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Suicide is a high-risk outcome, with rates increasing significantly in late adolescence and early adulthood. |
Functional Consequences of Neurobehavioral DisorderThe CNS dysfunction seen in individuals with ND—PAE often leads to decrements in adap- tive behavior and to maladaptive behavior with lifelong consequences. Individuals affected by prenatal alcohol exposure have a higher prevalence of disrupted school expe- riences, poor employment records, trouble with the law, confinement (legal or psychiat- ric), and dependent living conditions. |
Disorders that are attributable to the physiological effects associated with postnatal use of a substance, another medical condition, or environmental neglect. Other consid- erations include the physiological effects of postnatal substance use, such as a medication, alcohol, or other substances; disorders due to another medical condition, such as traumatic brain injury or other neurocognitive disorders (e.g., delirium, major neurocognitive dis- order [dementia]); or environmental neglect. |
Genetic and teratogenic conditions. Genetic conditions such as Williams syndrome, |
Down syndrome, or Cornelia de Lange syndrome and other teratogenic conditions such as behavioral characteristics. A careful review of prenatal exposure history is needed to clar- ify the teratogenic agent, and an evaluation by a clinical geneticist may be needed to dis- tinguish physical characteristics associated with these and other genetic conditions. |
Mental health problems have been identified in more than 90% of individuals with histo- ries of significant prenatal alcohol exposure. The most common co-occurring diagnosis is attention-deficit/hyperactivity disorder, but research has shown that individuals with |
ND-PAE differ in neuropsychological characteristics and in their responsiveness to phar- macological interventions. Other high- probability co-occurring disorders include oppo- sitional defiant disorder and conduct disorder, but the appropriateness of these diagnoses should be weighed in the context of the significant impairments in general intellectual and executive functioning that are often associated with prenatal alcohol exposure. Mood symptoms, including symptoms of bipolar disorder and depressive disorders, have been described. History of prenatal alcohol exposure is associated with an increased risk for later tobacco, alcohol, and other substance use disorders. |
A. Within the last 24 months, the individual has made a suicide attempt. |
Note: A suicide attempt is a seIf-initiated sequence of behaviors by an individual who, at the time of initiation, expected that the set of actions would lead to his or her own death. The “time of initiation" is the time when a behavior took place that involved ap- plying the method.) |
B. The act does not meet criteria for nonsuicidal seIf-injury—that is, it does not involve self-injury directed to the surface of the body undertaken to induce relief from a nega- tive feeling/cognitive state or to achieve a positive mood state. |
C. The diagnosis is not applied to suicidal ideation or to preparatory acts. |
D. The act was not initiated during a state of delirium or confusion. |
E. The act was not undertaken solely for a political or religious objective. |
Specify if:Current: Not more than 12 months since the last attempt. |
In early remission: 12—24 months since the last attempt.Suicidal behavior is often categorized in terms of violence of the method. Generally, over— doses with legal or illegal substances are considered nonviolent in method, whereas jump- ing, gunshot wounds, and other methods are considered violent. Another dimension for classification is medical consequences of the behavior, with high—lethality attempts being defined as those requiring medical hospitalization beyond a visit to an emergency depart- ment. An additional dimension considered includes the degree of planning versus impul— siveness of the attempt, a characteristic that might have consequences for the medical outcome of a suicide attempt. |
If the suicidal behavior occurred 12—24 months prior to evaluation, the condition is considered to be in early remission. Individuals remain at higher risk for further suicide at- tempts and death in the 24 months after a suicide attempt, and the period 12—24 months af— ter the behavior took place is specified as "early remission." |
The essential manifestation of suicidal behavior disorder is a suicide attempt. A suicide at— tempt is a behavior that the individual has undertaken with at least some intent to die. The behavior might or might not lead to injury or serious medical consequences. Several fac- tors can influence the medical consequences of the suicide attempt, including poor plan- ning, lack of knowledge about the lethality of the method chosen, low intentionality or ambivalence, or chance intervention by others after the behavior has been initiated. These should not be considered in assigning the diagnosis. |
Determining the degree of intent can be challenging. Individuals might not acknowl— edge intent, especially in situations where doing so could result in hospitalization or cause distress to loved ones. Markers of risk include degree of planning, including selection of a time and place to minimize rescue or interruption; the individual’s mental state at the time of the behavior, with acute agitation being especially concerning; recent discharge from inpatient care; or recent discontinuation of a mood stabilizer such as lithium or an anti- psychotic such as clozapine in the case of schizophrenia. Examples of environmental “trig- gers” include recently learning of a potentially fatal medical diagnosis such as cancer, experiencing the sudden and unexpected loss of a close relative or partner, loss of employ— ment, or displacement from housing. Conversely, features such as talking to others about future events or preparedness to sign a contract for safety are less reliable indicators. |
