DSM-5

1844 APA Predecessor - statistical classification of institutionalized patients (part of US Census).

1952 DSM (I) was established
1968 DSM-II 
1980 DSM-III , 1987-DSM-III-R,
1994 DSM-IV, 2000 DSM-IV-TR(Text Revision) .

DSM -IV Longest standing version (19 years) was a Multi-axial system of classification that makes use of axes I-V:

I-Clinical Disorders,II-Personality disorders, III- Medical conditions, IV- Psychosocial and environmental problems (Stressors), and V-Global assessment of functioning.

2013 - DSM-5 was developed as a "non-axial documentaion of diagnosis" (p. 16) based upon: field trials, expert review, public and professional reviews showing inter-rater reliability.

It recognizes a collection of disorders from neuro-developmental perspective (DSM-IV axes: I, II & III) along with "separate notations for important psychosocial and contextual factors [IV] and disability [V] (p. 16).

Enhancements over DSM-IV

Organizational structure of DSM-5

Following WHO International Classification of Disorders (ICD) it seeks to harmonize with the most recent Clinical Modification (CM) version (11). However, in 2013 US officially recognized ICD-9-CM but will move to ICD-10-CM in October 2014.

It recognizes heterogenetity and comorbidity of mental disorders leading to a variety of expressions of each. As such it also is expected to be "a living document" that is "adaptable to future discoveries in neurobiology, genetics, and epidemiology" (p. 13).

It is organized around neurodevelpomental disorders as well as internalizing (emotional and somatic disorders), externalizing (behavioural and substance disorders), neurocognitive disorders and "other" disorders assuming an underlying pathophysiological process as well as social and environmental determining factors.

It recognizes diagnostic co-morbidity and disorder clusters that mirror clinical reality that lead to symptom heterogeneity, and is designed to "facilitate identification of potential diagnoses by non-mental health specialists" (p. 13) such as primary care physicians.

Using DSM-5 requires clinical training in order to give a careful clinical history and summary of social, psychological, and biological factors and their contributions to the diagnosed mental disorder(s).

Each Disorder is presented with a:

Definition, Criteria for clinical symptoms, Diagnostic criteria and descriptions, subtypes and specifiers.

Clinicians are to provide: a principal diagnosis, provisional diagnoses as well identify any medically induced movement disorders and other conditions that may be a focus of clinical attention.

"Cautionary Statement" for its use in Forensic Situations:

"When DSM-5 categories, criteria, and textual descriptions are emplyed for forensic purposes, there is a risk that diagnostic information will be misused or misundertood. These dangers arise because of the imperfect fit between the questions of ultimate concern to the law and the information contained in a clinical diagnosis" (p. 25).

Additionally, "It is important to note that the DSM-5 does not provide treatment guidelines for any given disorder" (p. 25).

Developmental and Lifespan Considerations

Statement on Gender recognizing that gender may:

Distinguishes sex differences (XX, XY-reproductive organ comlpement) from gender differences - "variations that result from biological sex as well as an individual's self-representation that includes the psychological, behavioral, and social consequences of one's perceived gender" (p. 15).

Statement on Cultural Issues

"Culture provides interpretive frameworks that shape the expereince and expression of the symptoms, signs, and behaviors that are criteria for diagnosis" (p. 14) .

"Mental disorders are defined in relation to cultural, social and familial norms and values" (p. 14).

Section III recognizes cultural formulations and the role of cultural norms and coping strategies.

"Culture Bound Syndromes" of common discourse in transcultural psychiatry are to be replaced by:

Cultural Syndrome - "a cluster or group of co-occuring, relatively invariant symptoms found in a specific cultural group, community, or context. These may not be recognized as an illness in their host culture but are recognizable to an outside observer.

Cultural idiom of Distress - refers to "shared patterns (or concepts of pathology) and ways of expressing, communicating, or naming essential features of distress." They need not ber associated with "specific symptoms, syndromes, or perceived causes" (p. 14).

