Understanding The DSM-5 Implications for Juvenile

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Transcript Understanding The DSM-5 Implications for Juvenile

Understanding the DSM-5:
Implications for Juvenile Justice
David L. Hussey, Ph.D.
Associate Professor
Mandel School of Applied Social Sciences
• This seminar will review changes found in
the new DSM-5, specifically focusing on
those diagnoses that pertain to children and
adolescents. Attendees will become
familiar with the major structural and
organizational changes to DSM-5, and be
exposed to the critical disorder-specific
diagnostic changes most likely to intersect
and impact the work of juvenile justice
Elements of Diagnosis
• Diagnostic Criteria and Descriptors
• Subtypes and Specifiers
• Medication-Induced Movement Disorders
& Other Conditions That May be the
Focus of Clinical Attention
• Principal Diagnosis
DSM History
1952: The DSM-I
1968: The DSM-II
1974: The DSM-II Reprint
1980: The DSM-III
1987: The DSM-III-R
1994: The DSM-IV
2000: The DSM-IV-TR
2013: The DSM-5
Guiding Principles for New DSM-5
• Research evidence should support any
addition or substantive modification.
• Continuity with the current manual should
be maintained when possible.
• Routine clinical practices must be able to
implement any changes.
• No restraints should limit the degree of
change between DSM-5 and past editions.
DSM-5 Organization: Three Sections
• Section I: DSM-5 Basics
– Introduction, Use of the Manual, Cautionary Statement for Forensic
• Section II: Diagnostic Criteria and Codes
– 20 Chapters; Medication-Induced Movement Disorders and Other
Adverse Effects of Medication; Other Conditions that May Be a Focus
of Clinical Attention.
• Section III: Emerging Measures and Models
– Assessment Measures, Cultural Formulation, Alternative DSM-5
Model for Personality Disorder, Conditions for Further Study.
• Appendix: Highlights of Changes from DSM-IV to DSM-5,
Glossary of Technical Terms, Glossary of Cultural Concepts
of Distress, Alphabetical Listing of DSM-5 Diagnoses and
Codes (ICD-9-CM and ICD-10-CM), Numerical Listing of
DSM-5 Diagnoses and Codes (ICD-9-CM), Numerical Listing
of DSM-5 Diagnoses and Codes (ICD-10-CM), Advisors and
Other Contributors.
DSM-IV Flaws
• DSM-IV compartmentalizes diagnoses into
strict categories that do not reflect the
most common symptom patterns that
actually appear in patients.
– High rates of co-occurrence
– Frequent use of the NOS designation
– Heterogeneous mix of conditions
Dimensional Approach
• Restructuring of diagnostic groups thought to be biologically related
under the same headings.
• Multiple-gene susceptibility findings lend further support to a
reorganization of DSM that moves away from a strict, categorical,
“yes/no” approaches.
• Incorporation of dimensional measures for assessing syndromes within
broad diagnostic categories and supraordinate dimensions that cross
current diagnostic boundaries.
• Consider distinctive aspects that differ significantly within a disorder
(such as symptom severity; acute or chronic), as well as the presence
of symptoms that are outside the “pure” disorder definitions (such as
anxiety and somatic symptom levels for patients with depression).
• Help reduce the need for multiple diagnoses, provides background
explanation for an NOS diagnosis, clarifies the presence and severity
of individual symptoms and informs treatment planning.
• Recognizes presence of overlapping conditions (bipolar disorder and
DSM-5 Chapters
Neurodevelopmental Disorders
Schizophrenia Spectrum and Other Psychotic Disorders
Bipolar and Related Disorders
Depressive Disorders
Anxiety Disorders
Obsessive-Compulsive and Related Disorders
Trauma- and Stressor-Related Disorders
Dissociative Disorders
Somatic Symptom Disorders
Feeding and Eating Disorders
Elimination Disorders
Sleep-Wake Disorders
Sexual Dysfunctions
Gender Dysphoria
Disruptive, Impulse Control and Conduct Disorders
Substance Use and Addictive Disorders
Neurocognitive Disorders
Personality Disorders
Paraphilic Disorders
Other Disorders
Neurodevelopmental Disorders
Intellectual Disabilities
Communication Disorders
Autism Spectrum Disorder
Attention-Deficit/Hyperactivity Disorder minor wording changes.