In order for the criteria to be met, the individual must have made at least one suicide at- tempt. Suicide attempts can include behaviors in which, after initiating the suicide attempt, the individual changed his or her mind or someone intervened. For example, an individual might intend to ingest a given amount of medication or poison, but either stop or be stopped by another before ingesting the full amount. If the individual is dissuaded by another or changes his or her mind before initiating the behavior, the diagnosis should not be made. |
The act must not meet criteria for nonsuicidal self—injury—that is, it should not involve re- peated (at least five times within the past 12 months) self-injurious episodes undertaken to induce relief from a negative feeling/ cognitive state or to achieve a positive mood state. The act should not have been initiated during a state of delirium or confusion. If the individual deliberately became intoxicated before initiating the behavior, to reduce anticipatory anxi— ety and to minimize interference with the intended behavior, the diagnosis should be made. |
Suicidal behavior can occur at any time in the lifespan but is rarely seen in children under the age of 5. In prepubertal children, the behavior will often consist of a behavior (e.g., sit- ting on a ledge) that a parent has forbidden because of the risk of accident. Approximately 25%—30% of persons who attempt suicide will go on to make more attempts.There is sig- nificant variability in terms of frequency, method, and lethality of attempts. However, this is not different from what is observed in other illnesses, such as major depressive disorder, in which frequency of episode, subtype of episode, and impairment for a given episode can vary significantly. |
Suicidal behavior varies in frequency and form across cultures. Cultural differences might be due to method availability (e.g., poisoning with pesticides in developing countries; gunshot wounds in the southwestern United States) or the presence of culturally specific syndromes (e.g., ataques de nervios, which in some Latino groups might lead to behaviors that closely resemble suicide attempts or might facilitate suicide attempts). |
Laboratory abnormalities consequent to the suicidal attempt are often evident. Suicidal behavior that leads to blood loss can be accompanied by anemia, hypotension, or shock. |
Overdoses might lead to coma or obtundation and associated laboratory abnormalities such as electrolyte imbalances. |
Functional Consequences of Suicidal Behavior DisorderMedical conditions (e.g., lacerations or skeletal trauma, cardiopulmonary instability, in- halation of vomit and suffocation, hepatic failure consequent to use of paracetamol) can occur as a consequence of suicidal behavior. |
Suicidal behavior is seen in the context of a variety of mental disorders, most commonly bipo— lar disorder, major depressive disorder, schizophrenia, schizoaffective disorder, anxiety dis- orders (in particular, panic disorders associated with catastrophic content and PTSD flashbacks), substance use disorders (especially alcohol use disorders), borderline personality disorder, antisocial personality disorder, eating disorders, and adjustment disorders. It is rarely manifested by individuals with no discernible pathology, unless it is undertaken be- cause of a painful medical condition with the intention of drawing attention to martyrdom for political or religious reasons, or in partners in a suicide pact, both of which are excluded from this diagnosis, or when thiId-party informants wish to conceal the nature of the behavior. |
A. In the last year, the individual has, on 5 or more days, engaged in intentional seIf-inflicted damage to the surface of his or her body of a sort likely to induce bleeding, bruising, or pain (e.g., cutting, burning, stabbing, hitting, excessive rubbing), with the expectation that the injury will lead to only minor or moderate physical harm (i.e., there is no suicidal intent). |
Note: The absence of suicidal intent has either been stated by the individual or can be inferred by the individual’s repeated engagement in a behavior that the individual knows, or has learned, is not likely to result in death. |
B. The individual engages in the seIf-injurious behavior with one or more of the following expectations: 1. To obtain relief from a negative feeling or cognitive state. |
2. To resolve an interpersonal difficulty.3. To induce a positive feeling state.Note: The desired relief or response is experienced during or shortly after the self- injury, and the individual may display patterns of behavior suggesting a dependence on repeatedly engaging in it. |
C. The intentional self-injury is associated with at least one of the following: 1. Interpersonal difficulties or negative feelings or thoughts, such as depression, anx- iety, tension, anger, generalized distress, or seIf—criticism, occurring in the period immediately prior to the seIf-injurious act. |
2. Prior to engaging in the act, a period of preoccupation with the intended behavior that is difficult to control. |
3. Thinking about seIf-injury that occurs frequently, even when it is not acted upon. |
D. The behavior is not socially sanctioned (e.g., body piercing, tattooing, part of a religious or cultural ritual) and is not restricted to picking a scab or nail biting. |
E. The behavior or its consequences cause clinically significant distress or interference in interpersonal, academic, or other important areas of functioning. |
