An overview, changes and critical analysis of DSM-5

1. DSM-5
PRESENTER – DR.SRIRAM.R, FINAL YEAR MD PG IN PSYCHIATRY
CHAIRPERSON – DR.THENMOZHI, ASST. PROF OF PSYCHIATRY

2. N O S O L O G Y
•Nosology or taxonomy is a branch of medical science that deals with
classification of diseases.
•Most disciplines of medicine follow etiological classification.
•Since etiology is still obscure in most of the psychiatric illnesses , our
classifications are primarily based on symptomatology rather than on
etiology.

3. What is the need for classification systems?
•To distinguish one psychiatric diagnosis from another, so that
clinicians can offer the most effective treatment;
• To provide a common language among health care professionals;
•And to explore the still unknown causes of many mental disorders.

4. Systems of classifications in Psychiatry.
- ICD by WHO
- DSM by APA
- Chinese Classification of Mental Disorders [CCMD]
- Latin American Guide for Psychiatric Diagnosis
- The Research Domain Criteria [RDoC] by NIMH

5. The DSM classification.
In 1952, the APA published the DSM, followed by DSM-II
(1968); DSM-III (1980); DSM-III-R (1987); DSM-IV (1994);
and DSM-IV-TR (2000).

6. DSM-5
22 Chapters
DSM-IV
17 Chapters

7. EVOLUTION OF THE DSM-5
•DSM-I (1952) – 132 Pages – Mental disorders as “reactions” Definitions were simple, brief paragraphs with prototypical
descriptions
•DSM-II (1968) - 134 pages - “Reaction” terminology dropped, Users encouraged to record multiple psychiatric diagnoses
(in order of importance) and associated physical conditions coincided with ICD-8 (first time ICD included mental
disorders)
•DSM-III (1980) – 494 Pages - Descriptive and neutral “atheoretical”) regarding etiology. Coincided with ICD-9. Multiaxial
classification system. Goal was to introduce reliablilty.
•DSM-III-R (1987) – 567 Pages - Categories were renamed and reorganized, and significant changes in criteria were
made. Six categories were deleted while others were added. Controversial diagnoses, such as pre-menstrual
dysphoric disorder and masochistic personality disorder, were considered and discarded. "Ego-dystonic
homosexuality" was also removed and was largely subsumed under "sexual disorder not otherwise specified", which
can include "persistent and marked distress about one's sexual orientation."

8. EVOLUTION OF THE DSM-5
DSM-IV (1994) – 886 Pages - Inclusion of a clinical significance criterion. New
disorders introduced (e.g., Acute Stress Disorder, PTSD, Bipolar II Disorder,
Asperger’s Disorder), others deleted (e.g., Cluttering, Passive-Aggressive
Personality Disorder).
DSM-IV-TR (2000) - The text sections giving extra information on each diagnosis
were updated, as were some of the diagnostic codes to maintain consistency with
the ICD. The DSM-IV-TR was organized into a five-part axial system. The first axis
incorporated clinical disorders. The second axis covered personality
disorders and intellectual disabilities. The remaining axes covered medical,
psychosocial, environmental, and childhood factors functionally necessary to
provide diagnostic criteria for health care assessments.

9. DEVELOPMENT OF THE DSM-5
•Development started with 1999 meeting and Task force recruited in 2006
•Work Groups considered dimensional measures. e.g. severity scales or cross-cutting
across disorders, culture/gender issues.
•Field trials were organized to assess reliability. 2246 patients interviewed (86% twice)
based on DSM-5 criteria. Interviews were conducted by 279 clinicians in various
disciplines.
•Scientific reviews were written. Over 1000 members/consultants involved. Aimed to be
transformative.
•3 Internet postings of changes for review done, and a Scientific Review Committee
reviewed evidence for validating revisions. Peer Review process with hundreds of experts
considered clinical/public health risks and benefits of proposed changes.
•Finally approved by the APA Assembly in November 2012 and by the Board of trustees in
December 2012

10. The DSM - 5
947 pages - Research started in 1999, approved by the Board of
Trustees of the APA on December 1, 2012 and released on 18th May
2013. The DSM-5 is the first major edition of the manual in twenty
years.

11. The DSM - 5
Beginning with the fifth edition, it is intended that diagnostic
guidelines revisions will be added more frequently. It is notable that
The DSM-5 is identified with Hindu rather than Roman numerals.
Incremental updates will be identified with decimals (DSM-
5.1,DSM-5.2, etc.). A new edition will be signified by whole number
changes (DSM-5,DSM-6, etc.). The change reflects the intent of the
APA to respond more quickly when a preponderance of research
supports a specific change in the manual.

