Introduction to

DSM-5

Eva Miller, Ph.D., CRC

Licensed Psychologist
Introduction

•  Why change the

DSM?
•  The purpose of a
diagnosis
–  Common language
–  Inform clinical care
Overview
•  Reorganization of DSM-5

•  Highlight of Changes

•  Removal of Multiaxial System

•  Changes in Criteria for Specific Disorders

DSM 1952-2013
APA Web Sites
•  http://www.dsm5.org/Documents/changes
%20from%20dsm-iv-tr%20to%20dsm-5.pdf
Overview of changes from DSM-IV-TR

•  http://www.dsm5.org/Documents/IMPORTANT
%20CODING%20CORRECTIONS%20FOR
%20DSM-5%208-9-13.pdf
Coding corrections
Contents
•  Section I
–  Introduction and use of the manual
–  Forensic use of DSM-5
•  Section II
–  Diagnostic criteria and codes (22
disorders)
•  Section III
•  Assessment measures
•  Cultural formulation
•  Alternative DSM-5 model for personality
disorders
•  Conditions for further study
Reorganization of DSM-5
•  Lifespan approach: childhood and neurodevelopmental
disorders developing in adolescence and early adulthood
and neurocognitive disorders

•  Autism Spectrum Disorder: consolidates Autistic

Disorder, Asperger’s Disorder, and Pervasive
Developmental Disorder

•  Streamlined classification of bipolar and depressive

disorders: all component criteria included within
respective criteria for bipolar I, bipolar II, and major
depressive disorder
Reorganization of DSM-5

•  Substance abuse and substance

dependence: have been eliminated and
replaced with substance use disorders
–  “dependence” is often confused with
“addiction”
–  tolerance and withdrawal previously defined
as dependence are normal responses to
prescription medications that affect the CNS
and do not necessarily indicate the presence
of addiction
Reorganization of DSM-5
•  Alternative Model of Personality
Disorders:
–  Criterion A: Level of Personality Functioning
– disturbances in self and interpersonal
functioning constitute the core of personality
psychopathology, evaluated on a continuum
–  Criterion B: Pathological Personality Traits
organized into 5 broad domains: Negative
Affectivity, Detachment, Antagonism,
Disinhibition, and Psychoticism
Highlight of Changes
•  Autism Spectrum Disorder
•  Intellectual Disability (vs. Mental Retardation)
•  Bereavement Exclusion (Removed)
•  Disruptive Mood Dysregulation Disorder (new name
for childhood bipolar disorder and listed under
depressive disorders)
•  Binge Eating Disorder
•  Premenstrual Dysphoric Disorder
•  Major and Mild Neurocognitive Disorder
•  Hoarding Disorder
Coding and Billing
•  Effective October 1, 2015 all entities, including
health care providers, covered by the Health
Insurance Portability and Accountability Act
(HIPAA) must convert to using the ICD-10-CM
diagnosis code sets
–  Example: Schizophrenia 295.90 (F20.9)

•  ICD-11: Due out 2015

Multiaxial System
•  DSM-5 has moved to a nonaxial system
(formerly Axis I, Axis II, and Axis III)
•  Separate notation used for psychosocial and
contextual factors (formerly Axis IV)
•  Separate notation used for disability (formerly
Axis V)
•  Axes I and II have been combined
 Other Condition That May Be a Focus of
Clinical Attention: Replaces Psychosocial
Stressors (Axis IV)
1.  Relational
2.  Educational and Occupational Problems
3.  Housing and Economic Problems
4.  Other Problems Related to the Social Environment
5.  Problems Related to Crime or Interaction with the Legal
System
6.  Other Health Service Encounters for Counseling and
Medical Advice
7.  Problems Related to Other Psychosocial, Personal and
Environmental Circumstances
8.  Other Circumstances of Personal History
GAF
•  Global Assessment of Functioning (GAF)
represents clinician’s judgment of client’s
overall functioning has been dropped from
DSM-5

•  Use severity and specifiers instead

–  Listed under each disorder
–  Assessment Measures (pp. 733-748)
Severity and Course: Example
•  Clinician-Rated Dimension of Psychosis
Symptom Severity (pp. 743-744)
–  Current severity = within last 7 days
–  5-point scale ranging
0 = not present
4 = present and severe

Reference “Assessment Measures” (pp. 733-748)

Clinician-Rated Dimensions of Psychosis
Symptom Severity
Instructions: Based on all the information you have on the
individual and using your clinical judgment, please rate
(with checkmark) the presence and severity of the
following symptoms as experienced by the individual in
the past seven (7) days.

