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DSM5577 - SECTION 7: DIAGNOSTIC CATEGORIES REMOVED/REPLACED IN THE DSM-5

Section VII: Diagnostic Categories Removed/Replaced in the DSM-5  

 

Removed: Sub-types of Schizophrenia

Deleted in DSM-5:

Schizophrenia, Catatonic Type (DSM-IV-TR: 295.20)

Schizophrenia, Disorganized Type (DSM-IV-TR: 295.10)

Schizophrenia, Paranoid Type (DSM-IV-TR: 295.30)

Schizophrenia, Residual Type (DSM-IV-TR: 295.60) 

Schizophrenia, Undifferentiated Type (DSM-IV-TR: 295.90)

Replaced by: 

Schizophrenia (ICD-10: F20.9) 

Overview

Schizophrenia was traditionally conceptualized and diagnosed as presenting with different sub-types: paranoid, disorganized, catatonic, undifferentiated, and residual. However, in the DSM-5 these sub-types have been eliminated as separate diagnostic categories “due to their limited diagnostic stability, low reliability, and poor validity.” (APA, 2013) Clinicians will now simply use Schizophrenia (ICD-10: F20.9) as a diagnosis for all manifestations of schizophrenia.  

 

Removed: Dysthymia

Deleted in DSM-5: 

Dysthymia (DSM-IV-TR 300.4)

Replaced by: 

Persistent Depressive Disorder (Dysthymia) (ICD-10: F34.1)

Overview: 

Dysthymia, described as less severe, persistent depression, has been replaced as a diagnosistic term by Persistent Depressive Disorder, Mild. This new diagnosis represents “a consolidation of DSM-IV-TR chronic depressive disorder and dysthymic disorder.” (DSM, 2013) As noted by the APA, an “inability to find scientifically meaningful differences between these two conditions led to their combination, with specifiers included to identify different pathways to the diagnosis and to provide continuity with DSM-IV.” (APA, 2013)

Because this new diagnostic category essentially represents a broad range of degrees of persistent depression, there are numerous specifiers that must be used to provide clarity about the nature of the disorder. These are shown below.

Current severity:

Mild

Moderate

Severe

 

Concurrent features:

With anxious distress

With mixed features

With melancholic features

With atypical features

With mood-congruent psychotic features

With mood-incongruent psychotic features

With post-partum onset

 

Level of remission:

In partial remission

In full remission

 

Onset:

Early onset (Before age 21)

Late onset (At age 21 or after)

 

Degree of depression over most recent 2 years:

With pure dysthymic syndrome (Full criteria for a major depressive episode have not been met in at least the preceding 2 years)

With persistent major depressive episode (Full criteria for a major depressive episode have been met throughout the preceding 2 years)

With intermittent major depressive episodes, with current episode

With intermittent major depressive episodes, without current episode

 

Removed: Panic Disorders with and Without Agoraphobia

Removed: Agoraphobia without History of Panic Disorder

Deleted in DSM-5:

Panic Disorder With Agoraphobia (DSM-IV-TR: 300.21)

Panic Disorder Without Agoraphobia (DSM-IV-TR: 300.01)

Agoraphobia without History of Panic Disorder (DSM-IV-TR: 300.22)

Replaced by:

Panic Disorder (ICD-10: F41.0) 

Agoraphobia (ICD-10: F40.0)

Overview

In the DSM-IV-TR, panic disorder was defined as occurring with or without agoraphobia. In the DSM-5, these two disorders are now entirely unlinked. There now exist two diagnoses, Panic Disorder (ICD-10: F41.0) and Agoraphobia (ICD-10: F40.0). If both conditions present simultaneously, they are both recorded as diagnoses. This change also means that the diagnosis of Agoraphobia without History of Panic Disorder (DSM-IV-TR: 300.22) was deleted entirely as a diagnosis.

 

Removed: Dissociative Fugue

Deleted in DSM-5:

Dissociative Fugue (DSM-IV-TR 300.13)

Replaced by: 

Absorbed into Dissociative Amnesia (ICD-10: F44.0)

Overview

Dissociative Fugue, which was considered a separate disorder with its own diagnosis in the DSM-IV-TR, was deleted as a diagnosis. This state of reversible amnesia about one’s own identity is now considered a specifier to be noted as part of the diagnosis of Dissociative Amnesia.

