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

History

Timeline of DSM-5

1999-2001 Development of Research Agenda 2002-2007 APA/WHO/NIMH DSM-5/ICD-11

Research Planning conferences 2006 Appointment of DSM-5 Taskforce 2007 Appointment of Workgroups 2007-2011 Literature Review and Data Re-analysis 2010-2011 1st phase Field Trials ended July 2011 2011-2012 2nd phase Field Trials began Fall 2011 July 2012 Final Draft of DSM-5 for APA review May 2013 Publication Date of DSM-5

Grouping of Diagnostic Categories

The DSM-5 groups are:

1. Neurodevelopmental disorders

2. Schizophrenia and primary psychotic disorders

3. Bipolar and Related Disorders

4. Mood Disorders

5. Anxiety Disorders

6. Disorders Related to Environmental Stress

7. Obsessive Compulsive Spectrum

8. Somatic Symptom Disorder

9. Feeding and Eating Disorder

10. Sleep Disorders

11. Disorders of Sexual Function

12. Antisocial and Disruptive Disorders

13. Substance Abuse-Related Disorders

14. Neurocognitive Disorders

15. Personality Disorders

16. Paraphilias

17. Other Disorders

Personality and Personality Disorders^

Andrew E. Skodol, M.D.ChairJohn M. Oldham, M.D.Co-ChairRobert F. Krueger, Ph.D., Text CoordinatorRenato D. Alarcon, M.D., Carl C. Bell, M.D.Donna S. Bender, Ph.D.Lee Anna Clark, Ph.D.W. John Livesley, M.D., Ph.D. (2007-2012)Leslie C. Morey, Ph.D.Larry J. Siever, M.D.Roel Verheul, Ph.D. (2008-2012)

Borderline personality disorder controversy

In 2003, the Treatment and Research Advancements National Association for Personality Disorders (TARA-APD) campaigned to change the name and designation of borderline personality disorder in DSM-5.

  “The name BPD is confusing, imparts no relevant or

descriptive information, and reinforces existing stigma...". Instead, it proposed the name "emotional regulation disorder" or "emotional dysregulation disorder".

There was also discussion about changing borderline personality disorder, an Axis II diagnosis (personality disorders and mental retardation), to an Axis I diagnosis (clinical disorders).

Diagnosing Personality Disorders

How can it be “disordered”? An enduring pattern of inner experience and behavior that

deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.

DSM-IV-TR Clusters

• Cluster A : Odd or eccentric – Schizoid, Paranoid, Schizotypal

• Cluster B : Dramatic, emotional or erratic– Antisocial, Borderline, Narcissistic, Histrionic

• Cluster C : Anxious, fearful– Avoidant, Dependent, Obsessive-Compulsive

Could Redefine “Personality”

DSM-IV: A pervasive pattern of thinking/ behaving/emotionality.

Perhaps? A personality disorder reflects "adaptive failure" involving:

"Impaired sense of self-identity" or "Failure to develop effective interpersonal functioning."

DSM -5 and multiaxial system

DSM-5 moves from the multiaxial system to a new assessment that removes the arbitrary boundaries between personality disorders and other mental disorders.

Obvious Changes in DSM-5

The DSM-5 will discontinue the Multiaxial Diagnosis, No more Axis I,II, III, IV & V-which means that Personality Disorders will now appear as diagnostic categories and there will be no more GAF score or listing of psychosocial stressor or contributing medical conditions.

The Multi-axial model will be replaced by Dimensional component to diagnostic categories.

New DSM 5 Classifications

DSM IV TR DSM 5Avoidant Avoidant

Borderline Borderline

Narcissistic Narcissistic

Obsessive –Compulsive Obsessive Compulsive

Schizotypal Schizotypal

Antisocial Antisocial

Paranoid Personality Disorder Trait Specified

Schizoid

Histrionic

Dependent

Personality Disorder NOS

Borderline Personality

Condition in which people have long- term patterns of unstable or turbulent emotions, such as feelings about themselves and others. These inner experiences often cause them to take impulsive actions and have chaotic relationships uncertain about their identity. Interests and values may change rapidly

Narcissistic Personality Disorder

Pervasive pattern of social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation, and avoidance of social interaction

Obsessive Compulsive Disorder

People have unwanted and repeated thoughts, feelings, ideas, sensations (obsessions), or behaviors that make them feel driven to do something (compulsions). Often the person carries out the behaviors to get rid of the obsessive thoughts, but this only provides temporary relief. Not performing the obsessive rituals can cause great anxiety.

