2. Changes from DSM-IV-TR to DSM-5
Dr. Hani Hamed Dessoki, M.D.Psychiatry
Prof. Psychiatry
Chairman of Psychiatry Department
Beni Suef University
Supervisor of Psychiatry Department
El-Fayoum University
APA member

3. History

4. Timeline of DSM-5
 1999-2001 Development of Research Agenda
 2002-2007 APA/WHO/NIMH DSM-5/ICD-11
Research Planning conferences
 2006 Appointment of DSM-5 Taskforce
 2007 Appointment of Workgroups
 2007-2011 Literature Review and Data Re-analysis
 2010-2011 1st phase Field Trials ended July 2011
 2011-2012 2nd phase Field Trials began Fall 2011
 July 2012 Final Draft of DSM-5 for APA review
 May 2013 Publication Date of DSM-5

5. Grouping of Diagnostic
Categories
The DSM-5 groups are:
1. Neurodevelopmental
disorders
2. Schizophrenia and primary
psychotic disorders
3. Bipolar and Related
Disorders
4. Mood Disorders
5. Anxiety Disorders
6. Disorders Related to
Environmental Stress
7. Obsessive Compulsive
Spectrum
8. Somatic Symptom Disorder
9. Feeding and Eating Disorder
10. Sleep Disorders
11. Disorders of Sexual Function
12. Antisocial and Disruptive
Disorders
13. Substance Abuse-Related
Disorders
14. Neurocognitive Disorders
15. Personality Disorders
16. Paraphilias
17. Other Disorders

6. Personality and Personality Disorders^
Andrew E. Skodol, M.D.Chair
John M. Oldham, M.D.Co-Chair
Robert F. Krueger, Ph.D., Text Coordinator
Renato D. Alarcon, M.D.,
Carl C. Bell, M.D.
Donna S. Bender, Ph.D.
Lee Anna Clark, Ph.D.
W. John Livesley, M.D., Ph.D. (2007-2012)
Leslie C. Morey, Ph.D.
Larry J. Siever, M.D.
Roel Verheul, Ph.D. (2008-2012)

7. Borderline personality disorder controversy
 In 2003, the Treatment and Research Advancements
National Association for Personality Disorders (TARA-APD)
campaigned to change the name and designation
of borderline personality disorder in DSM-5.
 “The name BPD is confusing, imparts no relevant or
descriptive information, and reinforces existing stigma...".
Instead, it proposed the name "emotional regulation
disorder" or "emotional dysregulation disorder".
 There was also discussion about changing borderline
personality disorder, an Axis II diagnosis (personality
disorders and mental retardation), to an Axis I diagnosis
(clinical disorders).

8. Diagnosing Personality Disorders
How can it be ―disordered‖?
 An enduring pattern of inner experience and behavior that
deviates markedly from the expectations of the individual's
culture, is pervasive and inflexible, has an onset in
adolescence or early adulthood, is stable over time, and
leads to distress or impairment.

9. DSM-IV-TR Clusters
• Cluster A : Odd or eccentric
– Schizoid, Paranoid, Schizotypal
• Cluster B : Dramatic, emotional or erratic
– Antisocial, Borderline, Narcissistic, Histrionic
• Cluster C : Anxious, fearful
– Avoidant, Dependent, Obsessive-Compulsive

10. Could Redefine ―Personality‖
DSM-IV: A pervasive pattern of thinking/
behaving/emotionality.
Perhaps? A personality disorder reflects "adaptive
failure" involving:
 "Impaired sense of self-identity" or
 "Failure to develop effective interpersonal functioning."

11. DSM -5 and multiaxial system
DSM-5 moves from the multiaxial system to a new
assessment that removes the arbitrary boundaries
between personality disorders and other mental
disorders.

12. Obvious Changes in DSM-5
The DSM-5 will discontinue the Multiaxial Diagnosis,
No more Axis I,II, III, IV & V-which means that
Personality Disorders will now appear as diagnostic
categories and there will be no more GAF score or
listing of psychosocial stressor or contributing medical
conditions.
The Multi-axial model will be replaced by Dimensional
component to diagnostic categories.

13. New DSM 5 Classifications
DSM IV TR DSM 5
Avoidant Avoidant
Borderline Borderline
Narcissistic Narcissistic
Obsessive –Compulsive Obsessive Compulsive
Schizotypal Schizotypal
Antisocial Antisocial
Paranoid Personality Disorder Trait Specified
Schizoid
Histrionic
Dependent
Personality Disorder NOS

14. Borderline Personality
Condition in which people have
long- term patterns of unstable or
turbulent emotions, such as feelings
about themselves and others.
These inner experiences often cause
them to take impulsive actions and have
chaotic relationships uncertain
about their identity. Interests and
values may change
rapidly

15. Narcissistic Personality Disorder
Pervasive pattern of social inhibition, feelings of inadequacy, extreme
sensitivity to negative evaluation, and avoidance of social interaction

16. Obsessive Compulsive Disorder
People have unwanted and repeated
thoughts, feelings, ideas, sensations
(obsessions), or behaviors that make them
feel driven to do something (compulsions).
Often the person carries out the behaviors to
get rid of the obsessive thoughts, but this
only provides temporary relief. Not
performing the obsessive rituals can cause
great anxiety.

