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Update on DSM-5 . MICHAEL J. LABELLARTE, SR., M.D. Annapolis, Millersville, Towson, and Columbia, MD [email protected] cell:443-956-2463 www.cpeclinic.com. Tip of the Hat. Michael First, M.D. Master the Changes in the DSM-5 (TM). The Universe. School. Home. Everywhere Else.

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Update on dsm 5
Update on DSM-5


  • Annapolis, Millersville, Towson, and Columbia, MD

  • [email protected]

  • cell:443-956-2463

  • www.cpeclinic.com

Tip of the hat
Tip of the Hat

  • Michael First, M.D.

  • Master the Changes in the DSM-5 (TM)

The Universe



Everywhere Else


  • Preface

  • Highlights

  • Neurodevelopmental disorders

  • Other disorders of interest

  • Symptom/Disorder overlap


  • Field Trials: large academic and small clinal centers

  • Work Groups

  • DSM-5 Task Forces

  • Review committees

  • APA Board of Trustees

Dsm 5 tidbits
DSM-5 Tidbits

  • Not obligatory to use DSM in U.S.

  • ICD-CM (“clinical modification”) is obligatory (HIPPA!)

  • Implementation of ICD-9 and ICD-10 (lands 10-1-14)

  • Incorporated into boards 2017

  • “Online enhancements”: www.psych.org/dsm5

Axis i v replaced
AXIS I-V Replaced

  • Non-axial documentation

  • Important psychosocial /contextual factors (V and Z codes)

  • Disability (may be replaced with the “WHODAS”)

  • GAF is eliminated


  • WHO Disability Assessment Schedule

  • “For further study”

  • Based on International Classification of Functioning, Disability, and Health (ICF)

  • A “useful” STD “measure of disability”

  • Designed for medical; presumptively “for mental disorders”

  • Child version not included

Elements of a dx
Elements of a Dx

  • Dx criteria

  • Dx subtypes and specifiers

  • Severity qualifiers are gone

  • Principal Dx

  • Provisional Dx - “strong presumption full criteria will be met”

Dsm 5 components
DSM-5 Components

  • Section I

  • Section II

  • Section III

  • Appendices

Section i basics
Section I: Basics

  • Introduction

  • Use of the manual

  • Cautionary statement about forensics

Section ii dx criteria
Section II: Dx Criteria

  • Dx groupings of mental disorders

  • Medication-induced movement disorders/other adverse effects

  • Other conditions that may be a focus of clinical attention

Section ii other
Section II: Other ...

  • V codes and Z codes

  • Relational problems

    • “child affected by parental relationship distress”

  • Abuse and neglect

  • Etc.

Section iii emerging
Section III: Emerging

  • Assessment measures (e.g. WHODAS)

  • Cultural formulation

  • Alternative model for personality disorders

  • Conditions for further study


  • Highlights of changes DSM-IV to DSM-5

  • Glossary of technical terms

  • Glossary of cultural concepts of distress

  • Alphabetical and numerical listings of disorders

Mental disorders metastructure i
Mental Disorders:Metastructure I

  • Neurodevelopmental disorders: “intellectual disability”, global developmental delay, “ASD”, LDs, communication disorders (ex; social (pragmatic) communication disorder, ADHD, “motor disorders”

  • Schizophrenia spectrum and psychotic disorders: the usual, plus catatonia is expanded upon

Metastructure ii
Metastructure II

  • Bipolar and related disorders: includes “substance induced bipolar”

  • Depressive disorders: the usual plus DMDD (disruptive mood dysregulation disorder) and PMDD (premenstrual dysphoric disorder)

  • Bereavement exclusion eliminated from MDD

Metastructure iii
Metastructure III

  • Anxiety disorders: the usual

  • OCD and related disorders: body-dysmorphic disorder (BDD), hoarding, excoriation disorder, etc.

  • Trauma and stress-related disorders: PTSD, Acute SD, reactive attachment, disinhibited social engagement disorder, adjustment disorders

Metastructure iv
Metastructure IV

  • Dissociative disorders

  • Somatic symptom disorders

  • Feeding and eating disorders: AN, bulemia, binge eating disorder, avoidant/restrictive food intake, pica, rumination disorder

  • Elimination disorders

Metastructure v
Metastructure V

  • Sleep/wake disorders: several new disorders ICSD including REM sleep behavior, restless leg syndrome

  • Sexual dysfunctions

  • Gender dysphoria

Metastructure vi
Metastructure VI

  • Disruptive, impulse control, and conduct disorders: ODD, CD, antisocial PD, pyromania, kleptomania, IED

