17 the DSM-5: a System for Psychiatric Diagnosis Anna M

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PART V Psychiatric Diagnoses and Conditions 17 The DSM-5: A System for Psychiatric Diagnosis Anna M. Georgiopoulos, MD, and Abigail L. Donovan, MD

KEY POINTS disseminated internationally. The World Health Organiza- tion’s (WHO) International Statistical Classification of Diseases 6 Background and Related Health Problems, Tenth Revision (ICD-10) is also in wide use internationally. The ICD is used in the United States • A useful psychiatric diagnostic system allows clinical for coding purposes within medical billing systems, with a and research endeavors to flourish. switch from the previous version, the International Classifica- • The DSM-5, the most common diagnostic system tion of Diseases, Ninth Revision, Clinical Modification (ICD- used in the United States, encourages evaluation and 9-CM)7 to the ICD-10 planned for 2014, and subsequently description of multiple kinds of information: delayed to October 2015.8 psychiatric, medical, and psychosocial. The DSM-5, released in 2013, represents the latest in an • Careful use of the DSM-5 can promote rigorous ongoing process of change in our psychiatric diagnostic system.9 While the original Diagnostic and Statistical Manual: conceptualization of psychiatric issues and enhance 10 clinical communication. Mental Disorders was published in 1952, the transition from the second edition (DSM-II)11 to the third edition (DSM-III)12 History represented a major shift in the approach to psychiatric diag- • DSM-5, released in May 2013, is the most recent nosis. Psychodynamic formulations were no longer intrinsic revision to our psychiatric diagnostic system. to diagnostic categorization, and the DSM-III was considered • Several new disorders were added to DSM-5, while to be atheoretical and descriptive in orientation, using a diagnostic criteria for others were revised. multi-axial diagnostic system. As subsequent revisions were made,5,13,14 there were increasing efforts to ensure diagnostic Clinical and Research Challenges reliability and validity, to incorporate research findings, and • As part of an evolving diagnostic system, the DSM-5 to gather new information via field trials.3,15–18 remains subject to future revision based on new Prior to the advent of DSM-5, the DSM-IV, and its subse- research findings and changing diagnostic quently updated text revision (DSM-IV-TR)8 continued to use frameworks. the multi-axial diagnostic system. Axis I contained all psychi- Practical Pointers atric disorders except for the personality disorders and mental • Diagnostic formulation using the DSM-5 is an retardation, which were recorded on Axis II. Axis III listed non-psychiatric medical illnesses. Psychosocial and environ- ongoing process that requires clinical judgment and 19 skill. mental problems were listed on Axis IV. The Global Assess- ment of Functioning (GAF), a numerical value summarizing thes patient’ current degree of psychosocial, occupational, and educational impairment, was recorded on Axis V.20 For some applications, the DSM-5 is being gradually phased in to full DSM-5 IN CONTEXT: AN EVOLVING use. For example, the DSM-IV-TR criteria will continue to be DIAGNOSTIC SYSTEM used for psychiatric board certification examinations until 2017.21 , Therefore although the multi-axial system has been Psychiatric diagnostic classification serves a variety of pur- eliminated in DSM-5, familiarity with DSM-IV-TR constructs poses. Diagnosis marks the borders between mental disorders may continue to be relevant for some time in clinical and and non-disorders (such as normal personality variations) research contexts. and between one type of disorder and another.1 Diagnostic schemata have practical implications for helping clinicians to The Process of Change for DSM-5 conceptualize psychiatric issues, to communicate with patients and other clinicians, and, ideally, to make prognostic predic- Even as DSM-IV-TR was being published, efforts had begun to tions and to plan effective treatments.2,3 A useful diagnostic consider improvements for DSM-5. DSM-IV-TR’s Appendix system also enables psychiatric research to flourish. It permits contained diagnostic criteria sets for potential inclusion in valid and reliable classification of diseases that may benefit future editions. Additional suggestions for change reflected from basic research. Efforts to document, describe, and classify advances in psychiatric research, or appeals based on clinical mental illness go back thousands of years; they include utility.2 The American Psychiatric Association (APA), the attempts to group diseases by cross-sectional phenomenology, WHO, the World Psychiatric Organization, the National Insti- by theories of causation, and, later, by clinical course.4 tutes of Mental Health, and the National Institute on Alcohol- In the United States, the diagnostic system in widest use ism and Alcohol Abuse5,9 were all active in the preparation is the Diagnostic and Statistical Manual of Mental Disorders, phase for DSM-5. Work groups in the APA’s DSM-5 Task Force Fifth Edition (DSM-5).5 The DSM has been increasingly made proposals for revisions, field trials were conducted,22