– Addition of criteria for Attention-Deficit/Hyperactivity
Disorder Not Elsewhere Classified
• Specific Learning Disorder
• Motor Disorder
• Other Neurodevelopmental Disorders
Attention-Deficit/Hyperactivity Disorder (ADHD)
• ADHD placed in neurodevelopmental disorders chapter.
• Examples have been added to the criterion items to facilitate
application across the life span.
• The cross-situational requirement has been strengthened to “several”
symptoms in each setting.
• The onset criterion has been changed from “symptoms that caused
impairment were present before age 7 years” to “several inattentive or
hyperactive-impulsive symptoms were present prior to age 12.”
• Subtypes have been replaced with presentation specifiers that map
directly to the prior subtypes.
• A comorbid diagnosis with autism spectrum disorder is now allowed.
• A symptom threshold change has been made for adults, to reflect their
substantial evidence of clinically significant ADHD impairment, with the
cutoff for ADHD of five symptoms, instead of six required for younger
persons, both for inattention and for hyperactivity and impulsivity.
ADHD Changes
• Clustered within Neurodevelopmental Disorders
• Cross-cutting measures
• Six changes:
– Elimination of the DSM-IV subtypes with their replacement as
specifiers of current presentation
– Reduction of symptom threshold for ADHD in adults
– Raising age at onset
– Requirement for multiple informants
– Removal of autism and PDD from the exclusionary criteria
(permitting ADHD in presence of ASD)
– Elaboration of examples of symptoms to provide behavioral
descriptions for older adolescents and adults
ADHD: DSM-IV Criteria
• Symptom threshold: More than 6 of 9 symptoms of
inattention or more than 6 of 9 symptoms of hyperactivity–
impulsivity, persisting for at least 6 months, that are
maladaptive and developmentally inconsistent
• Age of onset: Some symptoms causing impairment were
present before age 7
• Pervasiveness of symptoms: Present in 2 or more settings
• Impairment: Social, academic, or work
• Exclusionary disorders: ADHD was not diagnosed in the
presence of autistic disorder or pervasive developmental
disorder (PDD)
Schizophrenia Spectrum and Other Psychotic Disorders
Schizotypal (Personality) Disorder
Delusional Disorder
Brief Psychotic Disorder
Schizophreniform Disorder
Schizoaffective Disorder
Substance/Medication-Induced Psychotic Disorder
Psychotic Disorder Due to Another Medical Condition
Catatonia Associated with Another Mental Disorder
Catatonic Disorder Due to Another Medical Condition
Unspecified Catatonia
Other Specified Schizophrenia Spectrum and Other Psychotic
• Unspecified Schizophrenia Spectrum and Other Psychotic Disorder
Schizophrenia Spectrum and Other Psychotic
• Reorganization of the disorders within this category to reflect a
gradient of psychopathology, from least to most severe.
• Schizoaffective Disorder - updated rationale for proposed
changes to this disorder.
• Other Specified Schizophrenia Spectrum and Other
Psychotic Disorder (new).
• Unspecified Schizophrenia Spectrum and Other Psychotic
Disorder renamed from Psychotic Disorder Not Otherwise
• Psychotic Disorder Due to Another Medical Condition renamed
from Psychotic Disorder Associated With a Known General
Medical Condition.
• Updated severity dimensions for these disorders.
Bipolar & Related Disorders
Bipolar I Disorder
Bipolar II Disorder
Cyclothymic Disorder
Substance/Medication -Induced Bipolar
• Bipolar & Related Disorder Due to Another
Medical Condition
• Other Specified Bipolar and Related Disorder
• Unspecified Bipolar and Related Disorder
Depressive Disorders
Disruptive Mood Dysregulation Disorder
Major Depressive Disorder
Persistent Depressive Disorder (Dysthymia)
Premenstrual Dysphoric Disorder
Substance/Medication-Induced Depressive
• Depressive Disorder Due to Another Medical
• Other Specified Depressive Disorder
• Unspecified Depressive Disorder
Depressive Disorders
• DSM-5 contains several new depressive
disorders, including disruptive mood
dysregulation disorder and premenstrual
dysphoric disorder.
• Dysthymia in DSM-IV now falls under the
category of Persistent Depressive Disorder,
which includes both chronic major
depressive disorder and the previous
dysthymic disorder.
