사회복지사를 위한 DSM-5 소개자료

Introduction to DSM-5 Gary M. Henschen, M.D., Chief Medical Officer - Behavioral Health Antoinette Cusick, M.D., Associate Medical Director, Florida Care Management Center

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Historical Perspective of DSM-5 How we arrived at this edition of the DSM

Historical Perspective

• A predecessor of the DSM was published by APA in 1844

– Established to classify institutionalized patients / promote communication

• Four major editions after 1945

– Developed to describe essential features of mental disorders

• DSM-5 is built on DSM-IV

– Revisions began in 1999, DSM-5 was published May 18, 2013

– Use DSM-5/ICD-9 CM codes through September 30, 2014

– Use DSM-5/ICD-10 CM codes starting October 1, 2014

• APA and NIMH leadership agreed that DSM-5 will harmonize with ICD-11

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The DSM-5 Development Process

• 1999-2002: The American Psychiatric Association (APA), National Institutes of Mental Health (NIMH), World Health Organization (WHO), and the World Psychiatric Association sponsored conferences to develop the research agenda for DSM-5

– 13 diagnostic work groups convened

– 90 academic and mental health institutions – 30% international – participated.

– Multidisciplinary participation included: 100 psychiatrists, 47 psychologists, two pediatric neurologists, three epidemiologists, pediatrician, speech and hearing specialist, social worker, psychiatric nurse, consumer and family representatives

• 2004-2008: APA, WHO, NIMH: 13 conferences

– 400 participants from 39 countries

– 10 monographs and hundreds of articles

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• APA worked with WHO for consistency with ICD-11

• Scientific review committee: guidance on strength of evidence supporting changes

• Clinical utility, consistency and public health impact assessed

• Draft criteria released to public for comment three times – 11,000 comments

• Large academic medical centers and investigators tested DSM-5 feasibility and utility

The DSM-5 Development Process

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What Is Included in DSM-5?

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DSM-5 Definition of a Mental Disorder

All elements must be included

• Mental disorder – syndrome characterized by a clinically significant disturbance in cognition, emotion regulation or behavior – reflects dysfunction in psychological, biological or developmental processes underlying mental functioning.

• Associated with significant distress or disability in social, occupational or other important activities. Expected cultural response to a common stressor or loss – not a mental disorder.

• Socially deviant behavior (political, religious, sexual) and conflicts between the individual and society – not mental disorders unless the deviance results from dysfunction described above.

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• Much of DSM-5 is unchanged from DSM IV-TR

• Approximately the same number of diagnoses

• Some diagnoses reclassified

• Some diagnostic criteria clarified

• Only 15 new diagnoses added

• NO MORE AXES!

Diagnoses

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No more axes in DSM-5

DSM-5 – non-axial documentation of diagnosis

Axis III – combined with Axes I and II; physical health conditions are to be listed

Axis IV – eliminated; psychosocial and environmental issues – use ICD-9 V codes and ICD-10 Z codes

Axis V GAF – eliminated; scale developed by WHO (WHODAS) is recommended by DSM-5 task force – best global measure of disability

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Scientifically-validated Assessment Measures Encouraged!

• DSM-5 recommends scientifically validated assessment measures, rating scales in diagnosis, monitoring and measuring treatment progress and assessing impact of culture of key aspects of clinical presentation and care

• Examples included in DSM-5

– Adult or parent/guardian DSM-5 self-rated cross-cutting symptom measure

– Disorder-specific severity measure (e.g., PHQ-9)

– Cultural Formulation Interview (CFI)

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DSM-5 Guiding Principles

• Research evidence to support any addition or modification

• Maintain continuity with DSM-IV-TR if possible

• Routine clinical practices must be able to implement changes

• No restraints in limiting degree of change between DSM-5 and earlier editions

All criteria are based on an extensive review of the literature

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Evidence to support changes must meet these tests:

Is the proposed diagnosis distinct enough to warrant separate

consideration?

Any potential harm to individuals or groups if the change was or was not

adopted?

Do the diagnostic criteria for a new entity reflect a true mental disorder or

variations of normal behavior?

