Diagnosing with the DSM-5

Copyright © 2015, Glenn Duncan Do not reproduce any workshop materials without express written consent.
Diagnosing with the DSM-5
Glenn Duncan LPC, LCADC, CCS,
ACS

PPT online at SlideShare
http://slidesha.re/Wp9KmB

DSM-5 Controversies
 National Institute of Mental Health – “NIMH will be re-orienting its research
away from DSM categories,” towards it’s own research oriented criteria. “NIMH has
launched the Research Domain Criteria (RDoC) project to transform diagnosis by
incorporating genetics, imaging, cognitive science, and other levels of information to
lay the foundation for a new classification system.”
http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml
 NIMH also stated that future research projects utilizing DSM-5 criteria will likely not
be funded, and researchers will need to use RDoC’s to gain funding.
 Saving Normal: An Insider's Revolt Against Out-of-Control Psychiatric
Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life
Hardcover - by Allen Frances (Chair of the DSM-IV Task Force)
http://www.amazon.com/Saving-Normal-Out-Control-Medicalization/dp/0062229257

DSM-5 Controversies
 Psychiatry's New Diagnostic Manual: “Don't Buy It. Don't
Use It. Don't Teach It.” ‘That's what psychiatrist Allen Frances, chair of
the DSM-IV task force, has to say about DSM-5.’ – Motherjones.com:
http://www.motherjones.com/politics/2013/05/psychiatry-allen-frances-
saving-normal-dsm-5-controversy
 Allen went on to make the following quote: “It's important that the
diagnostic system be taken away from the American
Psychiatric Association. It needs to be in safer hands.”
 He also had this to say about Big Pharma’s influence on the DSM: “We're
spending a fortune on treating kids who don't have ADD
with drugs rather than taking care of the schools.”

Differential Diagnosis as Used by the
DSM
 "Differential diagnosis" is the method by which a clinician determines what
DSM-5 disorder caused a client's symptoms.
 The clinician considers all relevant potential causes of the symptoms and then
eliminates alternative causes based on a clinical interview, use of
standardized assessment tool(s) that provide a DSM-5 diagnosis, and a
thorough case history using corroborative information from significant people
in the client’s life.
 Thus differential diagnosis is the determination of which of two or more
disorders with similar symptoms is the one from which the client is suffering,
by a systematic comparison and contrasting of the clinical findings.
 Differential Diagnosis looks at a disorder being discussed and how the
disorder is distinguished behaviors that are NOT classified as disorders.

Differential Diagnosis as Used by the
DSM
 Differential Diagnosis also looks at the disorder being discussed and how they
ARE distinguished from other disorders (of the same class) in the DSM.
 Finally, the disorder, or class of disorders, being discussed and how they ARE
distinguished from other disorders, diseases or conditions outside of the
DSM.
 The process of differential diagnosis can be broken down into 4 basic steps:
1. Ruling out malingering and factitious disorders (i.e., ruling out if the person
is not being honest about the nature of or severity of their symptoms)
2. Ruling out substance related cause for the disorder (i.e., whether the
symptoms exhibited are arising from a substance exerting a direct effect on
the central nervous system)
3. Ruling out a medical conditional causing the disorder (i.e., whether the
symptoms are due to a general medical condition).
4. Determining the primary disorder.

SUD exercise – The Secretary
A 35 year old secretary sought consultation for “anxiety
attacks”. A thorough history revealed that the attacks started
again within the past 2 days. She has a history of anxiety and
stated she was diagnosed with “an anxiety disorder” after the
attacks that occurred on 9/11 as she worked in NYC near
ground zero. She reported past feelings of nervousness and
anxiety, irritability and anger and difficulty sleeping. She stated
that shortly after being diagnosed, she tried many different
[benzodiazepine] medications that made her drowsy and
ineffective at work, so she stopped them.

SUD exercise – The Secretary
Due to the fact that no medications worked for her and her
“anxiety problem” persisted, she stated she took matters into
her own hand and started smoking marijuana. At first her
marijuana usage was once per week, but starting in 2008 she
increased her slowly, at first to 2-3 times per week, but by 2010
she was smoking marijuana daily. Since 2012 she smokes
daily, smoking several times per day at least 4-5 days of the
week. Her company recently initiated a new drug screen policy
and told all employees that there will be a mandatory drug test
for all within the next month, so she decided to stop smoking
marijuana. Her last use of marijuana was 3 days ago.
Using differential diagnosis, come up with 2 possible disorders
this person could be suffering from, and decide which of the 2
best fit the clinical picture.

What is “abnormal”?
Abnormal:
Statistically uncommon, maladaptive cognitions, affect, and/or
behaviors that are at odds with social expectations and that
result in distress or discomfort.
“What is defined as psychopathology are those characteristics
that differ from the dominant culture’s definition of normalcy, and
vary over time, and with culture.”

Clinically Significant (statistically
uncommon)
2.5% - 5%
In psychological testing clinically significant is 2 standard deviations
above the norm. For example, 130 I.Q., 70 on the MMPI-2
2.5% - 5%

What constitutes a “mental disorder”?
DSM-5 Definition of Mental Disorder:
 A mental disorder is a syndrome characterized by clinically significant disturbance in an
individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the
psychological, biological, or developmental processes underlying mental functioning.
 Mental disorders are usually associated with significant distress or disability in social,
occupational, or other important activities.
 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.
 Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are
primarily between the individual and society are not mental disorders unless the deviance
or conflict results from a dysfunction in the individual, as described above.
 NOTE: The diagnosis of a mental disorder is not equivalent to a need for treatment. Need for treatment is a
complex clinical decision that takes into consideration such factors as symptom severity, symptom salience (e.g.,
the presence of suicidal ideation), the patient’s distress (mental pain) associated with the symptom(s), disability
related to the patient’s symptoms, and other factors (e.g., psychiatric symptoms complicating other illness).

DSM-5 Symptoms vs. Signs
 Symptoms Versus Signs: Important to Keep in Mind
 In order to assess an individual using the DSM, a professional must be aware of
signs and symptoms reported by the client/patient.
 Symptoms
 Symptoms are subjective. They are what a patient can feel and therefore what they
complain about.
 Signs
 Signs are objective. Signs are what a counselor can see when looking at a patient.

 Cautionary Note regarding DSM-5 Symptoms
 The symptoms contained in the respective diagnostic criteria sets do not constitute
comprehensive definitions of underlying disorders, which encompass cognitive,
emotional, behavioral, and physiological processes that are far more complex than
can be described in the brief [DSM-5] summaries.

DSM-5 – Removal of the Multiaxial System
 DSM-5 will move to a nonaxial documentation of diagnosis, combining the former
Axes I, II, and III.
 Separate notations for psychosocial and contextual factors (formerly Axis IV) and
disability (formerly Axis V).
 DSM-5’s 20 chapters are restructured based on disorders’ apparent relatedness to
one another, as reflected by similarities in disorders’ underlying vulnerabilities and
symptom characteristics.
 The changes will align DSM-5 with the World Health Organization’s (WHO)
International Classification of Diseases, eleventh edition (ICD-11 – which is due out
in October, 2014) and are expected to facilitate improved communication and
common use of diagnoses across disorders within chapters.
 Axis V is dropped for “SEVERAL” reasons including its lack of clarity and
questionable psychometrics (that would be a “COUPLE” of reasons, not several).

Replacing the Multiaxial System Is …
 Non axial system
 Axis I, II and III are simply listed as independent diagnoses.
 Axis IV (psychosocial, environmental problems) can be listed in a paragraph form
using the DSM-IV content areas. It can also be listed as ICD-9 V codes.
 Axis V is eliminated. The argument being that diagnostic categories now have
severity scales (mild, moderate, severe) listed for each diagnosis.
 The DSM-5 does give some guidance that if you like, you can use the WHO
Disability Schedule (WHODAS) in place of Axis V (Global Assessment of
Functioning Scale). The DSM-5 includes instructions for using this measure, which
captures the degree of disability. However, they don’t endorse it and state it has not
been sufficiently validated.

Replacing Not Otherwise Specified (NOS) is …
 “Other Specified” or “Unspecified”
 Of course they would like you to diagnose it … at the very least see if it fits MILD on
a severity scale of a disorder.
 If not, use the classification “Other Specified” and explain what it is that keeps the
individual from meeting the standard diagnostic criteria (e.g., insufficient symptoms,
insufficient duration)
 Use the classification “Unspecified” if the clinician decides not to specify a reason
that the standard diagnostic criteria cannot be met.
 BOTTOM LINE: The DSM-5 stated they want to eliminate the NOS
category as some studies were showing upwards of 20% of diagnosing
used this category. In DSM-5 Beta, they first changed this to NEC (not
elsewhere classified), but then stated they were not going to allow this type of
categorization to occur in the DSM-5. What we ended up with are TWO NOS
categories … “Other Specified” and Unspecified”.