Cultural Explanation - or perceived cause which is an "explanitory model that provides a culturally conceived etiology or cause for symptoms, illness, or distress" and it may involve the "salient feaures of folk classifications of disease used by laypersons or healers" (p. 14).

List of Categories of Disorders and Mitigating Factors

NeuroDevelopmental Disorders

Schiophrenia Spectrum and other Psychotic Disorders

Bipolar and related Disorders

Depressive Disorders

Anxiety Disorders

Obsessive-Compulsive and Related Disorders

Trauma- and Stressor-Related Disorder

Dissociative Disorders

Somatic Symptom and Related Disorders

Feeding and Eating Disorders

Eliminative Disorders

Sleep-Wake Disorders

Sexual Dysfunctions

Gender Dysphoria

Disruptive, impulsive-control, and conduct Disorders

Substance-Related and Addictive Disorders

Neurocognitive Disorders

Personality Disorders

Paraphilic Disorders

Other Mental Disorders

Medication-Induced Movement Disorders and other Adverse Effects of Medication

Other conditions that may be a focus of Clinical Attention

Categories of Disorders and Mitigating Factors

DSM-5 is largely built around a few groups of disorders, where:

"the internalizating group (representing disorders with prominent anxiety, depressive, and somatic symptoms) and the externalizing group (representing disorders with prominent impulsive, disruptive conduct, and substance use symptoms), the sharing of genetic and environmental risk factors, as shown by twin studies, likely explains much of the systematic comorbidities seen in both clinical and community samples" (p. 13).

NeuroDevelopmental Disorders

Intellectual Disabilities

Communication Disorders

Autism Spectrum Disorder

Attention-Deficit/Hyperactivity Disorder

Specific Learning Disorder

Motor Disorders Tic Disorders

Other Neurodevelopmental Disorders

Schiophrenia Spectrum and other Psychotic Disorders

Schizotypal Disoder

Delusional Disorder

Brief Pscyhotic Disorder

Schizophreniform Disorder

Schizophrenia

Schizoaffective Disorder

Substance / Medication-Induced Psychotic Disorder

Psychotic Disorder Due to Another Medical Condition

Catatonia Assocaited with Another Mental Disorder

Cataonic Disorder Due to Another Medical COndition

Other Specified Schizophrenia Spectrum and Other Psychotic Disorder

Unspecified Schizophrenia Spectrum and Other Psychotic Disorder

Schizophrenic Disorders - literally "split mind" fragmented thought and emotional disturbance; break from reality.

General symptoms - trouble holding a job, irrational thought, deterioration of adaptive behaviour, distorted perception, disturbed emotion, social withdrawal, disturbed sense of self, poverty of speech, abnormal motor behaviour.

Positive Symptoms Behavioural excess (new aspects to behaviour and thought) including: Delusions - false beliefs or irrational thought without any connection to reality.

Hallucinations - sensory perceptions in absence of external stimulus or gross distortion of perceptual input (radio). Grandiose or "wild" thoughts of importance or the bizarre including disorganised speech (word salad).

Negative Symptoms Behavioural deficits or deterioration of adaptive behaviour. E.g., 'blunted' or flattened affect (also may include inappropriate emotional responses, e.g., laugh at funeral); social withdrawal, apathy, loss of attention, poverty of speech.

Subtypes of Schizophrenia

Parnoid type - is characterised by delusion of grandure and persecution. Commonly seen as "people are reading my thoughts" or "plotting against me" where there is a heightened sense of importance (having special information-cure for cancer-or are someone important-Jesus Christ).

Catatonic type - Extremely withdrawn (stupor) characterised by motor disturbances called "waxy flexibility" involving muscular rigidity or random motor activity. May also be hyperactive and incoherence where some alternate between these.

Disorganised type (hebephrenic) - Are characterised by emotional indifference and are frequently incoherent, exhibiting near total social withdrawal. Often involved in aimless babbling and giggling and may have delusions about body; e.g., brain is melting out of ears.