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DSM-5 Organization and Other Changes

• DSM-5 organized by the developmental lifespan

– Neurodevelopmental disorders in childhood

– Neurocognitive disorders in older adulthood

• Restructuring of chapters based on disorders’ relatedness to one another

• Restructuring based on symptom vulnerabilities and symptom characteristics

• Moves away from categorical model – required clinician to determine whether disorder present or absent

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DSM-5 Organization and Other Changes

• Sex differences – when variations are attributed to the presence of XX or XY chromosome or reproductive organs

• Gender differences – variations result from biological sex and perceived gender

• Uses dimensional approach – allows more latitude in assessing severity – no concrete threshold between normality and disorder

• Replaces NOS designation

– Other specified disorder – used when reason specified

– Unspecified disorder– reason not specified

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DSM-5 Chapters and Sequence

1. Neurodevelopmental Disorders

2. Schizophrenia Spectrum and Other Psychotic Disorders

3. Bipolar and Related Disorders

4. Depressive Disorders

5. Anxiety Disorders

6. Obsessive-Compulsive and Related Disorders

7. Trauma- and Stressor-Related Disorder

8. Dissociative Disorders

9. Somatic Symptom Disorders

10. Feeding and Eating Disorders

11. Elimination Disorders

12. Sleep-Wake Disorders

13. Sexual Dysfunctions

14. Gender Dysphoria

15. Disruptive, Impulse Control and Conduct Disorders

16. Substance-Use and Addictive Disorders

17. Neurocognitive Disorders

18. Personality Disorders

19. Paraphilic Disorders

20. Other Disorders

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Highlights of Changes DSM IV-TR to DSM-5

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Neurodevelopmental Disorders

• Intellectual Disabilities

• Communication Disorders

• Autism Spectrum Disorders

• Attention-deficit Hyperactivity Disorder

• Specific Learning Disorder

• Motor Disorders

• Other Specified Neurodevelopmental Disorder

• Unspecified Neurodevelopmental Disorder

• 319 (F70, F71, F72, F73)

• 315.39 (F80.9, 80.0, F80.81)

• 299.00 (F84.0)

• 314.00, 314.01 (F90.0, 90.1, 90.2)

• 315.00, 315.1, 315.2 (F81.0)

• 315.4, 307.xx (F82), 307.3 (F98.4)

• 315.8 (F88)

• 315.9 (F89)

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Intellectual Disability (Intellectual Developmental Disorder)

• Replaces the term “mental retardation”

• Requires adaptive-functioning assessments and cognitive capacity (IQ) for diagnosis

• Considered to be two standard deviations below the population (IQ~70)

• Codes: ICD-9 319

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Communication Disorders

• Language Disorder (combines DSM-IV expressive and mixed receptive-expressive language disorders) 315.39 (F80.9)

• Speech Sound Disorder (new name for phonological disorder) 315.39 (F80.0)

• Childhood-onset Fluency Disorder (formerly stuttering) 315.35 (F80.81)

• Social (Pragmatic) Communication Disorder – new disorder – persistent difficulties in social uses of verbal and non-verbal communication 315.39 (F80.89)

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• New name for DSM-5

• Encompasses autistic disorder, Asperger’s disorder, childhood disintegrative disorder, PDD-NOS

• Single disorder with differing levels of severity based on level of support required

• Must show deficits in BOTH

– (Criterion A) social communication and social interaction and

– (Criterion B) restricted repetitive behaviors, interests

and activities

• Includes expanded specifiers associated with known medical

or genetic conditions

• Symptoms from early childhood

Autism Spectrum Disorder (ASD) 299.00 (F84.0)

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Specific Learning Disorder

• Specifiers related to deficits in reading, written expression and mathematics with severity ratings

• Learning deficits commonly occur together – allows for all academic domains and subskills that are impaired

– with impairment in reading 315.00 (F81.0)

– with impairment in written expression 315.2 (F81.81)

– with impairment in mathematics 315.1 (F81.2)

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Attention-Deficit/Hyperactivity Disorder (ADHD)