 

Replaced: Depersonalization Disorder

Deleted in DSM-5:

Depersonalization Disorder (DSM-IV-TR 300.6)

Replaced by:

Depersonalization/Derealization Disorder (ICD-10: F48.1)

Overview 

Derealization is a sense of being disconnected or distant from what feels real, with a concurrent sense of detachment from one’s surroundings. It is experienced as being somewhat “foggy”, in a kind of dreamlike state, where it is difficult to focus on things to absorb their reality based characteristics. This symptom is now included in the name of what was formerly called Depersonalization Disorder, since it is considered an essential feature of the disorder. This means that Depersonalization Disorder was retired, to be replaced by the more clarifying Depersonalization/Derealization Disorder.

 

Removed: Reactive Attachment Disorder Sub-types

Deleted in DSM-5:

Reactive Attachment Disorder Emotionally Withdrawn/Inhibited type (DSM-IV-TR 313.89) 

Reactive Attachment Disorder Indiscriminately Social/Disinhibited type (DSM-IV-TR 313.89)

Replaced by:

Reactive Attachment Disorder (ICD-10: F94.1)

Disinhibited Social Engagement Disorder (ICD-10: F94.2)

Overview

In the DSM-IV-TR, the diagnosis of reactive attachment disorder held two sub-types which are now discarded and replaced with two distinct disorders. Reactive Attachment Disorder (ICD-9: 313.89; ICD-10: F94.1) replaces the emotionally withdrawn/inhibited sub-type and Disinhibited Social Engagement Disorder (ICD-9: 313.89; ICD-10: F94.2) replaces the indiscriminately social/disinhibited sub-type. You may note that the ICD-9 code is the same for both disorders, but the ICD-10 code is different between the two disorders and better clarifies that these are separate diagnoses. .

This differentiation was made because of several factors. Disinhibited social engagement disorder – where children inappropriately seek out interactions with and attachments to unfamiliar adults - can occur in children who have some history of successful and secure attachments with their caretaking adults. The driving force behind this set of behaviors may in some cases reflect some immaturity or insufficiency in behavioral control skills, rather than some failure in forming attachments. 

This calls into question whether this disorder is always accurately considered some kind of attachment concern. Accordingly, the course of treatment and the response to treatment can be significantly different than for Reactive Attachment Disorder.

 

Removed: Shared Psychotic Disorder

Deleted in DSM-5:

Shared Psychotic Disorder (DSM-IV-TR 297.3)

Replaced by:

Delusional Disorder (ICD-10: F22)

Overview

DSM-5 “no longer separates delusional disorder from shared delusional disorder. If criteria are met for delusional disorder, then that diagnosis is made.” (APA, 2013) If a diagnosis of Delusional Disorder is not warranted, then the diagnosis of Other Specified Shizophrenia Spectrum and Other Psychotic Disorder (ICD-10: F28) may be considered.

 

Part II: Disorders removed/replaced that are more typically the domain of other health professionals to assess and diagnose

Removed: Sexual Dysfunction Disorders

Most Appropriate Personnel to Initiate Diagnosis: Medical and Psychiatric

Deleted in DSM-5:

Dyspareunia not due to a Medical Condition (DSM-IV-TR 303.76)

Vaginismus not due to a Medical Condition (DSM-IV-TR 306.51)

Replaced by:

Genito-pelvic Pain/Penetration Disorder (ICD-10: F52.6)

Deleted in DSM-5:

Sexual Aversion Disorder (DSM-IV-TR 302.79)

Replaced by:

No replacement

Overview 

The DSM-5 has removed three sexual dysfunction disorder diagnoses. The first two, Dyspareunia not due to a Medical Condition (DSM-IV-TR 303.76) and Vaginismus not due to a Medical Condition (DSM-IV-TR 306.51),  have been merged into a new diagnosis, Genito-pelvic Pain/Penetration Disorder (ICD-10: F52.6) which combines the two diagnoses into a single category. The rationale for this change was that the two diagnoses “were highly co-morbid and difficult to distinguish”. (APA, 2013) 

The diagnosis of Sexual Aversion Disorder (DSM-IV-TR 302.79) was deleted altogether.  This topic described clients who presented with "persistent or recurrent extreme aversion to, and avoidance of, all or almost all, genital sexual contact with a sexual partner.” The decision to delete this diagnosis is “due to rare use and lack of supporting research.” The DSM-5 does retain diagnoses for both men and women concerned with reduced sexual appetite. For men, Male Hypoactive Sexual Desire Disorder (ICD-10: F52.0) and for women Female Sexual Interest/Arousal Disorder (ICD-10: F52.22). 

