Section X: Diagnostic Criteria with More Subtle Reformulations

In the DSM-5, there have been a number of changes to the criteria used to arrive at diagnoses. This chapter will cover some of the most important changes for the diagnoses most likely to be utilized by mental health clinicians.

Reformulated: Bi-Polar Disorder and Depressive Disorders 

Key Criteria Changes:

1) A new specifier has been added to accommodate circumstances in which the full criteria for the combination of mania and major depression are not present, but where major depression is present with some features of mania or hypomania, or when mania or hypomania predominate in conjunction with some depressive features. This specifier is “With mixed features”. This may be added as a specifier to either a diagnosis of Bipolar Disorder or Major Depression. When used as a specifier with Bipolar Disorder, it allows for a diagnosis that still falls on the Bipolar spectrum when there are subtler signs and symptoms of both mania and depression. When used as a specifier in conjunction with major depression, it denotes that the symptoms may be better conceptualized as approaching the bipolar spectrum, as opposed to just depression.  It should only be used in conjuction with major depression when there is evidence of some manic/hypomanic symptoms, but not enough to meet criteria for either a manic or hypomanic episode.

2) A new specifier, “With anxious distress”, has been added to the list of potential specifiers under Bipolar Disorder and under Depressive Disorders. This is meant to clarify the additional presence of anxiety over and above what occurs as a manifestation of the Bipolar Disorder or the Major Depression or Persistent Depressive Disorder.


Reformulated: Schizophrenia

Key Criteria Changes:

1) Bizarre delusions and Shneiderian first-rank auditory hallucinations no longer stand as special symptoms: where either one of these standing alone will suffice to meet diagnostic requirements for Schizophrenia under Criteria A (Presence of: delusions, hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative symptoms like diminished emotional expressiveness or avolition). A minimum of two symptoms in category A is now required.

2) At least one of the following three core symptoms must be present in order to warrant a diagnosis of schizophrenia under the DSM-5: delusions, hallucinations, and disorganized speech.


Reformulated: Delusional Disorder

Key Criteria Changes:

1) It is no longer required that delusions be non-bizarre in order to meet Criteria A for this disorder.

2) DSM-5 “no longer separates delusional disorder from shared delusional disorder


Reformulated: Specific Phobia Criteria

Reformulated: Social Anxiety Disorder (Social Phobia)

Key Criteria Changes:

1) For both of these diagnostic categories, there is no longer a requirement that individuals over 18 years of age recognize that their fear and anxiety are excessive or unreasonable.

2) For both of these diagnostic categories, there is now a requirement that the symptoms have a duration of 6 months or more.

3) For Social Phobia, there is now a specifier that notes whether the social anxiety disorder/social phobia is related exclusively to performance in public. According to the APA, individuals “who fear only performance situations(i.e., speaking or performing in front of an audience) appear to represent a distinct subset of social anxiety disorder in terms of etiology, age at onset, physiological response, and treatment response.” (APA, 2013) This specifier stands in opposition to the specifier in DSM-IV-TR, in which the social phobia was “generalized” to all or most social situations. This specifier has been deleted in the DSM-5.


Reformulated: Separation Anxiety Disorder Criteria

Key Criteria Changes:

1) This diagnosis is no longer included with disorders usually first diagnosed in infancy, childhood, or adolescence, but is rather included amongst anxiety disorders because, according to the APA, “a substantial number of adults report onset of separation anxiety after age 18.” (APA, 2013) Accordingly, diagnostic criteria no longer require that symptoms appear prior to the age of 18.

2) To accommodate the reformulation, symptoms must be present in adults for more than 6 months in order to warrant this diagnosis.


Reformulated: Intermittent Explosive Disorder

Key Criteria Changes:  

1) Verbal aggression and non-destructive/noninjurious physical aggression now can be considered valid criteria to warrant this diagnosis. In the DSM-IV-TR physical aggression was a required criterion. 


Reformulated: Oppositional Defiant Disorder

Key Criteria Changes:  

1) Symptoms are now grouped in three types: a) angry/irritable mood, b) argumentative/defiant behavior, and c) vindictiveness.

2) A severity rating has been added to help describe the pervasiveness and severity of the symptoms.


Reformulated: Conduct Disorder 

Key Criteria Changes:

1) A specifier has been added to denote clients with this disorder who also present with limited pro-social emotions. This specifier is “based on research showing that individuals with conduct disorder who meet criteria for the specifier tend to have a relatively more severe form of the disorder and a different treatment response.” (APA, 2013)


Reformulated: Anorexia Nervosa

Key Criteria Changes:  

1) The requirement for amenorrhea (loss of menstrual period) to be present has been deleted as a criterion for this diagnosis.

2) Persistent behavior that interferes with weight gain is another criterion that supports this diagnosis. This is an expansion of the criterion noting an overtly expressed fear of weight gain. 


Reformulated: Elimination Disorders

Key Criteria Changes:

1) This class of disorders has been removed from the category of disorders first diagnosed in infancy, childhood, or adolescence and are now placed in their own category of disorders.


Reformulated: Attention Deficit/Hyperactivity Disorder

Key Criteria Changes: 

1) The age of onset criteria have been changed from “symptoms that caused impairment were present prior to age 7” to “several inattentive or hyperactive-impulsive symptoms were present prior to age 12.” (DSM, 2013)

2) A co-morbid diagnosis with Autism Spectrum Disorder is permitted in the DSM-5.


Reformulated: Obsessive-Compulsive and Related Disorders

Key Criteria Changes:

1) A new specifier, “With poor insight”, has been added in the DSM-5 to allow for more subtle distinctions concerning degrees of insight about OCD beliefs held by clients. In the DSM-IV-TR, the only two choices were “good or fair insight” and “absent insight/delusional”.


Reformulated: Body Dysmorphic Disorder

Key Criteria Changes:

1) A new specifier, “With muscle dysmorphia”, has been added to this diagnosis to denote individuals who maintain an excessive focus on building and maintaining muscle mass and muscle definition as a manifestation of a dysmorphic relationship with their own bodies.