Undifferentiated - marked by idiosyncratic blends of the 3 other types.
 
 

Course and outcome

Favourable prognosis when: 1) sudden onset, 2) later age onset, 3) prior work/social is good, 4) relatively healthy and supportive family.

Etiology ofSchizophrenia

1) Genetic Vulnerability: Twin studies concordance rates -MZ=48% DZ=17% 2 parents with Schizophrenia = 46% chance that child will have it. Polygenetic vulnerability.

2) Neurochemical Factors - excess Dopamine as Da reducers will lessen the symptoms, yet not consistent results.

3) Structural abnomalities in the brain (cause or effect?)
enlarged ventricles & smaller thalamus (sensory integration), left with inability to 'filter out' information and attentional focus and shifting problems.

Neurodevelopmental hypothesis suggests that prenatal infection or malnutrition may increase vulnerability. Influenza during second trimester or malnutrition has suggested pregnancy complications change brain (and other minor physical abnormalities).

4) Emotional Expression - Family dynamics where highly critical and emotionally involved families may precipitate symptoms. Recidivism for those from high EE families is 3-4 X others

5) Precipitating stress is 'needed" to bring vulnerability into disorder, can also lead to relapse.
 
 

Bipolar and related Disorders

Bipolar I Disorder

Bipolar II Disorder

Cyclothymic Disoder

Bipolar and Related Disorder due to Another Medical Condition

Other Specified Bipolar and Related Disorder

Unspecified Bipolar and Relted Disorder

Bipolar Disorder (manic depression) is characterised by one or more bouts of mania and depression. Manic episode is sufficient including euphoric mood, high confidence, optimism, high energy, no sleep, fast talking, and grandiose plans and may involve sexual or financial recklessness.

Cyclothymic Disorder - chronic but mild bi-polar

Etiology of Bi-Polar?

Genetic Vulnerability is seen in twin studies where MZ=67% DZ=15% concordance. This is stronger for bi-polar and for women.

Neurochemical factors: Ne long suspected but Se also

Depressive Disorders

Disruptive Mood Dysregulation Disorder

Major Depression

Persistent Depressive Disorder (Dysthymia)

Premenstrual Dysphoric Disorder

Substance/Medication-Induced Depressive Disorder

Depressive Disorder due to Another Medical Condition

Other Specified Depressive Disorder

Unspecified Depressive Disorder

Seasonal Affective Disorder is a relatively minor mood disturbance that affects people usually during the winter months (blues).

(Major) Depression Disorders - persistent feelings of sadness and despair, often losing interest in previously enjoyed activities. Alterations in sleep & eating patterns, low energy slow speech, low self esteem, feeling worthless. May feel anxiety or irritable. Falls into feelings of hopelessness, dejection, massive guilt, worry, social withdrawal.

Dysthymic Disorder - mild chronic depression that doesn't produce deep despair seen in major depression.

Etiology of Depressive Disorders

Cognitive factors Beck's cog theory indicated that learned helplessness or hopelessness play roles. Pessimistic explanatory style and Negative thinking with reactions and interpretations learning to "its bad"...

Interpersonal Influences included shyness, poor social support & skills - don't get positive reinforcement

Precipitating Stress is the "push" over vulnerability

Anxiety Disorders

Separation Anxiety Disorder

Selective Mutism

Specific Phobia

Social Anxiety Disorder

Panic Disorder

Panic Attack Disorder

Panic Attack Specifier

Agoraphobia

Generalized Anxiety Disorder

Substance/Medication-Induced Anxiety Disorder

Anxiety Disorder due to Another Medical Condition

Other Specified Anxiety Disorder

Unspecified Anxiety Disorder

Anxiety Disorders - excessive apprehension and anxiety or fear

Generalised Anxiety Disorder - chronic high level of anxiety that does not have a specific cause or stimulus (e.g., muscle tension, diarrhea, dizziness…)

Phobic Disorder - persistent and irrational fear of object or situation that is unrealistic. E.g., claustrophobia, Brontophobia, ….