17. Schizotypal
Schizotypals believe
they have
magical powers

18. Avoidant Personality Disorders
Pervasive pattern of social
inhibition, feelings of
inadequacy, extreme
sensitivity to negative
evaluation, and avoidance
of social interaction

19. Antisocial

 When I
left, I joined the army, and when I
took the service
exam my psych profile fit a
certain... moral
flexibility would be the only
way to describe it...
and I was loaned out to a
CIA-sponsored
program, and we sort of
found each other. That's how it works.
 I know what I do
isn't... moral, per se...

20. Personality Disorders in the DSM-5
The good news is that none of the criteria for
personality disorders have changed in the DSM-5.
Based on feedback from a multilevel review of
proposed revisions, the American Psychiatric
Association Board of Trustees ultimately decided to
retain the DSM-IV categorical approach with the
same 10 personality disorders.

21. The Big Six
Six specific personality disorder types
(antisocial, avoidant, borderline,
narcissistic, obsessive-compulsive
and schizotypal) are defined by criteria based
on typical impairments in personality functioning and
pathological personality traits in one or more trait
domains.

22. Specific Changes Per Diagnostic
Category in DSM-5
 Schizotypal Personality Disorder T03 also under
Schizophrenia and Other Psychotic Disorders B02
 Antisocial Personality Disorder T04 also under Disruptive
Impulse Control and Conduct Disorders as Dyssocial
Personality Disorder Q07.

23. Personality Disorders in the DSM-5
 A new hybrid personality model was introduced in the DSM-
5′s Section III (disorders requiring further study) that included
evaluation of impairments in personality functioning.
 In the new proposed model, clinicians would assess
personality and diagnose a personality disorder based on an
individual’s particular difficulties in personality functioning and
on specific patterns of those pathological traits.

24. Personality Disorders in the DSM-5
The hybrid methodology retains six personality
disorder types:
Borderline Personality Disorder
Obsessive-Compulsive Personality Disorder
Avoidant Personality Disorder
Schizotypal Personality Disorder
Antisocial Personality Disorder
Narcissistic Personality Disorder

25. Personality Disorders in the DSM-5
According to the APA, each type is defined by a
specific pattern of impairments and traits.
This approach also includes a diagnosis of
Personality Disorder—Trait Specified (PD-TS)
that could be made when a Personality Disorder
is considered present, but the criteria for a
specific personality disorder are not fully met (PD-
TS) replaces personality disorder not otherwise.

26. Personality Disorders
The criteria for personality disorders in Section II
(clinical) of DSM-5 have not changed from those
in DSM-IV.
Section III (research) includes the proposed
research model for personality disorder diagnosis
and conceptualization developed by the DSM-5
Personality and Personality Disorders Work
Group.

27. Personality Disorders in the DSM-5
APA hopes that inclusion of the new methodology
in Section III of DSM-5 will encourage research
that might support this model in the diagnosis and
care of patients, as well as contribute to greater
understanding of the causes and treatments of
personality disorders.

28. Personality Disorders –
The way it almost was
• Personality types defined by personality
domains and facets:
– Negative affect (facets: lability,anxiety/
insecurity, hostility)
– Detachment (facets:
withdrawal/depression, suspicion)
– Antagonism (facets: difficult to get along with:
manipulative, deceitful, hostile)
– Disinhibition (facets: impulsive/irresponsible)
– Psychoticism (facets: unusual/bizarre
experiences, eccentric)

29. PDTS Levels of Personality
Functioning Scale
The diagnosis of Personality Disorder Trait
Specified (PDTS) is defined by significant
impairment in personality functioning, as
measured by the Levels of Personality
Functioning Scale, and one or more pathological
personality trait domains or trait facets

30. Guide to Implementation
1. Is impairment in personality functioning (self and interpersonal)
present or not?
2. If so, rate the level of impairment in self (identity or self-direction)
and interpersonal (empathy or intimacy) functioning on the Levels of
Personality Functioning Scale.
3. Is one of the 6 defined types present?
4. If so, record the type and the severity of impairment.
5. If not, is PD-Trait Specified present?
6. If so, record PDTS, identify and list the trait domain(s) that are
applicable, and record the severity of impairment.
7. If a PD is present and a detailed personality profile is desired and
would be helpful in the case conceptualization, evaluate the trait
facets.
8. If neither a specific PD type nor PDTS is present, evaluate the trait
domains and/or the trait facets if these are relevant and helpful in the
case conceptualization.

31. NOS categories
The new version replaces the NOS categories
with two options: other specified
disorder and unspecified disorder to increase the
utility to the clinician.
The first allows the clinician to specify the reason
that the criteria for a specific disorder are not met;
the second allows the clinician the option to forgo
specification.

32. More radical criticisms
The extremely high rates of comorbidity (ranging
from dimensional diagnosis to various forms of
etiopathogenetic diagnosis).
The financial association of DSM-5 panel members
with industry continues to be a concern for financial
conflict of interest.
Of the DSM-5 task force members, 69% report
having ties to the pharmaceutical industry, an
increase from the 57% of DSM-IV task force
members.