• Largely unchanged from DSM-IV

• Same 18 symptoms used in DSM-IV with additional examples applying to adults

• Two symptom domains – inattention and hyperactivity/impulsivity

– 314.01 (F90.2) Combined presentation

– 314.00 (F90.0) Predominantly inattentive presentation

– 314.01 (F 90.1) Predominantly hyperactive/impulsive presentation

• Onset criterion changed from symptoms present before age 7 to several symptoms present prior to age 12

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Attention-Deficit/Hyperactivity Disorder (ADHD)

• Inattentive, hyperactive and combined are used to describe the current presentation rather than the subtype

• Comorbid diagnosis with ADHD allowed

• Threshold for adult diagnosis – adjusted to five symptoms in either domain

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Motor Disorders – Largely Unchanged from DSM-IV

• Developmental Coordination Disorder 315.4 (F82)

• Stereotypic Movement Disorder 307.3 (F98.4)

• Tic Disorders

– Tourette’s Disorder 307.23 (F95.2)

– Persistent Chronic Motor or Vocal Tic Disorder 307.22 (F95.1)

• Tics may “wax and wane in frequency, but have persisted for more than a year.”

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Schizophrenia and Other Psychotic Disorders

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Schizophrenia Spectrum and Other Psychotic Disorders

• Schizotypal (Personality) Disorder 301.22 (F21)

• Delusional Disorder 297.1 (F22)

• Brief Psychotic Disorder 298.8 (F23)

• Schizophreniform Disorder 295.40 (F20.81)

• Schizophrenia 295.90 (F20.9)

• Schizoaffective Disorder (bipolar or depressive type) 295.70 (F25.0, F25.1)

• Substance/Medication-Induced Psychotic Disorder – see substance-specific codes

• Psychotic Disorder Due to Another Medical Condition (with delusions or with hallucinations) 293.81, 293.82 (F06.2, F06.0)

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Schizophrenia Spectrum and Other Psychotic Disorders

• Catatonia Associated with Another Mental Disorder 293.89 (F06.1)

• Catatonic Disorder Due to Another Medical Condition 293.89 (F06.1)

• Unspecified Catatonia 293.89 (F06.1)

• Other Schizophrenia Spectrum and Other Psychotic Disorder (other specified or unspecified) 298.8 (F28)

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General Changes in This Section

• Eliminates subtypes of schizophrenia such as paranoid, disorganized, catatonic, undifferentiated and residual types

• Limited diagnostic stability, low reliability and poor validity

• Catatonia specifier – can be used for psychotic, depressive and bipolar disorders. Requires three catatonic symptoms for this designation:

– Stupor Stereotypy

– Catalepsy Agitation, not influenced by internal stimuli

– Waxy flexibility Grimacing

– Mutism Echolalia

– Negativism Echopraxia

– Posturing Mannerism

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• Schizoaffective Disorder

– Requires a major mood episode be present for the majority of the disorder’s duration

– Bipolar type 295.70 (F25.0)

– Depressive type 295.70 (F25.1)

• Delusional Disorder 297.1 (F22)

– No longer requires that delusions must be non-bizarre

– No longer separates Delusional Disorder from Shared Delusional Disorder

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Bipolar and Related Disorders

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Bipolar and Related Disorders Categories

• Bipolar I Disorder 296.40-296.46 (F31 series), 296.50-56 (F31 series)

• Bipolar II Disorder 296.89 (F31.81)

• Cyclothymic Disorder 301.13 (F34.0)

• Substance/Medication-Induced Bipolar and Related Disorder – see substance abuse section

• Bipolar Disorder Due to Another Medical Condition 293.83 (F06.33, F06.34)

• Other Bipolar and Related Disorder 296.89 (F31.89)

• Unspecified Bipolar and Related Disorder 296.80 (F31.9)

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• Bipolar and related disorders

– Bipolar disorder includes emphasis on changes in activity and energy; not just mood

– Anxious distress specifier for bipolar disorder

• Bipolar I Disorder

– Mixed type has been eliminated

– Now includes “mixed state” specifier when mania episodes include depressive symptoms and for depression that includes mania or hypomania

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• Other Specified Bipolar and Related Disorders

– This designation – individuals with history of major depressive disorder who meet all criteria for hypomania except duration (four days)

