g., losing control, having a heart attack, going crazy).
(DSM-IV criteria 2a and 2b condensed)
2. A signicant maladaptive change in behavior related to the attacks (e.g.,
behaviors designed to avoid having panic attacks, such as avoidance of
exercise or unfamiliar situations).
ANXIETY DISORDERS
PANIC DISORDER
! Panic Disorder and Agoraphobia now unlinked
! Core features essentially the same, but some changes
! Criterion A (new requirement, more detail):
A. Marked fear or anxiety about two (or more) of the following ve situations:
1. Using public transportation (e.g., automobiles, buses, trains, ships, planes)
2. Being in open spaces (e.g., parking lots, marketplaces, bridges)
3. Being in enclosed places (e.g., shops, theaters, cinemas)
4. Standing in line or being in a crowd
5. Being outside of the home alone
! Criterion B (expanded from A, panic attack cut, more detail added):
B. The individual fears or avoids these situations because of thoughts that escape might
be difcult or help might not be available in the event of developing panic-like symptoms or
other incapacitating or embarrassing symptoms (e.g., fear of falling in the elderly; fear
of incontinence).
! Language standardized ! fear or anxiety and fear, anxiety or avoidance
! Added: The fear or anxiety is out of proportion to the actual danger posed by the agoraphobic
situation and to the sociocultural context.
! Time criterion added F. The fear, anxiety, or avoidance is persistent, typically lasting for 6
months or more
ANXIETY DISORDERS
AGORAPHOBIA
! Basically unchanged (minor wording changes in D,E,F criteria
consistent across DSM-5)
! (Considered changes NOT adopted):
- adding an avoidance requirement
- changing name to Generalized Worry Disorder
- decreasing required associated symptoms to 1-2/6 (from
3/6
ANXIETY DISORDERS
GENERALIZED ANXIETY DISORDER
OBSESSIVE-COMPULSIVE AND
RELATED DISORDERS
(NEW CATEGORY)
OBSESSIVE-COMPULSIVE AND
RELATED DISORDERS
(NEW CATEGORY)
! Obsessive-Compulsive Disorder (from Anxiety Disorders)
! Body Dysmorphic Disorder (from Somatoform Disorders)
! Hoarding Disorder (NEW)
! Trichotillomania (Hair-Pulling Disorder) (from Impulse Control
Disorders Not Elsewhere Classied)
! Excoriation (Skin-Picking) Disorder (NEW)
! Substance/Medication-Induced Obsessive-Compulsive and
Related Disorder (NEW)
! Obsessive-Compulsive and Related Disorder Due to Another
Medical Condition (NEW)
! Other Specied and Unspecied Obsessive-Compulsive and
Related Disorders (NEW)
! Common features
- obsessive preoccupation
- repetitive behaviors
! New insight specier
- With good or fair insight: recognizes that beliefs are
denitely or probably not true or that they may or may not be
true
- With poor insight: thinks beliefs are probably true
- With absent insight/delusional beliefs: completely
convinced that beliefs are true
O-C AND RELATED DISORDERS
! Minor changes
! Criterion A (wording, simplication)
Obsessions are dened by (1) and (2):
1. Recurrent and persistent thoughts, urges [cut: impulses], or images that are
experienced, at some time during the disturbance, as intrusive and unwanted
[cut: inappropriate], and that in most individuals cause marked anxiety or
distress.
2. The individual attempts to ignore or suppress such thoughts, urges, or
images, or to neutralize them with some other thought or action (i.e., by
performing a compulsion).
[CUT: (2) not simply excessive worries about real-life problems (4) person recognizes that
the obsessional thoughts, impulses, or images are a product of his or her own mind]
Compulsions dened by (1) and (2): (unchanged criteria)
- Note added: Young children may not be able to articulate the aims of
these behaviors or mental acts
O-C AND RELATED DISORDERS
OCD
! Minor changes (continued)
! CUT: [DSM-IV Criterion B the person has recognized that the
obsessions or compulsions are excessive or unreasonable]
! Speciers
- Insight (expanded)
- Tic-related: The individual has a current or past history of a tic
disorder
O-C AND RELATED DISORDERS
OCD
! Moved from Somatoform Disorders
! Criteria (many wording changes and Criterion B added)
CRITERION A
Preoccupation with one or more perceived [CUT: imagined] defects or aws in physical
appearance that are not observable or appear slight to others.#
(NEW) CRITERION B
B. At some point during the course of the disorder, the individual has performed
repetitive behaviors (e.g., mirror checking, excessive grooming, skin picking,
reassurance seeking) or mental acts (e.g., comparing his or her appearance with
that of others) in response to the appearance concerns.