Panic Disorder and Agoraphobia - recurrent attacks of overwhelming anxiety that usually occur suddenly & without warning. (fear of public places)

Obsessive-Compulsive Disorder - persistent and uncontrollable thoughts (obsessions) and urges to carryout ritualistic behaviours (compulsions).

Etiology of Anxiety disorders

-Biological factors concordance rates of twins
Mz=38% Dz=15%

-Some people have higher sensitivity for anxiety and changes in physiological conditions (circle)

-Neurotransmitters: GABA-anxiety; SE-panic & OCD; valium & prozac reduce anxiety

-Classical conditioning - phobias are acquired and maintained. Biologically prepared for some…

-Cognitive - misinterpretation of harmless threats and focus undue attention to such interpretations, selectively recall information that supports it.

Obsessive-Compulsive and Related Disorders

Obsessive-Compulsive Disorder

Body Dysmorphia Disorder

Hoarding Disorder

Trichotillomania (Hair-Pulling Disorder)

Excoriation (Skin-Picking) Disorder

Substance/Medication-Induced Obsessive-Compulsive Disorder

Obserssive Compulsive Disorder due to Another Medical Condition

Other Specified Obsessive-Comulsive Disorder

Unspecified Obsessive-Compulsive Disorder

Trauma- and Stressor-Related Disorder

Reactive Attachment Disorder

Disinhibited Social Engagement Disorder

Posttraumatic Sress Disorder (includes child version)

Acute Stress Disorder

Adjustment Disorders

Dissociative Disorders

Dissociative Identity Disorder

Dissociative Amnesia

Depersonalization / Derealization Disorder

Other Specified Dissociative Disoder

Unspecified Dissociative Disorder

Dissociative Disorders - are marked by a loss of memory and division of consciousness from personal identity.

Dissociative Amnesia and Fugue - the sudden break from past memories & personal identity. May be brief (amnesia) due to trauma or long lasting. Fugue involves the complete loss of identity and memory of past, starting a new life under a new identity.

Dissociative Identity Disorder (Multiple Personality Disorder)
Involves the presence of two or more distinct identities or personalities in one body. Each has name and characteristic style often opposite to "host" with sudden shifting from one to another.

1980s saw a large increase in occurrence Why?
Previously under-diagnosed or now "looking for it". Swiss psychiatry 6 of 655 had diagnosed 90% of cases.

Etiology of Dissociative Disorders - Excessive stress or trauma, fantasy prone personality (hypnosis), intentional role playing, American culture supports its development.
Or is it a real disorder in response to emotional abuse?

Somatic Symptom and Related Disorders

Somatic Symptom Disorder

Illness Anxiety Disorder

Conversion Disorder (Functional Neurological Symptom Disorder)

Psychological Factors affecting Other Medical Conditions

Factitious Disorder (includes Facitious Disorder Imposed on Self, Factitious Disorder Imposed on Another)

Other Specified Somatic Symptom and Related Disorder

Unspecified Somatic Symptom and Related Disorder

Somatoform Disorders

Psychosomatic diseases - (genuine)are influenced by thoughts and expectations & social support

Somatoform disorders have no organic basis to them, yet have real psychological consequences.

Somatisation Disorder - history of a variety of complaints about health and disease. Mostly affects women, often along with depression or anxiety disorder.
E.g., cardiovascular, gastrointestinal, neurologoical.

Conversion Disorder - usually in a single organ system or limb (loss of function - i.e., vision, hearing, glove anesthesia, loss of legs)

Hypochondriasis - excessive preoccupation with one's health and constant complaint about (serious) illness. Marked over-interpretation of symptoms.

Etiology of Somatoform disorders

Personality - histrionic: self-centred, suggestible, highly emotional, dramatic, thrive on attention. Neuroticism (trait).

Cognitive - focus on excessive attention on internal physiological states & amplify normal bodily sensations. Tend to make disaster conclusions about bodily complaints, apply faulty standard of good health.