Disruptive Mood Dysregulation
Disorder (DMDD)
• For children ages 6-10.
• Characterized by “temper outbursts are
manifest verbally and/or behaviorally in
the form of verbal rages, or physical
aggression towards people or property.”
Disruptive Mood Dysregulation Disorder
A.Severe recurrent temper outbursts manifested verbally (e.g., verbal rages)
and/or behaviorally (e.g., physical aggression toward people or property)
that are grossly out of proportion in intensity or duration to the situation or
B.Temper outbursts are inconsistent with developmental level.
C.The temper outbursts occur, on average, three or more times per week.
D.The mood between temper outbursts is persistently irritable or angry most
of the day, nearly every day, and is observable by others (e.g., parents,
teachers, peers).
E.Criteria A-D have been present for 12 or more months. Throughout that
time the individual has not had a period lasting 3 or more consecutive
months without all the symptoms in Criteria A-D.
F.Criteria A and D are present in at least two of three settings (i.e., at home,
at school, with peers) are are severe in at least one of these.
Disruptive Mood Dysregulation Disorder(continued)
G. The diagnosis should not be made for the first time before
age 6 years or after age 18 years.
H. By history or observation, the age at onset of Criteria A-E is
before 10 years.
I. There has never been a distinct period lasting more than 1
day during which the full symptom criteria, except duration,
for a manic or hypomanic episode have been met. Note:
Developmentally appropriate mood elevation, such as
occurs in the context of a highly positive event or its
anticipation, should not be considered as a symptom of
mania or hypomania.
Disruptive Mood Dysregulation Disorder(continued)
The behaviors do not occur exclusively during an episode of major
depressive disorder and are not better explained by another mental
disorder (e.g., autism spectrum disorder, PTSD, separation anxiety
disorder, persistent depressive disorder (dysthymia). Note: This
diagnosis cannot coexist with oppositional defiant disorder, intermittent
explosive disorder, or bipolar disorder, though it can coexist with others,
including major depressive disorder, ADHD, conduct disorder, and
substance use disorders. Individuals whose symptoms meet criteria for
both disruptive mood dysregulation disorder and oppositional defiant
disorder should only be given the diagnosis of disruptive mood
dysregulation disorder. If an individual has ever experienced a manic or
hypomanic episode, the diagnosis of disruptive mood dysregulation
disorder should not be assigned.
K. The symptoms are not attributable to the physiological effects of a
substance or another medical or neurological condition.
MDD Specifiers
• Specify course
• Specify severity
• Specify with: anxious distress, mixed
features, atypical features, psychotic
features, catatonia, peripartum, seasonal
Specifiers for Depressive Disorder and
Suicide Risk Assessment
• DSM-5 embrace a slightly more formal process
for assessing suicidal risk.
• A new specifier to indicate the presence of
mixed symptoms has been added across both
the bipolar and the depressive disorders,
allowing for the possibility of manic features in
individuals with a diagnosis of unipolar
Persistent Depressive Disorder
A.This disorder represents a consolidation of DSM-IV-defined chronic major
depressive disorder and dysthymic disorder.
1. Depressed mood most of the day, for more days than not, as
indicated by either subjective account or observation by others for at
least 2 years.
Note: In children and adolescents, mood can be irritable and duration must be at
least one year.
2. Presence, while depressed, of two (or more) of the following:
Poor appetite or overeating.
Insomnia or hypersomnia.
Low energy or fatigue.
Low self-esteem.
Poor concentration or difficulty making decisions
Feelings of hopelessness.
Persistent Depressive Disorder (continued)
During the 2-year period (1 year for children or adolescents) of the
disturbance, the individual has never been without the symptoms in
Criteria A an dB for more than 2 months at a time.
Criteria for a major depressive disorder may be continuously present
for 2 years.
There has never been a manic episode or a hypomanic episode, and
criteria have never been met for cyclothymic disorder.
The disturbance is not better explained by a persistent schizoaffective
disorder, schizophrenia, delusional disorder, or other specified or
unspecified schizophrenia spectrum or other psychotic disorder.
The symptoms are not attributable to the physiological effects of a
substance (e.g., a drug of abuse, a medication) or another medical
condition (e.g., hypothyroidism).
The symptoms cause clinically significant distress or impairment in
social, occupational, or other important areas of functioning.