DSM-5 and the ICD-10
 The official coding system in use in the United States is the International
Classification of Diseases, Tenth revision, Clinical Modification (ICD-10-CM). Most
DSM-5 disorders have a numerical ICD-10 code that precedes the name of the
disorder in the classification and accompanies the criteria set for each disorder.
ICD-10-CM codes are next to the DSM-5 codes.
 The International Classification of Diseases (ICD) is the standard diagnostic tool for
epidemiology, health management and clinical purposes.
 ICD is used by physicians, nurses, other providers, researchers, health information
managers and coders, health information technology workers, policy-makers,
insurers and patient organizations
 Finally, ICD is used for reimbursement and resource allocation decision-making by
countries.

Diagnostic Classification History
 Emil Kraepelin (1856-1926)
 Working as Director at the University of Dorpat in Livonia (now University of
Tartu in Estonia), Kraepelin created detailed histories of a variety of patients.
 These records led to his first breakthrough in psychiatry. Prior to Kraepelin, the
disorders “dementia praecox” (now called schizophrenia) and manic-depression
were viewed as a unitary concept.
 Kraepelin separated them and described the pattern of symptoms and course
associated with each disorder. He determined that manic-depression was
intermittent while dementia praecox was deteriorating. (Later, it became clear
that dementia praecox was not always associated with mental decline;
therefore, it was renamed by Eugene Bleuler.) Kraepelin’s contribution to
classification is significant because of its organization.
 Although predecessors had grouped diseases based on similarity of symptoms,
Kraepelin used a medical model and grouped them based on a pattern of
symptoms.
 He realized that the same symptom could occur across disorders but that
different disorders have different patterns of symptoms.

History of the DSM
 1840 1 Dx – U.S. Census – Idiocy/Insanity
 Also in the 1840s, southern alienists discovered
a malady called Drapetomania - the
inexplicable, mad longing of a slave for
freedom.
 1880 7 Dx’s – U.S. Census
 Mania – mostly as defined today, a condition
characterized by severely elevated mood.
 Melancholia – would be noted as depression today.
 Monomania - Pathological obsession with a single
subject or idea. Excessive concentration of interest
upon one particular subject or idea. The difference
between monomania and passion can be very subtle
and difficult to recognize.
 Paresis – general or partial paralysis. (This would not
be the last time that a physical affliction crept into the
psychological arena; among the disorders described in
the DSM-IV –TR is snoring, or Breathing Related
Sleep Disorder 780.59, pp. 615-622).
 Dementia – as described today as characterized by
multiple cognitive deficits that include impairment in
memory (most common Alzheimer's).
 Dipsomania - An insatiable craving for alcoholic
beverages.
 Epilepsy

History of the DSM
 1940 – 26 Dx's (ICD-6; WHO)
 Which took its nomenclature from the US Army and
Veterans Administration nomenclature. The WHO
system included 10 categories for psychoses, 9 for
psychoneuroses, and 7 for disorders of character,
behavior, and intelligence)
 1952 DSM – 106 Dx’s
 DSM-I included 3 categories of psychopathology:
organic brain syndromes, functional disorders, and
mental deficiency. These categories contained 106
diagnoses. Only one diagnosis, Adjustment
Reaction of Childhood/Adolescence, could be
applied to children.
 1968 DSM-II – 185 Dx’s (revised DSM-II, 1974)
 It had 11 major diagnostic categories. Increased
attention was given to the problems of children and
adolescence with the categorical addition of Behavior
Disorders of Childhood-Adolescence.
 This category included Hyperkinetic Reaction,
Withdrawing Reaction, Overanxious Reaction,
Runaway Reaction, Unsocialized Aggressive
Reaction, and Group Delinquent Reaction.

DSM-II and Homosexuality
Up until 1973 (and finally ratified in 1974) Homosexuality was considered a
form of deviant sexual acts and was psychiatric disorder.

DSM, Homosexuality and Science
 The famous decision to remove homosexuality did not come
about as a result of a lengthy professional debate on the
scientific merits, just as its inclusion was not based on science.
 Both came about as a political and social opinion/pressure.
 The outing of homosexuality from the DSM came from a time
when the APA (and many scholars) didn’t want to be seen as
Vietnam/Watergate/Establishment authoritarianism.

DSM, Homosexuality and Science
 This anti-authoritarian atmosphere undoubtedly contributed to the willingness of
the head of the APA to "do the right thing" and remove homosexuality from the
DSM.
 His decision occurred immediately before the actual vote, and as a result of
being taken into a room in which many psychiatrists he knew personally were
present and came out to him as homosexual.
 Thus, this major change in the legal status of homosexuals turned on a knife
edge and actually had nothing to do with "scientific evidence".
 The issue had never been about "science", only about political prejudice
posturing as "science".
 The fear that the APA would be stigmatized as an "establishment institution"
was the primary driving factor behind the change in the DSM.

History of the DSM
 1980 DSM-III – 265 Dx’s (roughly coincided with
ICD-9 which came out in 1979).
 DSM-III included multiaxial system.
 Explicit diagnostic criteria.
 Descriptive approach neutral to etiology theory.
 Unlike its predecessors, DSM-III was based on
scientific evidence. Its reliability was improved
with the addition of explicit diagnostic criteria and
structured interviews.
 Although ICD and DSM were similar in terms of
criteria, their codes were very different.
 1987 DSM-III-R – 297 Dx’s
 Occurred because DSM-III revealed a number of
inconsistencies in the system and a number of
instances in which the criteria were not entirely
clear.
 1994 DSM-IV – 365 Dx’s – (ICD 10)
 DSM-III nomenclature allowed more precise
research of disorders for the DSM-IV and DSM-
IV-TR.
 2000 DSM-IV-TR – 365 Dx’s

History of the DSM
 2013 DSM-5
 Excoriation (skin-picking) disorder is new to
DSM-5 and will be included in the Obsessive-
Compulsive and Related Disorders chapter.
 Hoarding disorder is new to DSM-5. This disorder
was added due to the ongoing popularity of
“Hoarders” – 7 p.m. Sunday’s on TLC.
 Autistic disorders will undergo a reshuffling and
renaming: “[Autism] criteria will incorporate several
diagnoses from DSM-IV including autistic disorder,
Asperger’s disorder, childhood disintegrative disorder
and pervasive developmental disorder (not otherwise
specified) into the diagnosis of Autism Spectrum
Disorder.” Other new proposed disorders include:
 Complex post-traumatic stress disorder
 Depressive personality disorder
 Olfactory Reference Syndrome
 Disruptive Mood Dysregulation Disorder (or DMDD)
 Relational disorder
 Sluggish cognitive tempo
 Binge Eating

History of the DSM
 "This is one of major public health significance
because every department of public health in every
county in the country has to deal with a hoarding
issue, whether it’s animal-related or other forms of
excessive acquisition," Dr. Regier (vice chair of the
DSM-5 task force) said.

IN BRIEF: Sluggish Cognitive
Tempo
 We have come full circle in the DSM … in a politically correct way!
 2013 – Sluggish Cognitive Tempo
 1840 1 Dx – U.S. Census – Idiocy?
 Meant to be added to the inattention category of Attention Deficit Hyperactivity
Disorder. Symptoms include:
 frequent daydreaming
 tendency to become confused easily
 mental fogginess
 sluggish-lethargic behavior
 drowsiness
 frequent staring into space
 slow processing of information
 poor memory retrieval
 social passiveness, reticence and withdrawal
 It was not added to the current DSM inattention category because they have
been found to have only a weak association with the other inattention
symptoms. It is the best diagnosis to never make it into the DSM!

Substance Use Disorders and
Science
 The removal of abuse and dependence from the DSM-5 was touted as being
because of clinical utility and the need for a better continuum of severity than
existed in previous versions of the DSM.
 Thus the replacement of abuse and dependence occurred with substance use
disorder mild (2-3 symptoms), moderate (4-5 symptoms) and severe (6 or more
symptoms).
 The decision to remove abuse and dependence occurred through a sub-
committee vote. During the time of publication for the DSM-IV the substance
abuse workgroup voted on whether or not to retain or remove abuse and
dependence and abuse and dependence were voted to remain in the DSM-IV by
one committee vote.
 The DSM-5 substance abuse workgroup voted to remove abuse and dependence.
The critique of this is that the decision was made not based on research but on
committee vote.

DSM-5 and Culture
 Historically, the construct of the culture-bound syndrome has been a key
interest in cultural psychiatry. In the DSM-5, this construct has been replaced
by three concepts that offer greater clinical utility:
1. Cultural syndrome is a cluster or group of co-occurring, relatively
invariant symptoms found in a specific cultural group, community, or
context. The syndrome may or may not be recognized as an illness
within the culture (e.g., it may be labeled in various ways), but such
cultural patterns of distress and features of illness may nevertheless be
recognizable by an outside observer.