– Too few symptoms of hypomania to meet criteria for full bipolar II

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Introduction to DSM-5, Part II

Gary M. Henschen, MD, Chief Medical Officer, Behavioral Health

Steven J. Lari, MD, Associate Medical Director, Southeast Care Management Center

• ICD-10 deadline is October 1, 2014

• Magellan will transition to ICD-10-CM at that time

• ICD-10-CM uses 3 to 7 digits instead of 3 to 5 digits as in ICD-9

• Affects all health care providers and payers in the United States

• ICD-10 does not affect CPT coding for outpatient procedures

• ICD-10-PCS may affect some inpatient procedures in behavioral health

The ICD-10 Transition

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Depressive Disorders


• Disruptive Mood Dysregulation Disorder 296.99 (F34.8)

• Major Depressive Disorder

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Severity/course specifier

Single episode Recurrent episode

Mild 296.21 (F32.0) 296.31 (F33.0)

Moderate 296.22 (F32.1) 296.32 (F33.1)

Severe 296.23 (F32.2) 296.33 (F33.2)

With psychotic features

296.24 (F32.3) 296.34 (F33.3)

In partial remission 296.26 (F32.4) 296.35 (33.41)

In full remission 296.26 (F32.5) 296.36 (F33.42)

Unspecified 296.20 (F32.9) 296.30 (F33.9)


• Persistent Depressive Disorder (Dysthymia) 300.4 (F34.1)

• Premenstrual Dysphoric Disorder 625.4 (N94.3)

• Substance/Medication Induced Depressive Disorder

– Codes are substance-specific and in the substance use section of DSM-5

• Depressive Disorder Due to Another Medical Condition 293.83

• With depressive features (F06.31)

• With major depressive-like episode (F06.32)

• With mixed features (F06.34)

• Other Specified Depressive Disorder 311 (F32.8)

• Unspecified Depressive Disorder 311 (F32.9)

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General Changes in this Section

• Major Depressive Disorder 296.210-296.36 (F32.0-F33.9)

– Coexistence of at least three manic symptoms now acknowledged by specifier “with mixed features”

– Bereavement exclusion to MDD criteria omitted

– Bereavement—now a severe psychosocial stressor—can precipitate a major depressive episode in a vulnerable individual after the loss

– Bereavement in MDD - most likely in individuals with past history of family history of MDD

– Bereavement-related MDD responds to traditional treatments for MDD

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• Disruptive Mood Dysregulation Disorder (DMDD) 296.99 (F34.8)

– New disorder in DSM-5

– Addresses concerns about overdiagnosing bipolar disorder in children

– Included for children up to age 18 with persistent irritability and frequent episodes of extreme dyscontrol

• Premenstrual Dysphoric Disorder 625.4 (N94.3)


– Moved from DSM-IV Appendix B to main body

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• Persistent Depressive Disorder 300.4 (F34.1)

– New “umbrella” disorder

– Combines previous dysthymic disorder and chronic MDD

• Suicidality

– Proposed criteria in “Conditions for Further Study”

– Suicidal Behavior Disorder, Non-suicidal Self-injury

– Gives clinicians guidance on assessment of suicidal thinking, plans, presence of other risk factors

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Anxiety Disorders

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Anxiety Disorders

• Separation Anxiety Disorder 309.21 (F93.0)

• Selective Mutism 312.23 (F94.0)

• Specific Phobia 300.29

– Animal (F40.218)

– Natural Environment (F40.228)

– Blood-injection-injury

• Fear of blood (F40.230)

• Fear of injections and transfusions (F40.231)

• Fear of other medical care (F40.232)

• Fear of injury (F40.233)

– Situational (F40.248)

– Other (F40.298)

Anxiety Disorders

• Social Anxiety Disorder (Social Phobia) 300.23 (F40.10)

• Panic Disorder 300.01 (F41.0)

• Agoraphobia 300.22 (F40.00)

• Generalized Anxiety Disorder 300.02 (F41.1)

• Substance/Medication-Induced Anxiety Disorder


• Anxiety Disorder Due to Another Medical Condition 293.84 (F06.4)