Anxiety Disorders
• Anxiety Disorders are now being broken into three
groups: Anxiety Disorders; Trauma-Related Disorders;
Obsessive Compulsive-Related Disorders.
• Changes in criteria for agoraphobia, specific phobia, and
social anxiety disorder include deletion of the
requirement that individuals over age 18 years recognize
that their anxiety is excessive or unreasonable.
• Panic Attack terminology simplified (expected,
unexpected) and can be listed as an applicable specifier
to all DSM-5 disorders.
• Panic Disorder and Agoraphobia unlinked, each with
separate criteria. Agoraphobia requires endorsement of
fears from 2 or more agoraphobic situations.
Anxiety Disorders
Separation Anxiety Disorder
Selective Mutism
Specific Phobia
Social Anxiety Disorder (Social Phobia)
Panic Disorder
Panic Attack Specifier
Generalized Anxiety Disorder
Substance/Medication-Induced Anxiety Disorder
Anxiety Disorder Due to Another Medical Condition
Other Specified Anxiety Disorder
Unspecified Anxiety Disorder
Anxiety Disorders: Overview of Changes
Broken down into three groups: Anxiety Disorders; Trauma-Related
Disorders; Obsessive Compulsive-Related Disorders.
Specific Phobia & Social Anxiety Disorder include deletion of requirement
that individuals >18 recognize their anxiety is excessive or unreasonable.
Panic Attack – Now listed as a specifier (not codable) applicable to all DSM5 disorders. Panic disorder (PD) and agoraphobia are unlinked.
PD with agoraphobia, PD without agoraphobia, and agoraphobia without a
history of panic disorder are now replaced by two diagnoses, panic disorder
and agoraphobia, each with separate criteria.
The “generalized” specifier for social anxiety disorder and been deleted and
replaced with a “performance only” specifier.
Separation anxiety and selective mutism are now classified as anxiety
disorders. The wording of the criteria is modified to more adequately
represent the expression of separation anxiety symptoms in adulthood.
Also, in contrast to DSM-IV, the diagnostic criteria no longer specify that
onset must be before age 18 years, and a duration statement – “typically
lasting for 6 months or more” – has been added for adults to minimize over
diagnosis of transient fears.
Obsessive-Compulsive and Related Disorders
Obsessive Compulsive Disorder
Body Dysmorphic Disorder
Hoarding Disorder
Excoriation (Skin Picking Disorder)
Substance-Induced Obsessive-Compulsive and Related
• Obsessive-Compulsive and Related Disorder Due to
Another Medical Condition
• Other Specified Obsessive-Compulsive and Related
• Unspecified Obsessive-Compulsive and Related Disorder
Trauma-and Stressor-Related Disorders
• Reactive Attachment Disorder
• Disinhibited Social Engagement Disorder
• Posttraumatic Stress Disorder
• Acute Stress Disorder
• Adjustment Disorders
• Other Specified Trauma- and StressorRelated Disorders
• Unspecified Trauma- and Stressor-Related
Trauma- and Stressor- Related
• Posttraumatic Stress Disorder - wording changes
(e.g., adding “directly” in criterion A1).
• PTSD in preschool children proposed as a subtype
of PTSD instead of a separate diagnosis.
• Specifier whether with dissociative symptoms.
• Acute Stress Disorder - minor wording changes.
• Addition of criteria for Persistent Complex
Bereavement Disorder (Section III).
• Addition of criteria for Unspecified Trauma- or
Stressor- Related Disorders.
Disruptive, Impulse-Control, and Conduct Disorders
• New chapter brings together disorders that were previously included in
the chapter “Disorders Usually First Diagnosed in Infancy, Childhood, or
Adolescence” all characterized by problems in emotional and behavioral
self-control. Because of its close association with conduct disorder (and
substance related and addictive disorders), antisocial personality
disorder has dual listing in this chapter and in the chapter on personality
• Oppositional Defiant Disorder. Symptoms are now grouped into three
types: angry/irritable mood, argumentative/defiant behavior, and
– Exclusion criterion for conduct disorder has been removed.
– A note has been added to the criteria to provide guidance on the
frequency typically needed for a behavior to be considered
– A severity rating has been added to the criteria to reflect research
showing the degree of pervasiveness of symptoms across settings.
• Conduct Disorder. A descriptive features specifier has been added for
individuals who meet full criteria for the disorder but also present with
limited prosocial emotions.