DSM-5 and Culture (continued)
2. Cultural idiom of distress is a linguistic term, phrase, or a way of talking about
suffering among individuals of a cultural group (e.g., similar ethnicity or
religion) referring to shared concepts of pathology and ways of expressing,
communicating, or naming essential features of distress. An idiom of distress
need not be associated with specific symptoms, syndromes, or perceived
causes. It may be used to convey a suffering due to social circumstances
rather than mental disorders. For example, most cultures have common
bodily idioms of distress used to express a wide range of suffering and
concerns.
3. Cultural explanation or perceived cause is a label, attribution, or feature of an
explanatory model that provides a culturally conceived etiology or cause for
symptoms, illness, or distress. Causal explanations may be salient features of
folk classifications of disease used by laypersons or healers.

DSM-5 Diagnoses Associated with Class of
Substance
Use -Mild Use – Mod/Sev Intoxication Withdrawal
Alcohol X X X X
Cannabis X X X New to DSM-
5
Caffeine X New to DSM-
5
Amphetamines X X X X
Cocaine X X X X
Hallucinogens X X X
Phencyclidine (PCP)
X X X
Tobacco New to DSM-
5
X X
Opioids X X X X
Inhalants X X X
Sedatives, Hypnotics
X X X X
Polysubstanc
e
Out in DSM-5

IN FOCUS: Substance-Use &
Addictive Disorders (DSM-5)
Substance-Use Disorders
Overall, the diagnosis of substance use disorder is based on a
pathological pattern of behaviors related to the use of the substance. To
assist with organization, Criterion A criteria can be considered to fit with 4
overall groupings:

1. Impaired control (Criteria 1 – 4)
2. Social impairment (Criteria 5 – 7)
3. Risky Use (Criteria 8 – 9)
4. Pharmacological Impairment (Criteria 10 – 11)

Substance-Use Disorder
A. A problematic pattern of [substance] use leading to clinically significant impairment or
distress.
B. Two (or more) of the following occurring within a 12-month period:
1. [Substance] is often taken in larger amounts or over a longer period than was
intended
2. There is a persistent desire or unsuccessful effort to cut down or control [substance]
use
3. A great deal of time is spent in activities necessary to obtain [substance] , use the
substance, or recover from its effects
4. Craving or a strong desire or urge to use [substance]
5. Recurrent [substance] use resulting in a failure to fulfill major role obligations at
work, school, or home.
6. Continued [substance] use despite having persistent or recurrent social or
interpersonal problems caused or exacerbated by the effects of the substance

Substance-Use Disorder (continued)
7. Important social, occupational, or recreational activities are given up or
reduced because of [substance] use
8. Recurrent [substance] use in situations in which it is physically hazardous.
9. Continued [substance] use despite knowledge of having a persistent or
recurrent physical or psychological problem that is likely to have been
caused or exacerbated by the substance
10. Tolerance, as defined by either or both of the following:
a. A need for markedly increased amounts of [substance] to achieve
intoxication or desired effect
b. Markedly diminished effect with continued use of the same amount of
the substance
(Note: This criterion is not considered to be met for those taking
[substance] solely under appropriate medical supervision)

11. Withdrawal, as manifested by either of the following:
a. The characteristic [substance] withdrawal syndrome (refer to Criteria
A and B of the criteria set for Withdrawal)
b. [Substance] (or a closely related substance) is taken to relieve or avoid
withdrawal symptoms
(Note: This criterion is not considered to be met for those taking
[substance] solely under appropriate medical supervision)

 Withdrawal symptoms vary greatly across drug classes. Marked and generally
easily measured physiological signs of withdrawal are provided for the drug
classes and will be spelled out below. Marked and generally easily measured
physiological signs of withdrawal are common with the following classes of
substances:
1. Alcohol
2. Opioids
3. Sedatives, Hypnotics or Anxiolytics
 Withdrawal signs and symptoms for the following classes are often present but
may be less apparent:
1. Caffeine
2. Cannabis
3. Stimulants (amphetamines and cocaine)
4. Tobacco

 Significant withdrawal has NOT been documented in humans after repeated use
of the following classes of substances:
1. Hallucinogens (Phencyclidine and other hallucinogens)
2. Inhalants
 Neither tolerance nor withdrawal is necessary for a diagnosis of a substance use
disorder. However, for most classes of substances, a past history of withdrawal
is associated with a more severe clinical course (i.e., an earlier onset of a
substance use disorder, higher levels of substance intake, and a greater number
of substance-related problems).

Specify if:
In early remission: After full criteria for [substance] use disorder were
previously met, none of the criteria for [substance] use disorder have been
met for at least 3 months but for less than 12 months (with the exception that
Criterion A4, (“Craving, or a strong desire to urge to use [substance],” may be
met).
In sustained remission: After full criteria for [substance] use disorder were
previously met, none of the criteria for [substance] use disorder have been
met at any time during a period of 12 months or longer (with the exception
that Criterion A4, (“Craving, or a strong desire to urge to use [substance],”
may be met).

Specify if:
On maintenance therapy: This additional specifier is used if the individual is
taking prescribed agonist medication such as methadone or buprenorphine
and none of the criteria for opioid use disorder have been met for that class
of medication (except for tolerance to, or withdrawal from, the agonist). This
category also applies to those individuals being maintained on a partial
agonist, an agonist/antagonist, or full antagonist such as oral naltrexone or
depot naltrexone.
In a controlled environment: This additional specifier is used if the individual
in an environment where access to [substance] is restricted.
NOTE: The “on maintenance therapy” specifier applies as a further specifier
of remission if the individual is both in remission and receiving
maintenance therapy (i.e., in early remission on maintenance therapy or
in sustained remission on maintenance therapy).

The Severity of each Substance Use Disorder is based on:
 0 criteria or 1 criterion: No diagnosis
 2-3 criteria: Mild Substance Use Disorder
 4-5 criteria: Moderate Substance Use Disorder
 6 or more criteria: Severe Substance Use Disorder
 Among adolescents, 2 or 3 criteria identify a group with severity of alcohol use
disorder very close to that of adolescents with DSM-IV alcohol abuse, while 4
or more criteria identify a group with severity very close to that of DSM-IV
dependence. Using criterion counts results in much more homogeneous
groups than DSM-IV’s abuse and dependence groups.
 In the empirical research among adults, the proposed cutoff points have been
shown to yield similar prevalence and high concordance in relation to the
combined DSM-IV substance abuse and dependence diagnoses. However,
it is still unclear as to whether 4-5 or 6 or more constitute what
used to be substance dependence in adults.

In a May 29, 2012 response to Washington Post article citing difficulties
with these proposed changes, the APA responded with the following:
Regarding Dependence, Addiction and the Changes: Research shows that
the symptoms of people with substance use problems do not fall neatly into two
discrete disorders. Also, the term “dependence” is misleading; people often confuse
that with “addiction” when in fact the tolerance and withdrawal patients experience are
actually very normal responses to some prescribed medications that affect the central
nervous system.
Regarding How the New System Reflects DSM’s Old Definition of
Dependence - By contrast, the higher end of the substance use disorder
spectrum would be more equivalent to the prior substance dependence
disorder and entails a distinct syndrome that includes compulsive drug-
seeking behavior, loss of control, craving, and marked decrease in social
and occupational functioning. Revising and clarifying these criteria should
alleviate some misunderstanding around these issues.

Substance-Use Disorder (Legal Problems – OUT; Cravings – IN)
Craving is defined as a strong desire for a substance, usually a specific
substance. It is a common clinical symptom, tending to be present on the severe
end of the severity spectrum. It has been variously defined as a trait with a time
component (present or recent past) or as a lifetime component (ever experienced
in your life).
Brain imaging studies have demonstrated subjective craving precipitated by
drug-related cues and correlated with increased activity (blood flow) and
dopamine release (PET study) in specific parts of the brain reward system.
Recurrent substance-related legal problems (e.g., arrests for substance related
disorderly conduct). DSM-5 aggregate research all indicate that the legal
problems criterion has an extremely low prevalence relative to other criteria, and
its removal from the diagnosis has very little effect on the prevalence of
substance use disorders while adding little information to the diagnoses in the
aggregate.

Substance-Use Disorder (Cravings)
"Craving." An innovation in the diagnosis of substance use disorders is a
requirement that the patient report or demonstrate craving for the particular
substance. Workgroup chairman Charles O'Brien, MD, of the University of
Pennsylvania, said this is the key symptom that separates addiction from
mere heavy use.
He added that a wealth of recent research has established that craving can
be measured -- he had hoped that an objective test might be included in the
DSM-5 criteria, but his workgroup felt it was not ready quite yet.