• Other Specified Anxiety Disorder 300.09 (F41.8)

• Unspecified Anxiety Disorder 300.00 (F41.9)

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• Anxiety Disorders

– Two former diagnoses in this category—reclassified

• Obsessive-compulsive disorder - now has own section

• Post-Traumatic Stress Disorder (PTSD) and Acute Stress Disorder (ASD) now in Trauma and Stressor-Related Disorders

• Located after anxiety disorders to show close relationship

• Agoraphobia, Specific Phobia and Social Anxiety Disorder (Social Phobia)

300.22, 300.29, 300.23 (F40.00, F40.218-40.298, F40.10)

– Important modifications made

• Deleted-requirement that individuals over 18 recognize their anxiety is excessive or unreasonable

• 6-month duration of symptoms required for all ages

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• Separation Anxiety Disorder 309.21 (F93.0)

– New positioning in DSM-5

– Was classified under DSM-IV “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence”

– Core features unchanged from DSM-IV

– Better descriptors for adult expression of separation anxiety from home or major attachment

– No longer specify that age onset must be before 18 years of age

– Duration should typically last for 6 months or more

• Specific Phobia 300.29 (F40.218-F40.298)

– Core features unchanged from DSM-IV

– Age of onset and symptom duration noted above

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• Social Anxiety Disorder (Social Phobia) 300.23 (F40.10)

– Essential features remain the same

– The “generalized” specifier from DSM-IV (“fears related to most social situations”) has been deleted

– A “performance only” specifier - new feature in DSM-5; coded when fear is restricted to speaking or performing in public

• Selective Mutism 312.23 (F94.0)

– New positioning in DSM-5

– Was classified in “Disorders Usually First Diagnosed in Infancy, Childhood or Adolescence”

– The majority of these children are anxious, so place in this category

– Diagnostic criteria unchanged from DSM-IV

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• Panic Disorder 300.01 (F41.0)

– Unlinked with agoraphobia in DSM-5

– Panic Disorder and Agoraphobia are now separate diagnoses with distinct criteria

– A significant number of individuals with agoraphobia do not experience panic symptoms

• Panic Attack Specifier

– Can be listed as a specifier that is applicable to all DSM-5 disorders

– Modifications include

• Criteria terminology clearer and less complicated

• Different types of panic attacks termed “expected” or “unexpected”

• Panic attacks - marker and prognostic factor for severity of diagnosis, course, comorbidity for many disorders

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• Agoraphobia 300.22 (F40.00)

– DSM-5 requires manifestation of fear, intense anxiety

– Triggered by at least two of the following:

• Public transportation

• Open spaces

• Enclosed spaces

• Standing in line

• Being in a crowd

• Being outside of the home alone

• Generalized Anxiety Disorder 300.02 (F41.1)

– Unchanged from DSM-IV

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Obsessive-Compulsive and Related Disorders

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• Obsessive-Compulsive Disorder (specify if Tic-related) 300.3 (F42)

• Body Dysmorphic Disorder (specify if with muscle dysmorphia)

300.7 (F45.22)

• Hoarding Disorder (specify if with excessive acquisition) 300.3 (F42)

• Trichotillomania (Hair-pulling Disorder) 312.39 (F63.2)

• Excoriation (Skin-picking Disorder) 698.4 (L98.1)

• Substance/Medication-induced Obsessive-Compulsive and Related Disorder


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• Obsessive-Compulsive and Related Disorder Due to Another Medical Condition 294.8 (F06.8)

– Specify if with

• Obsessive-compulsive-like symptoms

• Appearance preoccupations

• Hoarding symptoms

• Hair-pulling symptoms

• Skin-picking symptoms

• Other Specified Obsessive-Compulsive and Related Disorder 300.3 (F42)

• Unspecified Obsessive-Compulsive and Related Disorder 300.3 (F42)

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• Obsessive-Compulsive and Related Disorders

– New category and chapter in DSM-5

– New disorders and repositioning of older diagnoses reflect evidence of relatedness to one another