12. OVERVIEW OF CHANGES IN THE DSM-5
•New categories: Obsessive-Compulsive and Related Disorders, Trauma- and Stressor-Related
Disorders
•Transformed: Neurodevelopmental Disorders (Infancy, adolescence, childhood), Somatic
Symptom and Related Disorders
•Discontinued 5-Axis system
•NOS replaced by "Other Specified” or “Unspecified” and “Another Medical Condition"
instead of “General Medical Condition” NOTE: NOS DSM IV = 41 and
Other/Unspecified DSM-5 =65 (To match ICD-10)
•Axis 4 gone - might use V & (Z in ICD 10) codes
•Axis 5 gone - might use WHODAS from Section III
•List multiple diagnoses in order of attention or concern

13. NEW DISORDERS IN THE DSM-5
•Social (Pragmatic) Communication Disorder
•Disruptive Mood Dysregulation Disorder
•Premenstrual Dysphoric Disorder
•Hoarding Disorder
•Excoriation (Skin‐Picking) Disorder
•Disinhibited Social Engagement Disorder (split from Reactive Attachment
Disorder)
•Binge Eating Disorder
•Central Sleep Apnea

14. NEW DISORDERS IN THE DSM-5
•Sleep-Related Hypoventilation
•Rapid Eye Movement Sleep Behavior Disorder
•Restless Legs Syndrome
•Caffeine Withdrawal
•Cannabis Withdrawal
•Major Neurocognitive Disorder with Lewy Body Disease (Dementia Due to Other
Medical Conditions)
•Mild Neurocognitive Disorder

15. ELIMINATED DISORDERS IN THE DSM-5
•Sexual Aversion Disorder
•Polysubstance-Related Disorder

16. COMBINED DISORDERS IN THE DSM-5
•Specific Learning Disorder (Reading Disorder, Math Disorder, Disorder of Written
Expression)
•Delusional Disorder (Shared Psychotic Disorder, Delusional Disorder)
•Panic Disorder (Panic Disorder Without Agoraphobia Panic Disorder With Agoraphobia)
•Dissociative Amnesia (Dissociative Fugue and Dissociative Amnesia)
•Somatic Symptom Disorder (Somatization Disorder, Undifferentiated Somatoform
Disorder and Pain Disorder)
•Insomnia Disorder (Primary Insomnia and Insomnia Related to Another Mental
Disorder)
•Hypersomnolence Disorder (Primary Hypersomnia and Hypersomnia Related to Another
Mental Disorder)

17. COMBINED DISORDERS IN THE DSM-5
•Non-Rapid Eye Movement Sleep Arousal Disorders (Sleepwalking Disorder and Sleep
Terror Disorder)
•Genito‐Pelvic Pain/Penetration Disorder (Vaginismus and Dyspareunia)
•Alcohol Use Disorder (Alcohol Abuse and Alcohol Dependence)
•Cannabis Use Disorder (Cannabis Abuse and Cannabis Dependence)
•Phencyclidine Use Disorder (Phencyclidine Abuse and Phencyclidine Dependence)
•Other Hallucinogen Use Disorder (Hallucinogen Abuse and Hallucinogen Dependence)
•Inhalant Use Disorder (Inhalant Abuse and Inhalant Dependence)

18. COMBINED DISORDERS IN THE DSM-5
•Opioid Use Disorder (Opioid Abuse and Opioid Dependence)
•Sedative, Hypnotic, or Anxiolytic Use Disorder (Sedative, Hypnotic Anxiolytic Abuse
and Sedative, Hypnotic, or Anxiolytic Dependence)
•Stimulant Intoxication (Amphetamine Intoxication and Cocaine Intoxication)
•Stimulant Withdrawal (Amphetamine Withdrawal and Cocaine Withdrawal)
•Substance/Medication-Induced Disorders (aggregated categories: Mood , Anxiety ,and
Neurocognitive )

19. I n s i d e D S M - 5
Divided into three sections.
Section I - DSM 5 basics
Section II - Diagnostic criterion and codes
Section III - Emerging measures and models
and an Appendix.

20. Section I
•Orientation
•Historical back ground
•Development of DSM-5
•How to use it

21. Section I – DSM -5 basics.
Harmonized with ICD system.
Non-axial documentation of diagnosis.
Dimensional assessment.
Changes in diagnostic criterions.