F. The behavior does not occur exclusively during psychotic episodes, delirium, sub- stance intoxication, or substance withdrawal. In individuals with a neurodevelopmental disorder, the behavior is not part of a pattern of repetitive stereotypies. The behavior is not better explained by another mental disorder or medical condition (e.g., psychotic disorder, autism spectrum disorder. intellectual disability, Lesch-Nyhan syndrome, ste- reotypic movement disorder with seIf-injury, trichotillomania [hair-pulling disorder]. ex- coriation [skin-picking] disorder). |
The essential feature of nonsuicidal self-injury is that the individual repeatedly inflicts shallow, yet painful injuries to the surface of his or her body. Most commonly, the purpose is to reduce negative emotions, such as tension, anxiety, and self—reproach, and / or to re- solve an interpersonal difficulty. In some cases, the injury is conceived of as a deserved self—punishment. The individual will often report an immediate sensation of relief that oc- curs during the process. When the behavior occurs frequently, it might be associated with a sense of urgency and craving, the resultant behavioral pattern resembling an addiction. |
The inflicted wounds can become deeper and more numerous.The injury is most often inflicted with a knife, needle, razor, or other sharp object. Com- mon areas for injury include the frontal area of the thighs and the dorsal side of the forearm. |
A single session of injury might involve a series of superficial, parallel cuts—separated by 1 or 2 centimeters—on a visible or accessible location. The resulting cuts will often bleed and will eventually leave a characteristic pattern of scars. |
Other methods used include stabbing an area, most often the upper arm, with a needle or sharp, pointed knife; inflicting a superficial burn with a lit cigarette end; or burning the skin by repeated rubbing with an eraser. Engagement in nonsuicidal self—injury with mul- tiple methods is associated with more severe psychopathology, including engagement in suicide attempts. |
The great majority of individuals Who engage in nonsuicidal self—injury do not seek clinical attention. It is not known if this reflects frequency of engagement in the disorder, because accurate reporting is seen as stigmatizing, or because the behaviors are experi- enced positively by the individual who engages in them, who is unmotivated to receive treatment. Young Children might experiment with these behaviors but not experience re- lief. In such cases, youths often report that the procedure is painful or distressing and might then discontinue the practice. |
Nonsuicidal self—injury most often starts in the early teen years and can continue for many years. Admission to hospital for nonsuicidal self—injury reaches a peak at 20—29 years of age and then declines. However, research that has examined age at hospitalization did not provide information on age at onset of the behavior, and prospective research is needed to outline the natural history of nonsuicidal self—injury and the factors that promote or in- hibit its course. Individuals often learn of the behavior on the recommendation or observa- tion of another. Research has shown that when an individual who engages in nonsuicidal self—injury is admitted to an inpatient unit, other individuals may begin to engage in the behavior. |
Male and female prevalence rates of nonsuicidal self—injury are closer to each other than in suicidal behavior disorder, in which the female-to-male ratio is about 3:1 or 4:1. |
Two theories of psychopathology—based on functional behavioral analyses—have been proposed: In the first, based on learning theory, either positive or negative reinforcement sustains the behavior. Positive reinforcement might result from punishing oneself in a way that the individual feels is deserved, with the behavior inducing a pleasant and relaxed state or generating attention and help from a significant other, or as an expression of anger. Neg- ative reinforcement results from affect regulation and the reduction of unpleasant emotions or avoiding distressing thoughts, including thinking about suicide. In the second theory, nonsuicidal self-injury is thought to be a form of self—punishment, in which self—punitive ac- tions are engaged in to make up for acts that caused distress or harm to others. |
Functional Consequences of Nonsuicidal SeIf-lniuryThe act of cuttingkmight be performed with shared implements, raising the possibility of blood—bome disease transmission. |
Borderline personality disorder. As indicated, nonsuicidal self-injury has long been re- garded as a ”symptom" of borderline personality disorder, even though comprehensive clinical evaluations have found that most individuals with nonsuicidal self-injury have symptoms that also meet criteria for other diagnoses, with eating disorders and substance use disorders being especially common. Historically, nonsuicidal self-injury was regarded as pathognomonic of borderline personality disorder. Both conditions are associated with several other diagnoses. Although frequently associated, borderline personality disorder is not invariably found in individuals with nonsuicidal self—injury. The two conditions dif- fer in several ways. Individuals with borderline personality disorder often manifest dis- turbed aggressive and hostile behaviors, whereas nonsuicidal self—injury is more often associated with phases of closeness, collaborative behaviors, and positive relationships. At a more fundamental level, there are differences in the involvement of different neurotrans— mitter systems, but these will not be apparent on clinical examination. |