• Symptoms

• Neurobiological substrates

• Familiality

• Course of illness

• Treatment response

– Clinical features – drivenness and repetitive behaviors common feature

– New specifier – ‟with poor insight” added with cognitive component

– Allows for distinction between individuals with good or fair insight and absent insight/delusional OCD beliefs - but not psychotic disorder

– Tic-related specifier important – comorbidity affects clinical management

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• Body Dysmorphic Disorder 300.7 (F45.22)

– New criterion and new specifier added

– Requires repetitive behaviors or mental acts done in response to preoccupations with perceived defects or flaws in appearance

– Descriptors for above include

• Mirror checking, excessive grooming, skin picking, reassurance-seeking

• Comparing appearance with that of others

• “Muscle dysphoria” specifier - individual preoccupied with idea that body build too small or insufficiently muscular

• Hoarding Disorder 300.3 (F42)


– Research - not a variant of OCD

– Prevalent causes - impairment and distress

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• Excoriation (Skin Picking) Disorder 698.4 (L98.1)


– Prevalent disorder, causes distress and impairment (lesions and infection)

– Not attributable to another disorder

• Substance/Medication-induced OCD and Related Disorder* & Obsessive-Compulsive and Related Disorder Due to Another Medical Condition

294.8 (F06.8)

– Both changes consistent with intent of DSM-5

– Both replace former specifier “with OC symptoms” in diagnoses of anxiety disorders due to a general medical condition and substance-induced anxiety disorder

– Reflect recognition that substances, medication and medical conditions can present with symptoms similar to primary OC and related disorders such as pediatric acute-onset neuropsychiatric syndrome (PANS)

* Codes are substance-specific and in the substance use section of DSM-5

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• Other Specified Obsessive-Compulsive and Related Disorder 300.3 (F42)

– Presentation characteristic of these disorders but do not meet full criteria

– Includes many various presentations

• Body-dysphoric-like disorder with actual flaws

• Body dysphoric-like disorder without repetitive behaviors

• Nail biting, lip biting, cheek chewing, other body-focused repetitive behaviors

• Obsessional jealousy

• Excessive fear of having deformity

• Fear that sexual organs will recede into body

• Fear of offensive body odor

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Trauma and Stressor-Related Disorders

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• Reactive Attachment Disorder 313.89 (F94.1)

• Disinhibited Social Engagement Disorder 313.89 (F94.2)

• Post-traumatic Stress Disorder 309.81 (F43.10)

• Acute Stress Disorder 308.3 (F43.0)

• Adjustment Disorders Specify whether:

– With depressed mood 309.0 (F43.21)

– With anxiety 309.24 (F43.22)

– With mixed anxiety and depressed mood 309.28 (F43.23)

– With disturbance of conduct 309.3 (F43.24)

– With mixed disturbance of emotions and conduct 309.4 (F43.20)

– Unspecified 309.9 (F43.20)

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• Other Specified Trauma and Stressor-Related Disorder 309.89 (F43.8)

• Unspecified Trauma and Stressor-Related Disorder 309.9 (F43.9)


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General Changes to this Section

• Trauma and Stressor-Related Disorders

– A new chapter in DSM-5

– Brings together anxiety disorders preceded by a distressing or traumatic event

– New criteria - variability of psychological distress following exposure to traumatic event

– Anxiety or fear based

– Anhedonic/dysphoric symptoms

– Externalized anger/aggression or dissociative symptoms

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• Acute Stress Disorder 308.3 (F43.0)

– The stressor criterion (Criterion A) has been changed

– Requires qualifying the traumatic events - experienced directly, witnessed or experienced indirectly)

– DSM-IV Criterion A2 - subjective reaction to the traumatic event - eliminated

– DSM-IV emphasis on dissociative symptoms - overly restrictive

– Now may meet 9:14 symptoms in the following categories:

• Intrusion

• Negative mood

• Dissociation

• Avoidance

• Arousal

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• Adjustment Disorders 309.0-309.9 (F43.20-F43.25)

– The grouping has been reconceptualized from DSM-IV

– Heterogeneous array of stress-response syndromes after exposure to a distressing, traumatic or non-traumatic event

– DSM-IV subtypes retained and unchanged

• Post-Traumatic Stress Disorder (PTSD) 309.81 (F43.10)