Substance-Use and Addictive Disorders New Categories
Alcohol Use Disorder
Cannabis Use Disorder
Hallucinogen Use Disorder (which has subsumed Phencyclidine [PCP])
Inhalant Use Disorder
Opioid Use Disorder
Sedative/Hypnotic/Anxiolytic Use Disorder
Stimulant Use Disorder (combining DSM-IV-TR’s Cocaine and
Amphetamine Abuse and Dependence)
Tobacco Use Disorder
Unspecified Other (or Unknown) Substance Use Disorder
Gambling Disorder

IN FOCUS: Substance Use Disorders –
Cannabis Withdrawal
A. Cessation of cannabis use that has been heavy and prolonged (i.e.,
usually daily or almost daily use over a period of at least a few
months).
B. Three (or more) of the following signs and symptoms develop within
approximately 1 week after Criterion A:
 Irritability, anger or aggression.
 Nervousness or anxiety.
 Sleep difficulty (e.g., insomnia, disturbing dreams).
 Decreased appetite or weight loss.
 Restlessness.
 Depressed Mood.
 At least one of the following physical symptoms causing significant discomfort: abdominal
pain, shakiness/tremors, sweating, fever, chills, or headache.
C. The symptoms in Criterion B cause clinically significant distress or
impairment in social, occupational, or other important areas of
functioning.
D. The signs or symptoms are not attributable to another medical
condition and are not better explained by another mental disorder,
including intoxication or withdrawal from another substance.

IN FOCUS: Gambling Disorder
1. The reclassification of pathological gambling alongside other
addictive behaviors
 In the current edition (DSM-IV), gambling disorder is classified as part of “Impulse-
Control Disorders Not Elsewhere Classified,” which also includes disorders like
kleptomania. In the new edition, gambling disorder will join substance-related
addictions in a renamed group called “Addiction and Related Disorders.”
2. The lowering of the pathological gambling threshold to 4 symptoms
 To be diagnosed with a gambling disorder, a certain set of behaviors must be
present over a 12-month period—such as needing to bet with increased amounts
of money, being preoccupied with gambling, or tending to chase losses. Currently,
gamblers need to exhibit 5 of these behaviors to be diagnosed with a gambling
disorder. In the DSM-5, the threshold will be lowered to 4.

IN FOCUS: Gambling Disorder
3. The removal of the ‘‘illegal acts’’ criterion for the
disorder
 Another change is that, where in the DSM-IV there are 10
behaviors listed, in the DSM-5 there will only be 9. Whether or not
a gambler has committed an illegal act (like theft or fraud) to
finance gambling will no longer be considered a sign of
pathological gambling.
4. The Addition of a severity rating:
 Mild – 4-5 Criteria
 Moderate – 6-7 Criteria
 Severe – 8-9 Criteria

IN FOCUS: Substance Use and Addictive
Disorders – Final Points
 Internet Gaming and Caffeine Disorder put in Section 3
(for further study)
 Diagnostic Coding
 Use disorder “Mild” has the same coding as the DSM-IV’s
“abuse”. For example: Alcohol Use Disorder – Mild is 305.00 with
the ICD-10-CM code being (F10.10).
 Use disorder “Moderate” and “Severe” have the same diagnostic
code and should be separated by the wording. For example
moderate and severe alcohol use disorder are both coded 303.90
(F10.20) and will look like this:
1. 305.00 (F10.10) Mild Alcohol Use Disorder
2. 303.90 (F10.20) Moderate Alcohol Use Disorder
3. 303.90 (F10.20) Severe Alcohol Use Disorder

DSM-IV to DSM-5 Diagnosing Exercise
Alex Lifeson is an 18 year old African American male who has been
abusing substances since the age of 13. Alex reported using alcohol,
marijuana, and cocaine. Alex reported using alcohol at the age of 13.
At 13 he started out by drinking once a month (he reports that this was
1 - 40 oz. bottle of beer each time he drank). By 13 ½ he was
consuming 80 oz. of beer (2 - 40oz. bottles) 2 times per week. By age
14 he was he was drinking 80 oz. of beer at least 3 - 4 times per week.
This drinking frequency stayed the same till the age of 17 when he
began drinking beer and vodka. The frequency of drinking at ages 17
and 18 remained consistently 80 oz. of beer 3 - 4 times per week and a
fifth of vodka 1 - 2 times per week. Drinking the alcohol was the only
route of administration. Alex reported craving alcohol when not using.

Alex started smoking marijuana at the age of 15 by smoking 1 blunt per
week. By age 15 ½ he was smoking 1 blunt 2 - 3 times per week. By
age 16 he was smoking 1 blunt per day. By age 17 he started smoking
2 -3 blunts per day and this remained constant till this evaluation by
you. Smoking was the only route of administration. Alex reported
craving marijuana when not using.

Alex started snorting cocaine at age 16. From age 16 till age 17
Alex was snorting 1 line 1 - 2 times per week. At age 17 he
started snorting cocaine more frequently by snorting a gram per
week. He was unsure as to how many times per week he would
do cocaine because sometimes he would snort the whole gram
at a party during one day, and other times he would snort
smaller amounts several times per week till the gram was gone.
At age 18 this frequency stayed the same except for the last 2
weeks before being evaluated by you, he stated he was
snorting 2 grams of cocaine per week. His drug/alcohol use
was supported by his selling crack cocaine. Alex never smoked
cocaine, his only route of administration was snorting cocaine.
Alex reported craving cocaine when not using.

Alex is a substance user with no clear preference of drug from a
self report. However the only drug he stated that he used on a
daily basis was marijuana. Alex reported having blackouts on
several occasions due to too much alcohol usage. Alex also
has shown a definite increase in tolerance to all substances he
used. With alcohol, it currently takes him at least 60 oz. of beer
to “get high” and at the beginning of his alcohol usage it only
took him approximately 24 oz. to “get high”. It currently takes
him 2 - 3 marijuana blunts to “get high” and when he first started
smoking marijuana he would “get high” off of one blunt.
Cocaine tolerance also increased for Alex. At the beginning of
his cocaine usage he would “get high” off of one line, and upon
entering treatment it took him about 3 lines to “get high” off of
cocaine.

Alex also exhibited loss of control. He would often only intend
to drink 1 - 40 oz. of beer and would often end up drinking 2 - 40
oz. of beer and vodka. He also showed this loss of control with
his cocaine usage. It was Alex’s intention to make a gram of
cocaine last him throughout the week, but he would go to a
party and end up snorting the whole gram as opposed to the 2 -
3 lines he first set out to snort. This would occur at least once
every 2 months and sometimes once a month. Alex dropped
out of school in 10th grade so he could “be out on the street and
sell drugs more often”. He also continued usage despite
knowing he would get drug screens from Probation and from his
outpatient drug/alcohol programs, and that he could receive
negative consequences from these positive urines. Alex had
moderately elevated liver enzymes upon entering the
evaluation, but according to his medical doctor (whom you
requested information from), Alex didn’t have any other medical
complications from his substance abuse.

 What is Alex’s DSM-5 Diagnosis?

BRIEF FOCUS: Depressive Disorders
 DSM-5 contains several new depressive disorders, including
disruptive mood dysregulation disorder and premenstrual
dysphoric disorder.
 DMDD was added to address concerns about potential
overdiagnosis and overtreatment of bipolar disorder in children.
 Based on strong scientific evidence, premenstrual dysphoric
disorder has been moved from DSM-IV Appendix B, “Criteria
Sets and Axes Provided for Further Study,” to the main body of
DSM-5.

BRIEF FOCUS: Persistent Depressive
Disorder (Dysthymia) & Bipolar Disorders
 This disorder represents a consolidation of the DSM-IV defined Chronic
Major Depressive Disorder and Dysthymic Disorder
 The largest revelation from this consolidation was the fact that there was a
disorder in the DSM-IV called Chronic Major Depressive Disorder … who
knew?!
 Diagnostic criteria for bipolar disorders now include both changes in mood
and changes in activity or energy.
 Other Specified Bipolar and Related Disorders now allows for
diagnosing this condition if hypomania bipolar II is less than 4 days (i.e., 2-3
days), or if too few symptoms of hypomania are met but the duration is 4
days.
 Thus if you can’t meet the criteria to meet Bipolar II D/O, we’ll give you
another shot at having some Bipolar diagnosis. We LOVE Bipolar
Disorder!!!

Bereavement Exclusion Dropped
The bereavement exclusion is omitted in DSM-5 for several reasons.
1.The first is to remove the implication that bereavement typically lasts
only 2 months when both physicians and grief counselors recognize
that the duration is more commonly 1–2 years.
2.Second, bereavement is recognized as a severe psychosocial
stressor that can precipitate a major depressive episode in a
vulnerable individual, generally beginning soon after the loss. When
major depressive disorder occurs in the context of bereavement, it
adds an additional risk for suffering, feelings of worthlessness,
suicidal ideation, poorer somatic health, worse interpersonal and work
functioning, and an increased risk for persistent complex
bereavement disorder, which is now described with explicit criteria in
Conditions for Further Study in DSM-5 Section III.