Domain 0 1 2 3 4 Score
I. Hallucinations θ Not present θ Equivocal (severity or duration
not sufficient to be considered psychosis) θ Present, but mild
(little pressure to act upon voices, not very bothered by voices) θ
Present and moderate (some pressure to respond to voices, or is
somewhat bothered by voices) θ Present and severe (severe
pressure to respond to voices, or is very bothered by voices)
WHO Disability Assessment Schedule 2.0
•  Cognition – understanding & communicating

•  Mobility– moving & getting around

•  Self-care– hygiene, dressing, eating & staying alone

•  Getting along– interacting with other people

•  Life activities– domestic responsibilities, leisure,

work & school

•  Participation– joining in community activities

Specifiers
•  To define a homogenous subgrouping of
individuals with the disorder who share certain
features

•  Examples:
296.21 Major Depressive Disorder Single Episode,
Mild, With Anxious Distress
296.32 Major Depressive Disorder, Recurrent,
Moderate, With Atypical Features
Not Otherwise Specified (NOS)

•  NOS has been replaced with:

– “Other Specified Disorder”

– “Unspecified Disorder”
Other Specified Disorder
•  Developed so clinician can communicate
specific reason the presentation does not
meet the criteria for any specific disorder
within a diagnostic class
•  “Other Specified Depressive Disorder,
Depressive Episode with Insufficient
Symptoms”
Unspecified Disorder
•  Used when the clinician does not specify the
reason the criteria are not met for a disorder:
–  equivalent of the “Not Otherwise Specified” in
DSM-IV-TR

Example: “Unspecified Depressive Disorder”