– Significant differences in criteria from DSM-IV

– Stressors criterion (Criterion A) more explicit with regard to how an individual experiences a “traumatic event”- subjective reaction has been eliminated

– PTSD diagnostic thresholds - developmentally sensitive - lowered for children ages 6 and under

– Four symptom clusters (DSM-IV had only 3 clusters):

• Re-experiencing

• Avoidance

• Persistent negative alterations in cognitions and mood

• Arousal

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• Post-Traumatic Stress disorder (PTSD) - continued

– Negative alterations in cognitions and mood - retains most of DSM-IV numbing symptoms

– Includes new, reconceptualized symptoms

– Retains symptoms delineated in DSM-IV for arousal and reactivity

– Includes irritable or aggressive behavior and reckless or self-destructive behavior

• Reactive Attachment Disorder 313.89 (F94.1)

– DSM-IV subtypes are now distinct disorders

– Emotionally withdrawn/inhibited, indiscriminately social/disinhibited subtypes now discrete entities

• Reactive attachment disorder

• Disinhibited social engagement disorder

– Both disorders - result of social neglect, limit child’s forming selective attachments

– Dampened positive affect - lack of attachments to caregiving adults

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• Disinhibited Social Engagement Disorder 313.89 (F94.2)

– Occurs in children who do not lack attachment

– May have established secure attachment

– Closely resembles ADHD in DSM-5

– Correlates, course and response to intervention - differs from reactive attachment disorder

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Dissociative Disorders

Dissociative Disorders

• Dissociative Identity Disorder 300.14 F44.81

• Dissociative Amnesia 300.12 F44.0

– With Dissociative Fugue 300.13 F44.1

• Depersonalization/Derealization Disorder 300.6 F48.1

• Other Specified Dissociative Disorder 300.15 F44.89

• Unspecified Dissociative Disorder 300.15 F44.9

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• Dissociative Identity Disorder 300.14 (F44.81)

– Criterion A expanded (“disruption of identity…two or more distinct personality states”)

• Includes certain possession-form phenomena and certain neurological symptoms

• Accounts for more diverse presentations

• More reflective of diverse cultural presentations

• Transitions in identity - may be observable by others OR self-reported

– Criterion B - gaps in recall for everyday events - not just traumatic experiences

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• Dissociative Amnesia 300.12 (F44.0)

– Criteria largely unchanged from DSM-IV

– Dissociative Fugue 300.13 (F44.1)

• Purposeful travel or bewildered wandering

– Associated with amnesia for identity or other autobiographical information

• No longer a separate diagnosis

• Specifier to diagnosis of dissociative amnesia

• Depersonalization/Derealization Disorder 300.6 (F48.1)

– Derealization included in name and symptom structure of DSM-IV depersonalization disorder

– In DSM-5, essential feature - persistent or recurrent episodes of depersonalization, derealization, or both

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Somatic Symptom and Related Disorders

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• Somatic Symptom Disorder 300.82 (F45.1)

• Illness Anxiety Disorder 300.7 (F45.21)

• Conversion Disorder (Functional Neurological Symptom Disorder) 300.11

With weakness or paralysis (F44.4)

With abnormal movement (F44.4)

With swallowing symptoms (F44.4)

With speech symptom (F44.5)

With anesthesia or sensory loss (F44.6)

With special sensory symptom (F44.6)

With mixed symptoms (F44.7)

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• Psychological Factors Affecting Other Medical Conditions 316 (F54)

• Factitious Disorder 300.19 (F68.10)

• Other Specified Somatic Symptom and Related Disorder 300.89 (F45.8)

• Unspecified Somatic Symptom and Related Disorder 300.82 (F45.9)

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• New chapter - brings together disorders with:

– Disproportionate thoughts, feelings, behaviors related to somatic symptoms

• Were named Somatoform Disorders in DSM-IV

• Eliminates the following diagnoses:

– Somatization disorder

– Hypochondriasis

– Pain disorder

– Undifferentiated somatoform disorder

• Removes centrality of medically unexplained symptoms

• Somatic symptom disorders CAN accompany diagnosed medical conditions

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• Somatic Symptom Disorder 300.82 (F45.1)