  • Substance abuse and addictive disorders: substance use, substance induced, intoxication, withdrawal, gambling disorder

  • “Internet gaming disorder” in further research section (see appendix)

Metastructure vii
Metastructure VII

  • Neurocognitive disorders: delirium, major neurocognitive disorder, mild neurocognitive disorder

  • Personality Disorders

  • Paraphilias


  • No clear distinction between child and adult disorders

  • Child specific disorders are relocated to appropriate sections

  • Groupings are etiology/risk/comorbidity, not age at dx

  • Disorders listed along “lifespan” (within groupings), ex. anxiety

  • Developmental modifications appropriate for Dx

  • Text includes “Development and Course”

Intellectual disability
Intellectual Disability

  • MR language is out

  • Clinical and STD IQ testing needed

  • Severity of impairment based on adaptive scores (not IQ): mild, moderate, severe, profound

  • Severity specifiers: conceptual, social, and practical domains

Global developmental delay
Global Developmental Delay

  • Akin to MR NOS

  • Age < 5 years, severity of ID cannot be reliably assessed

  • Unable to undergo systematic assessments

Autism spectrum disorder
Autism Spectrum Disorder

  • Dimensional nature

  • Subsumes previous 5 types of PDD

  • Aspergers not distinct, but milder form of autism

  • False negatives could cause many w PDD to lose services

  • “Individuals with well-established DSM-IV dx” of PDD “should be given the dx of ASD”.

Autism spectrum disorder1
Autism Spectrum Disorder

  • Specifiers

  • Known med/gen/environ factor/other disorder

  • Severity (A, B): support, substantial, very substantial

  • If intelligence, if language, if catatonia

Autism spectrum disorder2
Autism Spectrum Disorder

  • A. Persistent deficits in social communication or social interaction across multiple contexts, current/by history (3/3)

  • 1. Social-emotional reciprocity

  • 2. Non-verbal communicative behavior used for social interaction

  • 3. Developing, maintaining, understanding relationships

Autism spectrum disorder3
Autism Spectrum Disorder

  • B. Restricted, repetitive behavior, interests, activities (2/4)

  • 1. Stereotyped or repetitive speech, motor movements, or use of objects

  • 2. Adherence to routines, ritualized patterns of verbal or non-verbal, or resistance to change

  • 3. Highly restricted, fixated interests (intense/focus)

  • 4. Hyper/hypo-reactivity to sensory input/aspects

Communication disorders
Communication Disorders

  • Language disorders: combines expressive and expressive-receptive language disorders

  • Speech sound disorder (formerly phonological disorder)

  • Childhood-onset fluency disorder (formerly stuttering)

Social pragmatic communication disorder
Social (Pragmatic) Communication Disorder

  • Persistent difficulty with verbal and non-verbal communication for social purposes (not better explained by ASD)

  • Previously PDD NOS


  • Age of onset before age 12

  • Age > 17: 5/9 symptoms diagnose

  • New (and better) text

  • Can officially be co-morbid with ASD


  • Specifiers

  • In partial remission

  • Severity: mild, moderate, severe

Adhd hallmarks
ADHD Hallmarks

  • Inattention & Hyperactivity/Impulsivity

  • (Diagnostic criteria)

  • Frustration and negative emotionality

  • (DSM V Text)

Adhd dsm 5 associated features dx
ADHD DSM-5: Associated Features...Dx

  • “Tests of attention, executive function, or memory...are not sufficiently sensitive or specific to serve as diagnostic indices.”

  • “No biological marker is diagnostic for ADHD.”

Specific learning disorder
Specific Learning Disorder

  • A single broader LD (subsumes the three Rs)

  • “Synthesis of history, school reports, and psycho-ed. testing.”

  • Impairment specifiers: reading, written expression, math

  • Ex.-word reading accuracy, grammar and punctuation accuracy, memorization of arithmetic facts (not just designate dyslexia or dyscalculia)

  • Severity specifier: mild, moderate, severe

Specific learning disorder1
Specific Learning Disorder

  • A. Difficulties learning and using academic skills (1/6, 6 mo) despite... provision of interventions... target those difficulties.

  • 1. Inaccurate/slow/effortful word reading

  • 2. Difficulty understanding meaning of what is read

  • 3. Difficulties with spelling

  • 4. Difficulties with written expression

  • 5. Difficulties mastering number sense, number facts, or calculation

  • 6. Difficulties with mathematical reasoning

  • 5

Motor disorders
Motor Disorders

  • Developmental coordination disorder

  • Stereotypic movement disorder

  • Tic disorders


  • Other specified neurodevelopmental disorder, e.g. FAE

  • Other unspecified neurodevelopmental disorder

Schizophrenia spectrum
Schizophrenia Spectrum

  • Schizotypal (personality) disorder

  • Delusional disorder

  • Brief psychotic disorder

  • Schizophreniform disorder

  • Schizophrenia

  • Schizoaffective disorder

Schizophrenia spectrum1
Schizophrenia Spectrum

  • Schizophrenia: “bizarre”/Schneiderian AH do not stand alone

  • Schizophrenia subtypes are eliminated!