NOTE: DSM-5 provides no category for Unspecified Mood

Disorder. This makes it impossible to diagnose and code the
frequently encountered presentations that are not yet clearly
unipolar or bipolar
Terminology
•  The phrase “general medical
condition” is replaced in DSM-5 with
“another medical condition” where
relevant across all disorders
Coding Sample
•  Diagnosis I: 301.83 Borderline Personality Disorder
•  Diagnosis II: 300.4 Persistent Depressive Disorder,
With Melancholic Features, Late Onset,
With Intermittent Major Depressive
Episodes, With Current Episode Severe
•  Other Condition That May Be a Focus of Clinical
Attention: V15.41 Past History of Sexual Abuse in
Childhood
Medical Conditions: Diabetes, HTN
Psychosocial Stressors: Unemployed
Coding Sample
Principal Diagnosis:
•  303.90 (F10.20) Alcohol Use Disorder Moderate
•  304.30 (F12.20) Cannabis Use Disorder Severe
Provisional Diagnosis:
•  291.89 (F10.14) Substance/Medication-Induced Depressive
Disorder with Moderate Alcohol Use Disorder
Other Condition That May Be a Focus of Clinical Attention
•  V61.10 (Z63.0) Relationship Distress with Spouse or Intimate
Partner
•  V61.8 (Z63.8) High Expressed Emotion Level within Family
•  V62.5 (Z65.3) Problem Related to Other Legal Circumstances
Intellectual Disability
(Intellectual Developmental Disorder)
•  Criteria include both cognitive capacity (IQ) and
adaptive functioning
•  Severity is determined by adaptive functioning
rather than IQ score
•  pp. 34-36 (Conceptual, Social, and Practical domains)
•  IQ or similar standardized test scores should still
be included in an individual’s assessment
•  In DSM-5, intellectual disability is considered to be
approximately 2 standard deviations or more
below the population, which equals an IQ score of
about 70 or below
Intellectual Disability
When typical assessment is difficult
or impossible:
• Global Developmental Delay-
children under age 5
• Unspecified Intellectual
Disability- individuals over age
5
Communication Disorders
•  Communication Disorders (formerly known as
phonological disorders)
–  Language Disorder- (combines expressive
language disorder and mixed receptive-
expressive language disorder)
–  Speech Sound Disorder- previously
phonological disorder
–  Childhood-Onset Fluency Disorder-
(formerly stuttering)
–  Social (pragmatic) Communication
Disorder- new condition that involves
persistent difficulties in the social use of
verbal and nonverbal communication
Autism Spectrum Disorder
•  Autism Spectrum Disorder- encompasses DSM-IV
autistic disorder, Asperger's disorder, childhood
disintegrative disorder, Rett’s disorder, and
pervasive developmental disorder NOS
•  Characterized by 2 main deficits: (vs. 3 in DSM-IV)
–  Deficits in social communication and social integration
(combined in DSM-5)
–  Restricted repetitive patterns of behavior, interests,
and activities
Attention-Deficit/Hyperactivity Disorder
•  Same 18 symptoms are used as in DSM-IV
•  Cross-situational requirement has been strengthened
•  Onset criterion has been changed from “symptoms that
caused impairment were present before age 7 years” to
“several inattentive or hyperactive-impulsive symptoms
were present prior to age 12”
•  Subtypes have been replaced with specifiers
•  Comorbid diagnosis with ASD is now allowed
•  Change has been made for adults age 17 and over (5
vs. 6 symptoms) and types of symptoms may be different
Specific Learning Disorder
•  Combines DSM-IV diagnoses of reading
disorder, mathematics disorder, disorder of
written expression, and learning disorder not
otherwise specified
•  Deficits in reading, written expression, and
math are now coded as separate specifiers:
– 315.00 Specific Learning Disorder With
Impairment in Reading, Reading
Comprehension
Motor Disorders
–  Developmental Coordination Disorder
–  Stereotypic Movement Disorder
–  Tourette’s Disorder
–  Persistent Motor or Tic Disorder
–  Provisional Tic Disorder
–  Other Specified Tic Disorder
–  Tic criteria have been standardized across above

Stereotypic movement disorder has been more clearly

differentiated from body-focused repetitive behavior
disorders in obsessive-compulsive disorders
Delusional Disorder
•  Delusions are no longer required to be
nonbizarre

•  Includes exclusion criteria for OCD and

body dysmorphic disorder with absent
insight/delusional beliefs
Schizophrenia
•  Eliminated the special attribution of bizarre delusions and
first-rank auditory hallucinations (i.e., 2 or more voices
conversing) which led to Criterion A symptoms for a
diagnosis

•  2 (vs. 1) Criterion A(e.g., negative symptoms) symptoms

are required for any diagnosis of schizophrenia

•  Added the requirement that at least 1of the Criterion A

symptoms must be delusions, hallucinations, or
disorganized speech (must be + symptoms)

•  Subtypes such as “Paranoid” were eliminated (now based

on severity)
Schizoaffective Disorder
Major change requires that a major mood episode be
present for a majority of the total disorder’s duration after
criterion A has been met

•  Reconceptualized as a longitudinal (vs. cross-sectional)

diagnosis—more comparable to schizophrenia, bipolar
disorder, and major depressive disorder which are
bridged by schizoaffective disorder

•  Criterion A for delusional disorder no longer has the

requirement that the delusions are nonbizarre
Bipolar and Related Disorders
•  Separated from other mood disorders
•  Now includes changes in mood and
changes in activity or energy

•  Bipolar I Disorder- “With Mixed

Features” replaced “Mixed Episodes”
Bipolar I and Bipolar II Disorders

•  Bipolar I Disorder
•  Must meet criteria for at least 1 Manic
Episode which may have been preceded
or followed by hypomanic or depressive
episodes
•  Bipolar II Disorder
•  Must meet criteria for at least 1 Hypomanic
Episode and at least 1 Depressive
Episode
Depressive Disorders
•  Disruptive Mood Dysregulation Disorder- for
children up to age 18 (persistently exhibit irritability
and extreme behavioral dyscontrol)
•  Premenstrual Dysphoric Disorder- added
• 
•  Persistent Depressive Disorder- replaced Dysthymic
Disorder
•  Major Depressive Disorder- if at least 3 manic
symptoms, acknowledged with specifier “with mixed
features”
•  Bereavement exclusion was omitted
Persistent Depressive Disorder