Sick role - reinforcement for complaints, can avoid life's problems & protect self esteem from failures, getting attention from others.

Feeding and Eating Disorders

Pica

Rumination Disorder

Avoidant/Restrictive Food Intake Disorder

Anorexia Nervosa

Bulimia Nervosa

Binge-Eating Disorder

Other Specified Feeding or Eating Disorder

Unspecified Feeding or EatingDisorder

Eliminative Disorders

Enuresis

Encopresis

Other Specified Eliminary Disorder

Unspecified Eliminary Disorder

Sleep-Wake Disorders

Insomnia

Narcolepsy

Breathing-Related Sleep Disorders

Obstructive Sleep Apnea

CEnral Sleep Apnea

SLeep-Related Hypoventilation

Circatdian Rhythm Sleep-Wake Disorders

Parasomnias

Non-Rapid Eyemovement Sleep Arousal Disorders

Nightmare Disorder

Rapid Eyemovement SLeep Behavior Disorder

Restless Legs Symdrome

Substance/Medication-Induced Sleep Disorder

Other Specified Insomnia Disorder

Unspecified Insomnia Disorder

Other Specified Hypersomnolesence Disorder

Unspecified Hypersomnolescence Disorder Unspecified Sleep-Wake Disorder

 

Sexual Dysfunctions

Delayed Ejaculation

Erectile Disorder

Female Orgasmic Disorder

Female Sexual Interest / Arousal Disorder

Genito-Pelvic Pain / Penetration Disorder

Male Hypoactive Sexual Desire Disorder

Premature (Early) Ejaculation

Substance/Medication-Induced Sexual Dysfunction

Other Specified Sexual Dysfunction

Unspecified Sexual Dysfunction

Gender Dysphoria

Gender Dysphoria in Children

Gender Dysphoria in Adolescents and Adults

Other Specified Gender Dysphoria

Unspecified Gender Dysphoria

Disruptive, impulsive-control, and conduct Disorders

Oppositional Defiant Disorder

Intermittent Explosive Disorder

Antisocial Personality Disorder

Pyromania

Kleptomania

Other Specified Impulse-Control, and Conduct Disorder

Unspecified Impulse-Control, and Conduct Disorder

Substance-Related and Addictive Disorders

Substance Related Disorders

Alcohol-Related Disorders

Caffiene-Related Disorders

Cannabis-Related Disorders

Hallucinogen-Related Disorders

Inhalant-Related Disorders

Opioid-Related Disorders

Sedative-, Hypnotic-, or Axiolytic Use Disorder

Stimulant-Related Disorders

Tobacco-Related Disorders

Other (or Uknown) Substance-Related Disorders

Non-Substance-Related Disorders

Neurocognitive Disorders

Delerium

Other Specified Delerium

Unspecified Delerium

Major and Mild Neurocognitive Disorders

MMND-Due to Alzheimer's Disease

MM Frontotemporal ND

MM ND with Lewy Bodies

MM Vascular ND

MMND due to Traumatic Brain Injury

MMND due to HIV Infection

MMND due to Prion Disease

MMND due to Parkinson's Disease

MMND due to Huntington's Disease

MMND due to Another Medical Condition

MMND due to Multiple Etiologies r

Unspecified Neurocognitive Disorder

Personality Disorders

Cluster A

Paranoid Personality Disorder

Schizoid Personality Disorder

Schizotypal Personality Disorder

Cluster B

Antisocial Personality Disorder

Borderline Personality Disorder

Histrionic Personality Disorder

Narcissistic Personality Disorder

Cluster C

Avoidant Personality Disorder

Dependent Personality Disorder

Obsessive-Comulsive Personaity Disorder

Other Personaity Disorders

Personality Change due to Another Medical Condition

Other Specified Personality Disorder

Unspecified Personaity Disorder

DSM-IV- Axis II Personality Disorders:
Rigid and inflexible personality types (from Weiten, 2001)
 
