Core slides from my presentation about the new DSM diagnostic system. The full presentation has more zing but I removed some to streamline and to whet the appetite.

1. DSM 5.0
(Just in Time or Too Late)
Laurence P. Karper, M.D.
Vice-Chair, Department of Psychiatry

2. What I’m not Going to Do
• I will not discuss subspecialty areas that require
focused review and attention
– Neurodevelopmental Disorders
– Neurocognitive Disorders
– Childhood-Onset Disorders
• I am only touching upon other areas without clinical
relevance to general inpatient or outpatient practice or
that merit more in-depth treatment (e.g. Somatic
Symptoms and Related Disorders, Trauma- and
Stressor-Related Disorders, etc.)
• I will not focus on ICD 10, Forensic, or Insurance Issues

3. Insurance Considerations
• Not the focus of this presentation
• DSM-5 is fully compatible with ICD-9 and 10
but the transition to ICD-10-CM is very
complicated and will need further delineation
• Crosswalks are currently available for your
delectation
• Since the codes are what drives insurance use
them and list the name separately (e.g.
hoarding disorder vs. OCD; both 300.3)

4. DSM Editions Page Count
1200
DSM-5
1000
DSM-IV
DSM-IV-R
800
600
DSM-III
DSM-III-R
400
200
DSM-II
DSM-I
0
1950
1960
1970
1980
1990
2000
2010

5. For More Information
• http://www.psychiatry.org/dsm5
– Assessment Measures
– Extensive Fact Sheets
– Videos of Thought Leaders
– News Articles

6. Where is the Mind in DSM-5?
Does not appear in the “Glossary of Technical
Terms” or the Index

7. Definition of a Mental Disorder
A mental disorder is a syndrome characterized
by clinically significant disturbance in an
individual’s cognition, emotional regulation, or
behavior that reflects a dysfunction in the
psychological, biological, or developmental
processes underlying mental functioning…. An
expectable or culturally approved response to a
common stressor or loss, such as the death of a
loved one, is not a mental disorder.

8. Who/What is Disordered?
“All drugs that are taken in excess have in
common direct activation of the brain reward
system…. They produce such an intense
activation of the reward system that normal
activities may be neglected. …[The] roots of
substance use disorders for some persons can
be seen in behaviors long before the onset of
actual substance use itself.” DSM-5, p. 481.

9. Disturbance of Behavior
Social
Deviance
Mental
Disorder
Stress
Response

10. The Primacy of Reliability
• A measure is said to have a high reliability if it
produces similar results under consistent
conditions.
• Validity is the extent to which a
concept, conclusion, or measurement is wellfounded and corresponds accurately to the
real world.

11. Multiaxial System: Deleted
• “DSM-5 has moved to a non-axial documentation of
diagnosis.” p.16
• Never needed in DSM-IV-TR
• GAF dropped due to “conceptual lack of clarity” and
“questionable psychometrics in routine practice.” Instead
WHODAS 2.0 is to be used
• The principal diagnosis (reason for visit) is listed first
• In the case of mental disorders due to another medical
condition “ICD coding rules requires that the etiological
medical condition be listed first.” p.23
• The phrase “general medical condition” is replaced in DSM-5
with “another medical condition” where relevant across all
disorders.

12. Changes: Schizophrenia
• Removal of subtypes of schizophrenia (dimensional measures)
• Two changes were made to DSM-IV Criterion A for schizophrenia.
The first change is the elimination of the special attribution of
bizarre delusions and Schneiderian first-rank auditory hallucinations
(e.g., two or more voices conversing). In DSM-IV, only one such
symptom was needed to meet the diagnostic requirement for
Criterion A, instead of two of the other listed symptoms. This
special attribution removed due to the non-specificity of
Schneiderian symptoms and the poor reliability in distinguishing
bizarre from non-bizarre delusions. Therefore, in DSM-5, two
Criterion A symptoms are required for any diagnosis of
schizophrenia. The second change is the addition of a requirement
in Criterion A that the individual must have at least one of these
three symptoms: delusions, hallucinations, and disorganized
speech. At least one of these core “positive symptoms” is necessary
for a reliable diagnosis of schizophrenia

13. Changes: Bipolar Disorders
• Bipolar disorders now include both changes in
mood and changes in activity or energy
• Mixed Type is Deleted
• Specifiers “with mixed features” and “anxious
distress” are added

14. Changes: Depressive Disorders
• Premenstrual Dysphoric Disorder (625.4) is
promoted from Appendix B
• Dysthymia is replace by Persistent Depressive
Disorder (dysthymia) (300.4)
• Specifiers “with mixed features” and “anxious
distress” are added
• Bereavement exclusion omitted

15. Changes: Substance Use Disorders
• Note Substance-Specific Issues
– No Withdrawal for PCP, Hallucinogens
– No Caffeine Use Disorder
• Severity Modifier is Key
– Mild: 2-3 Symptoms
– Moderate: 4-5 Symptoms
– Severe: >5 Symptoms
• If medications are taken under appropriate
medical supervision Tolerance/Withdrawal are
not used for diagnosis

16. Substance-Related Use Disorders
• Use of larger amounts or over a longer period
than was intended
• Persistent desire of unsuccessful efforts to cut
down or control
• A great deal of time spent to obtain or recover
from use
• Craving, or a strong desire or urge to use
• Failure to fulfill major role obligations