•  Formerly dysthymia

•  Includes both chronic major

depressive disorder and the previous
dysthymic disorder
Persistent Depressive Disorder:
Example

•  300.4 Persistent Depressive

Disorder, With Melancholic
Features, Late Onset, With
Intermittent Major
Depressive Episodes, With
Current Episode Severe
Anxiety Disorders
•  OCD and PTSD have been placed in separate
sections
–  Panic Disorder and Agoraphobhia are no longer
linked
–  Separation Anxiety Disorder and Selective
Mutism are now classified as anxiety disorders
•  Specific Phobia and Social Phobia- deletion of the
requirement that individuals over age 18 recognize
their anxiety is excessive or unreasonable
–  6-month duration extended to all ages
 Obsessive-Compulsive and
Related Disorders
•  Hoarding Disorder (new)
•  Excoriation Disorder (new)
•  Substance/Medication-Induced Obsessive-Compulsive and
Related Disorder and Obsessive-Compulsive and Related
Disorder Due to another Medical Condition
–  recognition that substances, medications, and
medical conditions can present with
symptoms similar to primary obsessive-
compulsive and related disorders
•  Trichotillomania (moved from impulse-control disorders)
Trauma- and Stressor-Related Disorders

•  Acute Stress Disorder- criterion now requires being explicit as

to whether qualifying traumatic events were experienced
directly, witnessed, or experienced indirectly and reduced focus
on dissociative symptoms
–  Criterion A2 regarding the subjective reaction to the
traumatic event (e.g., “the person’s response involved
intense fear, helplessness, or horror”) has been eliminated

•  Adjustment Disorders- stress response that occurs after

exposure to a distressing event rather than as a residual
category for individuals who exhibit clinical distress but whose
symptoms do not meet criteria for a more discrete disorder
•  Reactive Attachment Disorder and Disinhibited Social
Engagement Disorder (2 distinct disorders)
Trauma and Stressor-Related
Disorders: PTSD
–  Stressor criterion is more explicit with regard to
events that qualify as traumatic (1st responders)
–  Criteria for children under age 6 have been added
–  “Subjective reaction” has been eliminated (fear,
helplessness)
–  4 major clusters
•  re-experiencing the event
•  heightened avoidance
•  negative alterations in cognitions and mood
•  alterations in arousal and activity
Trauma and Stressor-Related
Disorders: PTSD
•  NOTE: Now includes:

1.  Directly experiencing the traumatic event(s)

2.  Witnessing in person, the event(s) as if it

occurred to others

3.  Learning that the traumatic event(s) occurred

to a close family member or close friend…
Somatic Symptom and Related
Disorders
•  Somatization disorder, hypochondriasis, pain
disorder have been removed; many of the
individuals diagnosed with one of these disorders
can now be diagnosed with SSD
•  Symptoms may or may not be associated with
another medical condition
•  DSM-IV diagnosis of somatization disorder required
a specific number of complaints from among 4
symptom groups; SSD criteria no longer have such
a requirement
Feeding and Eating Disorders
•  Avoidant/Restrictive Food Intake Disorder
(formerly feeding disorder of infancy or early
childhood)
–  large number of individuals, primarily but not
exclusively children and adolescents,
substantially restrict their food intake and
experience significant associated
physiological or psychosocial problems but did
not meet criteria for any DSM-IV eating
disorder
Feeding and Eating Disorders
•  Anorexia Nervosa- requirement for amenorrhea has
been eliminated
–  Criterion for judging if a person is at or below a
significantly low weight is provided
•  Bulimia Nervosa- reduced frequency of binge eating
and compensatory behaviors changed to once a week
vs. twice weekly
•  Binge-Eating Disorder- (used to be in Appendix B)
intended to increase awareness of the substantial
differences between binge eating and overeating
Sleep-Wake Disorders
•  Sleep disorder related to another mental disorder
and sleep disorder related to another medical
condition have been eliminated
•  Insomnia Disorder replaces Primary Insomnia
•  Integrates pediatric and developmental criteria and text
for numerous sleep-wake disorders