Bereavement Exclusion Dropped
The bereavement exclusion is omitted in DSM-5 for several reasons.
3.Third, bereavement-related major depression is most likely to occur
in individuals with past personal and family histories of major
depressive episodes. It is genetically influenced and is associated
with similar personality characteristics, patterns of comorbidity, and
risks of chronicity and/or recurrence as non–bereavement-related
major depressive episodes.
4.Finally, the depressive symptoms associated with bereavement-
related depression respond to the same psychosocial and medication
treatments as non–bereavement-related depression.

Specifiers for Depressive Disorders
The DSM-5 provides guidance on the assessment of suicidal thinking,
plans, and the presence of other risk factors in order to make a
determination of the prominence of suicide prevention in treatment
planning for a given individual.
A new specifier to indicate the presence of mixed symptoms has been
added across both the bipolar and the depressive disorders, allowing
for the possibility of manic features in individuals with a diagnosis of
unipolar depression.
A lot of research showing anxiety is a factor in depressive disorders,
thus the inclusion of the “with anxious distress” specifier (to rate the
severity of anxious distress) in all individuals with bipolar or
depressive disorders.

BRIEF FOCUS: Disorders of Infancy,
Childhood, or Adolescence
 In the DSM-IV-TR these disorders were largely gathered in this
section.
 In the DSM-5 they are now spread out in different sections:
 Neurodevelopmental Disorders – Intellectual Disabilities,
Autism Spectrum Disorder, Attention Deficit/Hyperactivity
Disorder, Specific Learning Disorders, Motor Disorders
 Elimination Disorders (now has its own section)
 Disruptive, Impulse-Control, and Conduct Disorders –
Oppositional Defiant Disorder, Conduct Disorder
 Trauma- and Stressor-Related Disorders – Adjustment
Disorders (while not a childhood disorder this class of
disorders is given to people under 18).
 Depressive Disorders – (NEW) – Disruptive Mood
Dysregulation Disorder

IN FOCUS: Disruptive Mood
Dysregulation Disorder (DMDD)
 Disruptive mood dysregulation disorder has two symptom criteria:
A. Severe recurrent temper outbursts manifested verbally (e.g., verbal
rages) and/or behaviorally (e.g., physical aggression towards people
or property) that are grossly out of proportion in intensity or duration
to the situation or provocation.
B. The temper outbursts are inconsistent with developmental level.
C. The temper outbursts occur, on average, 3-4 times per week.
D. The mood between outbursts is persistently irritable or angry most of
the day, nearly every day, and is observable by others (e.g., parents,
teachers, peers).

E. Criteria A-D have been present 12 months or more. During that time there
has not been a 3 consecutive month period (or more) without all of the
symptoms A-D.
F. Criteria A-D are present in at least 2 of the 3 following areas: home, school
or with peers, and are severe in at least one of these.
G. The diagnosis should not be made for the first time before the age of 6 or
after the age of 18.
H. By history of observation, the age of onset for Criteria A-E is before the age
of 10.
I. There has never been a distinct period lasting more than 1 day in which the
full symptom criteria, except duration, for a manic or hypomanic episode
have been met.
J. The behaviors do not occur exclusively during an episode of major
depressive disorder and are not better explained by another mental disorder.
NOTE: This diagnosis cannot coexist with Oppositional Defiant Disorder
(OPD). If an individual meets the criteria of both DMDD and OPD, the
diagnosis of DMDD should be made.

 The new diagnosis is designed to help families and children who “have never
been successfully treated for extreme, explosive rages,” says David Kupfer,
chairman of the DSM-5 task force and a professor of psychiatry at the
University of Pittsburgh
 “Too many severely impaired children like this have fallen through the cracks
because they suffer from a disorder that had not yet been defined.”
 In field trials this disorder had poor inter-rater reliability. There were 2 main
problems:
1. Field trials had trouble distinquishing between Oppositional Defiant
Disorder and DMDD.
2. There problems with “rage attack” durations, and commenters
emphasize the importance of the durations, frequency and persistence
criteria.

 Treatment Implications
 The treatment would differ from Bipolar disorder where the first line treatment
would be mood stabilizing drugs, which could have many side effects for
younger populations.
 The belief is that younger people with DMDD would, untreated, evolve into
depressive or anxiety disorders. There is talk of first line treatment being
either stimulants or antidepressants.
 The only treatment trial for this group, before the DSM-5 came out, was a
small trial of lithium, which produced negative impact.

Paraphillic Disorders
Characteristics of Paraphilic Disorders
Most people with atypical sexual interests do not have a mental disorder.
To be diagnosed with a paraphilic disorder, DSM-5 requires that people with
these interests:
1. Feel personal distress about their interest, not merely distress
resulting from society’s disapproval; or
2. Have a sexual desire or behavior that involves another person’s
psychological distress, injury, or death, or a desire for sexual
behaviors involving unwilling persons or persons unable to give legal
consent.
In the case of pedophilic disorder, the notable detail is what wasn’t revised
in the new manual. Although proposals were discussed throughout the DSM-
5 development process, diagnostic criteria ultimately remained the same as
in DSM-IV TR. Only the disorder name will be changed from pedophilia to
pedophilic disorder to maintain consistency with the chapter’s other listings.

The Controversy of Pedophilic
Disorder Being a “Sexual
Orientation”
 “The American Psychiatric Association’s (APA) Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition (DSM-5) has recently been
published after a comprehensive multi-year research and review of all of its
diagnostic categories,” the statement reads.
 “In the case of pedophilic disorder, the diagnostic criteria essentially
remained the same as in DSM-IV-TR. Only the disorder name was changed
from 'pedophilia' to ‘pedophilic disorder’ to maintain consistency with the
chapter’s other disorder listings.
 “'Sexual orientation’ is not a term used in the diagnostic criteria for
pedophilic disorder and its use in the DSM-5 text discussion is an error and
should read ‘sexual interest.’ In fact, APA considers pedophilic disorder a
‘paraphilia,’ not a ‘sexual orientation.’ This error will be corrected in the
electronic version of DSM-5 and the next printing of the manual.
 “APA stands firmly behind efforts to criminally prosecute those who sexually
abuse and exploit children and adolescents. We also support continued
efforts to develop treatments for those with pedophilic disorder with the goal
of preventing future acts of abuse.”

BRIEF FOCUS: Gender Dysphoria
 Gender dysphoria is a new diagnostic class in DSM-5 and reflects a
change in conceptualization of the disorder’s defining features by
emphasizing the phenomenon of “gender incongruence” rather than
cross-gender identification per se (DSM-IV delineation).
 In DSM-IV, the chapter “Sexual and Gender Identity Disorders” included
three relatively disparate diagnostic classes: gender identity disorders,
sexual dysfunctions, and paraphilias. Gender identity disorder, however,
is neither a sexual dysfunction nor a paraphilia.
 The experienced gender incongruence and resulting gender dysphoria
may take many forms.
 Gender dysphoria thus is considered to be a multicategory concept rather
than a dichotomy, and DSM-5 acknowledges the wide variation of gender
-incongruent conditions.
 Separate criteria sets are provided for gender dysphoria in children and in
adolescents and adults.

BRIEF FOCUS: Gender Dysphoria
 The previous Criterion A (cross-gender identification) and Criterion B
(aversion toward one’s gender) have been merged, because no
supporting evidence from factor analytic studies supported keeping the
two separate.
 In the wording of the criteria, “the other sex” is replaced by “some
alternative gender.” Gender instead of sex is used systematically because
the concept “sex” is inadequate when referring to individuals with a
disorder of sex development.
 The subtyping on the basis of sexual orientation has been removed
because the distinction is not considered clinically useful.
 A posttransition specifier has been added because many individuals, after
transition, no longer meet criteria for gender dysphoria; however, they
continue to undergo various treatments to facilitate life in the desired
gender.
 Although the concept of posttransition is modeled on the concept of full or
partial remission, the term remission has implications in terms of symptom
reduction that do not apply directly to gender dysphoria.