– Merging of two DSM-IV diagnoses: Somatization Disorder & Undifferentiated Somatoform Disorder

– No specific number of somatic symptoms required

– Most individuals previously diagnosed Somatization Disorder will meet criteria for Somatic Symptom Disorder, but…

– Only if they have maladaptive thoughts, feelings, behaviors in addition to their somatic symptoms

• Illness Anxiety Disorder 300.7 (F45.21)

– High health anxiety WITHOUT somatic symptoms

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• Conversion Disorder 300.11 (F44.4-F44.7)

– Emphasizes essential importance of neurological examination

– Relevant psychological factors may not be demonstrable at diagnosis

– Emphasizes somatic symptoms not compatible with recognized medical or neurological conditions

• Psychological Factors affecting Other Medical Conditions (PFAMC)

316 (F54)

– In DSM-IV, “Other Condition That May Be a Focus of Clinical Attention”

– One or more clinically significant psychological or behavioral factors that adversely affect a medical condition

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• Factitious Disorder 300.19 (F68.10)

– DSM-IV distinctions on the psychological or medical nature of falsified symptoms have been removed

– Factitious Disorder Imposed on Self

– Factitious Disorder Imposed on Another (by Proxy)

– “by Proxy” had been classified in DSM-IV as Factitious Disorder NOS

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Eating and Feeding Disorders

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Eating and Feeding Disorders

• Pica 307.52

– In children (F98.3)

– In adults (F50.8)

• Rumination Disorder 307.53 (F98.21

• Avoidant/Restrictive Food Intake Disorder 307.59 (F50.8)

• Anorexia Nervosa 307.1

– Restricting type (F50.01)

– Binge-eating/purging type (F50.02)

• Bulimia Nervosa 307.51 (F50.2)

• Binge-Eating Disorder 307.51 (F50.8)

• Other Specified Feeding or Eating Disorder 307.59 (F50.8)

• Unspecified Feeding or Eating Disorder 307.50 (F50.9)

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• Chapter renamed - several disorders from DSM-IV chapter “Disorders Usually Diagnosed in Infancy, Childhood or Adolescence” included

• Binge Eating Disorder now recognized - many previously diagnosed with Eating Disorder NOS in DSM-IV.

• Other Specified Feeding or Eating Disorder - brief descriptions and preliminary diagnostic criteria - atypical anorexia nervosa, bulimia nervosa of low frequency and/or limited duration, binge-eating disorder of low frequency and/or limited duration, purging disorder and night eating syndrome

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• Pica and Rumination Disorder 307.52 (F98.3, F50.8)

– Diagnoses can be made at any age

– Previous criteria reworded for clarity

• Avoidant/Restrictive Food Intake Disorder 307.59 (F50.8)

– New name for DSM-IV diagnosis “Feeding Disorder of Infancy or Early Childhood”

– Criteria expanded - individuals who restrict food intake and experience significant associated physiological or psychosocial problems but do not meet criteria for any other eating disorder

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• Anorexia Nervosa 307.1 (F50.01, F50.02)

– Amenorrhea requirement eliminated

– Criteria focuses on behaviors (restricting calorie intake)

– No longer includes “refusal” in terms of weight maintenance

– Criteria no longer uses “maintenance at less than 85% IBW”

– Denotes “significantly low weight” using WHO Body Mass Index percentiles

– Guidance provided to judge whether individual at or below significantly low weight

– Criterion B - expanded to include not overtly expressed fear of weight gain, but also persistent behavior that interferes with weight gain

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• Bulimia Nervosa 307.51 (F50.2)

– Reduces frequency of binge eating, compensatory behaviors that must be exhibited at least once/weekly over the previous 3 months

– DSM-IV required twice weekly for 6 months

• Binge-Eating Disorder 307.51 (F50.8)

– Research supported clinical validity

– Individuals who experience persistent, recurrent episodes of overeating marked by loss of control and significant clinical distress

– Binge eating at least once weekly for the last 3 months

– Cites differences between binge eating and simple overeating

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Questions?

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Confidential Information

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Healthcare

사회복지사를 위한 DSM-5 소개자료