Oppositional Defiant Disorder
A pattern of angry/irritable mood, argumentative/defiant behavior, or
vindictiveness lasting at least 6 months as evidenced by at least four
symptoms from any of the following categories, and exhibited during
interaction with at least one individual who is not a sibling:
Angry/Irritable Mood
Often loses temper.
Is touchy or easily annoyed.
Is often angry and resentful.
Argumentative/Defiant Behavior
Often argues with authority figures or, for children and adolescents, with adults.
Often actively defies or refuses to comply with requests from authority figures or with
Often deliberately annoys others.
Often blames others for his or her mistakes or behavior.
Has been spiteful or vindictive at least twice within the past 6 months.
Disruptive, Impulse-Control, and Conduct Disorders
• Intermittent Explosive Disorder. Types of aggressive outbursts
include physical aggression (required in DSM-IV) as well as verbal
aggression and nondestructive/noninjurious physical aggression.
– DSM-5 also provides more specific criteria defining frequency
needed to meet criteria and specifies that the aggressive
outbursts are impulsive and/or anger based in nature, and must
cause marked distress, cause impairment in occupational or
interpersonal functioning, or be associated with negative financial
or legal consequences.
– A minimum age of 6 years (or equivalent developmental level) is
now required.
– For youth, the relationship of this disorder to other disorders (e.g.,
ADHD, disruptive mood dysregulation disorder) has been further
Intermittent Explosive Disorder
Recurrent behavioral outburst representing a failure to control aggressive
impulses as manifested by either of the following:
Verbal aggression (e.g., temper tantrums, tirades, verbal arguments or fights) or
physical aggression toward property, animals, or other individuals, occurring twice
weekly, on average, for a period of 3 months. The physical aggression does not result
in damage or destruction of property and does not result in physical injury to animals or
other individuals.
Three behavioral outbursts involving damage or destruction of property and/or physical
assault involving physical injury against animals or other individuals occurirng within a
12-month period.
The magnitude of aggressiveness expressed during the recurrent outbursts is
grossly out of proportion to the provocation or to any precipitating psychosocial
The recurrent aggressive outbursts are not premeditated (i.e., they are impulsive
and/or anger-based) and are not committed to achieve some tangible objective
(e.g., money, power, intimidation).
Intermittent Explosive Disorder(continued)
The recurrent aggressive outbursts cause either marked distress in the individual
or impairment in occupational or interpersonal functioning, or are associated with
financial or legal consequences.
E. Chronological age is at least 6 years (or equivalent developmental level)
F. The recurrent aggressive outbursts are not better explained by another mental
disorder (e.g., major depressive disorder, bipolar disorder, disruptive mood
dysregulation disorder, a psychotic disorder, antisocial personality disorder,
borderline personality disorder) and are not attributable to another medical
condition (e.g., head trauma, Alzheimer’s disease) or to the physiological effects
of a substance (e.g., drug of abuse, a medication. For children ages 6 -18 years,
aggressive behavior that occurs as part of an adjustment disorder should not be
considered for this diagnosis.
Note: This diagnosis can be made in addition to the diagnosis of attentiondeficit/hyperactivity disorder, conduct disorder, oppositional defiant disorder, or autism
spectrum disorder when recurrent impulsive aggressive outbursts are in excess of
those usually seen in these disorders and warrant independent clinical attention.
Conduct Disorders
A repetitive and persistent pattern of behavior in which the basic rights of others
and major age-appropriate societal norms or rules are violated as manifested by
the presence of at least three of the following 15 criteria in the past 12 months
from any of the categories below, with at least one criterion present in the past 6
months: Three behaviors must be present in the last 12 months with at least
one present in the last six months.
Aggression to People and Animals
1. Often bullies, threatens, or intimidates others.
2. Often initiates physical fights.
3. Has used a weapon that can cause serious physical harm to others (e.g., a
bat, brick, broken bottle, knife, gun).
4. Has been physically cruel to people.
5. Has been physically cruel to animals.
6. Has stolen while confronting a victim (e.g., mugging, purse snatching,
extortion, armed robbery).
7. Has forced someone into sexual activity.
Conduct Disorders (continued)
Destruction of Property
8. Has deliberately engaged in fire setting with the
intention of causing serious damage.
9. Has deliberately destroyed others' property (other than
by fire setting).