Added Speciers
- With muscle dysmorphia (preoccupied with body build being too small
or insufciently muscular)
- Insight (expanded)
O-C AND RELATED DISORDERS
BODY DYSMORPHIC DISORDER
O-C AND RELATED DISORDERS
HOARDING DISORDER (NEW)
A. Persistent difculty discarding or parting with possessions, regardless of their
actual value.
B. This difculty is due to a perceived need to save the items and to distress
associated with discarding them.
C. Results in accumulation of possessions that congest and clutter active living
areas and substantially compromises their intended use.
- If living areas are uncluttered, it is only because of the interventions of third
parties (e.g., family members, cleaners, authorities)
D. Causes clinically signicant distress or impairment in social, occupational, or other
important areas of functioning (including maintaining a safe environment for self and
others)
E. Not attributable to another medical condition
F. Not better explained by another mental disorder
Speciers: With excessive acquisition; Insight (expanded)
O-C AND RELATED DISORDERS
HOARDING DISORDER (NEW)
! Moved from Impulse-Control Disorders Not Elsewhere Classied
! Criteria (signicant changes)
A. Recurrent pulling out of ones hair, resulting in [CUT: noticeable] hair loss.
B. Repeated attempts to decrease or stop hair pulling (NEW)
[CUT: B. An increasing sense of tension immediately before pulling out the hair
or when attempting to resist the behavior. C. Pleasure, gratication, or relief
when pulling out the hair. ]
C-E. Minor wording and order changes (for consistency across DSM-5)
O-C AND RELATED DISORDERS
TRICHOTILLOMANIA (HAIR PULLING DISORDER)
CRITERIA
A. Recurrent skin picking resulting in skin lesions.
B. Repeated attempts to decrease or stop skin picking.
C. Distress or impairment in functioning
D. Not attributable to substance (e.g., cocaine) or another medical condition
(e.g., scabies)
E. Not better explained by another mental disorder
(e.g., delusions or tactile hallucinations in a psychotic disorder, attempts to
improve a perceived defect or aw in appearance in body dysmorphic disorder,
stereotypies in stereotypic movement disorder, or intention to harm oneself in
nonsuicidal self-injury)
O-C AND RELATED DISORDERS
EXCORIATION (SKIN-PICKING) DISORDER (NEW)
TRAUMA- AND STRESSOR-
RELATED DISORDERS
(NEW CATEGORY)
! Reactive Attachment Disorder (from childhood disorders)
! Disinhibited Social Engagement Disorder (NEW)
! Posttraumatic Stress Disorder (from Anxiety Disorders) with
separate criteria for children younger than 6 years (NEW)
! Acute Stress Disorder (from Anxiety Disorders)
! Adjustment Disorders (from Adjustment Disorders)
! Other Specied Trauma-and Stressor-Related Disorder (NEW)
! Unspecied Trauma-and Stressor-Related Disorder (NEW)
! DSM-IV had 2 subtypes: emotionally withdrawn/inhibited and indiscriminately
social/disinhibited " in DSM-5, they are distinct disorders:
- Reactive Attachment Disorder
- Disinhibited Social Engagement Disorder
! CRITERIA (many wording changes; expanded, more detailed, specic criteria)
A. A consistent pattern of inhibited, emotionally withdrawn behavior toward adult
caregivers, manifested by both of the following:
1. The child rarely or minimally seeks comfort when distressed.
2. The child rarely or minimally responds to comfort when distressed.
B. A persistent social and emotional disturbance characterized by at least two of the
following:
1. Minimal social and emotional responsiveness to others.
2. Limited positive affect.
3. Episodes of unexplained irritability, sadness, or fearfulness that are
evident even during nonthreatening interactions with adult caregivers.