17. Substance-Related Use Disorders
• Use despite social or interpersonal problems
• Social, occupational, or recreational activities
given up or reduced
• Use in situations that are physically hazardous
• Use despite persistent or recurrent physical or
psychological problems
• Tolerance
• Withdrawal

18. Common Diagnoses
DSM-IV-TR
DSM-5
Bipolar Disorder, Mixed
Type
296.60
Bipolar Disorder, Manic with
mixed features, with anxious
distress
296.40
Alcohol Abuse
305.00
Alcohol Use Disorder, Mild
305.00
Alcohol Dependence
303.90
Alcohol Use Disorder, Severe
303.90
Alcohol-Induced Mood
Disorder
291.89
Alcohol-Induced Depressive
Disorder
291.89
Cocaine-Induced Mood
Disorder
292.84
Cocaine-Induced Bipolar and
Related Disorder
292.84
Amphetamine-Induced
Psychotic Disorder
292.9
Amphetamine-Induced Psychotic
Disorder
292.9
Polysubstance Dependence 304.80
List Each Disorder Separately

19. Not Otherwise Specified: Deleted
• Other Specified Disorder
– Used to communicate the atypical nature of the
situation
– For example: “other specified depressive
disorder, depressive episode with insufficient
symptoms.”
• Unspecified Disorder
– Used when the criteria are not met for a specific
disorder and no determination further is
necessary

20. NOS Diagnoses
DSM-IV-TR
Mood Disorder NOS
Depressive Disorder NOS
DSM-5
296.90
Unspecified Bipolar and
Related Disorder
296.89
311
Unspecified Depressive
Disorder
311
Anxiety Disorder NOS
300.00
Unspecified Anxiety
Disorder
300.00
Psychosis NOS
298.9
Unspecified Schizophrenia
Spectrum and Other
Psychotic Disorder
298.9
Personality Disorder NOS
301.9
Unspecified Personality
Disorder
301.9

21. A Way Out
State
Trait
Anger
Sadness
Anxiety
Pain
Lethargy
Irritable
Aggressive
Depressive
Anxious
Somatic
Lethargic
Unstable

22. How States Become Traits
Increasing Threat
Adaptive
Response
Rest
Vigilance
Freeze
Flight
Fight
Hyperarousal
Continuum
Rest
Crying
Resistance
Defiance
Aggression
Dissociative
Continuum
Rest
Avoidance
Compliance
Numbing
Fainting
Brain Areas
Neocortex
Subcortex
Limbic
Midbrain
Brainstem
Abstract
Concrete
Emotional
Reactive
Reflexive
CALM
AROUSAL
ALARM
FEAR
TERROR
Cognition
Mental State
Perry B: Infant Mental Health Journal, Vol. 16, No.4, 1995.

23. DSM-IV-TR: Categorical Method
• “The naming of categories is the traditional
method of organizing and transmitting
information in everyday life and has been the
fundamental approach used in all systems of
medical diagnosis.” p. xxxi
• “…[I]t is possible that the increasing research
on, and familiarity with, dimensional systems
may eventually result in their greater acceptance
both as a method of conveying clinical
information and as a research tool.” p. xxxii

24. Categorical Assessment

25. Dimensional vs. Categorical

26. DSM-5: A Dimensional Approach To
Diagnosis Begins
• “…[T]he once plausible goal of identifying
homogeneous populations for treatment and
research resulted in narrow diagnostic
categories that did not capture clinical
reality…. The historical aspiration of achieving
diagnostic homogeneity by progressive
subtyping with disorder categories no longer
is sensible….” DSM-5, p. 12

27. Personality Domains & Facets
Domains
Facets
Negative
Affect
Emotional Lability, Anxiousness, Separation Insecurity
Detachment
Withdrawal, Anhedonia, Intimacy Avoidance
Antagonism
Manipulativeness, Deceitfulness, Grandiosity
Disinhibition
Irresponsibility, Impulsivity, Distractibility
Psychoticism
Unusual Beliefs & Experiences, Eccentricity, Perceptual
Dysregulation
Krueger, R. F., Derringer, J., Markon, K. E., Watson, D., & Skodol, A. E. (2012). Initial construction
of a maladaptive personality trait model and inventory for DSM-5. Psychological Medicine, 42,
1879-1890.

28. Borderline Personality Disorder
• Negative Affect
– Emotional Lability
– Anxiousness
– Separation Insecurity
• Disinhibition
– Distractibility
– Irresponsibility
– Impulsivity
Hopwood, Thomas, et al., Journal of Abnormal Psychology 2012, 1-9.

29. Cross-Cutting Symptoms Measures
• Level 1
– Self-Rated, 23 Questions on 5 point scale (0-4)
– Rating of 2 (mild) or greater (except for substance
use, suicidal ideation, and psychosis where a 1 or
greater) suggests need for additional inquiry (level 2)
• Level 2
– Self-Rated, Separate Scales for Depression, Anger,
Mania, Anxiety, Somatic Symptoms, Sleep
Disturbance, Repetative Thoughts, Behaviors,
Substance Use
– Clininician-Rated, Non-Suicidal Self-Injury and
Psychosis

30. Self-Reflection
• Cosmetic Changes Reflecting a Putative
Revolution in Thought
• Cross-Cutting Symptoms Measures
• Personality Domains & Facet Measures
• Caring for the Psyche as Psychiatric Treatment