Deceitfulness or theft
10. Has broken into someone else's house, building or car.
11. Often lies to obtain goods or favors to avoid obligations
(i.e. "cons" others.
12. Has stolen items of nontrivial value without confronting
a victim (i.e. shoplifting, but without breaking and
entering; forgery).
Conduct Disorders (continued)
Serious Violations of Rules
13. Often stays out at night despite parental prohibitions
beginning before age 13 years.
14. Has run away from home overnight at least twice while
living in parental or parental surrogate home, or once
without returning for a lengthy period.
15. Is often truant from school, beginning before age 13
B. The disturbance in behavior causes clinically significant
impairment in social, academic, or occupational functioning.
C. If the individual is age 18 years of older, criteria are not met
for antisocial personality disorder.
Substance Use & Addictive Disorders
• Criteria in the chapter no longer include dependence and abuse as
separate entities; abuse, dependence, and addiction are viewed as one
continuous variable with severity based on number of endorsed criteria.
• Craving has been added to criteria, and recurrent legal difficulties has
been eliminated.
• The threshold for diagnosis of substance-related and addictive disorders
is two or more criteria, in contrast to a threshold of one or more criteria for
a diagnosis of DSM-IV substance abuse and three or more for DSM-IV
substance dependence.
• The DSM-IV specifier for a physiological subtype has been eliminated.
• Newly named: Hallucinogen Disorder; Sedative/Hypnotic-Related
Disorders; Stimulant Disorders. Cannabis Withdrawal is new for
DSM-5, as is Caffeine Withdrawal.
• Gambling Disorder is included in DSM-5, replacing pathological
gambling in the “Impulse-Control Disorders Not Elsewhere Classified”
section of earlier editions.
Substance Use and Addictive Disorders
Chapter order and numbering designations have been reorganized according to
substance (whereas these were previously organized according to the diagnosis).
Hallucinogen Disorders have now subsumed Phencyclidine Disorders.
Sedative/Hypnotic-Related Disorders renamed from Sedative, Hypnotic, or
Anxiolytic Disorders.
Stimulant Disorders renamed from Amphetamine and Cocaine Disorders.
Updated the Severity Specifiers.
Updated the Remission Specifiers.
Removal of Substance-Induced Dissociative Disorder.
Minor wording changes to most of the criteria.
Addition of criteria for Hallucinogen Persisting Perception Disorder.
Addition of criteria for Caffeine Use Disorder.
Addition of criteria for Cannabis Withdrawal.
Addition of criteria for Neurobehavioral Disorder Associated With Prenatal Alcohol
Exposure - proposed for Section III.
Addition of criteria for Internet Gaming Disorder - proposed for Section III.
Addition of criteria for Drug Specific "Not Elsewhere Classified" diagnoses.
Cannabis Use Disorder
A problematic pattern of cannabis use leading to clinically significant
impairment or distress, as manifested by at least two of the following
occurring within a 12-month period:
Cannabis is often taken in larger amounts or over a longer period than was intended.
There is a persistent desire or unsuccessful efforts to cut down or control cannabis use.
A great deal of time is spent in activities necessary to obtain cannabis, use cannabis, or
recover from its effects.
Craving, or a strong desire or urge to use cannabis.
Recurrent cannabis use resulting in a failure to fulfill major role obligations at work,
school, or home.
Continued cannabis use despite having persistent or recurrent social or interpersonal
problems caused or exacerbated by the effects of cannabis.
Important social, occupational, or recreational activities are given up or reduced
because of cannabis use.
Recurrent cannabis use in situations in which it is physically hazardous.
Cannabis use is continued despite knowledge of having a persistent or recurrent
physical or psychological problem that is likely to have caused or exacerbated by
Cannabis Use Disorder (Criteria A continued)
10. Tolerance, as defined by either of the following:
A need for markedly increased amounts of cannabis to achieve
intoxication or desired effect.
Markedly diminished effect with continued use of the same amount of
11. Withdrawal, as manifested by either of the following:
The characteristic withdrawal syndrome for cannabis (refer to Criteria A
and B of the criteria set for cannabis withdrawal).
Cannabis (or a closely related substance) is taken to relieve or avoid
withdrawal symptoms.