22. Harmonization with the ICD system has been done to avoid unwanted
hindrances in both scientific research and patient care.
Most importantly the salient differences between ICD and DSM does not have any
scientific basis rather they reflect historical byproducts of various committee
meetings.

23. DSM-5 has moved towards non-axial system of
diagnosis [formerly Axis I,II and III] with separate
notations for important psychosocial and contextual
factors [formerly Axis IV] and disability
[formerly Axis V]

24. Section II - Diagnostic criterion and codes

25. Section III
•Emerging Measures and Models
•Assessment measures -
http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-
measures
•Cultural formulation
•Alternative DSM-5 model for personality disorders
•“Criteria Sets for Conditions for Further Study”

26. Section III - Emerging measures and models
Alternative DSM-5 model of Personality disorders.
A typical patient meeting a criterion for a DSM-IV personality disorder
often qualifies for another personality disorder too. So an alternative
model have been introduced.
Antisocial, Avoidant, Borderline ,Narcissistic ,Obsessive –Compulsive
and Schizotypal PD can be diagnosed and Personality Disorder –Trait
Specific can be diagnosed if the criterion is not met , but if PD is
suspected.

27. Conditions for further study
Proposed criterion sets have been described for following conditions in which further
research is encouraged, namely
Attenuated Psychosis Syndrome
Depressive episodes with short duration hypomania
Persistent complex bereavement disorder
Caffeine use disorder
Internet gaming disorder
Neurobehavioral disorder associated with prenatal alcohol exposure
Suicidal behavior disorder
Nonsuicidal self injury

28. Appendix
•Highlights of changes from DSM-IV to DSM-5
•Glossary of technical terms
•Glossary of cultural terms
•Alpha & numeric listings of diagnoses and codes
•List of advisors and contributors

29. A p p e n d i x
Highlights changes from DSM-IV to DSM-5

30. Neurodevelopmental disorders
•Mental Retardation changed to Intellectual Disability
•Intellectual Developmental Disorder - World Health Organization’s
classification system
•Diagnostic criterion emphasize the need for assessment of both cognitive capacity
[IQ] & adaptive functioning.
•Severity is determined by adaptive functioning rather than IQ score.

31. Communication disorders
•Combines DSM-IV expressive and mixed receptive-expressive
language disorders, speech sound disorder (new name for
phonological disorder), and childhood-onset fluency disorder (new
name for stuttering).
•Social communication disorder – new condition for for persistent
difficulties in the social uses of verbal and nonverbal
communication.

32. Autism spectrum disorder
•New disorder encompassing Autism + Asperger’s disorder + Rett’s
disorder + Childhood disintegrative disorder + pervasive developmental
disorder NOS.
• The new criteria describe two principal symptoms: “deficits in social
communication and social interaction” and “restrictive and repetitive
behavior patterns”. Both of them should be present for diagnosis of
autism spectrum disorder.

33. ADHD
•Examples added to help apply dx throughout life span.
•Several changes to diagnostic criterion.
•The onset criterion has been changed from “symptoms that caused impairment
were present before age 7 years” to “several inattentive or hyperactive-impulsive
symptoms were present prior to age 12”;
•Co morbid diagnosis with Autism spectrum disorders allowed.
•Only 5 symptoms required for adults compared to 6 for children
•Placement in Neurodevelopmental disorders chapter

34. SPECIFIC LEARNING DISORDER
• Combines DSM –IV diagnoses of reading disorder, mathematics disorder,
disorders of written expression and learning disorders NOS.
•Combined because learning deficits in reading, written expression, and
mathematics commonly occur together.

35. MOTOR DISORDERS
•Developmental Coordination Disorder
•Stereotypic movement Disorder
•Tourette’s Disorder
•Persistent (Chronic) motor or vocal tic disorder
•Provisional Tic Disorder
•Other Specified Tic Disorder
•Unspecified Tic Disorder
– Tic criteria standardized across all disorders
– Stereotypic movement disorder more clearly differentiated from body-focused repetitive
behavior disorders