(Continued)
TRAUMA- AND STRESSOR-RELATED
DISORDERS
REACTIVE ATTACHMENT DISORDER
C. The child has experienced a pattern of extremes of insufcient care as evidenced by
at least one of the following:
1. Social neglect or deprivation in the form of persistent lack of having basic
emotional needs for comfort, stimulation, and affection met by caregiving adults.
[CUT: persistent disregard of childs basic physical needs]
2. Repeated changes of primary caregivers that limit opportunities to form
stable attachments (e.g., frequent changes in foster care).
3. Rearing in unusual settings that severely limit opportunities to form
selective attachments (e.g., institutions with high child-to-caregiver
ratios).
D. Care in C presumed to be responsible for the disturbed behavior in Criterion A
E. The criteria are not met for autism spectrum disorder (changed from PDD)
F. The disturbance is evident before age 5 years.
G. The child has a developmental age of at least 9 months.
Specify if: Persistent: The disorder has been present for more than 12 months.
Specify current severity: Reactive attachment disorder is specied as severe when
a child exhibits all symptoms of the disorder, with each symptom manifesting at
relatively high levels.
TRAUMA- AND STRESSOR-RELATED
DISORDERS
REACTIVE ATTACHMENT DISORDER
! NEW Disorder (from Reactive Attachment Disorder)
! CRITERIA (signicantly expanded from those in DSM-IV Reactive Attachment
Disorder)
A. A pattern of behavior in which a child actively approaches and interacts
with unfamiliar adults and exhibits at least two of the following:
1. Reduced or absent reticence in approaching and interacting with unfamiliar
adults.
2. Overly familiar verbal or physical behavior (that is not consistent with
culturally sanctioned and with age-appropriate social boundaries).
3. Diminished or absent checking back with adult caregiver after venturing
away, even in unfamiliar settings.
4. Willingness to go off with an unfamiliar adult with minimal or no hesitation.
B. The behaviors in Criterion A are not limited to impulsivity (as in
attention-decit/hyperactivity disorder) but include socially disinhibited
behavior.
TRAUMA- AND STRESSOR-RELATED
DISORDERS
DISINHIBITED SOCIAL ENGAGEMENT DISORDER
(NEW)
C. The child has experienced a pattern of extremes of insufcient care as evidenced
by at least one of the following:
1. Social neglect or deprivation in the form of persistent lack of having basic
emotional needs for comfort, stimulation, and affection met by caregiving adults.
[CUT: persistent disregard of childs basic physical needs]
2. Repeated changes of primary caregivers that limit opportunities to form
stable attachments (e.g., frequent changes in foster care).
3. Rearing in unusual settings that severely limit opportunities to form
selective attachments (e.g., institutions with high child-to-caregiver
ratios).
D. Care in C is presumed to be responsible for the disturbed behavior in Criterion A
E. The child has a developmental age of at least 9 months.
Specify if: Persistent: The disorder has been present for more than 12 months.
Specify current severity: Disinhibited social engagement disorder is specied as
severe when the child exhibits all symptoms of the disorder, with each symptom
manifesting at relatively high levels.
TRAUMA- AND STRESSOR-RELATED
DISORDERS
DISINHIBITED SOCIAL ENGAGEMENT DISORDER
PTSD signicant changes
! Criterion A (stressor criterion)
- Much more detail about how individual experienced the
traumatic event
- DSM-IV Criterion A2 CUT: [the persons response involved
intense fear, helplessness, or horror.]