Gambling Disorder
Persistent and recurrent problematic gambling behavior leading to
clinically significant impairment or distress, as indicated by the individual
exhibiting 4 (or more) of the following in a 12-month period:
Needs to gamble with increasing amounts of money in order to achieve the desired
Is restless or irritable when attempting to cut down or stop gambling.
Has made repeated unsuccessful efforts to control, cut back, or stop gambling.
Is often preoccupied with gambling (e.g., having persistent thoughts of reliving past
gambling experiences, handicapping or planning the next venture, thinking of ways to
get money with which to gamble).
Often gambles when feeling depressed (e.g., helpless, guilty, anxious, depressed).
After losing money gambling, often returns another day to get even (“chasing one’s
Lies to conceal the extent of involvement with gambling.
Has jeopardized or lost a significant relationship, job, or educational or career
opportunity because of gambling.
Relies on others to provide money to relieve desperate financial situations caused by
Personality Disorders
• Problems with existing DSM-IV
classification include
– High rates of co-morbidity between disorders
– Extreme heterogeneity
– Lack of synchrony with medicine
– Poor convergent validity
Types of Personality Disorders
Personality disorders that are odd or eccentric
(Cluster A, paranoid, schizoid, schizotypal);
dramatic, erratic, and labile (Cluster B, histrionic,
narcissistic, antisocial, and borderline), and
disorders where individuals are fearful, inhibited,
and anxious (Cluster C, avoidant, dependent,
obsessive-compulsive, and NOS categories such as
depressive personality disorder or passiveaggressive).
Paraphilic Disorders
• Are all paraphilias ipso facto mental
– A paraphilia is a necessary but not a sufficient
condition for having a paraphilic disorder.
• Criterion A specifies the qualitative nature
of the paraphilia and Criterion B specifies
the negative consequences of the
Paraphilic Disorders (continued)
• All Paraphilic Disorders now include two
new specifiers: In a Controlled Environment
and In Remission.
• Paraphilias chapter renamed Paraphilic
• Hypersexual Disorder - proposed for
Section III, but eventually excluded.
• Paraphilic Coercive Disorder - proposed for
Section III but eventually excluded.
Paraphilic Disorders
• Voyeuristic Disorder
• Exhibitionistic Disorder
• Frotteuristic Disorder
• Sexual Masochism Disorder
• Sexual Sadism Disorder
Paraphilic Disorders
(types continued)
Pedophilic Disorder
Fetishistic Disorder
Transvestic Disorder
Other Specified Paraphilic Disorder
Unspecified Paraphilic Disorder
Other Conditions that May Be A Focus of Clinical
Relational Problems
Abuse & Neglect Problems
Educational and Occupational Problems
Housing and Economic Problems
Other Problems Related to Social Environment
Problems Related to Crime or Interaction with Legal System
Other Health Service Encounters for Counseling and Medical Advice
Problems Related to Other Psychosocial, Personal, and
Environmental Circumstances
• Other Circumstances of Personal History
• Problems Related to Access to Medical and Other Health Care
Section III
Emerging Measures and Models
• Assessment measures
• Guidance on cultural formulation
• Alternative model for diagnosing
personality disorders
• Conditions for further study
• Patient Assessment Measures (“emerging”)
Level I Cross-Cutting Measures
Level II Cross-Cutting Measures
Disorder-Specific Severity Measures
Disability Measures
Personality Inventories
Early Development and Home Background
Cultural Formulation Interviews
• http://www.psychiatry.org/practice/dsm/dsm
Section III: Personality Disorders
Several proposed revisions were drafted proposing significant changes, however, the
APA ultimately decided to retain the same 10 personality disorders. Early complex
versions attempted to replace rigid categories with a trait-specific method (symptoms
indicate traits ranked by severity) and an alternative hybrid dimensional-categorical
model included in a separate chapter in Section III of DSM-5.
The hybrid model includes evaluation of impairments in personality functioning (how
an individual typically experiences himself or herself as well as others) plus five broad
areas of pathological personality traits. Each type is defined by a specific pattern of
impairments and traits.
The Alternate DSM-5 model retains six personality disorder types:
– Borderline Personality Disorder
– Obsessive-Compulsive Personality Disorder
– Avoidant Personality Disorder
– Schizotypal Personality Disorder
– Antisocial Personality Disorder
– Narcissistic Personality Disorder
This approach also includes a diagnosis of Personality Disorder—Trait Specified (PDTS).
