DSM-V at a Glance

The Work in Progress..

Dr Subas Pradhan
The Shrink’s Bible
 Understanding 50 Years of Change
DSM-II: 182 disorders 134 pages

DSM-III: 265 disorders 494 pages

DSM-III-R: 265 disorders 567 pages

DSM-IV: 365 disorders 886 pages

DSM-IV-TR: 365 943 pages

disorders

In 50 years: 800% increase in the number of diagnoses

Why change DSM-IV
 Clinical Utility
 Research Evidence
 Category Vs Dimensionality
 Reducing the junk i.e. 40% of all
diagnosis are NOS category!
 The Future of the DSM:
Towards
The begining:
DSM -V
http://www.dsm5.org/
 DSM 5 in last decade..

2004-2007: “The Future of Psychiatric Diagnosis: Refining the
Research Agenda” APA/NIH/WHO global research planning
conferences. “Phase 2: Refining the Research Agenda for DSM-5:
NIH Conference Series”


April 2006: Drs. David Kupfer and Darrel Regier are appointed as
chair and vice-chair, respectively, of the DSM-5 Task Force.


July 2007: DSM-5 Work Group Chairs are appointed. Assembling
of DSM-5 Work Groups begins. 


May 2008: DSM-5 Work Group members announced. APA Names
DSM-5 Work Group Members.
 Phase 1 Field Trial ..2010

January– May 2010: Site Recruitment for Field Trial
Testing.  

February – May 2010: Pilot Testing for DSM-5 Field
Trials.  

May 2010 – March 2011: DSM-5 Field Trials, Phase 1.
The first phase of DSM-5 field trials will begin in May
2010 and is scheduled to run for 10 months.

 

Initial text for DSM-5 & case studies will also be
developed, which will be published after DSM-5’s
release in a series of case books.
 DSM 5 in 2011

March – April 2011: Revisions to Proposed Criteria.

 

April – May 2011: Review of Revised Criteria.

 

May-July 2011: Online Posting of Revised Criteria
till June 30 2011.

 

August 2011 – February 2012: DSM-5 Field Trials,
Phase II.

DSM 5 in 2012
February – August 2012: Prepare Final Draft Text.
 

March 2012: Presentation of DSM-5 Structure to APA’s Board of Trustees.


August 2012: Final Review.
 

September 2012: The National Center for Vital and Health Statistics’ Annual
ICD-10-CM Revision Conference. The final, approved overall structure of DSM-
5 will be complete in time for this conference so that organization of ICD-10-
CM can be aligned with DSM-5.
 

September – November 2012: Final Revisions to Draft Criteria.


November 2012: APA Assembly Approval of DSM-5.


December 2012: APA Board of Trustees Approval of DSM-5 and submission to
APA’s publishing division, American Psychiatric Publishing, Inc.
May 2013: Publication of DSM-5.
The release of DSM-5 will take
place during the APA’s 2013
Annual Meeting in San
Francisco, CA.
 Proposed Field Trials

Generalized Anxiety Disorder

Minor Neurocognitive Disorder 
Agoraphobia

Major Neurocognitive Disorder

PTSD

Autism Spectrum Disorder

Obsessive-Compulsive Disorder

Learning Disabilities 
Hoarding

Intellectual Disabilities 
Nicotine (Tobacco Use Disorder)

ADHD (in children and adults)

Alcohol Use Disorder

Callous/Unemotional Specifier for Conduct 
Cannabis Use Disorder
Disorder 
Opioid Use Disorder

Oppositional Defiant Disorder (linked to 
Complex Somatic Symptom Disorder
Field Trial for Temper Dysregulation 
Binge Eating Disorder
Disorder) 
Avoidant/Restrictive Food Intake Disorder

Temper Dysregulation Disorder 
Primary Insomnia

Non-Suicidal Self Injury 
Hypersexual Disorder

Preschool PTSD 
Gender Incongruence (in children,

Psychotic Risk Syndrome adolescents and adults)