Suicidal behavior disorder. The differentiation between nonsuicidal self-injury and sui- cidal behavior disorder is based either on the stated goal of the behavior being a wish to die (suicidal behavior disorder) or, in nonsuicidal self—injury, to experience relief as de- scribed in the criteria. Depending on the circumstances, individuals may provide reports of convenience, and several studies report high rates of false intent declaration. Individu- als with a history of frequent nonsuicidal self—injury episodes have learned that a session of cutting, while painful, is, in the short-term, largely benign. Because individuals with nonsuicidal self—injury can and do attempt and commit suicide, it is important to check past history of suicidal behavior and to obtain information from a third party concerning any recent change in stress exposure and mood. Likelihood of suicide intent has been as- sociated with the use of multiple previous methods of self—harm. |
In a follow-up study of cases of ”self—harm" in males treated at one of several multiple emergency centers in the United Kingdom, individuals with nonsuicidal self-injury were significantly more likely to commit suicide than other teenage individuals drawn from the same cohort. Studies that have examined the relationship between nonsuicidal self-injury and suicidal behavior disorder are limited by being retrospective and failing to obtain ver- ified accounts of the method used during previous "attempts.” A significant proportion of have ever engaged in self-cutting (or their preferred means of self—injury) with an intention to die. It is reasonable to conclude that nonsuicidal self-injury, while not presenting a high risk for suicide when first manifested, is an especially dangerous form of self—injurious behavior. |
This conclusion is also supported by a multisite study of depressed adolescents who had previously failed to respond to antidepressant medication, which noted that those with pre- vious nonsuicidal self—injury did not respond to cognitive-behavioral therapy, and by a study that found that nonsuicidal self-injury is a predictor of substance use/misuse. |
Trichotillomania (hair-pulling disorder). Trichotillomania is an injurious behavior con- fined to pulling out one’s own hair, most commonly from the scalp, eyebrows, or eyelashes. |
The behavior occurs in ”sessions" that can last for hours. It is most likely to occur during a period of relaxation or distraction. |
Stereotypic seIf-injury. Stereotypic self—injury, which can include head banging, self- biting, or self—hitting, is usually associated with intense concentration or under conditions of low external stimulation and might be associated with developmental delay. |
Excoriation (skin-picking) disorder. Excoriation disorder occurs mainly in females and is usually directed to picking at an area of the skin that the individual feels is unsightly or a blemish, usually on the face or the scalp. As in nonsuicidal self-injury, the picking is often preceded by an urge and is experienced as pleasurable, even though the individual real- izes that he or she is harming himself or herself. It is not associated with the use of any im- plement. |
Highlights of Changes From DSM-IV to DSM-5 ................... 809Glossary of Technical Terms .................................. 817Glossary of Cultural Concepts of Distress ....................... 833Alphabetical Listing of DSM-5 Diagnoses and Codes (lCD-9-CM and lCD—10-CM) ................................. 839 |
Numerical Listing of DSM—5 Diagnoses and Codes (ICD-9-CM) ...... 863 |
Numerical Listing of DSM-5 Diagnoses and Codes (|CD-10-CM) ..... 877 |
DSM-5 Advisors and Other Contributors ......................... 897 ‘ Highlights °f Changes Fro . |
DSM-IV to DSMC ham 9% mad 9 IO DSM-5 diagnostic criteria and texts are outlined in this chapter in the same order in which they appear in the DSM-S classification. This abbreviated descrip- tion is intended to orient readers to only the most significant changes in each disorder cate- gory. An expanded description of nearly all changes (e.g., except minor text or wording changes needed for clarity) is available online (www.psychiatry.org/ dsmS). It should also be noted that Section I contains a description of changes pertaining to the chapter organization in DSM-S, the multiaxial system, and the introduction of dimensional assessments. |
The term mental retardation was used in DSM-IV. However, intellectual disability (intel- lectual developmental disorder) is the term that has come into common use over the past two decades among medical, educational, and other professionals, and by the lay public and advocacy groups. Diagnostic criteria emphasize the need for an assessment of both cognitive capacity (IQ) and adaptive functioning. Severity is determined by adaptive func- tioning rather than IQ score. |
The communication disorders, which are newly named from DSM-IV phonological dis- order and stuttering, respectively, include language disorder (which combines the previous expressive and mixed receptive-expressive language disorders), speech sound disorder (pre- viously phonological disorder), and childhood-onset fluency disorder (previously stutter- ing). Also included is social (pragmatic) communication disorder, a new condition involving persistent difficulties in the social uses of verbal and nonverbal communication. |
Autism spectrum disorder is a new DSM-S disorder encompassing the previous DSM- |
IV autistic disorder (autism), Asperger’s disorder, Childhood disintegrative disorder,Rett’s disorder, and pervasive developmental disorder not otherwise specified. It is char- acterized by deficits in two core domains: 1) deficits in social communication and social in- teraction and 2) restricted repetitive patterns of behavior, interests, and activities. |
Several changes have been made to the diagnostic criteria for attention-deficit/hyperactiv- ity disorder (ADHD). Examples have been added to the criterion items to facilitate application across the life span; the age at onset description has been changed (from “some hyperactive- to ”Several inattentive or hyperactive-impulsive symptoms were present prior to age 12”); subtypes have been replaced with presentation specifiers that map directly to the prior sub- types; a comorbid diagnosis with autism spectrum disorder is now allowed; and a symptom threshold change has been made for adults, to reflect the substantial evidence of Clinically sig- nificant ADHD impairment, with the cutoff for ADHD of five symptoms, instead of six re- quired for younger persons, both for inattention and for hyperactivity and impulsivity. |
