Section IX: Important Reformulations of Diagnostic Criteria

Reconceptualized: Posttraumatic Stress Disorder Criteria

Reconceptualized: Acute Stress Disorder Criteria 

In the DSM-IV-TR, the client’s subjective reaction to a stressful or traumatic event was one of the factors considered when determining whether PTSD or Acute Stress Disorder was present. This criterion has been deleted in favor of more objective markers that demonstrate the presence of a problematic stress reaction in either of these conditions.  

For Acute Stress Disorder, there are 14 listed symptoms in five categories: intrusion, negative mood, dissociation, avoidance and arousal. 

This change has occurred in conjunction with an expansion of the major symptom clusters in PTSD. In the DSM IV-TR there were three symptom clusters to look for to determine whether PTSD was present. In the DSM-5 there are four.

In the DSM-IV-TR the three major symptom clusters were: re-experiencing, avoidance/numbing, and arousal. Assessment would look at whether the client was re-experiencing the trauma through flashback events, responding to the trauma through avoidance of things and certain kinds of emotional numbing, and/or experiencing periods of excessive over-arousal and hyper-vigilance. 

In the DSM-5, the avoidance/numbing cluster has been broken down into two separate clusters: 1) avoidance and 2) persistent negative alterations in cognitions and mood. Negative alterations in cognitions and moods retains the numbing states that were present in the DSM-IV-TR list of symptoms in this cluster, but also adds other kinds of altered cognitions or emotional states that persist as a result of the traumatic event: persistent exaggerated beliefs about the self or the world pursuant to the trauma; fear, horror, anger, guilt, or shame.

The arousal cluster has also been expanded to include behavioral changes from the increased state of arousal: irritable or aggressive behaviors, reckless or self-destructive actions.

 

Reconceptualized: Bereavement Exclusions 

In the DSM-IV-TR, depressive episodes that were believed to be precipitated by the death of a loved one could not be classified as major depression until the depressive symptoms had persisted beyond 2 months, as the grieving behind the depressive episode was thought to be normal. This exclusion has been removed in the DSM-5.

The rationale for this change in definitions is based upon several principles noted by the APA: “The first is to remove the implication that bereavement typically lasts only 2 months when both physicians and grief counselors recognize that the duration is more commonly 1-2 years. Second, bereavement is recognized as a severe psychological stressor that can precipitate a major depressive episode in a vulnerable individual, generally beginning soon after the loss. . . Third, bereavement-related major depression is most likely to occur in individuals with past personal and family histories of major depressive episodes. . . Finally, the depressive symptoms associated with bereavement-associated depression respond to the same psychosocial and medication treatments as non-bereavement related depression. . .Thus, although most people experiencing the loss of a loved one experience bereavement without developing a major depressive episode, evidence does not support the separation of loss of a loved one from other stressors in terms of its likelihood of precipitating a major depressive episode or the relative likelihood that the symptoms will remit spontaneously.” (APA, 2013)

Reconceptualized: Gender Identity Disorder

Deleted in DSM-5:

Gender Identity Disorder in Adolescents or Adults (DSM-IV-TR 302.85) 

Gender Identity Disorder in Children (DSM-IV-TR 302.6)

Gender Identity Disorder NOS (DSM-IV-TR 302.6) 

Replaced by:

Gender Dysphoria in Children (ICD-10: F64.2) 

Gender Dysphoria in Adolescents or Adults (ICD-10: F64.1) 

Other Specified Gender Dysphoria (ICD-10: F64.8) 

Unspecified Gender Dysphoria (ICD-10: F64.9)

Overview

There has been a major re-conceptualization of gender identity disorders. A new diagnostic class, Gender Dysphoria, has been introduced. This terminology is believe to express more accurately the  central feature of this disorder, specifically the client’s distress at having his/her physiological gender be different from his/her perceived psychological/emotional  gender.

The introduction of this new diagnosis category means that the following three diagnoses have been deleted in DSM-5: Gender Identity Disorder in Adolescents or Adults (DSM-IV-TR 302.85), Gender Identity Disorder in Children (DSM-IV-TR 302.6),Gender Identity Disorder NOS (DSM-IV-TR 302.6).  They have been replaced by the term Gender Dysphoria in Children (ICD-10: F64.2), and Gender Dysphoria in Adolescents or Adults (ICD-10: F64.1).

There are two other diagnoses in this category to note: Other Specified Gender Dysphoria and Unspecified Gender Dysphoria, which shared the same ICD-9 diagnosis, 302.6. However, ICD-10 provides separate codes for these two diagnostic categories, F64.8 for Other Specified Gender Dysphoria and F64.9 for Unspecified Gender Dysphoria.

 

Reconceptualized: Substance-Related and Addictive Disorders

Diagnoses revised based upon reconceptualization

All diagnoses that differentiate between 1) substance abuse and 2) substance dependence for all misused substances have been deleted.

Replaced by:

Substance Use Disorders

Diagnoses revised based upon reconceptualization

Polysubstance dependence (DSM-IV-TR 304.80) has been deleted

Replaced by:

Each individual Substance Use Disorder noted

Overview

In the DSM-IV-TR, there were separate diagnoses to distinguish between substance abuse and substance dependence. Both diagnoses were based upon the presence of certain symptoms or criteria that were evidence of the misuse of substances.  In the DSM-IV, the presence of a single symptom or criterion could be sufficient to arrive at a substance abuse diagnosis, while it took the presence of three or more symptoms or criteria to support the diagnosis of substance dependence.