Schizoaffective Disorder 
Sexual Interest Arousal Disorder

Psychotic Disorder 
Schizotypal Personality Disorder

Major Depressive Disorder 
Antisocial Personality Disorder

Anxious Depression 
Borderline Personality Disorder

Bipolar Disorder 
General Criteria for Personality Disorder
 Proposed Draft Revisions to
DSM Disorders and Criteria 
• Structural, Cross-Cutting, and General Classification Issues for DSM-5
Adjustment Disorders
Anxiety Disorders
Delirium, Dementia, Amnestic, and Other Cognitive Disorders
Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence
Dissociative Disorders
Eating Disorders
Factitious Disorders
Impulse-Control Disorders Not Elsewhere Classified
Mental Disorders Due to a General Medical Condition Not Elsewhere Classified
Mood Disorders
Other Clinical Conditions That May Be a Focus of Clinical Attention
Personality and Personality Disorders
Schizophrenia and Other Psychotic Disorders
Sexual and Gender Identity Disorders
Sleep Disorders
Somatoform Disorders
Substance-Related Disorders
 General format of
DSM-5 website

Proposed Revision

Rationale

Severity

DSM IV
 Structural, Cross-Cutting, and General
Classification Issues for DSM-5 


Use of the multi-axial system to record
diagnoses and clinical variables of interest
(collapsing axis-I,II&III into one)

Consideration of factors that cut across all
diagnoses (e.g., gender and cultural
issues)

The use of dimensional measures to refine
diagnostic assessment and treatment
planning i.e. depression in many disorders
 Adjustment Disorders

The work group is recommending that this
disorder be included in a grouping of
Trauma and Stress-Related Disorders

Specify if With PTSD-Like or ASD-Like
symptoms: when the predominant
manifestation is PTSD-like or ASD-like
symptoms, but the PTSD/ASD stressor
and/or symptom criteria are not met.
 Anxiety Disorders

OCD as another diagnostic category

Remove Agoraphobia without panic disorders

Disorders Not Currently Listed in DSM-IV
– Substance-Induced (indicate substance) Tic Disorder 
– Tic Disorder Due to a General Medical Condition 
– Hoarding Disorder 
– Olfactory Reference Syndrome 
– Skin Picking Disorder
 Conditions Proposed
by Outside Sources

Apathy Syndrome

Body Integrity Identity Disorder

Complicated Grief Disorder

Developmental Trauma Disorder

Disorders of Extreme Stress Not Otherwise Specified
(DESNOS)

Fetal Alcohol Syndrome

Internet Addiction

Male-to-Eunuch Gender Identity Disorder

Melancholia

Parental Alienation Disorder

Seasonal Affective Disorder

Sensory Processing Disorder
 Delirium, Dementia, Amnestic,
and Other Cognitive Disorders 
1)    Removing the term “Dementia” and adding
“Major Neurocognitive Disorders”,
2)    Adding a category of “Minor Neurocognitive
Disorders”,
3)    Categorizing behavioral disturbances,
particularly the syndromes of psychosis and
depression, associated with Neurocognitive
Disorders, and
4)    Selecting specific domains as well as
measures of severity of cognitive functional
impairment
 Disorders Usually
First Diagnosed in Infancy,
Childhood, or Adolescence 

New name for category, autism spectrum
disorder, which includes
Asperger’s disorder,autistic disorder
childhood disintegrative disorder, Pervasive
Developmental Disorder

Mental retardation (Renamed Intellectual
Disability)
 Code no longer based on IQ level
 Disorders Usually
First Diagnosed in Infancy,
Childhood, or Adolescence 

*Childhood Disorders Proposed for Possible
Reclassification in Another Diagnostic
Category
– Pica
– Rumination Disorder
– Feeding Disorder of Infancy or Early Childhood
– Separation Anxiety Disorder
 *Childhood Disorders Proposed for Possible
Removal from DSM (No DSM-5 Criteria Proposed)
• Expressive Language Disorder
• Mixed Receptive-Expressive Language Disorder
• Communication Disorder Not Otherwise Specified
• Rett's Disorder
 Disorders Usually
First Diagnosed in Infancy,
Childhood, or Adolescence 