Specific learning disorder combines the DSM-IV diagnoses of reading disorder, math- ematics disorder, disorder of written expression, and learning disorder not otherwise specified. Learning deficits in the areas of reading, written expression, and mathematics are coded as separate specifiers. Acknowledgment is made in the text that specific types of reading deficits are described internationally in various ways as dyslexia and specific types of mathematics deficits as dyscalculia. |
810 Highlights of Changes From DSM-IV to DSM-5The following motor disorders are included in DSM-S: developmental coordination disor- der, stereotypic movement disorder, Tourette’s disorder, persistent (chronic) motor or vocal tic disorder, provisional tic disorder, other specified tic disorder, and unspecified tic disorder. |
The tic criteria have been standardized across all of these disorders in this chapter. |
Two changes were made to Criterion A for schizophrenia: 1) the elimination of the special at- tribution of bizarre delusions and Schneiderian first-rank auditory hallucinations (e.g., two or more voices conversing), leading to the requirement of at least two Criterion A symptoms for any diagnosis of schizophrenia, and 2) the addition of the requirement that at least one of the |
Criterion A symptoms must be delusions, hallucinations, or disorganized speech. The DSM-IV subtypes of schizophrenia were eliminated due to their limited diagnostic stability, low reli- ability, and poor validity. Instead, a dimensional approach to rating severity for the core symp- toms of schizophrenia is included in DSM-S Section III to capture the important heterogeneity in symptom type and severity expressed across individuals with psychotic disorders. |
Schizoaffective disorder is reconceptualized as a longitudinal instead of a cross-sectional di- agnosis—more comparable to schizophrenia, bipolar disorder, and major depressive disorder, which are bridged by this condition—and requires that a major mood episode be present for a majority of the total disorder’s duration after Criterion A has been met. Criterion A for delu- sional disorder no longer has the requirement that the delusions must be nonbizarre; a spec- ifier is now included for bizarre type delusions to provide continuity with DSM-IV. Criteria for catatonia are described uniformly across DSM-5. Furthermore, catatonia may be diagnosed with a specifier (for depressive, bipolar, and psychotic disorders, including schizophrenia), in the context of a known medical condition, or as an other specified diagnosis. |
activity or energy. The DSM-IV diagnosis of bipolar I disorder, mixed episodes—requiring that the individual simultaneously meet full criteria for both mania and major depressive ep- isode—is replaced with a new specifier "with mixed features.“ Particular conditions can now be diagnosed under other specified bipolar and related disorder, including categori- zation for individuals with a past history of a major depressive disorder whose symptoms meet all criteria for hypomania except the duration criterion is not met (i.e., the episode lasts only 2 or 3 days instead of the required 4 consecutive days or more). A second condition con- stituting an other specified bipolar and related disorder variant is that too few symptoms of hypomania are present to meet criteria for the full bipolar II syndrome, although the dura- tion, at least 4 consecutive days, is sufficient. Finally, in both this chapter and in the chapter ”Depressive Disorders,” an anxious distress specifier is delineated. |
To address concerns about potential overdiagnosis and overtreatment of bipolar disorder in children, a new diagnosis, disruptive mood dysregulation disorder, is included for children up to age 18 years who exhibit persistent irritability and frequent episodes of extreme behav- ioral dyscontrol. Premenstrual dysphoric disorder is now promoted from Appendix B, ”Cri- teria Sets and Axes Provided for Further Study,” in DSM-IV to the main body of DSM-S. What was referred to as dysthyrnia in DSM-IV now falls under the category of persistent depressive disorder, which includes both chronic major depressive disorder and the previous dysthymic disorder. The coexistence within a major depressive episode of at least three manic symp- toms (insufficient to satisfy criteria for a manic episode) is now acknowledged by the specifier |
Highlights of Changes From DSM-IV to DSM-5 811 ”with mixed features." In DSM-IV, there was an exclusion criterion for a major depressive ep- isode that was applied to depressive symptoms lasting less than 2 months following the death of a loved one (i.e., the bereavement exclusion). This exclusion is omitted in DSM—S for several reasons, including the recognition that bereavement is a severe psychosocial stressor that can precipitate a major depressive episode in a vulnerable individual, generally beginning soon after the loss, and can add an additional risk for suffering, feelings of worthlessness, suicidal ideation, poorer medical health, and worse interpersonal and work functioning. It was critical to remove the implication that bereavement typically lasts only 2 months, when both physi- cians and grief counselors recognize that the duration is more commonly 1—2 years. A detailed footnote has replaced the more simplistic DSM-IV exclusion to aid clinicians in making the critical distinction between the symptoms characteristic of bereavement and those of a major depressive disorder. Finally, a new specifier to indicate the presence of mixed symptoms has been added across both the bipolar and the depressive disorders. |