This formulation is no longer supported. The DSM-5 does not separate out these two different levels of substance misuse, but rather combines them into the larger category of substance use disorders, with specifiers to rate the level of severity from mild to severe.

In order to arrive at a diagnosis of substance use disorder, it is now necessary to note the presence of two or more symptoms or criteria from the list offered in the DSM-5. 2-3 criteria indicate a mild disorder, 4-5 criteria indicate a moderate disorder, and 6 or more indicate a severe disorder. The symptom or criteria list in the DSM-5 is virtually identical to the DSM-IV list, except that recurrent legal problems related to substance use is out as one of the criteria, and craving or strong urge to use the substance is in as a criterion.

There is less change here than might first meet the eye. Under DSM-IV the diagnosis for alcohol abuse used to be 300.5, while the diagnosis for alcohol dependence used to be 303.90. Under DSM-5, 300.50 is the diagnosis for alcohol related disorder, mild, while 303.90 is the diagnosis for alcohol related disorder, moderate or severe. For other substances, this pattern is also present.

In actuality, only the names have been changed. The DSM-IV diagnosis codes for the different kinds of substance abuse will now simply be noted as substance use disorder, mild, and the diagnosis codes for different kinds of substance dependence will now be noted as substance use disorder, moderate or severe.

This general approach will also be noted in the use of ICD-10-CM codes, as the code for alcohol related disorder, mild will be F10.10, while the code for alcohol related disorder, moderate or severe will be F10.20.

 

Reconceptualized: Paraphilias

Diagnoses revised based upon reconceptualization

Exhibitionism (DSM-IV-TR 302.4)

Fetishism (DSM-IV-TR 302.81)

Frotteurism (DSM-IV-TR 302.89)

Paraphilia NOS (DSM-IV-TR 302.9)

Pedophilia (DSM-IV-TR 302.2)

Sexual Masochism (DSM-IV-TR 302.83)

Sexual Sadism (DSM-IV-TR 302.84)

Transvestic Fetishism (DSM-IV-TR 302.3)

Voyeurism (DSM-IV-TR 302.82) 

Replaced by:

Exhibitionistic Disorder (ICD-10: F65.2)

Fetishistic Disorder (ICD-10: F65.0)

Frotteuristic Disorder (ICD-10: F65.81)

Other Specified Paraphilic Disorder (ICD-10: F65.89)

Pedophilic Disorder (ICD-10: F65.4)

Sexual Masochism Disorder (ICD-10: F65.51)

Sexual Sadism Disorder (ICD-10: F65.52)

Transvestic Fetishism Disorder (ICD-10: F65.1)

Unspecified Paraphilic Disorder (ICD-10: F65.9)

Voyeuristic Disorder (ICD-10: F65.3)

Overview

In the DSM-5, certain paraphilias are not automatically considered mental disorders and are not automatically considered to warrant clinical intervention. In order for a paraphilia to be considered a mental disorder under DSM-5, the paraphilia must 1) be causing distress or impairment to the person exhibiting the paraphilia, and/or 2) the paraphilia must be presenting itself in a way that can create personal harm or the risk of harm to others.

Paraphilias are diagnosed by the presence of two criteria. Criterion A specifies the nature of the paraphilia, and Criterion B specifies whether the paraphilia causes distress or impairment to the person with the paraphilia, and/or creates harm or the risk of harm to others. Only those individuals who meet both Criterion A and Criterion B would now be diagnosed with a Paraphilic Disorder.

People whose sexual behaviors include paraphilias in the absence of these two criteria will no longer be automatically labeled as sexually deviant. While their sexual preferences are non-normative and different than socially mainstream behaviors, alternative or different sexual behaviors will no longer automatically demand a diagnosis. 

Clearly, paraphilias that involve the violation of the rights of others (e.g., pedophilia, frotteurism, voyeurism, exhibitionism) will in virtually all conceivable circumstances still be viewed as disorders. However, paraphilias that do not involve the participation of other people (transvestic behaviors, certain fetishes) or paraphilias engaged in with the consent of other adults who possess the capacity to give consent (e.g., Bondage and Discipline sexual behaviors between consenting adults) are now not automatically viewed as disorders. The clinician must determine that distress or impairment is occurring to the client or harm is occurring to others from the presence of the paraphilia in order to justify the diagnosis in this area. 

 

Part II: Disorders Introduced that are More Typically the Domain of Other Health Professionals to Assess and Diagnose

Reconceptualized: Dementia and Amnestic Disorders

Most Appropriate Personnel to Initiate Diagnosis: Medical and Psychiatric

Diagnoses revised based upon reconceptualization

All diagnoses that include the term Dementia have been deleted

Amnestic Disorder (DSM-IV-TR 294.8) has been deleted

Replaced by:

Neurocognitive Disorder

Overview 

There are numerous different neurological disorders arising from damage to the brain that diminish a person’s cognitive abilities, and have deleterious effects on emotions, and behaviors. These have previously fallen under the general label of dementia and have been diagnosed using the underlying condition responsible for the neurological injury. This includes such conditions as HIV, Parkinson’s, Huntington Disease, Pick’s Disease, or Creutzfeldt-Jakob Disease. It can also include head injuries, Alzheimer’s, and other more less prominent and common sources of neurological damage.

In the DSM-5, all of these disorders, as well as Amnestic Disorder, have been reclassified under the general category of Neurocognitive Disorders. Mental health clinicians will typically not originate these diagnoses, as they are conditions that must be identified by physicians and other neurological health specialists with the specialized training needed to make such a determination.

 

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