It is important to note that Erectile Disorder has the same ICD-9 code as Female Sexual Interest/Arousal Disorder. ICD-10-CM, however, provides better clarity and distinguishes between these two codes with an ICD-10-CM code of F52.21 for Erectile Disorder.

There were changes made to subtypes of sexual disorders from the DSM-IV-TR to the DSM-5. Sexual dysfunction due to a general medical condition and sexual dysfunction due to psychological versus combined factors are both deleted as subtypes of sexual problems “due to findings that the most frequent clinical presentation is one in which both psychological and biological factors contribute.”

 

Removed: Language and Communication Disorders

Most Appropriate Personnel to Initiate Diagnosis: Psychologist, Learning Specialist  

Deleted in DSM-5:

Expressive Language Disorder (DSM-IV-TR: 315.31)

Mixed Receptive-Expressive Disorder (DSM-IV-TR: 315.32)

Replaced by:

Language Disorder (ICD-10: F80.9)

Deleted in DSM-5:

Phonological Disorder (DSM-IV-TR: 315.39)

Replaced by: 

Speech Sound Disorder (ICD-10: F80.0)

Deleted in DSM-5:

Stuttering (DSM-IV-TR: 307.0)

Replaced by:

Childhood-Onset Fluency Disorder (ICD-10: F80.81) 

Overview

Expressive language disorder and mixed receptive-expressive disorder will disappear as diagnostic categories, to be replaced by Language Disorder (ICD-10: F80.9) that will encompass both problems with expressive and receptive language skills. Additionally, phonological disorder will disappear to be replaced by Speech Sound Disorder (ICD-10: F80.0). Please note that under ICD-9-CM the diagnostic code number for Language Disorder and Speech Sound Disorder is the same, but under ICD-10-CM the two disorders are coded differently. Stuttering will also disappear as a diagnostic term, to be replaced by Childhood-onset Fluency Disorder (ICD-10: F80.81).

 

Removed: Learning Disorders

Most Appropriate Personnel to Initiate Diagnosis: Psychologist, Learning Specialist

Deleted in DSM-5:

Mathematics Disorder (DSM-IV-TR: 315.1) 

Reading Disorder (DSM-IV-TR: 315.0)

Disorder of Written Expression (DSM-IV-TR: 315.2)

Learning Disorder Not Otherwise Specified (DSM-IV-TR: 315.9)

Replaced by:

Specific Learning Disorder with impairment in reading (ICD-10: F81.0

Specific Learning Disorder with impairment in written expression (ICD-10: F81.81)

Specific Learning Disorder with impairment in mathematics (ICD-10: F81.2)

Overview

Mathematics Disorder, Reading Disorder, Disorder of Written Expression and Learning Disorder Not Otherwise Specified will disappear as diagnostic categories, and have been replaced by an overlying diagnosis of Specific Learning Disorder. The new diagnosis is sub-divided into Specific Learning Disorder with: 1) impairment in reading (ICD-10: F81.0), 2) impairment in written expression (ICD-10: F81.81), and 3) impairment in mathematics (ICD-10: F81.2).

 

Removed: Somatic Symptom and Related Disorders 

Most Appropriate Personnel to Initiate Diagnosis: Medical and Psychiatric

Deleted in DSM-5:

Somatization Disorder (DSM-IV-TR 300.81)

Hypochondriasis (DSM-IV-TR 300.7)

Pain Disorder (DSM-IV-TR 307.80 & 307.89)

Undifferentiated Somatoform Disorder/Somatoform Disorder NOS (DSM-IV-TR 300.82)

Replaced by: 

Somatic Symptom Disorder (ICD-10: F45.1)

Overview

The DSM-5 engaged in a major revision of somatic and somatoform disorders. These are the disorders that exist in the complex interface between physical/medical symptoms and psychological symptoms. Pain and physical discomfort can create and/or intensify psychological/emotional difficulties, and psychological/emotional factors can produce, mimic or intensify the experience of physical pain and discomfort.

Because the relationship between the physical and psychological is so complex, it can be difficult to assess the degree to which a person’s discomfort and distress is predominately created by medical/physical problems versus underlying psychological difficulties versus a person’s unique psychological response to physical/medical events. The change in DSM-5 reflects an attempt to take a somewhat humbler position with regard to our capacity to understand a client’s subjective experience of physical pain and discomfort and our ability to accurately diagnose all of the physical/medical conditions that may legitimately be creating physical symptoms.