36. SCHIZOPHRENIA
•Elimination of the special attribution of bizarre delusions and Schneiderian first-rank
auditory hallucinations (e.g., two or more voices conversing). Eliminated due to poor
reliability in distinguishing bizarre from nonbizarre delusions, and poor specificity of
Schneiderian symptoms
•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
•The DSM-IV subtypes of schizophrenia (i.e., paranoid, disorganized, catatonic,
undifferentiated, and residual types) are eliminated due to their limited diagnostic stability,
low reliability, and poor validity.
•Instead, a dimensional approach to rating severity for the core symptoms of schizophrenia
IS INCLUDED IN SECTION 3

37. SCHIZOAFFECTIVE DISORDER
•The primary change to schizoaffective disorder is the requirement that a
major mood episode be present for a majority of the disorder’s total
duration [after Criterion A FOR schizophrenia has been met].
•It makes schizoaffective disorder a longitudinal instead of a cross-
sectional diagnosis—more comparable to schizophrenia, bipolar disorder,
and major depressive disorder, which are bridged by this condition.
•Improves reliability, diagnostic stability and validity of this disorder.

38. Delusional disorder
•Criterion A no longer requires that the delusions are nonbizarre.
•Now there is a nonbizarre specifier.
•No longer separated from shared delusional disorder.
•If diagnosis cannot be made, but shared beliefs are present, then the diagnosis
“other specified schizophrenia spectrum and other psychotic disorder” is used.

39. Catatonia
•All contexts require three catatonic symptoms
•The same criteria are used to diagnose catatonia whether the
context is a psychotic, bipolar, depressive, or other medical
disorder

40. B i p o l a r a n d r e l a t e d d i s o r d e r s
•Criterion A for manic and hypomanic episodes now includes an emphasis on changes
in activity and energy as well as mood. This was done to enhance accuracy of
diagnosis and facilitate earlier detection in clinical settings.
•The DSM-IV diagnosis of bipolar I disorder, mixed episode, requiring that the individual
simultaneously meet full criteria for both mania and major depressive episode, has
been removed. Instead, a new specifier, “with mixed features,” has been added that
can be applied to episodes of mania or hypomania when depressive features are
present, and to episodes of depression in the context of major depressive disorder or
bipolar disorder when features of mania/hypomania are present.

41. Other Specified Bipolar and Related Disorder
•A category for individuals with a past history of a major depressive disorder who
meet all criteria for hypomania except the duration criterion (i.e., at least 4
consecutive days).
•A second condition constituting an other specified bipolar and related disorder is
that too few symptoms of hypomania are present to meet criteria for the full
bipolar II syndrome, although the duration is sufficient at 4 or more days.
•Anxious distress specifier intended to identify patients with anxiety symptoms that
are not part of the bipolar diagnostic criteria

42. D e p r e s s i v e d i s o r d e r s
•Disruptive Mood Dysregulation Disorder – New diagnosis to include children upto 18 years of age with
persistent irritability and extreme dyscontrol. Created to address concerns about potential over
diagnosis and over treatment of bipolar disorder in children
•Premenstrual Dysphoric Disorder – promoted from appendix to main body. Based on strong scientific
evidence, PMDD has been moved from DSM-IV Appendix B “Criteria Sets and Axes Provided for Further
Study,” to the main body of DSM-5
•Persistent depressive disorder – New term for dysthymia and chronic MDD. This change was made due
to a lack of scientifically meaningful differences between these two conditions

43. D e p r e s s i v e d i s o r d e r s
•No more bereavement exclusion for diagnosing MDD. Bereavement is now recognized as a severe
psychosocial stressor that can precipitate a major depressive episode in a vulnerable individual. This
exclusion is omitted in DSM-5 for several reasons:
– To remove implication that bereavement typically lasts only 2 months
– The depressive symptoms associated with bereavement related depression respond to the
same psychosocial and medication treatments as non-bereavement-related major depressive
episodes
•Specifiers for depressive disorders –
Guidance for assessment of suicidality (e.g., suicidal thinking, plans, and presence of other risk factors).
Research points to the importance of anxiety as relevant to prognosis and treatment decision making.
The “anxious distress” allows the clinician to rate the severity of anxious distress in all individuals with
bipolar and depressive disorders

44. A n x i e t y d i s o r d e r s
•OCD and PTSD have been omitted and made into separate categories.
•Separation anxiety and selective mutism are included in anxiety disorders.
•Anxiety disorders no longer need age >18 for diagnosis. Instead, anxiety must
be out of proportion to the actual danger or threat in the situation after taking
cultural contextual factors into account. 6-month duration used to be limited to
individuals under age 18, but is now extended to all ages
•Panic disorder and Agoraphobia are unlinked. The co-occurrence of these two
disorders is now coded with two diagnoses. This change was made because there
is a substantial number of individuals with agoraphobia who do not experience
panic symptoms.
•Panic attacks can be listed as a specifier to ALL DSM-5 diagnoses.