  • Delusional disorder: no longer just “non-bizarre”

  • Catatonia can be diagnosed with a specifier

  • 0-4 Severity ratings for psychosis (not included in desk ref)

Bipolar and related
Bipolar and Related

  • Bipolar I

  • Bipolar II

  • Cyclothymia

Bipolar disorder
Bipolar Disorder

  • BPAD criteria same in children/adults

  • A. 1. mood disturbance (e.g elevated, expansive, irritable) and 2. increase in activity or energy

  • “Mixed episode” eliminated in BPAD I, but can be specified as “mixed features”

  • Duration: 4 days hypomania, 7 days mania; every day

  • Treatment-induced mania is “true mania”

Bipolar disorder1
Bipolar Disorder

  • B. 3/7 or 4/7 (if irritable mood)

  • 1. Inflated self-esteem grandiosity

  • 2. Decrease need for sleep

  • 3. More talkative/pressured speech

  • 4. Flights of ideas/racing thoughts

  • 5. Distractibility

  • 6. Goal directed activity/psychomotor agitation

  • 7. Increase... activities/painful consequences

Bipolar disorder and depressive disorders
Bipolar Disorder and Depressive Disorders

  • Specify: With anxious distress (2/5; m,m,m/s, s)

  • 1. Feeling keyed up/tense

  • 2. Feeling unusually restless

  • 3. Difficulty concentrating because of worry

  • 4. Fear that something awful may happen

  • 5. Feeling that the individual might lose control

Bpad vs adhd miller chiang ketter 2013
BPAD vs. ADHD(Miller, Chiang, Ketter 2013)

  • FeatureBPADADHD

  • Age adoles./adult <12 yo

  • Gender M=F M>F

  • Course episodic persistent

  • Suicidal common rare

  • Psychotic “ “

  • Euphoria “ “

  • Less need sleep “ “

  • Grandiose “ “

  • Hypersexuality “ “


Depressive disorders
Depressive Disorders

  • DMDD

  • Major depressive disorder (MDD)

  • Persistent depressive disorder (Dysthymia)

  • Premenstrual dysphoric disorder (PMDD)

Disruptive mood dysregulation disorder dmdd
Disruptive Mood Dysregulation Disorder (DMDD)

  • Controversial

  • Grouped with depressive disorders, not bipolar disorders

  • “Cannot coexist” with ODD, IED, or BPAD


  • A.  Severe recurrent temper outbursts manifested verbally (e.g. verbal rages) and/or behaviorally (e.g. physical aggression toward people or property) ... grossly out of proportion in intensity or duration to situation/provocation

  • B. Inconsistent with developmental level. 

  • C. Frequency: tantrums on average >3 /week.


  • D. Mood between temper outbursts is persistently irritable/angry

  • 1.  Nearly every day, most of the day

  • 2.  The irritable/angry mood is observable by others


  • E. Duration: >12 months (< 3 consecutive months w/o)

  • F. At least two settings (severe in at least one)

  • G. Dx Age 6 - 18

  • H. Onset before age 10.

  • I. Mania caveat (>1 day)

  • J. Not during MDD... not other mental dx

  • K. Not attributable to substances or other medical condition

Anxiety disorders
Anxiety Disorders

  • Separation anxiety disorder

  • Selective mutism

  • Specific phobia

  • Social anxiety disorder

  • Panic disorder; Panic attack specifier

  • Agoraphobia

  • Generalized anxiety disorder

Oc and related disorders
OC and Related Disorders

  • OCD

  • Body dysmorphic disorder

  • Hoarding Disorder

  • Trichotillomania

  • Excoriation (skin-picking) disorder

Trauma and stressor related disorders
Trauma and Stressor-Related Disorders

  • Reactive attachment disorder

  • Disinhibited social engagement disorder

  • PTSD

  • ASD

  • Adjustment disorders

Dissociative disorders
Dissociative Disorders

  • Dissociative identity disorder (DID)

  • Dissociative amnesia

  • Depersonalization/derealization disorder

Somatic symptoms and related
Somatic Symptoms and Related

  • Somatic symptom disorder

  • Illness anxiety disorder

  • Conversion (Functional neurological symptom disorder)