The DSM-5 removed a number of somatic disorders and related subcategories that were noted in the DSM-IV-TR. Gone are Somatization Disorder (DSM-IV-TR 300.81), Hypochondriasis (DSM-IV-TR 300.7), Pain Disorder (DSM-IV-TR 307.80 & 307.89), and Undifferentiated Somatoform Disorder/Somatoform Disorder NOS (DSM-IV-TR 300.82). These have replaced by the overlaying Somatic Symptom Disorder (ICD-9: 300.82; ICD-10: F45.1), which can be modified to specify that the predominant physical symptom is pain. 

To replace the diagnosis of Hypochondriasis – which has come to be taken as a pejorative term – the DSM-5 has created instead the diagnosis of Illness Anxiety Disorder (ICD-10: F45.21). This diagnosis retains the same diagnostic code as Hypochondriasis and may be used in instances where clients seek medical care for physical/medical conditions that are not present. However, it may also be used in instances where clients avoid seeking medical care for physical/medical conditions that are present.

 

Removed: Sleep-Wake Disorders

Most Appropriate Personnel to Initiate Diagnosis: Medical and Psychiatric, Sleep Specialists

Deleted in DSM-5:

Sleep Disorders Related to Another Medical Condition

Hypersomnia type (DSM-IV-TR 327.14)

Insomnia type (DSM-IV-TR 327.01)

Mixed type (DSM-IV-TR 327.8)

Parasomnia type (DSM-IV-TR 327.44) 

Sleep Disorders Related to a Another Mental Disorder

Hypersomnia type (DSM-IV-TR 327.15)

Insomnia type (DSM-IV-TR 327.02)

Dyssomnia Not Otherwise Specified (DSM-IV-TR 307.47)

Replaced by:

Insomnia Disorder (ICD-10: G47.00)

Hypersomnolence Disorder (ICD-10: G47.10)

Overview

The DSM-5 removed several sleep disorder diagnoses, including all diagnoses for Sleep Disorder Related to Another Medical Condition (Hypersomnia type: DSM-IV-TR 327.14; Insomnia type: DSM-IV-TR 327.01; Mixed type: DSM-IV-TR 327.8; Parasomnia type: DSM-IV-TR 327.44) and Sleep Disorder Related to a Another Mental Disorder (Hypersomnia type: DSM-IV-TR 327.15; Insomnia type: DSM-IV-TR 327.02).

As a replacement for the removal of these diagnoses, DSM-5 uses two larger diagnostic categories, Insomnia Disorder (ICD-10: G47.00) and Hypersomnolence Disorder (ICD-10: G47.10) to which specifiers can be added to identify other factors that may be contributing to the presence of a sleep-wake disorder, including other medical conditions or mental disorders. 

There are two key rationales for this change. The first is to support the idea that sleep problems should always be viewed as potentially warranting individual attention apart from medical or mental health conditions that typically cause disruptions to sleep. The second is a change in orientation that more directly “acknowledges the bidirectional and interactive effects between sleep disorders and co-existing medical conditions.”

Why cover these changes in this course? 

Fact 1: Estimates by the National Institute of Health suggest that approximately 30% of adults across the world suffer some kind of sleep disturbance. (NIH)  Mental health clinicians typically underestimate the prevalence of these disorders and make too few referrals to sleep specialists.

Fact 2. There are direct correlations between the amount of sleep that people get and their intellectual, psychological, and emotional functioning. In many instances, clients who present with symptoms of anxiety and depression may in fact be suffering from sleep insufficiency. This sleep insufficiency may be one of the signs and symptoms of depression or anxiety – or it may actually be the cause of the depression and anxiety. Among the other tasks of good differential diagnosis, a thorough bio-psycho-social assessment must be successful in discerning when the primary problem leading to mental health concerns is simply not enough sleep.

While Sleep-Wake disorders will typically be diagnosed by a physician who is a sleep specialist, mental health clinicians must be aware of the prevalence of sleep problems and include these diagnoses as part of a comprehensive assessment process.

Current research clarifies that clear distinctions between where a sleep disorder ends and other medical/psychological conditions begin can be a challenge to make.  

This is a similar phenomenon to what has occurred in our understanding of the complex relationship between physical pain/distress and psychological disorders. The medical community is moving more towards a holistic, systems based approach to conceptualizing how complex mind/body events occur.

Another sleep-wake diagnostic category, Dyssomnia Not Otherwise Specified (DSM-IV-TR 307.47) has also been removed in the DSM-5. This diagnostic category was applied to cover Rapid Eye Movement Sleep Behavior Disorder (ICD-10: G47.52) and Restless Legs Syndrome (ICD-10: G25.81). In the DSM-5, these two syndromes now have diagnostic codes of their own, as shown above.

 

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