45. A n x i e t y d i s o r d e r s
•Specific phobia - No longer required that individuals over age 18 recognize their fear and anxiety as
excessive or unreasonable. Duration requirement (6 months or more) now applies to all ages
•Social anxiety disorder - Formerly called Social Phobia, but now called Social Anxiety Disorder. Deleted
requirement of recognizing anxiety as excessive duration of 6 months or more and now required for all
ages. Generalized specifier has been deleted and replaced with a “performance only” specifier.
Individuals who fear only performance (i.e., speaking or performing in front of others) seems to
represent a distinct subset of individuals regarding etiology, age at onset, physiological response, and
treatment response.
•Separation anxiety disorder - Formerly in the section “Disorders Usually First diagnosed in Infancy,
Childhood, or Adolescence.” Now, classified as an anxiety disorder. Includes symptoms in adulthood as
well as childhood. No longer specifies that age at onset is before 18. To minimize overdiagnosis, for
adults, a duration criterion was added “typically lasting for 6 months or more.”

46. A n x i e t y d i s o r d e r s
•Selective Mutism - Was formerly classified in the section “Disorders
Usually First Diagnosed in Infancy, Childhood, or Adolescence.” Now
classified as an anxiety disorder, given that a majority of children with
selective mutism are anxious.

47. Obsessive Compulsive and related disorders
•New chapter. New disorders include hoarding disorder, excoriation(skin picking)disorder ,
Substance/Medication induced obsessive –compulsive and related disorders and obsessive-compulsive
disorders due to another medical condition.
•Detailed specifiers introduced for insight like fair, poor and absent.
•Hoarding disorder - New Diagnosis, previously listed in DSM-IV as a possible symptom of OCD and OCPD.
Research has found evidence for the diagnostic validity and clinical utility of a separate diagnosis of
hoarding disorder. Reflects persistent difficulty discarding or parting with possessions due to a perceived
need to save the items, and distress associated with discarding them.
•Excoriation disorder - Added due to strong evidence for its diagnostic validity and clinical utility
•Substance/Medication-Induced Obsessive-Compulsive and Related Disorder - In DSM-IV, anxiety disorders
due to a general medical condition, and substance-induced anxiety disorders included a specifier “with
obsessive-compulsive symptoms.” Reflects the recognition that substances, medications, and medical
conditions can present with symptoms similar to primary obsessive-compulsive and related disorders

48. Obsessive Compulsive and related disorders
•Obsessive-Compulsive and Related Disorder Due to Another Medical Condition - OCD and related
disorder includes body-focused repetitive behavior disorder and obsessional jealousy. Body-focused
repetitive behavior disorder is characterized by recurrent behaviors other than hair pulling and skin
picking (e.g., nail biting, lip biting, cheek chewing) and repeated attempts to decrease or stop the
behaviors. Obsessional jealousy is characterized by nondelusional preoccupation with a partner’s
perceived infidelity.
•Trichotillomania (hair-pulling disorder) - Moved from DSM-IV classification of impulse-control
disorders not elsewhere classified to obsessive-compulsive and related disorders in DSM-5. “Hair-
pulling disorder” has been added in parentheses. No reason given.
•Body Dysmorphic Disorder - Added a diagnostic criterion describing repetitive behaviors or mental
acts in response to preoccupations with perceived defects or flaws in physical appearance. Muscle
dysmorphia specifier added. Delusional variant for those who are completely convinced that the
perceived defects/flaws are abnormal appearing.

49. Obsessive Compulsive and related disorders
•Specifiers for Obsessive-Compulsive and Related Disorders - “with poor
insight” specifier has been refined to allow a distinction between those
with good or fair insight, poor insight, and “absent insight/delusional”
obsessive-compulsive disorder beliefs (i.e., complete conviction that OCD
beliefs are true).