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Downloaded for Rohul Amin ([email protected]) at Uniformed Services Univ of the Health Sciences from ClinicalKey.com by Elsevier on September 29, 2018. For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved. 166 PART V Psychiatric Diagnoses and Conditions and public and professional commentary was elicited. A Sci- entific Review Committee provided peer review,23 and a Clini- BOX 17-1 “Other Specified” and “Unspecified” cal and Public Health Committee, as well as forensic and Diagnoses: Case Examples statistical consultants weighed in regarding proposed changes.5 In addition, efforts were made to coordinate the format of EXAMPLE 1: OTHER SPECIFIED DIAGNOSIS DSM-5 with the anticipated updating of the ICD-10 to ICD-11, A 20-year-old man is seen for an intake appointment at an resulting in structural changes to the groupings of disorders in outpatient clinic. He reports significant distress about his the DSM.24 prominent acne scars. He spends at least 4 hours every day examining his skin in the mirror, and picking at the skin around his scars. He has been unable to attend college or keep a job The Three-Section Structure of DSM-5 for the past 3 years due to this behavior and his appearance Section I concerns. He is diagnosed with “other specified obsessive- compulsive and related disorder: body dysmorphic-like disorder DSM-5 is divided into three sections. Section I provides a with actual flaws.” history of the DSM and guidance for its use. Of note, DSM-5 diagnostic criteria are not meant to be rigidly applied to EXAMPLE 2: UNSPECIFIED DIAGNOSIS mandate or exclude individuals from treatment when clinical A 25-year-old female is brought into the emergency room by an circumstances dictate otherwise. In addition, given that DSM-5 ambulance after some passers-by called 911. She had been has been created primarily for use in health care and research, running through the streets, dressed in only a nightgown, yelling it is not intended to be sufficient for making legal determina- that “Judgment Day is coming.” On exam, she was noted to be tions. In all settings, clinical judgment must be applied in extremely distractible and she had rambling and voluminous gathering and interpreting diagnostic information, ensuring speech. Her mood was irritable, and her affect was labile. She the presence of distress or functional impairment, and incor- reported hearing the voice of God telling her that Judgment Day porating all available data into a clinical formulation. was near. She also reported delusions that her neighbors were demons sent by Satan to monitor her whereabouts until the Section II Time of Judgment. The patient was unable to report any prior psychiatric or medical history, the time course of her current Section II lists DSM-5 diagnoses and codes, separated into symptoms, or any recent alcohol or substance abuse. categories of related disorders. Disorders are described begin- In the ER, she was given working diagnoses of: Unspecified ning with those which have a neurodevelopmental origin bipolar and related disorder; Unspecified schizophrenia early in the life span, and ending with diseases that most often spectrum and other psychotic disorder. appear late in life. Within the developmental framework, dis- The patient is admitted to the hospital’s inpatient psychiatric orders have also been grouped according to current neuro- unit. Her laboratory results are within normal limits, and her scientific understanding that links disorders based on shared toxicology screens are negative. All subsequent medical genetic findings (i.e., between bipolar and psychotic disor- work-up is negative. The patient’s parents, with whom she was 24 ders), clinical courses, and patterns of co-morbidity. Variabil- close, provided the following collateral information: For the past ity and changes in presentation that occur through the 2 weeks, the patient had been acting strangely. She slept only a life span—such as the age-dependent change in hyperactive few hours a night, and then stopped sleeping altogether. She symptoms that typically occurs in attention-deficit/hyperactiv- was very irritable, and quick to anger. She complained that her ity disorder (ADHD)—are also included for individual disor- thoughts were racing, and she was much more talkative than ders under the subheading of “Development and Course.” usual. She was also highly distractible. The day prior to her ER Gender-related factors that may have an impact on risk, pres- visit, she told them she was hearing God speak to her. She had entation, or clinical course are incorporated throughout one prior episode of depression in adolescence, and had never Section II as “Gender-related Diagnostic Issues.” These two heard voices or been paranoid before. She had normal function new sub-sections were added to highlight the importance of until 2 weeks prior to admission. At the time of discharge, her 25 development and gender in psychiatric diagnosis. diagnosis was modified to bipolar I disorder, with psychotic When determining which diagnoses best fit a particular features, most recent episode manic. patient, one must consider which diagnoses are hierarchical and mutually exclusive, and which may be co-morbid/ co-existing at the same time. For example, a patient may have a separation anxiety disorder beginning in pre-school, develop eliminated. Instead, clinicians can use the term “other speci- impairing social phobia in early adolescence, and then experi- fied” when wishing to indicate the reason that full diagnostic ence a specific phobia of heights following a trip to the Grand criteria are not met (Box 17-1). “Unspecified” can be used Canyon during high school, resulting in three co-morbid when a disorder is clearly present, but no specific reason is anxiety disorders at the time of presentation at age 15. Alter- given for not meeting full criteria. This situation could occur natively, the adjustment disorders exclude other diagnoses, as when insufficient historical information is available, as in an the clinician must determine that the presenting symptoms do emergency evaluation of a patient. The “unspecified” label can not fulfil criteria for another psychiatric disorder. Likewise, a be used to broadly indicate the presence of a psychiatric dis- non-psychiatric medical or substance-induced etiology must order (e.g., unspecified mental disorder), or, when possible, typically be ruled out to clinical satisfaction before any other to place a diagnosis within a certain family of disorders (e.g., disorder can be diagnosed. unspecified bipolar and related disorder) (see Box 17-1). A procedure is needed to describe disorders that, although Another option to signal diagnostic uncertainty is to mark a clinically significant, do not fit neatly into the major diagnos- diagnosis as provisional, meaning that the selected diagnosis tic categories, or where more data are required before assign- is expected to emerge more clearly over time or with addi- ing a more precise diagnosis. In DSM-IV-TR, “Not Otherwise tional information. Specified (NOS)” diagnoses were used for this situation; for Specifiers may also be added to diagnoses to provide addi- example, “eating disorder NOS” could be used for patients tional information about the clinical course, features, and who did not meet full criteria for either anorexia nervosa severity. For many diagnoses, current severity can be indicated or bulimia nervosa. In DSM-5, NOS diagnoses have been with specifiers (i.e., mild, moderate, or severe). When

TABLE 17-1 Other Conditions That May Be a Focus BOX 17-2 The Interplay between Psychiatric and 17 Medical Conditions of Clinical Attention Problem Examples EXAMPLE 1: PSYCHIATRIC DISORDER DUE TO A Primary support Disruption of family by separation or divorce ANOTHER MEDICAL CONDITION group Relationship distress with spouse or intimate A 38-year-old woman with no prior psychiatric history develops partner new panic attacks, weight loss, and heat intolerance over Uncomplicated bereavement several months, resulting in problems at work; she is found to Social environment Acculturation difficulty have an abnormally low thyroid-stimulating hormone level. Given Social exclusion or rejection Occupational Adverse effect of work environment the assumption that the panic attacks have been precipitated by Unemployment the thyrotoxic state, the diagnostic assessment might look as follows: Housing Homelessness Discord with neighbor, lodger, or landlord 1. Hyperthyroidism Economic Low income 2. Anxiety Disorder due to Hyperthyroidism, with Panic Attacks Extreme poverty 3. Discord with work supervisor Insufficient social insurance or welfare support EXAMPLE 2: PSYCHOLOGICAL FACTORS AFFECTING Legal Imprisonment or other incarceration Victim of crime OTHER MEDICAL CONDITIONS Other psychosocial/ Religious or spiritual problem A 38-year-old woman with no prior psychiatric history is environmental Exposure to disaster, war or other hostilities diagnosed with ovarian carcinoma after a pelvic ultrasound performed in the course of an infertility evaluation. Following surgery, she develops a pattern of missing chemotherapy treatments, which she attributes to forgetting or her busy responses that have a negative impact on the course of a schedule. Despite repeated feedback from her oncologist, she medical condition are given a diagnosis of “psychological continues to downplay the effect delaying treatment could have factors affecting other medical conditions” (see Box 17-2). In on her prognosis. Neither the carcinoma itself, nor the adverse addition “other conditions that may be the focus of clinical cognitive effects of treatment, is believed to be directly causing attention” may be listed, including as many problems or stres- this behavior, although there is concern that stressful sors as are relevant to diagnosis and clinical management discussions with her husband over adopting a baby may be (Table 17-1). These conditions are typically listed with their contributory, and her avoidance is clearly interfering with corresponding ICD code (V codes for ICD-9, Z codes for consistent cancer treatment. At work, she has had a pattern of ICD-10). avoiding help from her supervisor during critical projects, but she does not meet criteria for an anxiety disorder, personality Section III disorder, or other mental disorder. Given this diagnostic Section III contains a collection of new material. Analogous formulation, the diagnostic assessment in this case could be as to Appendix B of DSM-IV-TR, Section III lists candidate disor- follows: ders that require additional research before consideration for 1. Stage IA clear-cell epithelial carcinoma of the left ovary inclusion in future revisions. These include such constructs as 2. Psychological factors affecting treatment of ovarian Internet Gaming Disorder26 and Non-suicidal Self-Injury. carcinoma In addition, Section III presents a Cultural Formulation 3. Infertility Interview to assist in gathering culturally-relevant information affecting diagnosis and treatment-planning with