  • Psychological factors affecting medical condition

  • Factitious disorder

Feeding and eating disorders
Feeding and Eating Disorders

  • Pica

  • Rumination disorder

  • Avoidant/restrictive food intake disorder

  • Anorexia nervosa

  • Bulimia nervosa

  • Binge eating disorder

Elimination disorders
Elimination Disorders

  • Enuresis

  • Encopresis

Sleep wake disorders
Sleep-Wake Disorders

  • Insomnia disorder

  • Hypersomnolence disorder

  • Narcolepsy

  • Breathing-related sleep disorder

  • Circadian rhythm sleep wake disorder

  • Parasomnias

  • Restless leg syndrome

Sexual dysfunctions
Sexual Dysfunctions

  • Delayed ejaculation

  • Erectile disorder

  • Female orgasmic disorder

  • Female sexual interest/arousal disorder

  • Genito-pelvic pain/penetration disorder

  • Male hypoactive sexual desire disorder

  • Premature (early) ejaculation disorder

Gender dysphoria
Gender Dysphoria

  • Gender Dysphoria

  • Other

  • Unspecified

Problems with emotional and behavioral self control
“Problems With Emotional and Behavioral Self Control”

  • Oppositional defiant disorder (ODD)

  • Intermittent Explosive Disorder (IED)

  • Conduct disorder (CD)

  • Antisocial personality disorder (ASPD)

  • Pyromania

  • Kleptomania


  • “A pattern angry/irritable mood, argumentative/defiant behavior, or vindictiveness

  • ... >6 mo... >4 symptoms... interaction with one individual not a sibling.”


  • Angry/irritable mood:

  • Often loses temper

  • Is often touchy or easily annoyed

  • Is often angry and resentful


  • Argumentative/defiant behavior:

  • Often argues with authority figures (C and A: adults)

  • Often actively defies/refuses to comply w requests/rules

  • Often deliberately annoys others

  • Often blames others for his/her mistakes/behavior


  • Vindictiveness:

  • Has been spiteful or vindictive >2 within past 6 months

  • ODD Specifiers: mild, moderate, severe

More changes
More Changes

  • IED: verbal aggression and nondestructive/non-injurious physical aggression are criteria


  • A: Recurrent behavioral outbursts representing a failure to control aggressive impulses... either:

  • 1. Verbal aggression

  • 2. 3... outbursts...damage or destruction... and/or physical assault/injury...animals/other... 12 months

  • B. Out of proportion

  • C. Not premeditated. Not to achieve... objective

  • E. Age > 6 years

Conduct disorder
Conduct Disorder

  • Repetitive and persistent pattern... basic rights or major... societal norms or rules are violated; > 3/15 (12 mo) and > 1/15 (6 months)

  • Aggression to people or animals

  • Destruction of Property

  • Deceitfulness or theft

  • Serious violation of rules

Aggression people animals
Aggression: People/Animals

  • 1. Often bullies, threatens, or intimidates

  • 2. Often initiates physical fights

  • 3. Has used a weapon... serious physical harm

  • 4. Has been physically cruel to people

  • 5. “ animals

  • 6. Has stolen while confronting a victim

  • 7. Has forced someone into sexual activity

Destruction of property
Destruction of Property

  • 8. Deliberately engaged in fire setting/cause damage

  • 9. Has deliberately destroyed others property

Deceitfulness or theft
Deceitfulness or Theft

  • 10. Broken into someone’s house, building, car

  • 11. Often lies to obtain goods... obligations (“cons”)

  • 12. Stolen nontrivial items without confrontation

Serious violation of rules
Serious Violation of Rules

  • 13. Often stays out at night despite parental (<13 y)

  • 14. Run away overnight >2, or 1 “lengthy period”

  • 15. Often truant from school (<13 y)

Cd specifiers
CD Specifiers

  • Child onset (10 y) or adolescent onset

  • Severity: mild, moderate, severe

  • “With limited prosocial emotions”

With limited prosocial emotions 2 4 12 m
With Limited Prosocial Emotions (2/4, 12 m)

  • Lack of remorse or guilt

  • Callous-lack of empathy

  • Unconcerned about performance

  • Shallow or deficient affect

Substance related and addictive disorders
Substance Related and Addictive Disorders

  • __-related disorder

  • Use disorder

  • Induced disorder

  • Intoxication

  • Withdrawal (cannabis!)