50. Trauma and Stressor related disorders
•Qualifying traumatic events are now explicit as to whether they were experienced directly, witnessed or
experienced indirectly. Four symptom clusters instead of three namely
-Re-experiencing
-Arousal
-Avoidance
-Persistent negative alterations in cognition and mood.
•Acute Stress Disorder - Requires being explicit as to whether qualifying traumatic events were
experienced directly, witnessed, or experienced indirectly. Criterion A2 regarding subjective reaction has
been eliminated (e.g., “the person’s response involved intense fear, helplessness, or horror”). Based on
evidence that acute posttraumatic reactions are very heterogeneous and that DSM-IV’s emphasis on
dissociative symptoms is overly restrictive, individuals may meet diagnostic criteria in DSM-5 for acute
stress disorder if they exhibit any 9 or 14 listed symptoms in the following categories: intrusion, negative
mood, dissociation, avoidance, and arousal

51. Trauma and Stressor related disorders
•Adjustment Disorders - Reconceptualized as a heterogeneous array of stress-response
syndromes that occur after exposure to a distressing (traumatic or nontraumatic)
event. Residual category for those exhibiting clinically significant distress without
meeting criteria for a more discrete disorder.
•PTSD - Significant Differences. More explicit regarding how the individual experienced
the “traumatic” event(s). Subjective reaction was eliminated (A2). Now 4 symptom
clusters: re-experiencing, avoidance/numbing, and arousal (previous clusters). Now,
avoidance/numbing cluster is divided into two distinct clusters: avoidance and
persistent negative alterations in cognitions and mood. Developmentally sensitive with
lowered diagnostic threshold for children and adolescents. More criteria added for
children age 6 or younger.

52. Trauma and Stressor related disorders
•Reactive Attachment Disorder - In DSM-IV: 2 subtypes (emotionally
withdrawn/inhibited, and indiscriminately social/disinhibited). In DSM-5, the subtypes
are defined as distinct disorders: Reactive attachment disorder & Disinhibited social
engagement disorder. Both disorders are result of social neglect or limitations to a
child’s attachments. Due to dampened positive affect, RAD resembles internalizing
disorders. There is a lack of or incompletely formed preferred attachments to
caregiving adults.
•Disinhibited Social Engagement Disorder - More closely resembles ADHD. Occurs in
children who may have established secure attachments

53. Dissociative disorders
•Depersonalization Disorder - Now called “depersonalization/derealization disorder”
•Dissociative fugue is now a specifier of dissociative amnesia rather than a specific
diagnosis.
•Dissociative Identity Disorder - Criterion A has been expanded to include certain
possession-form phenomena, and functional neurological symptoms to account for
more diverse symptom presentation. Criterion A now specifically states that
transitions in identity may be observable by others or self-reported. Criterion B now
states that individuals with DID may have recurrent gaps in recall for everyday
events, not just for traumatic experiences. Experiences of pathological possession in
some cultures are included in the description of identity disruption.

54. Somatic symptom and related disorders
•New name for somatoform disorders.
•To avoid problematic overlap , many subcategories have been omitted including -
-Somatization disorder
-Hypochondriasis
-Pain disorder
-Undifferentiated somatoform disorder
•Criterion for conversion disorder have been revised to emphasize importance of
neurological examination and the fact that psychosocial stressor may not be
demonstrable at the time of diagnosis.

55. Somatic symptom and related disorders
•Somatic Symptom Disorder - Recognition that individuals with somatic symptoms
plus abnormal thoughts, feelings, and behaviors may or may not have a diagnosed
medical condition. Symptom count required to meet criteria for somatization disorder
(DSM-IV) was very high. Individuals previously diagnosed with somatization disorder
will usually meet DSM-5 criteria for somatic symptom disorder only if they have the
maladaptive thoughts, feelings, and behaviors.
•Hypochondriasis and Illness Anxiety Disorder - Hypochondriasis eliminated (negative
connotation). Changed to Illness Anxiety Disorder.
•Pain disorder - DSM-IV assumed that some pain was associated solely with
psychological factors. This assumption has not been supported by research.

56. Feeding and eating disorders
•Includes many conditions found in DSM-IV chapter “disorders usually first diagnosed
during Infancy, Childhood or Adolescence” like pica.
•Anorexia nervosa diagnosis does not need amenorrhea as a criterion.
•Slight changes to Bulimia nervosa criterion too.
•Avoidant/Restrictive Food Intake Disorder - New name for DSM-IV feeding disorder
of infancy or early childhood. Children and adolescents who substantially restrict
their food intake and experience significant associated physiological or psychosocial
problems, but do not meet criteria for any DSM-IV eating disorder included here.
This new category is more broad and is intended to be a better fit for such
individuals.