Anxious/Fearful  Avoidant

Dependent

Obsessive/ Compulsive

 Withdrawn, senstitive to rejection, shame or blame

Lacking self-esteem, passive, defers to others (needy)

Preoccupied with order, control, unable to be 'warm'

 % male 50

31
 

50
Odd/

Eccentric

 Schizoid

Schizotypal

Paranoid 

 Poor at forming relationships, absence of warmth, feelings

Resembles schizophrenia without psychotic symptoms

Suspicious, sensitive, jealous 

 78
 

55

67
Dramatic/ Impulsive Histrionic 

Borderline

Narcissistic
 
 

Anti-Social 

 Dramatic, exaggerate emotions, egocentric attention grabbing

Unstable self image, mood &relationships. Impulsive.

Grandiosity, success fantasies, expect special treatment

Persistent violations of others, eject social norms, no emotional attachment, exploitative, reckless

 15
 
 

38

70
 
 

82

Paraphilic Disorders

Voyeristic Disorder

Exhibitionistic Disorder

Frotteruristic Disorder

Sexual Masochism Disorder

Sexual Sadism Disorder

Fetishistic Disorder

Transvestic Disorder

Other Specified Paraphilic Disorder

Unspecified Paraphilic Disorder

Other Mental Disorders

Other Specified Mental Disorder due to Another Medical Condition

Unspecified Mental Disorder due to Another Medical Condition

Other Specified Mental Disorder

Unspecified Mental Disorder

Medication-Induced Movement Disorders and other Adverse Effects of Medication

Neuroleptic-Induced Parkinsonism

Other Medication-Induced Parkinsonism

Neuroleptic Malignant Syndrome

Medication-Indiced Acute Dystonia

Medication-Induced Acute Akathisia

Tardive Dyskinesia

Tardive Dystonia

Tardive Akathisia

Medication-Induced Postrual Tremor

Other Medication-Induced Movement Disorder

Antidepressive Discontinuation Syndrome

Other Adverse Effect of Medication

Other conditions that may be a focus of Clinical Attention
Relational Problems

Problems Related to Family Upbringing

Parent-Child Relational Problems

Sibling Relational Problem

Upbringing Away from Parents

Child Affected by Parental Relationship Distress

Other Problems Related to Primary Support Group

Relationship Distress with Spouce or Intimate Partner

Disruption of Family by Speration or Divorce

High Expressed Emotion Level Within Family

Uncomplicated Bereavement

Abuse and Negelct

Child Maltreatment and Neglect Problems

Child Physical Abuse

Child Sexual Abuse

Child Neglect

Child Psychological Abuse

Adult Maltreatment and Neglect Problems

Spouse of Partner Violence, Physical

Spouce or Partner Violence, Sexual

Spouce or Partner, Neglect

Spouce or Partner Abuse, Psychological

Adult Abuse by Nonspouse or Nonpartner

Educational and Occupational Problems

Educational Problems

Ocupatioanl Problems

Housing and Economic Problems

Housing Problems

Economic Problems

Other Problems Related to The Social Environment

Problems Related to Crime or INteraction with the Legal System

Other Health Service Encounters for Counslling and Medical Advice

Problems Related to Other Psychosocial, Personal, and Environmental Circumstances

Other Circusmstances of Personal History

Problems Related to Access sto Medical and Other Health Care

Nonadherence to Medical Treatment

Any external conditions that may affect diagnosis on axis I or II. E.g., environmental challenges, interpersonal distress, lack of social support, …


Global Disorder - International Classification of Disorders

Controversy about the DSM

Challenges facing psychologists are threefold:
-Do disorders as we describe them really exist?
-Do the categories we use make sense and are they clearly able to tell us about disorders, or are they too mixed up?
-Labelling and other problems with the morality of disorder.
 
 

Insanity Defense / fitness to stand trial

This is a legal status term used to describe those who are deemed not responsible for their actions due to their mental illness. Having an inability to distinguish right from wrong.