Substance Use Disorder Exercise #2
 Francis is a client referred to you for an evaluation. The client has been
sent to you for her 3rd
VOP on a 4 year old charge of fraudulent
prescription writing (opiates). Since that time, the client has been to a
new doctor and continues getting a prescription of opiates from a different
doctor. Francis reported an increase in tolerance to the prescription
opiates. When contacting the doctor (Dr. Bombay), he reported that
Francis is doing well on her medication and has the physical pain and
problems proven in her MRI/CAT scan workups that back up her claims.
 When asked if the doctor ever performs urine drug screens or monitoring
of medication counts while in the office, the doctor stated he did not. The
client came up positive for oxycodone upon the evaluation, but refused to
bring in her medication (during both the evaluation and the follow-up
session). She stated that her reason for “refusing” was that she simply
forgot. When asking the Probation Officer if she was aware of the
medications that Francis was on she stated she was and has done pill
counts on 5 occasions (in the past 5 months due to her suspicions of
Francis), 2 of which the pill counts were off by 17 – 24 pills. Francis also
pulled 2 negative urine drug screens on those 2 occasions while the other
3 were positive for oxycodone, which is consistent with her prescription.
Her test was positive for oxycodone & morphine during your evaluation.

 Francis admitted to developing a tolerance to her prescription, and stated
she goes through withdrawals when not using the medications. When
asked about substituting other drugs (confronting her about the
morphine/codeine positive that came up on her most recent urine drug
screen), she admitted to hoarding her pills in fear that she will run and
substituting her pill use with either heroin or suboxone at times. She
stated that she only uses heroin or suboxone when not taking her
medication, and usually uses 4 bags per day of heroin to account for the
number of pills she takes, or takes 16-24mg of suboxone per day. She
stated she only needed 2 bags of heroin at first but within the past year
she has increased her tolerance and needs 4 bags, which she stated she
takes by snorting.
 When asked about her pill count being off, and her negative urine drug
screens, she denied selling her pills and stated that she merely “saves”
them “just in case”.
 She spends a great time of time using her substances, and trying to
obtain and use substitute substances. She gets into frequent fights with
her husband over her use as he feels she does not need the medications
anymore. She feels strongly that she still does.

 She has tried going without all opiates, but when she does she does not
successfully do so for long. She states this occurs for 2 reasons: 1) she
endures terrible withdrawal feelings and cannot stop thinking about using
the substances and has repeated strong desires to use the substances;
and 2) she states that the pain becomes so bad that it is unbearable and
has to return to using the opiate medication.
 She is currently on short-term disability and unable to return to work. She
reported that her husband complains that she is unable to do many things
that she used to do, and now that she has more time since she is home
all the time, she is unable to do (such as her designated home-related
work assignments that she reports she and her husband used to divide
equally, but admits that he now does mostly all of them).
1. Give her DSM-5 Diagnosis and justification of specific criteria
used to decide 1) if she has a substance use disorder, and 2)
if so, is it mild (2-3), moderate (4-5) or severe (6 or more).

The Relationship between Substance Use
Disorders and Anxiety Disorders
 Substance use can increase anxiety – it is postulated that 3 factors
increase anxiety vulnerability among substance users:
1. The physiological effects of drug/alcohol use. Some substances
have clear anxiety-increasing properties that may produce chronic
anxiety as a result of prolonged and/or heavy usage.
2. Craving – people may use drugs or alcohol to manage not only
craving but the associated anxiety that comes with craving.
3. Withdrawal – anxiety, stress and irritability are among the most
common withdrawal symptoms associated with a variety of
substances.
 Mutual Maintenance Model
1. Anxiety can lead to substance use.
2. Substance use and withdrawal can increase anxiety.
3. Subsequently continued substance use occurs to manage anxiety
symptoms, which then can cause the very symptoms they are
trying to manage, causing a circular, continuous feeding effect.

DSM-5 Changes to Anxiety Disorders
Anxiety Disorders are being carved out into 3 categories.
Anxiety Disorders
1. Separation Anxiety Disorder
2. Selective Mutism
3. Specific Phobia
4. Social Anxiety Disorder (Social Phobia)
5. Panic Disorder
6. Agoraphobia
7. Generalized Anxiety Disorder
8. Substance/Medication-Induced Anxiety Disorder
9. Anxiety Disorder Due to Another Medical Condition
10. Other Anxiety Disorder
11. Unspecified Anxiety Disorder
Panic Attack

Obsessive-Compulsive and Related Disorders
1. Obsessive-Compulsive Disorder
2. Body Dysmorphic Disorder
3. Hoarding Disorder
4. Trichotillomania (Hair-Pulling Disorder)
5. Excoriation (Skin Picking Disorder)
6. Substance/Medication-Induced Obsessive-Compulsive or Related
Disorders
7. Obsessive-Compulsive or Related Disorder Attributable to Another
Medical Condition
8. Other Specified Obsessive-Compulsive or Related Disorder
9. Unspecified Obsessive-Compulsive or Related Disorder

Trauma- and Stressor-Related Disorders
1. Reactive Attachment Disorder
2. Disinhibited Social Engagement Disorder
3. Posttraumatic Stress Disorder
4. Acute Stress Disorder
5. Adjustment Disorders (with depressed mood, with anxiety, with mixed
anxiety and depressed mood, with disturbance of conduct, with mixed
disturbance of emotions and conduct)
6. Other Specified Trauma- or Stressor- Related Disorder
7. Unspecified Trauma- or Stressor- Related Disorder

IN FOCUS: Hoarding Disorder
A. Persistent difficulty discarding or parting with possessions, regardless of
their actual value.
B. This difficulty is due to a perceived need to save the items and to distress
associated with discarding them.
C. The difficulty discarding possessions results in the accumulation of
possessions that congest and clutter active living areas and substantially
compromises their intended use. If living areas are uncluttered, it is only
because of the interventions of third parties (e.g., family members,
cleaners, authorities or The Learning Channel).
D. The hoarding causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning (including
maintaining a safe environment for self and others).
E. The hoarding is not attributable to another medical condition (e.g., brain
injury, cerebrovascular disease, Prader-Willi syndrome).

F. The hoarding is not better explained by the symptoms of another mental
disorder (e.g., obsessions in obsessive-compulsive disorder, decreased
energy in major depressive disorder, delusions in schizophrenia or
another psychotic disorder, cognitive deficits in major neurocognitive
disorder, restricted interests in autism spectrum disorder).
Specify if:
With excessive acquisition: If difficulty discarding possessions is
accompanied by excessive acquisition of items that are not needed or for
which there is no available space.
Specify if:
With good or fair insight: The individual recognizes that hoarding-related
beliefs and behaviors (pertaining to difficulty discarding items, clutter, or
excessive acquisition) are problematic.
With poor insight: The individual is mostly convinced that the hoarding-
related beliefs and behaviors (listed above) are not problematic despite
evidence to the contrary.
With absent insight/delusional beliefs: The individual is completely convinced
that the hoarding-related believes and behaviors are not problematic
despite evidence to the contrary.

 Hoarding Disorder appears to be comorbid with clients organic brain
disorders such as schizophrenia, autism, and developmental delays.
 People found to be living in squalor as a result of their hoarding behavior
have a high prevalence of the following disorders:
1. Depression 51%
2. ADHD 28%
3. Anxiety 24%
 Hoarding does not appear to respond well to SSRI’s or typical
psychotherapy approaches.
 The best approach is a cognitive therapy approach, working with clients
by supervising them in the practice organizing and discarding items, along
with working on irrational belief systems.
 Studies have shown this work to be difficult as many hoarding participants
are unable to complete homework assignments.

IN BRIEF: Anxiety Disorders
 Agoraphobia is now distinct from panic disorder
 Panic Attack (not-coded) can be used as a specifier across other diagnoses.
 Social Phobia is now labeled as Social Anxiety Disorder.
 Separation Anxiety Disorder may have “adult onset”.
 Specific Phobia and Social Anxiety Disorder will have a duration requirement.
 Specific Phobia and Social Anxiety Disorder will no longer require the client
recognize the fear as unreasonable. The clinician will make that decision.
 Obsessive-Compulsive Disorder (the class of disorders were all removed from
anxiety disorders) was removed due to the belief that OCD is not due to
anxiety but is due to a neurological “short-circuit” that causes obsessive
thoughts and behaviors (similar to Body Dysmorphic and Tourrettes Disorder.

PTSD – No longer an “anxiety disorder”
Posttraumatic Stress Disorder – The Shared Anxiety
Symptoms
 Phenomenologically, PTSD shares a number of symptoms (especially
from its Hyperarousal/D Criterion cluster) with other anxiety disorders
such as insomnia, irritability, poor concentration, and startle reactions.
PTSD avoidance behavior is similar to phobic and anxious avoidance.
 Physiological arousal and dissociation (e.g., derealization and
depersonalization) also occur in panic disorder.
 Persistent intrusive thoughts or memories are commonly observed
across anxiety disorders, including generalized anxiety disorder (GAD),
obsessive-compulsive disorder (OCD), panic disorder, and social
Phobia.