57. Feeding and eating disorders
•Anorexia Nervosa - Requirement for amenorrhea has been eliminated. Can be
diagnosed in males and females taking contraceptives. Those meeting all criteria
except amenorrhea show similar profiles to those who meet all DSM-IV criteria
(same population).
•Bulimia Nervosa - Reduction in required minimum average frequency of binge
eating and inappropriate compensatory behavior frequency from twice to once
weekly. Clinical characteristics and outcome of those meeting the slightly lower
threshold are similar to those meeting the DSM-IV criterion.
•Binge Eating Disorder - Moved from Appendix B of DSM-IV, to Eating Disorders
section of DSM-5. Minimum average frequency of binge eating changed from at
least twice weekly for 6 months, to at least once weekly over the last 3 months

58. Sleep-Wake disorders
•Sleep disorders related to another mental disorder removed.
•Sleep disorder related to a general medical condition removed.
•Moves away from making causal attributions between coexisting disorders.
•Primary insomnia renamed “insomnia disorder”
•Narcolepsy differentiated from other forms of hypersomnolence.

59. Sexual dysfunctions
•Female sexual desire and arousal disorders combined into one disorder “female
sexual interest/arousal disorder”
•Vaginismus and Dyspareunia combined to form Genito-Pelvic pain/Penetration
disorder.
•Genito-Pelvic Pain/Penetration Disorder - New diagnosis that represents a
merging of the DSM-IV categories of vaginismus and dyspareunia. Sexual aversion
disorder removed due to rare use and lack of supporting research.
•Gender Dysphoria - New diagnostic class. New conceptualization of defining
features by emphasizing the phenomenon of “gender incongruence” rather than
cross-gender identification. Removed from “Sexual and Gender Identity Disorders”
section to separate this diagnosis from sexual dysfunctions and paraphilias.

60. Disruptive, Impulse-Control and Conduct disorders
•Oppositional Defiant Disorder - Symptoms now grouped into 3 categories:
Angry/irritable mood, argumentative/defiant behavior, and vindictiveness
•Conduct Disorder - Specifier added for individuals meeting full criteria for the
disorder, but also present with limited prosocial emotions. This specifier applies to
those with conduct disorder who show a callous and unemotional interpersonal
style across multiple settings and relationships.
•Intermittent Explosive Disorder - Changed the type of aggressive outbursts. In
DSM-IV, physical aggression was required. Now, verbal aggression and non-
destructive/noninjurious physical aggression also meet criteria. Must be at least 6
years of age to be diagnosed.

61. Substance related and addictive disorders
•Gambling disorder, Cannabis withdrawal and Caffeine withdrawal are
new conditions introduced.
•No more substance abuse and dependence, only substance use
disorders.

62. Neurocognitive Disorders
•Dementia and Amnestic disorder are now subsumed under the new
name of “Major Neurocognitive disorder.”
•The term “Dementia” is not precluded from use.
•DSM-5 recognizes a less severe level of cognitive impairment called
mild NCD.
•Major or mild vascular NCD and major or mild NCD due to Alzheimer’s
disease have been retained.

63. Neurocognitive Disorders
New separate criteria presented for major or mild NCD due to Frontotemporal NCD:
– Lewy Bodies
– Traumatic Brain Injury
– Parkinson’s Disease
– HIV infection
– Huntington’s Disease
– Prion Disease
– Another medical condition
– Multiple etiologies
– Substance/medication-induced NCD
– Unspecified NCD

64. Personality Disorders
•Alternative approach to diagnosis developed for further study and can
be found in section 3.
•Moderate level of impairment in personality functioning required now.
•Diagnostic thresholds for both Criterion A and Criterion B have been set
empirically to minimize change in prevalence and overlap with other
personality disorders.
•Personality disorder, trait specified replaces NOS.

65. Paraphiliac Disorders
•Addition of course specifiers:
– “in a controlled environment”
– “in remission”
•Differences between paraphilias and paraphilic disorders:
– Disorder is a paraphilia that is currently causing distress or impairment to the
individual
– Paraphilia alone does not automatically justify or require clinical intervention

66. Critical Analysis of DSM -5

67. NEGATIVES
Source - Frances, Allen J. (December 2, 2012). "DSM 5 Is Guide Not Bible—Ignore Its Ten Worst Changes APA approval of
DSM-5 is a sad day for psychiatry".Psychology Today. Retrieved 9 March 2013.