Childhood Disorders Proposed to be Divided into
New Childhood Disorders
– Reactive Attachment Disorder of Infancy or Early Childhood

Childhood Disorders Proposed to be Subsumed Under Other

Diagnoses (No DSM-5 Criteria Proposed)
– Disorder of Written Expression
– Learning Disorder Not Otherwise Specified
– Childhood Disintegrative Disorder
– Asperger's Disorder
– Pervasive Developmental Disorder Not Otherwise Specified
 Childhood Disorders Not
Currently Listed in DSM-IV
• Posttraumatic Stress Disorder in Preschool Children 
• Temper Dysregulation Disorder with Dysphoria 
• Callous and Unemotional Specifier for Conduct Disorder 
• Learning Disabilities 
• Non-Suicidal Self Injury 
• Non-Suicidal Self Injury Not Otherwise Specified 
• Language Impairment 
• Late Language Emergence 
• Specific Language Impairment 
• Social Communication Disorder 
• Voice Disorder
 Factitious Disorder

The work group has proposed that this
diagnosis be reclassified from Facitious
Disorders to Somatic Symptom Disorders

Proposed Subtype: 
 Factitious Disorder imposed on another
(previously, factitious disorder by proxy)
 Substance-Related Disorders

Work group’s proposals is the recommendation that the
diagnostic category include both substance use disorders
and non-substance addictions

Gambling disorder has been moved into this category and
there are other addiction-like behavioral disorders such as
“Internet addiction”

Pathological gambling: The work group has proposed that
this diagnosis be reclassified from Impulse-Control Disorders
Not Elsewhere Classified to Substance-Related Disorders
which will be renamed as Addiction and Related Disorders.
 Mood Disorders

Mood Disorders Being Recommended for
Removal or Reclassification-Mixed Episode


Mood Disorders Not Currently Listed in
DSM-IV
 Mixed Anxiety Depression 
– Mixed Features Specifier 
 Premenstrual Dysphoric Disorder

Mood Disorders Proposed for Possible
Removal from DSM (No DSM-5 Criteria
Proposed)
Bipolar I Disorder - Most Recent Episode Mix
ed
 Major Depressive Episode

The exclusion of symptoms judged better
accounted for by Bereavement is
removed because evidence does not
support separation of loss of loved one
from other stressors

"Do not include symptoms due to... mood-
incongruent delusions or hallucinations" is
eliminated because meaning and purpose
are unclear. 
 Dysthymic Disorder

The work group is proposing that this
disorder be renamed Chronic Depressive
Disorder, and will not require the
exclusion of a Major Depressive Episode.

The category of major depression with
chronic specifier to be combined with
dysthymic disorder under the term
“chronic depressive disorder”.
 Depressive Disorder
Not Otherwise Specified

Depressive Conditions Not Elsewhere
Classified (Depressive CNEC) 
 Depressive CNEC with insufficient information to
make a specific diagnosis.
 Subsyndromal Depressive CNEC  

Prodromal depression.

Subsyndromal depression that meets duration criteria but
not symptom count criteria for Major Depressive Episode
(MDE.)

Mixed Subsyndromal Anxiety-Depressive Disorder.
 Other Depressive CNEC

Major Depressive Episode (MDE) superimposed on a
psychotic disorder.

Recurrent Brief Depressive Disorder.
 Schizophrenia and
Other Psychotic Disorders 

Schizophrenia and Other Psychotic
Disorders Not Currently Listed in DSM-IV
 Attenuated Psychotic Symptoms Syndrome 

– Catatonia Specifier

Removing all sub-typing of schizophrenia!
 As it’s rarely used diagnostically (<5%), with
the exception of paranoid schizophrenia (50-
75%) and, to a lesser extent, undifferentiated
schizophrenia
 Personality and Personality
Disorders 

Significant reformulation of the approach
to the assessment and diagnosis of
personality psychopathology
 Definition: Personality disorders represent
the failure to develop a sense of self-
identity and the capacity for interpersonal
functioning that are adaptive in the context
of the individual’s cultural norms and
expectations. 
 Personality and Personality
Disorders 
Work Group recommends 5 specific
personality disorder types (Reduced from
10 in DSM IV to 5)
– Antisocial/Psychopathic Type
 Avoidant Type
 Borderline Type
 Obsessive-Compulsive Type
 Schizotypal Type
 Personality Traits

The Work Group recommends that patients
be rated on 6 broad, higher order personality
trait domains each comprised of several
lower order, more specific trait facets.