PTSD – No longer an “anxiety disorder”
Posttraumatic Stress Disorder – The Differentiation
 PTSD is primarily a disorder of reactivity, along with specific and social
phobia, rather than a syndrome with a consistent alteration of the
tonic/basal state, such as depression and GAD.
 Furthermore, anxiety is present in most psychiatric disorders. It is not a
particularly sensitive and specific index to posttraumatic reactions,
normal or abnormal.
 A number of symptoms observed in PTSD, such as numbing,
alienation, and detachment, are frequent depressive symptoms, and
can be responsible for the high co-morbidity between the two disorders.
 Although there is overlap between other anxiety disorders and
depression, as well, this pattern suggests that PTSD is more than
simply an anxiety disorder.

IN BRIEF – PTSD (Changes to Criterion A in
the DSM-5)
A. Exposure to actual or threatened a) death, b) serious injury, or c)
sexual violation, in one or more of the following ways:
1. directly experiencing the traumatic event(s)
2. witnessing, in person, the traumatic event(s) as they occurred to
others
3. learning that the traumatic event(s) occurred to a close family
member or close friend; cases of actual or threatened death must
have been violent or accidental
4. experiencing repeated or extreme exposure to aversive details of
the traumatic event(s) (e.g., first responders collecting human
remains; police officers repeatedly exposed to details of child
abuse); this does not apply to exposure through electronic media,
television, movies, or pictures, unless this exposure is work-
related.

IN BRIEF – PTSD (DSM-5)
H. The disturbance is not attributed to the direct physiological effects of a
substance (e.g., medication, drugs, or alcohol) or another medical
condition (e.g. traumatic brain injury).
 Specify if:
 With Delayed Expression: if the diagnostic threshold is not exceeded
until at least 6 months after the event (although the onset and
expression of some symptoms may be immediate).

 Subtype: Posttraumatic Stress Disorder in Preschool
Children
 Subtype: Posttraumatic Stress Disorder – With Prominent
Dissociative (Depersonalization/Derealization) Symptoms

Brief Overview – Schizophrenia
Changes
 The requirement of at least 2 Criterion A symptoms must be
present).
1. Delusions
2. Hallucinations
3. Disorganized Speech (e.g., frequent derailment or incoherence)
4. Grossly Disorganized or Catatonic Behavior
5. Negative Symptoms (i.e., diminished emotional expression or
avolition).
 One of those Criterion A symptoms must be either delusions,
hallucinations or disorganized speech.
 The DSM-IV subtypes have been eliminated (Paranoid,
Bizarre, Catatonic, Undifferentiated, Residual) due to their
limited diagnostic stability, low reliability, and poor validity.

Brief Overview – Schizophrenia
Changes
 Specifiers include:
 First episode, currently in acute episode – first manifestation of
the disorder meeting the defining diagnostic symptom and time criteria.
An acute episode is a time period in which the symptom criteria are
fulfilled.
 First episode, currently in partial remission – partial remission is a
period of time during which an improvement after a previous episode is
maintained and in which the defining criteria of the disorder are partially
fulfilled.
 First episode, currently in full remission – full remission is a period
of time after a previous episode during which no disorder-specific criteria
are present.
 Also multiple episodes (more than 2), currently in acute
episode, currently in partial remission, or currently in full
remission, Continuous (symptoms remain for the majority of

Brief Overview – Catatonia
 In DSM-5, catatonia may be diagnosed as a specifier for depressive,
bipolar, and psychotic disorders; as a separate diagnosis in the context of
another medical condition; or as an other specified diagnosis.
 DSM-5 states that research shows that catatonia is under-diagnosed and
is present in more disorders than previously thought.
 Therefore they are proposing that it be removed from the psychotic
disorders as being exclusively part of this set of disorders.
 It is now a specifier for ALL the psychotic disorders, as well as for various
medical conditions and mood disorders (depressive and bipolar disorders).

Brief Overview – Schizophreniform D/O
 The main thing that remains the same between the DSM-IV-TR
and the DSM-5 with this disorder is:
1. Still nobody knows what this disorder is.
2. Nor what purpose it still serves.
 Think of schizophreniform as the transient period between:
1. Brief Psychotic Reaction (which lasts for more than 1 day but remits
after 1 month) and;
2. Schizophrenia (which cannot be diagnosed until a duration of 6
months.
3. Meet … Schizophreniform – (1 month – 6 month duration).
 Think of schizophreniform as middle school between elementary and high
school.

 Mark, a 48 year old male, comes to you for a drug court evaluation. He
reports using marijuana and alcohol in his lifetime. He reported that his
alcohol use has always been sporadic in his lifetime. He did state that his
use was heavier in college, and he received 1 DWI while in college.
However, he did not admit to any signs or symptoms of alcohol use
disorder besides the occasional college binge drinking and the 1 DWI. He
reported that his father was killed by a drunk driver and after the DWI he
changed his drinking pattern to what it is now, drinking 1-2 times per year,
usually consuming 1-2 glasses of wine per occasion. He also reported
that he only drank and drove that one time, which caused guilt in him for
doing so because after his father’s death (which occurred when he was
15) he swore he would never engage in such behaviors.
 Mark’s marijuana history is more pronounced and starting at the age of 18
he began smoking once a week. This use stayed constant throughout
college and throughout his 20’s. When he was 32 he started smoking
more, and started to sell marijuana to add to his job income and support
his increasing smoking frequency. In his late 30’s he received his first
legal charge for CDS. He was put on probation for 1 year, and had 2
subsequent VOPs for continued CDS charges and the last charge was
CDS with the intent to distribute.

 Mark stated his use increased to smoking 1-2 times per week, but would
often smoke 3-4 times per week, finances depending. He reported last
year his job found out about his marijuana use after a random urine test
and fired him on the spot. He did state that he would often drive after
smoking pot and didn’t see this as the same issue regarding his
viewpoints on drinking and driving. He stated within the past year he has
driven under the influence of marijuana approximately 12 times.
 He also stated that he would get into verbal fights about his marijuana
often with his girlfriend and when he lost his job last year, she told him
that was the final straw and left him due to his continued marijuana use.
 When asked if he ever tried to cut down, he stated no because he never
thought his use was problematic. He denied ever using more than he
intended to, and denied ever building up a tolerance to marijuana or
having any types of withdrawal symptoms from it. When asked if his
marijuana use caused any psychological changes/problems such as
paranoia or memory loss, he denied this and he denied having any
physical problems caused by, or made worse by his marijuana use.
When asked if he ever experienced any strong desires to use, or any
psychological or physiological cravings for pot, he denied experiencing
these.

 When asked how much time he put into smoking, obtaining the substance
he stated that his selling supported his ability to smoke, and between
smoking and all other activities he stated he spent about 30 – 40 hours
per week engaged around his pot use/selling.
 He is legally eligible for admission into drug court, and your team has to
decide if he meets the clinical criteria to support admission into the drug
court program, which will of course depend on the results of your
evaluation.
1. Give her DSM-5 Diagnosis and justification of specific criteria
used to decide 1) if she has a substance use disorder, and 2)
if so, is it mild (2-3), moderate (4-5) or severe (6 or more).
2. Does he meet admission criteria? Why/Why not? Do the
types of criteria he does meet impact your decision on
whether or not to accept him into drug court?

What is Personality?
This is a solo exercise.
Identify 3 important factors that characterize you as a
person.
Personality is made up the characteristic patterns of
thoughts, feelings, and behaviors that make a person
unique. It arises from within the individual and remains
fairly consistent throughout life.

What is a Personality Disorder?
 Personality disorders are a class of mental disorders characterized
by enduring maladaptive patterns of behavior, cognition, and inner
experience, exhibited across many contexts and deviating markedly
from those accepted by the individual's culture.
1. These patterns develop early, are inflexible, and are associated with
significant distress or disability.
2. Personality disorders are defined by experiences and behaviors that
differ from societal norms and expectations.
3. Those diagnosed with a personality disorder may experience difficulties
in cognition, emotiveness, interpersonal functioning, or control of
impulses.
4. In general, personality disorders are diagnosed in 40–60 percent of
psychiatric patients, making them the most frequent of all psychiatric
diagnoses.

Changes from the DSM-IV-TR to the
DSM-5
In developing diagnostic criteria for personality disorders, the DSM-5 Work
Group initially proposed a somewhat dramatic new approach:
1.Maintain 6 personality disorder diagnoses from the prior 10 in DSM-IV,
and move from a categorical to a trait-based, dimensional classification
system (dropped are Dependent • Histrionic • Paranoid • Schizoid).
2.Per the categorical system, a patient either has a diagnosis or not,
whereas a dimensional system better captures the nuances of human
personality by measuring a variety of traits on a continuum.
3.The proposal was ultimately voted down; however, the alternative hybrid
dimensional-categorical model is included in a separate chapter in Section
3 of DSM-5 to stimulate further research on this modified classification
system.