The chapter on anxiety disorders no longer includes obsessive-compulsive disorder (which is in the new chapter ”Obsessive-Compulsive and Related Disorders”) or posttraumatic stress disorder (PTSD) and acute stress disorder (which are in the new chapter ”Trauma- and Stressor-Related Disorders"). Changes in criteria for specific phobia and social anxiety disorder (social phobia) include deletion of the requirement that individuals over age 18 years recognize that their anxiety is excessive or unreasonable. Instead, the anxiety must be out of proportion to the actual danger or threat in the situation, after cultural contextual fac- tors are taken into account. In addition, the 6-month duration is now extended to all ages. |
Panic attacks can now be listed as a specifier that is applicable to all DSM-5 disorders. Panic disorder and agoraphobia are unlinked in DSM-S. Thus, the former DSM-IV diagnoses of panic disorder with agoraphobia, panic disorder without agoraphobia, and agoraphobia without history of panic disorder are now replaced by two diagnoses, panic disorder and ag- oraphobia, each with separate criteria. The ”generalized" specifier for social anxiety disor- der has been deleted and replaced with a ”performance only” specifier. Separation anxiety disorder and selective mutism are now classified as anxiety disorders. The wording of the criteria is modified to more adequately represent the expression of separation anxiety symp- toms in adulthood. Also, in contrast to DSM-IV, the diagnostic criteria no longer specify that onset must be before age 18 years, and a duration statement—"typically lasting for 6 months or more”—has been added for adults to minimize overdiagnosis of transient fears. |
The chapter ”Obsessive-Compulsive and Related Disorders" is new in DSM-S. New disor- ders include hoarding disorder, excoriation (skin-picking) disorder, substance/medica- tion-induced obsessive-compulsive and related disorder, and obsessive-compulsive and related disorder due to another medical condition. The DSM-IV diagnosis of trichotillo- mania is now termed trichotillomania (hair-pulling disorder) and has been moved from a |
DSM—IV classification of impulse—control disorders not elsewhere classified to obsessive- compulsive and related disorders in DSM-5. The DSM-IV ”with poor insight” specifier for obsessive-compulsive disorder has been refined to allow a distinction between individuals with good or fair insight, poor insight, and "absent insight/delusional” obsessive-compul- sive disorder beliefs (i.e., complete conviction that obsessive-compulsive disorder beliefs are true). Analogous "insight” specifiers have been included for body dysmorphic disorder and hoarding disorder. A "tic-related" specifier for obsessive-compulsive disorder has also been added, because presence of a comorbid tic disorder may have important clinical im- plications. A ”muscle dysmorphia” specifier for body dysmorphic disorder is added to re- flect a growing literature on the diagnostic validity and clinical utility of making this 812 Highlights of Changes From DSM-IV to DSM-5 distinction in individuals with body dysmorphic disorder. The delusional variant of body dysmorphic disorder (which identifies individuals who are completely convinced that their perceived defects or flaws are truly abnormal appearing) is no longer coded as both delu- sional disorder, somatic type, and body dysmorphic disorder; in DSM-S, this presentation is designated only as body dysmorphic disorder with the absent insight/ delusional specifier. |
Individuals can also be diagnosed with other specified obsessive-compulsive and related disorder, which can include conditions such as body-focused repetitive behavior disorder and obsessional jealousy, or unspecified obsessive-compulsive and related disorder. |
For a diagnosis of acute stress disorder, qualifying traumatic events are now explicit as to whether they were experienced directly, witnessed, or experienced indirectly. Also, the |
DSM-IV Criterion A2 regarding the subjective reaction to the traumatic event (e.g., expe- riencing ”fear, helplessness, or horror”) has been eliminated. Adjustment disorders are reconceptualized as a heterogeneous array of stress-response syndromes that occur after exposure to a distressing (traumatic or nontraumatic) event, rather than as a residual cat- not meet criteria for a more discrete disorder (as in DSM-IV). |
DSM-S criteria for PTSD differ significantly from the DSM-IV criteria. The stressor cri- terion (Criterion A) is more explicit with regard to events that qualify as ”traumatic” ex- periences. Also, DSM-IV Criterion A2 (subjective reaction) has been eliminated. Whereas there were three major symptom clusters in DSM-IV—reexperiencing, avoidance/numb- ing, and arousal—there are now four symptom clusters in DSM-5, because the avoidance/ numbing cluster is divided into two distinct clusters: avoidance and persistent negative al- terations in cognitions and mood. This latter category, which retains most of the DSM-IV numbing symptoms, also includes new or reconceptualized symptoms, such as persistent negative emotional states. The final cluster—alterations in arousal and reactivity—retains most of the DSM-IV arousal symptoms. It also includes irritable behavior or angry out- bursts and reckless or self—destructive behavior. PTSD is now developmentally sensitive in that diagnostic thresholds have been lowered for children and adolescents. Furthermore, separate criteria have been added for children age 6 years or younger with this disorder. |
The DSM-IV childhood diagnosis reactive attachment disorder had two subtypes: emotionally withdrawn/ inhibited and indiscriminately social/disinhibited. In DSM-S, these subtypes are defined as distinct disorders: reactive attachment disorder and disin- hibited social engagement disorder. |