! Symptom clusters
DSM-IV DSM-5
Reexperiencing Intrusion symptoms
Avoidance/numbing Avoidance
Negative alterations in
cognitions and mood
Increased arousal Alterations in arousal and
reactivity
TRAUMA- AND STRESSOR-RELATED
DISORDERS
PTSD
PTSD signicant changes (continued)
! DSM-IV Criterion C7 CUT: [foreshortened sense of future]
! NEW DSM-5 Criteria D2-D4 (Negative alterations in cognitions/mood):
D2. Persistent and exaggerated negative beliefs or expectations
about ones self, others or the world (e.g., I am bad, No one can
be trusted, The world is completely dangerous, My whole
nervous system is permanently ruined)
D3. Persistent, distorted cognitions about the cause or
consequences of the traumatic event(s) that lead the individual to
blame himself/herself or others
D4. Persistent negative emotional state (e.g., fear, horror, anger,
guilt, or shame)
TRAUMA- AND STRESSOR-RELATED
DISORDERS
PTSD
PTSD signicant changes (continued)
! Irritability expanded, now can be experienced in two ways:
- Irritable emotional state (Criterion D4)
- Irritable behavior (Criterion E1)
! NEW arousal and reactivity symptom:
Reckless or self-destructive behavior (E2)
! NEW Criterion H: The disturbance is not attributable to the
physiological effects of a substance (e.g., medication, alcohol) or
another medical condition
! Speciers:
- CUT: DSM-IV acute vs. chronic (>3 months) specier
- NEW With dissociative symptoms specier
TRAUMA- AND STRESSOR-RELATED
DISORDERS
PTSD
For adults, adolescents, and children older than 6 years (NEW)
A. Exposure to actual or threatened death, serious injury, or sexual
violence in one (or more) of the following ways: (NEW)
1. Directly experiencing the traumatic event(s).
2. Witnessing, in person, the event(s) as it occurred to others.
3. Learning that the traumatic event(s) occurred to a close family
member or close friend. In cases of actual or threatened death of a
family member or friend, the event(s) must have been violent or
accidental.
4. Experiencing repeated or extreme exposure to aversive details of
the traumatic event(s) (e.g., rst responders collecting human
remains; police ofcers repeatedly exposed to details of child
abuse).
Note: Criterion A4 does not apply to exposure through electronic media, television,
movies, or pictures, unless this exposure is work related.
TRAUMA- AND STRESSOR-RELATED
DISORDERS
PTSD
B. Presence of one (or more) of the following intrusion symptoms
associated with the traumatic event(s), beginning after the traumatic
event(s) occurred:
1. Recurrent, involuntary, and intrusive distressing memories of the traumatic
event(s). (Note: In children older than 6 years, repetitive play may occur in which
themes or aspects of the traumatic event(s) are expressed.)
2. Recurrent distressing dreams in which the content and/or affect of the
dream are related to the traumatic event(s). (Note: In children, there may be
frightening dreams without recognizable content.)
3. Dissociative reactions (e.g., ashbacks) in which the individual feels or
acts as if the traumatic event(s) were recurring. (Such reactions may occur on a
continuum, with the most extreme expression being a complete loss of awareness
of present surroundings.) (Note: In children, trauma-specic reenactment may
occur in play.)
4. Intense or prolonged psychological distress at exposure to internal or
external cues that symbolize or resemble an aspect of the traumatic event(s).
5. Marked physiological reactions [changed from: physical reactivity] to internal
or external cues that symbolize or resemble an aspect of the traumatic event(s).
TRAUMA- AND STRESSOR-RELATED
DISORDERS
PTSD
C. (NEW CRITERION) Persistent avoidance of stimuli associated with
the traumatic event(s), beginning after the traumatic event(s) occurred,
as evidenced by one or both of the following:
1. Avoidance of or efforts to avoid distressing memories, thoughts, or
feelings about or closely associated with the traumatic event(s).
2. Avoidance of or efforts to avoid external reminders (people, places,
conversations, activities, objects, situations) that arouse distressing
memories, thoughts, or feelings about or closely associated with the
traumatic event(s).
TRAUMA- AND STRESSOR-RELATED
DISORDERS
PTSD
D. (NEW CRITERION) Negative alterations in cognitions and mood associated with
the traumatic event(s), beginning or worsening after the traumatic event(s)
occurred, as evidenced by two (or more) of the following:
1. Inability to remember an important aspect of the traumatic event(s) (typically
due to dissociative amnesia and not to other factors such as head injury,
alcohol, or drugs).
2. Persistent and exaggerated negative beliefs or expectations about oneself,
others, or the world (e.g., I am bad, No one can be trusted, The world is
completely dangerous, My whole nervous system is permanently ruined).
3. Persistent, distorted cognitions about the cause or consequences of the
traumatic event(s) that lead the individual to blame himself/herself or others.