diverse popu- lations. DSM-5 introduces a more fine-grained approach to understanding how culture may impact clinical care to replace symptoms have substantially improved, the specifiers “in the “culture-bound syndromes” of DSM-IV-TR. A glossary in partial remission” or “in full remission” are sometimes used. the appendix describes important cultural concepts of distress. Some disorders have their own specifiers listed in DSM-5, such These include cultural syndromes (such as ataque de nervios), as “with dissociative fugue” for dissociative amnesia. Others cultural idioms of distress (such as kufungisisa), and cultural have various mutually-exclusive subtypes, such as blood- explanations (such as maladi moun). Information on cultural injection-injury type or natural environment type for specific variation in clinical presentations is also included in the phobia. The DSM-5 Appendix provides a guide for represent- description of specific disorders in Section II. For example, in ing specifiers or subtypes via the final digits of the ICD-9-CM the discussion of pica, it is noted that some groups may ascribe or0 ICD-1 diagnostic codes. spiritual value to the eating of specific non-food substances, As noted above, the multi-axial format has been eliminated which should not be diagnosed as a mental disorder. in DSM-5. All psychiatric and medical diagnoses that are rel- A major critique of DSM-IV-TR focused on limitations of evant to care should be listed in order of clinical concern, with the categorical model and encouraged the inclusion of dimen- the most important diagnosis prompting the clinical encoun- sional approaches in future editions. Based on these critiques, ter listed first. These may include diagnoses involving the DSM-5 offers incremental changes toward a dimensional interplay between medical and psychiatric conditions. For model of diagnosis. A standardized measure of “cross-cutting example, substance ingestion may be thought to cause symptoms,” such as anger and sleep problems, which appear the psychiatric problem, resulting in a diagnosis such as in multiple psychiatric disorders, is featured in Section III of “substance-induced psychotic disorder.” Alternatively, a the DSM-5. In addition, a dimensional measure of psychosis medical illness can be understood as provoking the mental symptom-severity is included. Given that the GAF has been disorder, leading to a diagnosis in the format “[psychiatric removed from DSM-5, an alternative measure for assessing disorder] due to [another medical condition]” (Box 17-2). disability, the WHO Disability Assessment Schedule 2.0 Subthreshold psychiatric symptoms (e.g., anxiety or over- (WHODAS 2.0) is provided. eating), personality traits or defenses, maladaptive coping Work has also been conducted along dimensional lines in (e.g., non-adherence to medical care) or physiological stress the area of personality disorders research. Although the APA

TABLE 17-2 Personality Disorders Neurodevelopmental Disorders

Cluster A Paranoid Personality Disorder Perhaps the most controversial change in this chapter is the Schizoid Personality Disorder elimination of the distinct diagnostic categories of autism, Schizotypal Personality Disorder Asperger’s disorder, childhood disintegrative disorder, and Cluster B Antisocial Personality Disorder pervasive developmental disorder NOS. Instead, these disor- Borderline Personality Disorder ders are incorporated into the single diagnosis of autism spec- Histrionic Personality Disorder trum disorder (ASD) due to consensus that the disorders are Narcissistic Personality Disorder Cluster C Avoidant Personality Disorder the same diagnostic entity, manifest along a spectrum of Dependent Personality Disorder severity. Additional specifiers can be added to the diagnosis Obsessive-Compulsive Personality Disorder (allowing for more specificity) to note the presence or absence of intellectual impairment, language impairment, catatonia, or association with another condition, such as Fragile X syndrome. Patients with persistent challenges in the social aspects of verbal and non-verbal communication, but TABLE 17-3 New Diagnostic Categories in DSM-5 who lack restrictive repetitive behaviors, are now diagnosed Section Diagnosis with a social (pragmatic) communication disorder rather Neurodevelopmental disorders Social (pragmatic) communication than ASD. disorder The changes made to ADHD are more moderate. The diag- Autism spectrum disorder nostic threshold for older adolescents and adults was reduced Intellectual disability (intellectual toe fiv symptoms, with examples given describing the different developmental disorder) presentations of symptoms across the life span. The age of (formerly mental retardation) onset has been changed to require the presence of several Depressive disorders Disruptive mood dysregulation symptoms before age 12, instead of symptoms “causing disorder impairment” prior to age 7, and a co-morbid diagnosis with Pre-menstrual dysphoric disorder Persistent depressive disorder ASDw is no allowed. The ADHD subtypes from DSM-IV-TR (dysthymia) arew no documented as specifiers, although their content is Obsessive-compulsive and Hoarding disorder unchanged. related disorders Excoriation (skin picking) disorder Finally, mental retardation was renamed “Intellectual Dis- Substance/medication-induced ability (intellectual developmental disorder).” The severity of obsessive-compulsive and illness is