hani hamed dessoki, dsm 5 anxiety

Changes from DSM-IV-TR to DSM-5

Dr. Hani Hamed Dessoki, M.D.Psychiatry

Prof. Psychiatry

Chairman of Psychiatry Department

Beni Suef University

Supervisor of Psychiatry Department

El-Fayoum University

APA member

Anxiety Disorders

Anxiety Disorders

The anxiety must be out of proportion to the actual danger or threat in the situation”

This chapter no longer includes OCD and PTSDDSM 5 creates new chapters for OCD and PTSD

Chapter is arranged developmentally. Sequenced by age of onset Now includes Separation Anxiety and

Selective Mutism

Anxiety Disorders

Split into 3 chapters:– Anxiety Disorders:

• Fight or flight system (Amygdala).

– Trauma- & Stressor-Related Disorders.• Greater focus on affective response to external stressors.

– OCD & Related Disorders. • Based on imaging and genetic studies, and treatment response. • Basal ganglia – movement circuit – focus on urge and behavior,

less on anxiety.

Anxiety Disorders

The DSM-5 chapter on anxiety disorder no longer includes obsessive-compulsive disorder (which is included with the obsessive-compulsive and related disorders) or posttraumatic stress disorder and acute stress disorder (which is included with the trauma- and stressor-related disorders).

However, the sequential order of these chapters in DSM-5 reflects the close relationships among them.

Anxiety Disorders

Separation Anxiety Disorder Selective Mutism Specific Phobia Social Anxiety Disorder (Social Phobia) Panic Disorder Panic Attack (Specifier) Agoraphobia Generalized Anxiety Disorder Substance/Medication-Induced Anxiety Disorder Anxiety Disorder Due to Another Medical Condition Other Specified Anxiety Disorder Unspecified Anxiety Disorder

Agoraphobia, Specific Phobia, and Social Anxiety Disorder (Social

Phobia)

Changes in criteria :

1. Clients over 18 do not have to recognize that their anxiety is excessive or unreasonable.

2. Duration of 6 months or longer is required for all ages

Panic Attack

The essential features of panic attacks remain unchanged

DSM-IV terminology for describing different types of panic attacks is replaced with the terms unexpected and expected panic attacks.

panic attack can be listed as a specifier that is applicable to all DSM-5 disorders.

Panic Disorder and Agoraphobia

Panic disorder and agoraphobia are unlinked in DSM-5.

are now replaced by two diagnoses, panic disorder and agoraphobia, each with separate criteria.

Specific Phobia

The core features of specific phobia remain the same but there is no longer a requirement that individuals

over age 18 years must recognize that their fear and anxiety are excessive or unreasonable.

the duration requirement (“typically lasting for 6 months or more”) now applies to all ages.

they are now referred to as specifiers, the different types of specific phobia have essentially

remained unchanged.

Social Anxiety Disorder (Social Phobia)

The essential features of social anxiety disorder remain the same.

However, a number of changes have been made:1. deletion of the requirement that individuals over age 18

years must recognize that their fear or anxiety is excessive or unreasonable

2. duration criterion of “typically lasting for 6 months or more” is now required for all ages.

3. the “generalized” specifier has been deleted and replaced with a “performance only” specifier.

Separation Anxiety Disorder

In DSM-IV, separation anxiety disorder was classified in the section “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence,” it is now classified as an anxiety disorder.

The core features remain mostly unchanged, the wording of the criteria has been modified to more

adequately represent the expression of separation anxiety symptoms in adulthood.

the diagnostic criteria no longer specify that age at onset must be before 18 years.

a duration criterion—“typically lasting for 6 months or more”—has been added for adults to minimize over diagnosis of transient fears.

Selective Mutism

In DSM-IV, selective mutism was classified in the section “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence.” It is now classified as an anxiety disorder.

The diagnostic criteria are largely unchanged from DSM-IV.

Obsessive-Compulsive & Related Disorders

OCD. Hoarding Disorder. Excoriation (Skin Picking Disorder). Trichotillomania (Hair Pulling Disorder) Substance/Medication Induced Obsessive-

Compulsive & Related Disorder. Due to Another Medical Condition.

OCD

The chapter on obsessive-compulsive and related disorders, which is new in DSM-5.

New disorders include hoarding disorder, excoriation (skin-picking) disorder, substance-/medicaton-induced obsessive-compulsive disorder.

trichotillomania is now termed trichotillomania (hair-pulling disorder) and has been moved from a DSM-IV classifcation of impulse-control disorders.

