DSM-5 Introduction

A Guide not Bible

Time-line
12 years of research
Released in May 2013


Why Changes?
intended to more clearly and accurately
define the criteria for that mental disorder.
doing so helps to ensure that the diagnosis is
accurate as well as consistent from one
clinician to anotherbenefiting patients and
the care they receive
Major Changes
Changes in the organizational structure
Non-axial diagnostic system
Use of dimensional and cross-cutting measures
Consistency with ICD
Structure of DSM-5
Section I - provides a basic introduction on how to
use the new manual, how to diagnose using a non-
axial system.
Section II - provides 20 classifications of disorders
that focus on diagnostic criteria and codes.
Section III - Emerging Measures and Models,
includes assessment measures, cultural formulation,
an alternative model for personality disorders, and
conditions for further study.
DSM-5 Def: Mental Disorder
a syndrome that causes clinically significant
problems with
cognitions,
emotion regulation
or behaviour
that results in dysfunctional mental functioning
and is associated with significant distress or
disability in social, occupational, or other
important activities
Appendix
highlights of the changes made from DSM-IV
to DSM-5, glossaries of terms and cultural
concepts of distress, and ICD-9 and ICD-10
codes
Non-axial system
combines Axis I, Axis II, and Axis III with all
mental and other medical diagnoses listed
together
Consistent with ICD - listing as many
diagnoses as necessary to provide the clinical
picture.
Non-axial system
The principal diagnosis is the one listed first
296.51 Bipolar I disorder, mild, most recent
episode depressed
301.83 Borderline Personality Disorder
other conditions that may be the focus of
clinical attention will continue to be listed
along with the diagnosis

Non-axial system
list of psychosocial and environmental problems
has been expanded in DSM-5 with additional V
codes and Z codes (from ICD)
exacerbation of his bipolar depression as a result
of separation from his wife
296.51 Bipolar I disorder, mild, most recent episode
depressed
301.83 Borderline Personality Disorder
V61.03 Disruption of Family by Separation or Divorce
Global assessment of functioning
GAF (Axis V) removed
Replaced with WHOs Disability Assessment
Schedule (WHODAS 2.0)
36 item, self administered or proxy administered
over last 30 days
0-5 scale
Cultural applicability - ??

Dimensional Approach
DSM-IV was based on a categorical system
Shortcomings
many diagnoses are not discrete entities that fit neatly
into categories
excessive comorbidity
fuzzy boundaries between disorders
excessive reliance by clinicians on the NOS
Dimensional Approach
separate disorders are not really separate at all
but are actually related conditions on a
continuum of behaviour, with some conditions
reflecting mild symptoms, whereas other
conditions are much more severe
Example
Bipolar disorder as a spectrum
mild (cyclothymia), to moderate (bipolar II), or more severe
(bipolar I)
Dimensional Approach
DSM-5 adopts the spectrum concept for many
disorders, including substance abuse, autism,
and schizophrenia
Specifiers
specifiers apply to the clients current
presentation, and only when the full criteria for
a disorder have been met.
Various types of specifiers in DSM-5 include:
Course (e.g., in partial remission)
Severity (e.g., mild, moderate, severe)
Frequency (e.g., two times per week)
Duration (e.g., minimum duration of 6 months)
Descriptive features (e.g., with poor insight)
Cross-cutting measures
are provided to measure symptoms frequently
observed in clients regardless of their
presenting concern
used in the initial assessment interview to
measure other symptoms the client may be
experiencing (e.g., anxiety, depression,
substance abuse), and re-administered at a later
date to monitor treatment progress.
Other specified disorder
symptoms are clinically significant,
but do not meet the full criteria for a disorder,
and to state the specific reason why the diagnostic
criteria for any given disorder has not been met
Unspecified disorder
presentation is clinically significant
does not meet the full criteria for a disorder,
the clinician chooses not to specify the reason that
the criteria have not been met
Cross-cutting & assessment tools
WHODAS 2.0
Assessment and cross-cutting symptom measures
Online measures to determine symptom severity
Clinician-rated dimensions of severity for psychotic
symptoms
Early Development and Home Background (EDHB)
Cultural Formulation Interview (CFI), Informant
Version
An alternative model for diagnosing personality
disorders
Developmental & Lifespan
approach
reclassifies disorders into 20 sections based on
their relatedness to each other and their
similarities in characteristics
Example
childhood trauma -> trauma and related disorders
autism spectrum disorder -> neurodevelopmental
disorders
oppositional defiant disorder (ODD) and conduct
disorder -> Disruptive, Impulse Control, and Conduct
Disorders
Developmental & Lifespan
approach
DSM-5 chapters have been organized in keeping
with a developmental focus across the lifespan
Classification ranges from neurodevelopmental
disorders (conditions that develop early in life,
such as autism) to neurocognitive disorders that
develop later in life (e.g., Alzheimers)
The chapters in between commonly manifest in
adolescence and young adulthood.
Developmental & Lifespan
approach
Disorders have also been reclassified into
clusters of disorders based on internalizing and
externalizing factors
Internalizing disorders are those in which
anxiety, depression, and somatic symptoms are
prevalent
Externalizing disorders have more
disturbances of conduct, impulse control, and
substance use
Developmental & Lifespan
approach
Some familiar disorders have been subsumed
into other sections or eliminated completely
Aspergers disorder, for example, has been
subsumed into the broader diagnosis of autism
spectrum disorders
Adjustment disorder has been re-classified as a
trauma- or stressor-related disorder
Developmental & Lifespan
approach
Name changes
Conversion disorder is now called functional
neurological symptom disorder
New disorders
Disruptive mood dysregulation disorder
Emerging disorders
Attenuated psychosis syndrome
Internet gaming
Non-suicidal self-injury and suicidal behavior

Concluding remarks
A comprehensive clinical assessment must
include a complete bio-psycho-social
assessment of factors that have contributed to,
and that continue to sustain, the mental
disorder. The underlying goal is to conduct an
accurate diagnosis so that the appropriate
evidence-based treatment can begin.