now determined by adaptive functioning, rather than related disorder by IQ, as in DSM-IV-TR. Obsessive-compulsive and related disorder due to another medical Schizophrenia Spectrum and other condition Trauma- and stressor-related Disinhibited social engagement Psychotic Disorders disorders disorder Somatic symptom and related Somatic symptom disorder In DSM-5, all subtypes of schizophrenia have been removed disorders due to limited diagnostic stability, poor validity, low reliability Feeding and eating disorders Binge eating disorder and lack of prognostic value. As such, catatonia is no longer Gender dysphoria Gender dysphoria a subtype of schizophrenia, and instead is now a specifier of Substance-related and Gambling disorder a mood or psychotic disorder, part of a medical condition or addictive disorders Substance use disorder another specified diagnosis. The unique importance given to Cannabis withdrawal bizarre delusions and two voices conversing (previously Caffeine withdrawal allowed to fulfill the Criterion A requirement for schizophre- Tobacco use disorder Neurocognitive disorders Mild neurocognitive disorder nia alone) has been eliminated. Two criterion A symptoms are Major neurocognitive disorder now required universally for a diagnosis of schizophrenia. There is the additional requirement that patients have at least one of three “core” symptoms: delusions, hallucinations or disorganized speech. In DSM-5, a diagnosis of schizoaffective disorder now opted to keep the system for diagnosing personality disorders requires that a major mood episode be present for the major- unchanged in Section II of DSM-5 (Table 17-2), a different way ity (rather than a “substantial portion”) of the disorder’s total to conceptualize personality disorders is introduced in Section duration. In delusional disorder, delusions are no longer III.27 This model considers four areas of personality function- required to be “non-bizarre.” In addition, the diagnosis of a ing: identity, self-direction, empathy, and intimacy. In addi- shared psychotic disorder (folie à deux) has been eliminated as tion, personality traits falling within one of five domains (for a separate category, and subsumed by the general diagnosis of example, negative affectivity) are assessed, each featuring more delusional disorder. specific “trait facets” (such as emotional lability or hostility). Bipolar and Related Disorders Diagnostic Criteria Changes Bipolar and related disorders are now in a separate chapter DSM-5 introduced several new diagnoses (Table 17-3) and from the depressive disorders. The diagnostic criteria for numerous changes in diagnostic criteria. In addition to manic episodes now include a requirement for change in changes in nomenclature or classification, some disorders activity or energy, in addition to mood. In addition, the mixed have been created by combining or separating previous diag- episode diagnosis has been removed; instead, the specifier nostic categories, and specific diagnostic criteria have been “with mixed features” can be added to any mood disorder added or removed. These changes are fully described in DSM- (including depressive disorders). A new specifier of “anxious 5’s Appendix.5 Some of the more prominent changes are dis- distress” can also be added to bipolar disorders, as well as cussed below. depressive disorders.

Depressive Disorders attachment disorder, disinhibited social engagement disorder, PTSD, acute stress disorder, and adjustment disorders. 17 Two new depressive disorders have been added to DSM-5. The Diagnostic criteria for PTSD and acute stress disorder have disruptive mood dysregulation disorder (DMDD) diagnosis been modified. The definition of traumatic exposure has been was added to address controversy regarding the diagnosis of expanded, to include direct and indirect experience, as well as children with bipolar disorder. The disorder describes children repeated exposure (as in the case of first-responders). The who exhibit chronic irritability and frequent episodes of symptom clusters have also been expanded to include new extreme behavioral dysregulation. The symptoms are present symptoms, such as persistent negative emotional states. nearly every day, for a year or more. Thus, DSM-5 makes the The diagnosis of reactive attachment disorder (RAD) has distinction between chronic irritability and long-standing out- also undergone revision. The two previously described sub- bursts of extreme dysregulation, consistent with DMDD, and types (emotionally withdrawn/inhibited and indiscriminately clearly episodic and intermittent mood symptoms, represent- social/disinhibited) are now distinct disorders: reactive attach- ing a change from baseline, consistent with bipolar disorder. ment disorder and disinhibited social engagement disorder. Premenstrual dysphoric disorder is the second addition, The separation was made based on the recognition that the having been elevated from the DSM-IV-TR appendix into two subtypes have sufficiently different correlates, courses, and Section II of DSM-5 due to increased scientific support for its responses to interventions. diagnostic stability and reliability. DSM-5 also combines the diagnoses of dysthymia and chronic major depressive disorder (MDD) into a single diag- Somatic Symptom and Related Disorders nosis: persistent depressive disorder (dysthymia). The diag- DSM-5 eliminated the diagnoses of somatization disorder, nostic criteria