•  rapid eye movement sleep behavior disorder and

restless legs syndrome as independent disorders (vs.
not otherwise specified)

•  10 different sleep disorders

Sexual Dysfunctions
•  Genito-Pelvic Pain/Penetration Disorder (added)
•  Gender-specific sexual dysfunctions have been
added, and, for females, sexual desire and arousal
disorders have been combined into one disorder:
“Female Sexual Interest/Arousal Disorder”
•  Minimum duration of approximately 6 months and
more precise severity criteria
•  Sexual Aversion Disorder (removed due to rare use
and lack of research)
Sexual Dysfunctions: Types
•  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
•  Substance/Medication-Induced Sexual Dysfunction
Gender Dysphoria
•  Neither a sexual dysfunction nor a paraphilia so
separated from them in DSM-5
•  Must be a marked difference between the
individual’s expressed/experienced gender and
the gender others would assign him or her, and
it must continue for at least six months
•  Added a post-transition specifier for people who
are living full-time as the desired gender (with or
without legal sanction of the gender change)
Disruptive, Impulse-Control, and
Conduct Disorders: ODD
–  Symptoms now grouped into 3 types to reflect
emotional and behavioral symptoms:
•  Angry/irritable mood
•  Argumentative/defiant behavior
•  Vindictiveness
–  Criteria to differentiate ODD and “normal” behavior
–  Severity rating has been added

NOTE: Disruptive Behavior Disorder Removed

Conduct Disorder
•  A descriptive features specifier has been added for
individuals who meet full criteria for the disorder but
also present with limited prosocial emotions

•  This specifier applies to those with conduct disorder who

show a callous and unemotional interpersonal style
across multiple settings and relationships

•  Overall, little change to this diagnosis

Disruptive, Impulse-Control, and Conduct
Disorders: IED
•  Physical aggression was required in DSM-IV whereas verbal
aggression and nondestructive or noninjurious physical
aggression also meet criteria in DSM-5
•  DSM-5 provides specific criteria defining frequency needed to
meet 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
•  Minimum age of 6 years (or equivalent developmental level) is
now required
Substance-Related and Addictive Disorders

•  Substance Use Disorders- combines

substance abuse and substance dependence
•  Gambling Disorder- added
•  Cannabis Withdrawal- added
•  Caffeine Withdrawal- added
•  Specifiers
–  “in a controlled environment”
–  “on maintenance therapy”
Substance-Related and Addictive
Disorders
•  Whereas a diagnosis of substance abuse
previously required only one symptom, mild
substance use disorder in DSM-5 requires 2-3
symptoms from a list of 11

•  Drug craving has been added to the list and

problems with law enforcement will be eliminated
because of cultural considerations that make the
criteria difficult to apply internationally
 Neurocognitive Disorders
•  “Dementia” is excluded

•  Major Neurocognitive Disorder

•  Mild Neurocognitive Disorder- permits diagnosis

of less disabling syndromes
–  level of cognitive decline that requires
compensatory strategies and accommodations to
help maintain independence and perform
activities of daily living
Personality Disorders
•  No longer coded separately from other disorders
•  None of the criteria for personality disorders
have changed in the DSM-5
•  An alternative approach to the diagnosis of
personality disorders was developed for DSM-5
for further study and can be found in Section III
Paraphilic Disorders
•  Specifiers “in a controlled environment” and
“in remission” added to the diagnostic criteria
sets for all the paraphilic disorders
•  “In remission” specifier has been added to
indicate remission from a paraphilic disorder
–  No expert consensus about whether a long-standing paraphilia can
entirely remit, but there is less argument that consequent
psychological distress, psychosocial impairment, or the propensity
to do harm to others can be reduced to acceptable levels.
Therefore, the “in remission” specifier has been added to indicate
remission from a paraphilic disorder
Comments or Questions??

evamiller@utpa.edu