4. Persistent negative emotional state (e.g., fear, horror, anger, guilt, or
shame).
5. Markedly diminished interest or participation in signicant activities.
6. Feelings of detachment or estrangement from others.
7. Persistent inability to experience positive emotions (e.g., inability to
experience happiness, satisfaction, or loving feelings).
TRAUMA- AND STRESSOR-RELATED
DISORDERS
PTSD
E. Marked alterations in arousal and reactivity associated with the
traumatic event(s), beginning or worsening after the traumatic
event(s) occurred, as evidenced by two (or more) of the following:
1. Irritable behavior and angry outbursts (with little or no
provocation) typically expressed as verbal or physical
aggression toward people or objects.
2. Reckless or self-destructive behavior. (NEW)
3. Hypervigilance.
4. Exaggerated startle response.
5. Problems with concentration.
6. Sleep disturbance (e.g., difculty falling or staying asleep or
restless sleep).
TRAUMA- AND STRESSOR-RELATED
DISORDERS
PTSD
F. Duration of the disturbance (Criteria B, C, D, and E) is more than 1
month.
G. The disturbance causes clinically signicant distress or impairment in
social, occupational, or other important areas of functioning.
H. (NEW) The disturbance is not attributable to the physiological
effects of a substance (e.g., medication, alcohol) or another
medical condition.
TRAUMA- AND STRESSOR-RELATED
DISORDERS
PTSD
! Specify whether:
- (NEW) With dissociative symptoms:
Depersonalization
Derealization
(Note: dissociative symptoms must not be attributable to the physiological
effects of a substance or another medical condition)
- [CUT: acute vs. chronic specier]
! Specify if:
With delayed expression: If the full diagnostic criteria are not met until at least 6 months
after the event (although the onset and expression of some symptoms may be
immediate).
TRAUMA- AND STRESSOR-RELATED
DISORDERS
PTSD
(NEW) Different criteria for children younger than 6 years
BACKGROUND
- DSM-IV came before many studies in younger children
- Many adult criteria rely on verbal expression and cognitive
abstraction abilities not yet developed in preschoolers
- 3-8 times more children meet new child criteria
TRAUMA- AND STRESSOR-RELATED
DISORDERS
PTSD (CHILDREN < 6 YRS) (NEW)
MODIFICATIONS
- Criteria focus on observable behavior rather than internal
states
e.g. C5. Socially withdrawn behavior
- Diagnostic thresholds lowered
CRITERIA
- A. Trauma only 3 ways in which it can be experienced
(does not include exposure through work or media)
- B. Intrusion symptoms (1 required): may not appear distressing
- C. Avoidance or Negative alterations in cognition/mood
(combined criteria, only 1 required): focus on
observable behavior
- D. Arousal and Reactivity (2 required)
(Does not include reckless or self-destructive behavior )
TRAUMA- AND STRESSOR-RELATED
DISORDERS
PTSD (CHILDREN < 6 YRS) (NEW)
! More specics required as to how trauma was experienced (same as
PTSD)
! De-emphasis of dissociative symptoms (based on evidence of wide
range of posttraumatic reactions)
! CRITERIA
- A. Trauma (same as PTSD)
- B. Need at least 9 of 14 symptoms from any of following 5 categories:
- intrusion (4)
- Negative mood (1)
- Dissociation (2)
- Avoidance (2)
- Arousal (5)
- C. Duration criteria 3 days (increased from 2 days) to 1 month

TRAUMA- AND STRESSOR-RELATED
DISORDERS
ACUTE STRESS DISORDER
! Moved from their own category
- Reconceptualizing them as stress-response syndromes
! Minor Changes to Criteria
B1. Marked distress that is out of proportion to the severity or
intensity of the stressor, taking into account the external context
and the cultural factors that might inuence symptom severity and
presentation.