for MDD remain largely unchanged in DSM-5, hypochondriasis, pain disorder, and undifferentiated somato- with the exception of the removal of the bereavement exclu- form disorder. Instead, somatization disorder and undifferen- sion, the prior restriction that MDD could not be diagnosed tiated somatoform disorder are combined into somatic in a patient grieving the death of a loved one within the symptom disorder (SSD). This disorder now includes somatic preceding 2 months. A note is included in the text to assist symptoms that are either distressing or disruptive to daily life, clinicians in distinguishing between normal grieving and a in addition to excessive thoughts, feelings and behaviors depressive disorder. related to the somatic symptoms or health concerns. The requirement for a specific number of symptoms from four Anxiety Disorders organ groups has also been eliminated, as has the requirement that symptoms be “medically unexplained.” The anxiety and related disorders have been re-organized within the manual. Separation anxiety disorder and selective mutism are now included within the anxiety disorders chapter, Eating Disorders as all disorders previously grouped together as occurring in The existing eating disorders underwent minor revisions. The infancy, childhood or adolescence have been moved into cat- criteria for anorexia nervosa no longer include the amenorrhea egories with the related adult diagnoses. In addition, obsessive- requirement, which could not be applied to males, or to pre- compulsive disorder (OCD), post-traumatic stress disorders menarchal or post-menopausal women. The required fre- (PTSD), and acute stress disorder are now separate chapters, quency of binge eating for the diagnosis of bulimia has been occurring sequentially with anxiety disorders in order to reflect decreased to once a week (from twice a week). Binge eating their close relationship. Finally, panic disorder and agorapho- disorder, now supported by extensive scientific research, is a bia are now considered as separate diagnoses, and panic attack new diagnosis in this chapter. Finally, pica, rumination, and can now be listed as a specifier for a variety of disorders avoidant/restrictive food-intake disorder have all been moved as well. into this chapter, as all childhood disorders are now grouped with their adult counterparts. Obsessive-compulsive and Related Disorders Obsessive-compulsive and related disorders comprise a new, Gender Dysphoria separate, chapter in DSM-5, reflecting recent advances that Gender dysphoria is a new diagnostic category in DSM-5. It indicate that these disorders are related to each other, and replaces gender identity disorder, and emphasizes distress distinct from other anxiety disorders. This chapter includes about gender incongruence, rather than cross-gender identifi- OCD, as well as several new disorders, including hoarding cation, as in DSM-IV-TR. This gender incongruence and result- disorder and excoriation (skin picking) disorder. Hoarding ing dysphoria can manifest in a variety of presentations, and disorder has been removed as a subtype of OCD due to current separate criteria are listed for children and adolescents and understanding that it is a distinct disorder with different treat- adults, based on developmental stage. The term “disorder” was ments and outcomes. Trichotillomania (hair-pulling disorder) replaced with “dysphoria” in order to reduce stigma and to has been moved into this chapter, from the impulse-control become more consistent with clinical terminology. Finally, disorders chapter. Specifiers have been added for OCD, body sexual dysfunction and paraphilias have been moved to sepa- dysmorphic disorder, and hoarding disorder to signal that rate chapters, given the lack of relationship between these absent insight or delusional beliefs should trigger the diagno- disorders and gender dysphoria. sis of the particular obsessive-compulsive or related disorder, rather than a psychotic disorder. A tic-related specifier has also been added due to recognition that a co-morbid tic disorder Disruptive, Impulse Control, and Conduct Disorders has important clinical implications. This chapter is new to the DSM-5. It combines disorders that were previously in “Disorders Usually First Diagnosed in Trauma- and Stressor-related Disorders Infancy, Childhood or Adolescence,” including oppositional defiant disorder (ODD), conduct disorder, disruptive behavior A new chapter on trauma- and stressor-related disorders disorder, with disorders from “Impulse Control Disorders has been added to DSM-5. This chapter contains reactive Not Otherwise Specified,” including intermittent explosive