Major changes in dissociative disorders in DSM-S include the following: 1) derealization is included in the name and symptom structure of what previously was called depersonali- zation disorder (depersonalization/derealization disorder); 2) dissociative fugue is now a specifier of dissociative amnesia rather than a separate diagnosis, and 3) the criteria for dissociative identity disorder have been changed to indicate that symptoms of disruption of identity may be reported as well as observed, and that gaps in the recall of events may occur for everyday and not just traumatic events. Also, experiences of pathological pos- session in some cultures are included in the description of identity disruption. |
In DSM-5, somatoform disorders are now referred to as somatic symptom and related dis- orders. The DSM-S classification reduces the number of these disorders and subcategories to avoid problematic overlap. Diagnoses of somatization disorder, hypochondriasis, pain dis- order, and undifferentiated somatoform disorder have been removed. Individuals previ- |
Highlights of Changes From DSM-IV to DSM—5 813 ously diagnosed with somatization disorder will usually have symptoms that meet DSM-5 criteria for somatic symptom disorder, but only if they have the maladaptive thoughts, feel- ings, and behaviors that define the disorder, in addition to their somatic symptoms. Because the distinction between somatization disorder and undifferentiated somatoform disorder was arbitrary, they are merged in DSM—S under somatic symptom disorder. Individuals pre- viously diagnosed with hypochondriasis who have high health anxiety but no somatic symp- toms would receive a DSM-S diagnosis of illness anxiety disorder (unless their health anxiety was better explained by a primary anxiety disorder, such as generalized anxiety dis- order). Some individuals with chronic pain would be appropriately diagnosed as having so- matic symptom disorder, with predominant pain. For others, psychological factors affecting other medical conditions or an adjustment disorder would be more appropriate. |
Psychological factors affecting other medical conditions is a new mental disorder in |
DSM-5, having formerly been listed in the DSM-IV chapter ”Other Conditions That May |
Be a Focus of Clinical Attention.” This disorder and factitious disorder are placed among the somatic symptom and related disorders because somatic symptoms are predominant in both disorders, and both are most often encountered in medical settings. The variants of psychological factors affecting other medical conditions are removed in favor of the stern diagnosis. Criteria for conversion disorder (functional neurological symptom disorder) have been modified to emphasize the essential importance of the neurological examina- tion, and in recognition that relevant psychological factors may not be demonstrable at the time of diagnosis. Other specified somatic symptom disorder, other specified illness anx- iety disorder, and pseudocyesis are now the only exemplars of the other specified somatic symptom and related disorder classification. |
Because of the elimination of the DSM-IV-TR chapter ”Disorders Usually First Diagnosed |
During Infancy, Childhood, or Adolescence,” this chapter describes several disorders found in the DSM-IV section ”Feeding and Eating Disorders of Infancy or Early Childhood,” such as pica and rumination disorder. The DSM-IV category feeding disorder of infancy or early childhood has been renamed avoidant/restrictive food intake disorder, and the criteria are significantly expanded. The core diagnostic criteria for anorexia nervosa are conceptually un- changed from DSM-IV with one exception: the requirement for amenorrhea is eliminated. As in DSM—IV, individuals with this disorder are required by Criterion A to be at a significantly low body weight for their developmental stage. The wording of the criterion is changed for clarification, and guidance regarding how to judge whether an individual is at or below a sig- nificantly low weight is provided in the text. In DSM-S, Criterion B is expanded to include not only overtly expressed fear of weight gain but also persistent behavior that interferes with weight gain. The only change in the DSM-IV criteria for bulimia nervosa is a reduction in the required minimum average frequency of binge eating and inappropriate compensatory be- havior frequency from twice to once weekly. The extensive research that followed the prom- ulgation of preliminary criteria for binge-eating disorder in Appendix B of DSM-IV documented the clinical utility and validity of binge—eating disorder. The only significant dif- ference from the preliminary criteria is that the minimum average frequency of binge eating re- quired for diagnosis is once weekly over the last 3 months, identical to the frequency criterion for bulimia nervosa (rather than at least 2 days a week for 6 months in DSM-IV). |
There have been no significant changes in this diagnostic class from DSM-IV to DSM-S. |
The disorders in this chapter were previously classified under disorders usually first di- agnosed in infancy, childhood, or adolescence in DSM-IV and exist now as an independent classification in DSM-S. |