  • Other

  • Unspecified

Neurocognitive disorders
Neurocognitive Disorders

  • Delirium

  • Major and minor neurocognitive disorders

  • Due to Alzheimers

  • Frontotemporal

  • With Lewy bodies

  • Vascular disorder

  • Traumatic brain injury

  • HIV, Prion disease

  • Parkinsons, Huntingtons

Dsm 5 personality disorders
DSM-5 Personality Disorders

  • Cluster A: Paranoid, Schizoid, Schizotypal

  • Cluster B: Antisocial, Borderline, Histrionic, Narcissistic

  • Cluster C: Avoidant, Dependent, Obsessive Compulsive

  • Other specified PD and unspecified PD

General personality disorder
General Personality Disorder

  • A. An enduring pattern of inner experience and behavior that deviates markedly from expectations... culture (2/4):

    • Cognition

    • Affectivity

    • Interpersonal functioning

    • Impulse control

General pd cont
General PD (cont.)

  • B. Inflexible and pervasive..

  • C. Significant distress and impairment

  • D. Stable and long duration, at least adol./early adult

  • E. Not better explained

  • F. Not attributable to SA or GMC

Pediatric application
Pediatric Application

  • ASP cannot be diagnosed <18 yo

  • PD otherwise can be diagnosed <18 yo (> 1 y duration)

  • “... particular maladaptive personality traits appear pervasive, persistent, and unlikely to be limited to a particular developmental stage or mental disorder”.

Dsm 5 alternative model pd
DSM-5 Alternative Model (PD)

  • Level of personality functioning

  • Pathological personality traits

  • Pervasiveness and stability

  • Alternative explanations for personality pathology (differential diagnosis)

1 level of personality functioning
1. Level of Personality Functioning

  • Elements of personality functioning

    • Self: identity, self-direction

    • Interpersonal: empathy, intimacy

2 pathological personality traits
2. Pathological Personality Traits

  • Domains (with 25 corresponding trait facets)

    • Negative affectivity (v. emotional stability)

    • Detachment (vs. extraversion)

    • Antagonism (vs. agreeableness)

    • Disinhibition (vs. conscientousness)

    • Psychoticism (vs. lucidity)

Negative affectivity
Negative Affectivity

  • Emotional lability

  • Anxiousness

  • Separation insecurity

  • Submissiveness

  • Hostility

  • Perseveration


  • Withdrawn

  • Intimacy avoidance

  • Anhedonia

  • Depressivity

  • Restricted affectivity

  • Suspiciousness


  • Manipulativeness

  • Deceitfulness

  • Grandiosity

  • Attention seeking

  • Callousness


  • Irresponsibility

  • Impulsivity

  • Distractibility

  • Risk taking

  • Rigid perfectionism (lack of)


  • Unusual beliefs and experiences

  • Eccentricity

  • Cognitive and perceptual dysregulation

3 pervasiveness and stability
3. Pervasiveness and Stability

  • Relative impairments in function/trait (disposition)

    • “All but the most extreme” have some adaptability

    • Traits more stable than symptoms

    • Impairment more stable than symptoms

4 alternative explanations for personality pathology differential diagnosis
4. Alternative Explanations for Personality Pathology (differential diagnosis)

  • PD diagnosis “not made” if manifestations “clearly are an expression of the other mental disorder”

  • PD “can be accurately diagnosed in the presence of another mental disorder”

Dsm 5 alternative specific
DSM-5 Alternative “Specific” (differential diagnosis)

  • A. Schizotypal

  • B. Antisocial

    • Borderline

    • Narcissistic

  • C. Obsessive Compulsive personality (OCP)

    • Avoidant

  • *Personality Disorder-Trait Specified (PDTS)

Paraphilic disorders
Paraphilic Disorders (differential diagnosis)

  • Voyeuristic

  • Exhibitionistic

  • Frotteuristic

  • Sexual masochism

  • Sexual sadism

  • Pedophilic

  • Fetishistic

  • Transvestic

Last but not least
Last But Not Least... (differential diagnosis)

  • Other mental disorders

  • Medication-induced movement disorders and other adverse effects

  • Other conditions that may be focus of clinical attention

Other clinical attention
Other/Clinical Attention (differential diagnosis)

  • Relational problems

  • Abuse and neglect

  • Education and occupational problems

  • Housing and economic problems

  • ... related to social environment

  • ...crime/interaction with legal system

  • ...counseling or medical advice

  • ... other psychosocial, personal, environmental

  • Other circumstances of personal history

Dsm 5 conclusions
DSM-5 Conclusions (differential diagnosis)

  • Ready or not...

  • Much more informative text section

  • Few surprises (which is surprising)

  • More strict criteria can lead to under-diagnosis

  • ASD and DMDD are noteworthy conceptualizations