Downloaded for Rohul Amin ([email protected]) at Uniformed Services Univ of the Health Sciences from ClinicalKey.com by Elsevier on September 29, 2018. For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved. 170 PART V Psychiatric Diagnoses and Conditions disorder (IED), pyromania, and kleptomania. These disorders diagnostic systems whose emerging findings, as they become arew no grouped together due to the recognition that they are more directly clinically relevant, could ultimately be incorpo- all characterized by challenges with emotional and behavioral rated into future versions of the DSM.28,45 self-regulation. Other writers express ambivalence about the idea of psy- Several disorders in this section have undergone revision. chiatric diagnosis and the “medical model” altogether, object- For example, symptoms of ODD are now grouped in three cat- ing, for example, to potentially counter-therapeutic legal, egories (angry/irritable mood, argumentative/defiant behav- ethical, social, and economic uses and misuses of diagnostic ior, and vindictiveness) in order to reflect the presence of both information.28,46,47 DSM-5 recognizes the need to incorporate emotional and behavioral symptoms. The exclusion criterion information sensitive to patients’ experience of illness,48 as for conduct disorder has now been removed and specific dura- well as sociocultural,30,49 gender-based,24 and developmental/ tion criteria have been added, in order to distinguish between life-span perspectives.50–52 Processes for incorporating these normal child or adolescent behavior and pathology. Criteria perspectives in more sophisticated ways should continue to for IED have also been expanded to include verbal aggression, evolve. Some additional critiques of DSM from specific theo- as well as physical aggression, and a minimum age of 6 years retical orientations are described next. isw no required, to distinguish it from developmentally- normal tantrums. Psychodynamic Approaches Substance-related and Addictive Disorders One criticism of psychiatric evaluation focused solely on determining DSM-based diagnoses is that psychodynamic for- The diagnoses of substance abuse and dependence are no mulation may be neglected. Some have suggested that psy- longer separate in DSM-5. Rather, a new diagnosis of sub- chodynamic principles be returned to the DSM. Meanwhile, a stance use disorder combines the prior DSM-IV-TR diagnostic coalition of psychoanalytically-oriented organizations has criteria. Previously, substance abuse was thought to be a developed its own diagnostic manual separate from the milder form of a substance-related disorder; however, there DSM.53 isw no recognition that substance abuse can present with severe symptomatology, and thus the removal of these diag- Behavioral Approaches nostic boundaries. DSM-5 also adds the new category of behavioral addic- Behaviorally-oriented clinicians argue that describing a behav- tions. The sole diagnosis in this category is gambling disorder. ior divorced from its context and function is meaningless, and The inclusion of this disorder in the substance-related disor- that behavioral functional analysis should be incorporated ders chapter is a reflection of the similarity between substance into diagnostic classification.54,55 For example, it may be more and behavioral addictions in presentation, co-morbidity, helpful in behavioral treatment-planning to create categories physiology, and treatment. that account for what is reinforcing rule-breaking behavior in a child, rather than listing the types or numbers of rules 56 Neurocognitive Disorders broken, to create a category such as “Conduct Disorder.” Dementia is now replaced by the diagnosis of “neurocognitive Family/Systems Theory disorder.” Mild neurocognitive disorder was included in order to encourage early diagnosis and proactive treatment before The DSM-5 identifies mental disorders as occurring solely “in the onset of more incapacitating symptoms. Subtypes are an individual.”5 Critics operating from a family therapy or determined by specific criteria for each etiology, and the term systems orientation have questioned this fundamental “dementia” can still be used to specify etiologic subtype. assumption, particularly for children. The DSM-5 notes the clinical relevance of problematic relationship patterns but CRITIQUES AND LIMITATIONS OF DSM-5 does not recognize them as mental disorders. This may result in the practical problem of difficulty receiving third-party Even before its release, critiques of DSM-5 began to emerge.28–31 reimbursement for treatment, no matter how impairing the Some felt that normative experiences were pathologized in relational difficulties may be for the individuals involved.4 DSM-5.32,33 Others noted that diagnostic criteria were more 34 restrictive for some disorders, with potential real-world rami- CONCLUSION fications for service delivery, as in the case of autism spectrum disorder.35 Additional authors voiced dissent around decisions A variety of arguments have been made for improving—or made regarding aspects of specific diagnoses.36–39 Concern even discarding—the DSM diagnostic system. Given the com- regarding diagnostic reliability in field trials40 and the imple- plexity of the human brain and behavior and the variety of mentation of new dimensional approaches to personality dis- natural and social environments in which people live, it is orders were also expressed.41,42 likely that any future psychiatric diagnostic system will need More fundamentally, efforts have been made over the to be considered provisional: subject to change on the basis years to challenge the “atheoretical” basis of the DSM and of empirical evidence and clinical utility. Nonetheless, the to re-introduce explicitly theoretically-driven diagnostic sche- DSM-5 can be used powerfully by clinicians who are attentive mata. Some researchers have suggested the need for an explicitly to its limitations and who maintain a pragmatic focus on what biologically-based model resulting in major re-classification of benefits their individual patients. The DSM-5 provides a disorders on the basis of underlying pathophysiology.32 This framework that can help clinicians to gather and synthesize change has remained difficult to implement with the current information systematically and to communicate clearly. A state of scientific knowledge. The National Institute of Mental careful assessment allows the clinical psychiatrist to proceed Health’s Research Domain Criteria (RDoC) project43 is a major beyond the diagnostic purview of the DSM, toward effective effort conceived “to create a framework for research on patho- treatment. physiology, especially for genomics and neuroscience, which ultimately will inform future classification schemes.”44 The Access the complete reference list and multiple choice questions RDoC can be seen as a strategy “complementary” to current (MCQs) online at https://expertconsult.inkling.com