814 Highlights of Changes From DSM-IV to DSM-5In DSM-5, the DSM-IV diagnoses named sleep disorder related to another mental disorder and sleep disorder related to another medical condition have been removed, and instead greater specification of coexisting conditions is provided for each sleep-wake disorder. The diagnosis of primary insomnia has been renamed insomnia disorder to avoid the differen- tiation between primary and secondary insomnia. DSM-S also distinguishes narcolepsy— now known to be associated with hypocretin deficiency—from other forms of hypersomno- lence (hypersomnolence disorder). Finally, throughout the DSM-S classification of sleep- wake disorders, pediatric and developmental criteria and text are integrated where existing science and considerations of clinical utility support such integration. Breathing-related sleep disorders are divided into three relatively distinct disorders: obstructive sleep apnea hypopnea, central sleep apnea, and sleep-related hypoventilation. The subtypes of circadian rhythm sleep disorders are expanded to include advanced sleep phase type and irregular sleep-wake type, whereas the jet lag type has been removed. The use of the former “not oth- ment sleep behavior disorder and restless legs syndrome to independent disorders. |
In DSM-5, some gender-specific sexual dysfunctions have been added, and, for females, sexual desire and arousal disorders have been combined into one disorder: female sexual interestlarousal disorder. All of the sexual dysfunctions (except substance/medication-in- duced sexual dysfunction) now require a minimum duration of approximately 6 months and more precise severity criteria. Genito-pelvic pain/penetration disorder has been added to |
DSM-S and represents a merging of vaginismus and dyspareunia, which were highly co- morbid and difficult to distinguish. The diagnosis of sexual aversion disorder has been re- moved due to rare use and lack of supporting research. |
There are now only two subtypes for sexual dysfunctions: lifelong versus acquired and generalized versus situational. T0 indicate the presence and degree of medical and other nonmedical correlates, the following associated features have been added to the text: partner factors, relationship factors, individual vulnerability factors, cultural or religious factors, and medical factors. |
Gender dysphoria is a new diagnostic class in DSM-S and reflects a change in conceptual- ization of the disorder’s defining features by emphasizing the phenomenon of ”gender in- congruence” rather than cross-gender identification per se, as was the case in DSM-IV gender identity disorder. Gender dysphoria includes separate sets of criteria: for children and for adults and adolescents. For the adolescents and adults criteria, the previous Criterion A (cross-gender identification) and Criterion B (aversion toward one’s gender) are merged. In the wording of the criteria, ”the other sex” is replaced by ”the other gender" (or ”some alter- native gender").” Gender instead of sex is used systematically because the concept ”sex” is in- adequate when referring to individuals with a disorder of sex development. In the child criteria, ”strong desire to be of the other gender” replaces the previous ”repeatedly stated de- sire to be...the other sex” to capture the situation of some children who, in a coercive envi- ronment, may not verbalize the desire to be of another gender. For children, Criterion A1 (”a strong desire to be of the other gender or an insistence that he or she is the other gender.. .)” is now necessary (but not sufficient), which makes the diagnosis more restrictive and conser- vative. The subtyping on the basis of sexual orientation is removed because the distinction is no longer considered clinically useful. A posttransition specifier has been added to identify |
Highlights of Changes From DSM-IV to DSM-S 815 individuals who have undergone at least one medical procedure or treatment to support the new gender assignment (e.g., cross-sex hormone treatment). Although the concept of post- transition is modeled on the concept of full or partial remission, the term remission has impli- cations in terms of symptom reduction that do not apply directly to gender dysphoria. |
Disruptive, Impulse-Control, and Conduct DisordersThe chapter “Disruptive, Impulse—Control, and Conduct Disorders” is new to DSM-S and combines disorders that were previously included in the chapter “Disorders Usually First Di- agnosed in Infancy, Childhood, or Adolescence” (i.e., oppositional defiant disorder; conduct disorder; and disruptive behavior disorder not otherwise specified, now categorized as other specified and unspecified disruptive, impulse—control, and conduct disorders) and the chap- ter ”Impulse—Control Disorders Not Elsewhere Classified” (i.ei, intermittent explosive disor- der, pyromania, and kleptomania). These disorders are all characterized by problems in emotional and behavioral self—control. Notably, ADHD is frequently comorbid with the dis- orders in this chapter but is listed with the neurodevelopmental disorders. Because of its close association with conduct disorder, antisocial personality disorder is listed both in this chapter and in the chapter ”Personality Disorders,” where it is described in detail. |
The criteria for oppositional defiant disorder are now grouped into three types: an- gry/irritable mood, argumentative/defiant behavior, and vindictiveness. Additionally, the exclusionary criterion for conduct disorder has been removed. The criteria for conduct the disorder but also present with limited prosocial emotions. The primary change in in- termittent explosive disorder is in the type of aggressive outbursts that should be consid- ered: DSM-IV required physical aggression, whereas in DSM-5 verbal aggression and nondestructive/noninjurious physical aggression also meet criteria. DSM-S also provides more specific criteria defining frequency needed to meet the criteria and specifies that the aggressive outbursts are impulsive and / or anger based in nature, and must cause marked distress, cause impairment in occupational or interpersonal functioning, or be associated with negative financial or legal consequences. Furthermore, a minimum age of 6 years (or equivalent developmental level) is now required. |
An important departure from past diagnostic manuals is that the chapter on substance—related disorders has been expanded to include gambling disorder. Another key change is that |