[changed from: is in excess of what would be expected from exposure
to the stressor ]
Speciers:
- CUT: [Acute/Chronic specier]
- Subtype speciers unchanged
TRAUMA- AND STRESSOR-RELATED
DISORDERS
ADJUSTMENT DISORDERS
! May include Persistent Complex Bereavement Disorder
TRAUMA- AND STRESSOR-RELATED
DISORDERS
OTHER SPECIFIED (NEW)
DSM-5 DISSOCIATIVE DISORDERS
! Dissociative Identity Disorder
! Dissociative Amnesia (with dissociative fugue specier)
! Depersonalization/Derealization Disorder
! Other Specied/Unspecied Dissociative Disorder
CHANGES IN DSM-5
! Derealization included in name and symptoms of what was
depersonalization disorder in DSM-IV
! Dissociative fugue is now a specier of dissociative
amnesia (no longer a separate diagnosis)
DISSOCIATIVE DISORDERS
MANY CHANGES
! CRITERION A
- Expanded to include
- Possession
- Functional neurological symptoms
- Identity transitions may be observable OR self-reported
! CRITERION B
- May have recall gaps for everyday events (not just traumatic)
- CUT: identities recurrently take control
- gaps in recall inconsistent with ordinary forgetting
! CRITERION C (NEW) must cause distress or impairment
! CRITERION D (NEW)
- not part of broadly accepted religious or cultural practice
- in children, not part of imaginary playmates or fantasy play
DISSOCIATIVE DISORDERS
DISSOCIATIVE IDENTITY DISORDER
SOME CHANGES
! CRITERION A
- Inability to recall inconsistent with ordinary forgetting.
(replaces too extensive to be explained by)
- Note: Dissociative amnesia most often consists of localized or
selective amnesia for a specic event or events; or generalized
amnesia for identity and life history.
! CRITERIA B, C, D minor changes (standardizing order across
DSM5 and more detail about other medical conditions
! Dissociative fugue NOW a specier instead of separate disorder
DISSOCIATIVE DISORDERS
DISSOCIATIVE AMNESIA
! DEREALIZATION ADDED
! CRITERION A. The presence of persistent or recurrent experiences
of depersonalization, derealization, or both:
1. Depersonalization: Experiences of unreality, detachment, or
being an outside observer with respect to ones thoughts,
feelings, sensations, body, or actions (e.g., perceptual
alterations, distorted sense of time, unreal or absent self,
emotional and/or physical numbing).
2. Derealization: Experiences of unreality or detachment with
respect to surroundings (e.g., individuals or objects are
experienced as unreal, dreamlike, foggy, lifeless, or visually
distorted).
! CRITERIA B-E: VERY MINOR CHANGES
DISSOCIATIVE DISORDERS
DEPERSONALIZATION/DEREALIZATION
DISORDER
EXAMPLES OF POSSIBLE OTHER SPECIFIED
DISSOCIATIVE DISORDERS:
! Chronic and recurrent syndromes of mixed dissociative
symptoms
! Identity disturbance due to prolonged and intense
coercive persuasion
! Acute dissociative reactions to stressful events
! Dissociative trance
DISSOCIATIVE DISORDERS
OTHER SPECIFIED
! Two new categories
- Obsessive-Compulsive and Related Disorders
- Trauma- and Stressor-Related Disorders
! Childhood disorders now included
! Summary of changes within categories
Anxiety Disorders
- standardization of wording to capture
common features (fear, anxiety, avoidance)
- panic attack specier
- panic disorder and agoraphobia now
unlinked
SUMMARY
Summary of changes within categories (continued)
! O-C and Related Disorders
- all include common elements of obsessive
preoccupation and repetitive behaviors
- NEW disorders (including Hoarding and Skin
Picking)
- Body Dysmorphic and Trichotillomania moved in


SUMMARY (CONTINUED)
Summary of changes within categories (continued)
! Trauma- and Stressor-Related Disorders
- common element of having experienced trauma or
stressor
- NEW disorders (including Disinhibited Social
Engagement Disorder)
- now includes Adjustment Disorders
- signicant changes to PTSD and Acute Stress
Disorder
- new PTSD criteria for children < 6 years

SUMMARY (CONTINUED)
Summary of changes within categories (continued)
! Dissociative Disorders
- Signicant changes to Dissociative Identity Disorder
- Dissociative fugue now a specier (to Dissociative
Amnesia)
- Derealization added to Depersonalization "
Depersonalization/Derealization Disorder
SUMMARY (CONTINUED)
SUMMARY
DSM-5 cover is reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association.