Hoarding is no longer a variant of obsessive-compulsive disorder.

Separate diagnosis of hoarding disorder, reflects persistent difficulty discarding or parting with possessions due to a perceived need to save the items and distress associated with discarding them.

Hoarding disorder may have unique neurobiological correlates.

Specifiers

DSM-5 to allow a distinction between individuals with good or fair insight, poor insight, and “absent insight/delusional” obsessive-compulsive disorder beliefs (i.e., complete conviction that obsessive-compulsive disorder beliefs are true).

This warrants a diagnosis of the relevant obsessive-compulsive or related disorder, rather than a schizophrenia spectrum and other psychotic disorder.

OCD and Related Disorders

Specifiers listed for each OCD disorder

-Specifier “with poor insight” in DSM- IV has been expanded in DSM- 5-New Specifiers are

- “with good or fair insight”- “with poor insight”- “with absent insight/delusional beliefs”

Intent of these specifiers is to improve

differential diagnoses

Body dysmorphic disorder

“with muscle dysmorphia” specifier has been added to reflect a growing literature on the diagnosis.

The delusional variant of body dysmorphic disorder (is no longer coded as both delusional disorder, somatic type, and body dysmorphic disorder; in DSM-5 this presentation is designated only as body dysmorphic disorder with the absent insight/delusional beliefs specifier.

DSM-5 includes new categories for substance-/medication-induced obsessive-

compulsive and related disorder and for obsessive-compulsive and related

disorder due to another medical condition.

Other Specified and Unspecified Obsessive-Compulsive and Related Disorders

DSM-5 includes conditions in this chapter such as

Body-focused repetitive behavior disorder

- other than excoriation and trichotillomania

i.e. nail biting, lip chewing

Obsessional jealousy

Truama and Stress related disorder

Qualifying traumatic events were experienced directly, witnessed, or experienced indirectly.

individuals may meet diagnostic criteria in DSM-5 for acute stress disorder if they exhibit any 9 of 14 listed symptoms in these categories: intrusion, negative mood, dissociaition, avoidance, and arousal.

Trauma- and Stressor-Related Disorders

New chapter in DSM-5 brings together anxiety disorders that are preceded by a distressing or traumatic event

Reactive Attachment Disorder

Disinhibited Social Engagement Disorder (new)

PTSD (includes PTSD for children

6 years and younger)

Acute Stress Disorder

Adjustment Disorders

Disinhibited Social Engagement Disorder

“The essential feature of disorder is a pattern of behavior that involves culturally inappropriate, overly familiar behavior with relative strangers. This behavior violates the social boundaries of the culture.” DSM-5, p. 269


Acute Stress Disorder

-Stressor criterion in DSM -5 is changed

-Criterion requires being explicit whether qualifying traumatic events were experienced directly, witnessed, or experienced indirectly.

-DSM-IV Criterion A2 regarding reaction to the event- “the person’s response involved intense fear, helplessness, or horror” –

has been eliminated


Adjustment Disorders -DSM-5

Adjustment Disorders are redefined as an array of stress-response syndromes occurring after exposure to a distressing event.

Adjustment Disorder subtypes are unchanged

- with depressed mood

- with anxiety

- with disturbance of conduct


PTSD

Postraumatic stress disorder is now developmentally sensitive in that diagnostic thresholds have been lowered for children and adolescents and separate criteria have been added for children age 6 years or younger.

Changes in PTSD Criteria

Four symptom clusters, rather than three

-Re-experiencing

-Avoidance

-Persistent negative alterations in

mood and cognition

-Arousal: describes behavioral symptoms



DSM-5 more clearly defines what constitutes a traumatic event

Sexual assault is specifically included

Recurring exposure, that could apply to first responders



Recognition of PTSD in Young children

Developmentally sensitive:

Criteria have been modified for children age 6 years and younger

Thresholds – number of symptoms in each cluster - have been lowered


Exploration of Delayed-Onset Posttraumatic Stress Disorder After Severe Injury

Approximately half of the patients with delayed-onset PTSD had minimal PTSD symptoms at 3 months; therefore, their delayed-onset PTSD could not be accounted for by a small number of fluctuating symptoms. As we move toward DSM-V, it is important that research continues to explore the factors that underpin the development of delayed-onset PTSD.

(O’Donnell et al,Psychosom Med, Jan 2013; 75: 68 - 75)

hani hamed dessoki, dsm 5 anxiety

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