68. Allen J. Frances (born 1942 in Thessaloniki, Greece) is an American psychiatrist best known for
chairing the task force that produced the DSM-IV and for his critique of the current
version, DSM-5. He warns that the expanding boundary of psychiatry is causing a diagnostic
inflation that is swallowing up normality and that the over-treatment of the "worried well" is
distracting attention from the core mission of treating the more severely ill.

69. In a December 2, 2012 blog post in Psychology Today, Frances lists the ten "most potentially harmful changes" to DSM-5:
1. Disruptive Mood Dysregulation Disorder, for temper tantrums
2. Major Depressive Disorder, includes normal grief
3. Minor Neurocognitive Disorder, for normal forgetting in old age
4. Adult Attention Deficit Disorder, encouraging psychiatric prescriptions of stimulants
5. Binge Eating Disorder, for excessive eating
6. Autism, defining the disorder more specifically, possibly leading to decreased rates of diagnosis and the disruption of
school services
7. First time drug users will be lumped in with addicts
8. Behavioral Addictions, making a "mental disorder of everything we like to do a lot."
9. Generalized Anxiety Disorder, includes everyday worries
10. Post-traumatic stress disorder, changes opening "the gate even further to the already existing problem of
misdiagnosis of PTSD in forensic settings."

70. 1) Disruptive Mood Dysregulation Disorder may turn temper tantrums into a mental
disorder.
2) Normal grief may become Major Depressive Disorder.
3) The everyday forgetting characteristic of old age will now be misdiagnosed as
Minor Neurocognitive Disorder.
4) DSM 5 will likely trigger a fad of Adult Attention Deficit Disorder leading to
widespread misuse of stimulant drugs for performance enhancement and
recreation.
5) Excessive eating 12 times in 3 months is no longer just a manifestation of gluttony
but it is a psychiatric illness called Binge Eating Disorder.

71. 6) The changes in the DSM 5 definition of Autism will result in lowered rates-
perhaps by 50% according to outside research groups.
7) First time substance abusers will be lumped in definitionally with hard core
addicts despite their very different treatment needs and prognosis and the
stigma this will cause.
8) Behavioral Addictions that eventually can spread to make a mental disorder of
everything we like to do a lot. Eg; New proposed internet addiction
9) DSM 5 obscures the already fuzzy boundary been Generalized Anxiety Disorder
and the worries of everyday life.
10) DSM 5 has opened the gate even further to the already existing problem of
misdiagnosis of PTSD in forensic settings.

72. POSITIVES
Source - https://www.karger.com/Article/Pdf/356572

73. •The Revision Was Needed and in Fact Overdue - It is essential to stress that diagnostic systems by
their very nature are always time-limited constructs – they are never final and perfect. They simply
reflect the best possible international expert consensus regarding science and research evidence
and issues concerning the provision of interventions in healthcare systems at a given point in time.
•DSM-5 Is a Significant Improvement over and beyond DSM-IV-TR - The improved organization and
consistency of the manual associated with a substantial reduction of pages and diagnoses will
hopefully improve the utility and the frequency of its appropriate application in practice and
research.
•The Revision Process Was of Unprecedented Quality and Transparency - The 5-year revision
process was based on internationally balanced experts grouped by diagnostic domains. They
identified critical issues and domains potentially in need for revision. In dozens of work groups and
overarching task forces, they provided hundreds of systematic reviews as well as original and
position papers.
Hans-Ulrich Wittchen, Dresden, 2013

74. •DSM-5 was not driven by Interests of ‘Big Pharma’ - There was continuous, unprecedented
scrutiny regarding the involvement of experts that might have a conflict of interests, concerning for
example (but not limited to) industry. All advisors with potential conflicts of interests were excluded
and all experts involved in the revision had to refrain from such activities during the revision
process.
•DSM-5 Does Not ‘Invent’ or ‘Inflate’ Diagnoses - not a single diagnosis was ‘invented’ or promoted
by the DSM-5 work groups. All proposals came from the field, namely the users in practice and
research settings, substantiated and weighted by research evidence, proof of utility, and appraisals
of potential benefits and harms.
•DSM-5 Did Tighten Up the Criteria – Sensibly and in the Interest of Patients - Thousands of papers
provide conclusive evidence that the degree of suffering and the associated burden of disability of
even a relatively small spectrum of mental disorders create a higher disability burden than any
other disease group. Similarly, there is strong evidence for the effectiveness of early treatment,
both from a trans-generational as well as a health economic perspective.

75. Thank you