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MULTIPLE CHOICE QUESTIONS were compiled (with DSM-IV’s publication in 1994 and the DSM-5 in 2013), there have been increased attempts to ensure Select the appropriate answer. diagnostic reliability and validity, to incorporate research findings, and to gather new information from field trials. Q1 In what year was the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) published? Q2 The answer is: Axis II. ○ 1949 All psychiatric disorders included in the DSM, except for per- ○ 1952 sonality disorders and intellectual impairment (which were recorded on Axis II), were recorded on Axis I. ○ 1955 ○ 1958 Q3 The answer is: Axis IV. ○ 1961 Psychosocial and environmental problems were listed on Axis IV. Much of the time, Axis IV included only current problems, Q2 On which of the following DSM Axes were personality but in some cases, past stressors are particularly relevant to disorders and intellectual impairment located? diagnosis and clinical management and should be listed as well. For example, though it occurred several years previously, ○ Axis I a contentious parental divorce that has exacerbated a teenag- ○ Axis II er’s anxiety disorder and is critical to understanding the current family environment should be included on Axis IV, with the ○ Axis III anxiety disorder listed as usual on Axis I. Sometimes the psy- ○ Axis IV chosocial or environmental problem is important as a main target of treatment, rather than primarily via its effects on a ○ Axis V separate psychiatric disorder. Q3 On which of the following DSM Axes were psychosocial and environmental problems listed? Q4 The answer is: <50. ○ Axis I The Global Assessment of Functioning (GAF is a number between 0 and 100 that summarizes the clinician’s view of the ○ Axis II patient’s current degree of impairment in terms of psychoso- ○ Axis III cial and occupational or educational function. Generally, normal function is coded in the 70-to-100 range, mild psychi- ○ Axis IV atric symptoms fall in the 70-to-80 range, and moderate symp- ○ Axis V toms are assigned a number between 60 and 70. Severe symptoms are coded as 50 and below; higher levels of psychi- Q4 Which of the following Global Assessment of Function atric support (such as intensive community-based treatment, (GAF) scores signifies severe symptoms? residential settings, or inpatient hospitalization) are often required as function drops further down the scale. Although ○ 80–100 it may be difficult to determine in complicated cases, func- ○ 70–80 tional difficulty that results from “physical (or environmental) limitations” should not be considered in assigning a GAF ○ 60–70 score; the intent is to focus on the effects of mental illness. So, ○ 50–60 a patient who is no longer able to work or to live independ- ently due to paraplegia may nonetheless receive a GAF score ○ <50 well above 70 if he has a wide social network, remains active in local politics, feels satisfied with life, and experiences frus- Q5 On which of the following DSM Axes would atrial tration but takes effective action in the face of setbacks related fibrillation have been recorded? to his physical problems. ○ Axis I The GAF score is not a static number; it changes for each ○ Axis II patient over time. It can be used to track and succinctly communicate the course of psychiatric disorders over time and to ○ Axis III monitor response to treatment. An increase in the GAF score ○ Axis IV from 35 to 55 during the course of an inpatient hospitalization, for example, would suggest that the treatment plan has ○ Axis V been at least somewhat effective, while a decline from 35 to 20 might suggest that it has not. Reporting the highest and lowest GAF score in the past year along with the current GAF score can also help to paint a concise picture of overall func- MULTIPLE CHOICE ANSWERS tion. However, it is important to consider the limitations of Q1 The answer is: 1952. the GAF scale in clinical decision-making. Neither the GAF score alone nor the entire multi-axial assessment, for that From the first edition’s publication in 1952, to the second matter, can be a substitute for psychiatric clinical skill and edition’s publication in 1968, and the third edition’s publica- judgment. tion in 1980 (with a revised third edition in 1987), a change in emphasis took place; psychodynamic formulations were no Q5 The answer is: Axis III. longer intrinsic to diagnostic categorization, and the DSM-III was considered to be atheoretical and descriptive in its orien- Axis III lists all relevant “General Medical Conditions,” tation (using a multiaxial system). As subsequent editions meaning non-psychiatric illnesses. If the evaluator considers