Section III: Personality Disorders
• Criterion A: Level of Personality Functioning. Disturbances of self
and interpersonal functioning are evaluated on a continuum. Self
functioning involves identity and self –direction; interpersonal
functioning involves empathy and intimacy. The Level of
Personality Functioning Scale (LPFS) uses these elements to
differentiate 5 levels of impairment: no impairment (0) to extreme
• Criterion B: Pathological Personality Traits. 5 broad domains:
Negative Affectivity, Detachment, Antagonism, Disinhibition, and
Psychoticism, and 25 specific trait facets (subsets applied to
different personality disorders).
General Criteria for Personality Disorder
The essential features of a personality disorder are:
A. Moderate or greater impairment in personality (self/interpersonal) functioning.
B. One or more pathological personality traits.
C. The impairments in personality functioning and the individual’s personality trait
expression are relatively inflexible and pervasive across a broad range of
personal and social situations.
D. The impairments in personality functioning and the individual’s personality trait
expression are relatively stable across time, with onsets that can be traced back
to at least adolescence or early adulthood.
E. The impairments in personality functioning and the individual’s personality trait
expression are not better explained by another mental disorder.
F. The impairments in personality functioning and the individual’s personality trait
expression are not solely attributable to the physiological effects of a substance
or another medical condition (e.g., severe head trauma).
G. The impairments in personality functioning and the individual’s personality trait
expression are not better understood as normal for an individual’s
developmental stage or sociocultural environment.
DSM-5 Alternative Model of Personality
Personality Disorder Types
-Borderline Personality Disorder
-Obsessive-Compulsive Personality Disorder
-Avoidant Personality Disorder
-Schizotypal Personality Disorder
-Antisocial Personality Disorder
-Narcissistic Personality Disorder
Core Functional Impairments
Personality Disorder Trait Domains (Polar
Opposites) & Facets
Negative Affectivity (vs. Emotional Stability) – 9 Facets
Detachment (vs. Extroversion) – 6 Facets
Antagonism (vs. Agreeableness) – 6 Facets
Disinhibition (vs. Consciousness) – 5 Facets
Psychoticism (vs. Lucidity) – 3 Facets
Section III: Antisocial Personality Disorder
Moderate or greater impairment in personality functioning, manifested by characteristic
difficulties in two or more of the following areas:
Identity: Egocentrism; self-esteem derived from personal gain, power, or pleasure.
Self-direction: Goal setting based on personal gratification; absence of prosocial
internal standards, associated with failure to conform to lawful or culturally normative
ethical behavior.
Empathy: Lack of concern for feelings, needs, or suffering of others; lack of remorse
after hurting or mistreating another.
Intimacy: Incapacity for mutually intimate relationships, as exploitation is a primary
means of relating to others, including by deceit and coercion; use of dominance or
intimidation to control others.
B. Six or more of the following seven pathological personality traits:
Manipulativeness (an aspect of Antagonism): Frequent use of subterfuge to influence
or control others; use of seduction, charm, glibness, or ingratiation to achieve one’s
ends. Attention seeking (an aspect of Antagonism): Excessive attempts to attract and
be the focus of attention of others; admiration seeking.
Callousness (an aspect of Antagonism): Lack of concern for feelings or problems of
others; lack of guilt or remorse about the negative or harmful effects of one’s actions
on others; aggression; sadism.
Section III: Antisocial Personality Disorder
Deceitfulness (an aspect of Antagonism): Dishonesty and fraudulence;
misrepresentation of self; embellishment or fabrication when relating events.
Hostility (an aspect of Antagonism): Persistent or frequent angry feelings; anger
or irritability in response to minor slights and insults; mean, nasty, or vengeful
Risk taking (an aspect of Disinhibition): Engagement in dangerous, risky, and
potentially self-damaging activities, unnecessarily and without regard for
consequences; boredom proneness and thoughtless initiation of activities to
counter boredom; lack of concern for one’s limitations and denial of the reality of
personal danger.
Impulsivity (an aspect of Disinhibition): Acting on the spur of the moment in
response to immediate stimuli; acting on a momentary basis without a plan or
consideration of outcomes; difficulty establishing and following plans.
Irresponsibility (an aspect of Disinhibition): Disregard for—and failure to honor—
financial and other obligations or commitments; lack of respect for—and lack of
follow-through on—agreements and promises.