Schizotypal

Schizotypals believe

they have magical powers

Avoidant Personality Disorders

Pervasive pattern of social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation, and avoidance of social interaction

Antisocial

When I left, I

joined the army, and when I took the service exam my psych profile fit a certain... moral flexibility would be the only

way to describe it... and I was loaned out to a

CIA-sponsored program, and we sort of found each other. That's how it works.

I know what I do isn't... moral, per se...

Personality Disorders in the DSM-5

The good news is that none of the criteria for personality disorders have changed in the DSM-5.

Based on feedback from a multilevel review of proposed revisions, the American Psychiatric Association Board of Trustees ultimately decided to retain the DSM-IV categorical approach with the same 10 personality disorders.

The Big Six

Six specific personality disorder types

(antisocial, avoidant, borderline, narcissistic, obsessive-compulsive and schizotypal) are defined by criteria based on typical impairments in personality functioning and pathological personality traits in one or more trait domains.

Specific Changes Per Diagnostic Category in DSM-5

Schizotypal Personality Disorder T03 also under Schizophrenia and Other Psychotic Disorders B02

Antisocial Personality Disorder T04 also under Disruptive Impulse Control and Conduct Disorders as Dyssocial Personality Disorder Q07.

Personality Disorders in the DSM-5

A new hybrid personality model was introduced in the DSM-5′s Section III (disorders requiring further study) that included evaluation of impairments in personality functioning.

In the new proposed model, clinicians would assess personality and diagnose a personality disorder based on an individual’s particular difficulties in personality functioning and on specific patterns of those pathological traits.

Personality Disorders in the DSM-5

The hybrid methodology retains six personality disorder types:

Borderline Personality DisorderObsessive-Compulsive Personality DisorderAvoidant Personality DisorderSchizotypal Personality DisorderAntisocial Personality DisorderNarcissistic Personality Disorder

Personality Disorders in the DSM-5

According to the APA, each type is defined by a specific pattern of impairments and traits.

This approach also includes a diagnosis of Personality Disorder—Trait Specified (PD-TS) that could be made when a Personality Disorder is considered present, but the criteria for a specific personality disorder are not fully met (PD-TS) replaces personality disorder not otherwise.

Personality Disorders

The criteria for personality disorders in Section II (clinical) of DSM-5 have not changed from those in DSM-IV.

Section III (research) includes the proposed research model for personality disorder diagnosis and conceptualization developed by the DSM-5 Personality and Personality Disorders Work Group.

Personality Disorders in the DSM-5

APA hopes that inclusion of the new methodology in Section III of DSM-5 will encourage research that might support this model in the diagnosis and care of patients, as well as contribute to greater understanding of the causes and treatments of personality disorders.

Personality Disorders – The way it almost was

• Personality types defined by personality domains and facets:

– Negative affect (facets: lability,anxiety/ insecurity, hostility)

– Detachment (facets: withdrawal/depression, suspicion)

– Antagonism (facets: difficult to get along with: manipulative, deceitful, hostile)

– Disinhibition (facets: impulsive/irresponsible)– Psychoticism (facets: unusual/bizarre experiences,

eccentric)

PDTS Levels of Personality Functioning Scale

The diagnosis of Personality Disorder Trait Specified (PDTS) is defined by significant impairment in personality functioning, as measured by the Levels of Personality Functioning Scale, and one or more pathological personality trait domains or trait facets

Guide to Implementation

1.   Is impairment in personality functioning (self and interpersonal) present or not?

 2.   If so, rate the level of impairment in self (identity or self-direction) and interpersonal (empathy or intimacy) functioning on the Levels of Personality Functioning Scale.

 3.   Is one of the 6 defined types present?

 4.   If so, record the type and the severity of impairment.

 5.   If not, is PD-Trait Specified present?

 6.   If so, record PDTS, identify and list the trait domain(s) that are applicable, and record the severity of impairment.

 7.   If a PD is present and a detailed personality profile is desired and would be helpful in the case conceptualization, evaluate the trait facets.

 8.   If neither a specific PD type nor PDTS is present, evaluate the trait domains and/or the trait facets if these are relevant and helpful in the case conceptualization.

NOS categories

The new version replaces the NOS categories with two options: other specified disorder and unspecified disorder to increase the utility to the clinician.

The first allows the clinician to specify the reason that the criteria for a specific disorder are not met; the second allows the clinician the option to forgo specification.

More radical criticisms

The extremely high rates of comorbidity (ranging from dimensional diagnosis to various forms of etiopathogenetic diagnosis).

The financial association of DSM-5 panel members with industry continues to be a concern for financial conflict of interest.

Of the DSM-5 task force members, 69% report having ties to the pharmaceutical industry, an increase from the 57% of DSM-IV task force members.