Changes from the DSM-IV-TR to the
DSM-5
 In the DSM-5 field trials, only borderline personality disorder had
good inter-rater reliability.
 Inter-rater reliability: inter-rater agreement, or concordance is
the degree of agreement among raters. It gives a score of how
much homogeneity, or consensus, there is in the ratings given by
judges.
 In contrast, obsessive-compulsive personality disorder and
antisocial personality disorder were in the questionable reliability
range.
 All other personality disorders had too few patients to test their
reliability.

Current Personality Disorder
Configuration
Current Configuration (10 Personality Disorders):
Cluster A • Paranoid • Schizoid • Schizotypal
Cluster B • Antisocial • Borderline • Histrionic • Narcissistic
Cluster C • Avoidant • Dependent • Obsessive-compulsive
Cluster A personality disorders: these are disorders in which odd or
eccentric behavior is considered to be central. For example in schizotypal,
schizoid and paranoid personality disorders.
Cluster B personality disorders: this group includes personality
disorders in which dramatic and erratic emotional responses are common.
Borderline, antisocial, histrionic and narcissistic personality disorders
belong in this cluster.
Cluster C personality disorders: personality disorders which are
classified as belonging to cluster C are those in which anxious and fearful
behavior are central – including avoidant, dependent and obsessive
compulsive personality disorders.

Proposed Overarching Changes to PD
Current Configuration (10 Personality Disorders):
Cluster A • Paranoid • Schizoid • Schizotypal
Cluster B • Antisocial • Borderline • Histrionic • Narcissistic
Cluster C • Avoidant • Dependent • Obsessive-compulsive
Proposed Configuration (6 Personality Disorders):
Antisocial Personality Disorder
Avoidant Personality Disorder
Borderline Personality Disorder
Narcissistic Personality Disorder (almost didn’t make the cut)
Obsessive-Compulsive Personality Disorder
Schizotypal Personality Disorder

General Criteria for Personality Disorder
The essential features of a personality disorder are:
A.Moderate or greater impairment in personality (self/interpersonal) functioning
(Criterion A for each disorder).
B.One or more pathological personality traits (Criterion B for each disorder).
C.The impairments in personality functioning and the individual’s personality trait
expression are relative inflexible and pervasive across a broad range of personal and
social situations.
D.The impairments in personality functioning are the individual’s trait expression are
relatively stable across time, with onsets that can be traced back to at least
adolescence or early adulthood.
E.The impairments in personality functioning and the individual’s personality trait
expression are not better explained by another mental disorder.
F.The impairments in personality functioning and the individual’s personality trait
expression are not solely attributable to the physiological effects of a substance or
another medical condition (e.g., severe head trauma).
G.The impairments in personality functioning and the individual’s trait expression are
not better understood as normal for an individual’s developmental stage or sociocultural
environment.

Alternative DSM-5 Model for Personality
Disorders
Criterion A: Level of Personality Functioning
Disturbances in self and interpersonal functioning constitute the core of personality
psychopathology. Self (Identity and Self-direction) and Interpersonal (Empathy and Intimacy).
Self
1.Identity: Experience of oneself as unique, with clear boundaries between self and others;
stability of self-esteem and accuracy of self-appraisal; capacity for, and ability to regulate, a range
of emotional experience.
2.Self-direction: Pursuit of coherent and meaningful short-term and life goals; utilization of
constructive and prosocial standards of behavior; ability to self-reflect productivity.
Interpersonal
nEmpathy: Comprehension and appreciate of others’ experiences and motivations; tolerance of
differing perspectives; understanding of one’s own behavior on others.
nIntimacy: Depth and duration of connection with others; desire and capacity for closeness;
mutuality of regard reflected in interpersonal behavior.
Impairment in personality functioning predicts the presence of a personality disorder, and the
severity of impairment predicts whether a person has more than 1 personality disorder, or one of
the more particularly severe personality disorders. A MODERATE LEVEL OF IMPAIRMENT IN
PERSONALITY FUNCTIONING IS REQUIRED FOR THE DIAGNOSIS OF A PERSONALITY
DISORDER.

Disorders
Criterion B: Pathological Personality Traits
Pathological personality traits are organized into broad
domains:
1. Negative Affectivity
2. Detachment
3. Antagonism
4. Disinhibition
5. Psychoticism
Within the 5 broad trait domains are 25 specific trait
facets.

Personality Disorders – 5 Traits and
Facets
 Negative Affectivity (vs. Emotional Stability) – traits include Emotional Liability,
Anxiousness, Separation Insecurity, Submissiveness, Hostility, Perseveration,
Depressivity, Suspiciousness, Restricted Affectivity (or lack of).
 Detachment (vs. Extraversion) – Withdrawal, Intimacy Avoidance, Anhedonia
(lack of enjoyment, enjoyment or energy in life’s experiences), Depressivity,
Restricted Affectivity, Suspiciousness.
 Antagonism (vs. Agreeableness) – Manipulativeness, Deceitfulness,
Grandiosity, Attention Seeking, Callousness.
 Disinhibition (vs. Conscientiousness) – Irresponsibility, Impulsivity, Distractibility,
Risk Taking, Rigid Perfectionism (or lack of).
 Psychoticism (vs. Lucidity) – Unusual Beliefs and Experiences, Eccentricity,
Cognitive and Perceptual Dysregulation (odd or unusual thought processes).

Disorders
 Criterion C and D: Pervasiveness and Stability
 Impairments in personality functioning across a range of social
contexts (social, occupational, or other important pursuits).
 Criterion E, F, and G: Alternative Explanations for
Personality Pathology (Differential Diagnosis)
 On some occasions, what appears to be a personality disorder be
better explained by another mental disorder, the effects of a
substance or another medical condition, or a normal
developmental stage (e.g., adolescence, late life).

Section 3: Borderline Personality Disorder
PROPOSED DIAGNOSTIC CRITERIA
A.Moderate or greater impairment in personality functioning, manifested by
characteristic difficulties in two or more of the following four areas:
1. Identity: Markedly impoverished, poorly developed, or unstable self-
image, often associated with excessive self-criticism; chronic feelings
of emptiness, dissociative states under stress.
2. Self-direction: Instability in goals, aspirations , values, or career
plans.
3. Empathy: Compromised ability to recognize the feelings and needs
of others associated with interpersonal hypersensitivity (i.e., prone to
feel slighted or insulted); perceptions of others selectively biased
towards negative attributes or vulnerabilities.
4. Intimacy: Intense, unstable, and conflicted close relationships,
marked by mistrust, neediness, and anxious preoccupation with real or
imagined abandonment; close relationships often viewed in extremes
of idealization and devaluation and alternating between over-
involvement and withdrawal.

PROPOSED DIAGNOSTIC CRITERIA
B.Four or more of the following seven pathological personality traits, at least one of
which must be (5) Impulsivity, (6) Risk taking, or (7) Hostility:
1. Emotional liability (an aspect of Negative Affectivity): Unstable
emotional experiences and frequent mood changes; emotions that are easily
aroused , intense, and/or out of proportion to events and circumstances.
2. Anxiousness (an aspect of Negative Affectivity): Intense feelings of
nervousness, tenseness or panic, often in reaction to interpersonal stresses;
worry about the negative effects of past unpleasant experiences and future
negative possibilities; feeling fearful, apprehensiveness, or threatened by
uncertainty; fears of falling apart or losing control.
3. Separation insecurity (an aspect of Negative Affectivity): Fears of
rejection by – and/or separation from – significant others , associated with fears
of excessive dependency and complete loss of autonomy.
4. Depressivity (an aspect of Negative Affectivity): Frequent feelings of
being down, miserable, an/or hopeless; difficulty recovering from such moods;
pessimism about the future; pervasive shame; feelings of inferior self-worth;
thoughts of suicide and suicidal behavior.

PROPOSED DIAGNOSTIC CRITERIA (B CONTINUED)
B.Four or more of the following seven pathological personality traits, at least
one of which must be (5) Impulsivity, (6) Risk taking, or (7) Hostility:
5. Impulsivity (an aspect of Disinhibition): Acting on the spur of
the moment in response to immediate stimuli; acting on momentary
basis without a plan or consideration of outcomes; difficulty
establishing or following plans; a sense of urgency and self-harming
behavior under emotional distress.
6. Risk taking (an aspect of Disinhibition): Engagement in
dangerous, risky, and potential self-damaging activities, unnecessarily
and without regard to consequences; lack of concern for one’s
limitations and denial of the reality of personal danger.
7. Hostility (an aspect of Antagonism): Persistent or frequent
angry feelings; anger or irritability in response to minor slights and
insults.

Bibliography
 American Psychiatric Association. (1952). Diagnostic and statistical manual of mental
disorders. Washington, DC: Author.
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disorders (4th
ed., text rev.). Washington, DC: Author.
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ed.). Washington, DC: Author.

Bibliography
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relationship between criteria A and B.” The Journal of Nervous and Mental Disease. 202(5), 412-
418.

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