Trait Domains:
 Negative Emotionality
 Introversion
 Antagonism
 Disinhibition
 Compulsivity
 Schizotypy 
 Domains and Facets

Negative Emotionality: Experiences a wide range of negative emotions (e.g.,
anxiety, depression, guilt/ shame, worry, etc.), and the behavioral and
interpersonal manifestations of those experiences
 Trait facets: Emotional lability, anxiousness, submissiveness,
separation insecurity, pessimism, low self-esteem, guilt/ shame,
self-harm, depressivity, suspiciousness

Introversion: Withdrawal from other people, ranging from intimate
relationships to the world at large; restricted affective experience and
expression; limited hedonic capacity
 Trait facets: Social withdrawal, social detachment, restricted
affectivity, anhedonia, intimacy avoidance

Antagonism: Exhibits diverse manifestations of antipathy toward others, and
a correspondingly exaggerated sense of self-importance
 Trait facets: Callousness, manipulativeness, narcissism,
histrionism, hostility, aggression, oppositionality, deceitfulness
 Domains and Facets contd.

Disinhibition: Diverse manifestations of being present- (vs. future- or past-)
oriented, so that behavior is driven by current internal and external stimuli,
rather than by past learning and consideration of future consequences
 Trait facets: Impulsivity, distractibility, recklessness,
irresponsibility

Compulsivity: The tendency to think and act according to a narrowly defined
and unchanging ideal, and the expectation that this ideal should be adhered
to by everyone
 Trait facets: Perfectionism, perseveration, rigidity, orderliness,
risk aversion

Schizotypy: Exhibits a range of odd or unusual behaviors and cognitions,
including both process (e.g., perception) and content (e.g., beliefs)
 Trait facets: Unusual perceptions, unusual beliefs, eccentricity,
cognitive dysregulation, dissociation proneness
 Substance-Related Disorders

Work group’s proposals is the recommendation that the
diagnostic category include both substance use disorders
and non-substance addictions

Gambling disorder has been moved into this category and
there are other addiction-like behavioral disorders such as
“Internet addiction”

Pathological gambling: The work group has proposed that
this diagnosis be reclassified from Impulse-Control Disorders
Not Elsewhere Classified to Substance-Related Disorders
which will be renamed as Addiction and Related Disorders.
 Sleep Disorders

Proposed Sleep Disorders Not Currently Listed in DSM-IV
 Kleine Levin Syndrome
 Obstructive Sleep Apnea Hypopnea Syndrome (previously
Breathing Related Sleep Disorder)
 Primary Central Sleep Apnea (previously Breathing Related
Sleep Disorder)
 Primary Alveolar Hypoventilation (previously Breathing Related
Sleep Disorder)
 Rapid Eye Movement Behavior Disorder
 Restless Legs Syndrome
 Circadian Rhythm Sleep Disorder - Advanced Sleep Phase Type
 Disorder of Arousal
 Circadiam Rhythm Sleep Disorder - Free-Running Type
 Circadiam Rhythm Sleep Disorder - Irregular Sleep-Wake Type
 Criticisms of the DSM
The DSM More of a Political (and economic) Art Than
a Science
Pharmaceutical companies have played a big part in
maintaining a “medical model” classification
system
With profits to gain,
pharmaceutical companies
have readily funded research

?The writers of DSM have

also benefited from the
DSM’s medical model
More Criticisms of the DSM
The DSM Pathologizes “Normal” Behaviors