Being a Good Diagnostician: Changes in Diagnosis

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Rhoda Olkin, Ph.D.Distinguished Professor

California School of Professional Psychology – SFrolkin@alliant.edu

7 Facts1) DSM 5 (not V) to allow for numbering of

revisions (5.1, 5.2, etc).2) Was targeted for 2009, then 2011, now

May 22, 2013. 3) Am Psychiatric Assoc mtg in SF.4) 2-year grace period for implementation.5) Complete interface with ICD-11; codes in

parentheses.6) NIMH7) Cost: $139 – $199

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Pet Peeves?

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History

• Each DSM has tried to resolve problems in previous versions.

• Problems in DSM-IV-TR–Not very user friendly.–9 categories for diagnostic uncertainty. –NOS predominated.– Insufficient on culture.– Index not as good.

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Guiding Principles for Changes to DSM

Research evidence should support any addition or substantive modification.

Continuity with the current manual should be maintained when possible.

No restraints should limit the degree of change between DSM-5 and past editions. (Contradiction)

Routine clinical practices must be able to implement any changes.

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6 Types of Changes1) Structural changes.2) Shifting criteria.3) New diagnoses.4) Reclassification of diagnoses. 5) Deleted diagnoses. 6) Code #s

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Sections• Section 1: Intro to updates, how to use.

• Section II: The diagnoses (22 chapters)

• Section III: Conditions requiring further research; cultural formulations; glossary.

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Overall Structural Changes What is the order of chapters (chronology?

Relatedness?). No axes info goes elsewhere. Ego syntonic / dystonic (insight) specifiers:–Good or Fair (dystonic)–Poor insight (ambivalent)–Absent insight (syntonic)

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Overall Structural Changes p. 2

• Some require direct knowledge over 12 mos. • Severity indicators (replaces Axis V: GAF). • Severity level is “over time & circumstances.”• Some diagnoses go up to severity level 2, some

to 3. Rating scales. 0 = None (>70 GAF)1 = Mild (>70 GAF)2 = Severe3 = Very severe (<31 GAF)

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Changes• Axis III: Part of diagnosis on Axis I.• Axis IV: Make notation of psychosocial and

contextual factors. • What happened to The Big 4 from DSM IV?– (GMC, substance use, malingering or factitious,

normal)?

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The Big 4

• GMC: –Not in index. –But evident throughout.–Often option of X Disorder Due to Another

Medical Condition (e.g., Depressive Disorder Due to MS).–Sometimes not (e.g., Bipolar Dis Due to

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The Big 4

• Malingering Factitious Disorder – In Somatic Symptom & Related Disorders chapter.– Factitious Disorder Imposed on Self– Factitious Disorder Imposed on Another (was “by

proxy).– Single vs Recurrent Episodes– “Surreptitious actions to misrepresent, simulate, or

cause signs or symptoms of illness or injury in absence of obvious external rewards.” (p. 325)

– May co-occur with medical condition (e.g., manipulating blood sugar in person with diabetes).

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The Big 4

• Substance Abuse: and Suicidality: –Elevated status. –Will always note the correlation. –Some disorders can be: “Substance/Medication-Induced.

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The Big 4

• Normal:–Less of a concern?• Bereavement (V code).• Disruptive Mood Dysregulation Disorder (new).• ASD (increased stigma?).

– “Saving normal” (Allen Francis, 2013)

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Overall Structural Changes p. 3• NOS CNEC (conditions not

elsewhere classified):–Only for 6 months. –Only for specific reasons:

1) Diagnosis unclear (e.g., psychotic disorder CNEC)2) Clinician not trained to make the dx.3) Clinician cannot get info (e.g., client uncooperative;

records not available).4) You do not have enough info.5) Clinicians needs or is required to take more time of

direct observation (e.g., 12 months).

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Implications?• Positives: –More reliability?–Better treatment planning?–Longer therapy authorized?

• More work & time in the diagnostic process.• Demand for outcome studies; clinicians to

validate their treatments (Dept of Corrections)• Responsibilities of diagnostician.– Severity index.– Symptom scales for some disorders.

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The Chapters

• 22 chapters.• New order (?).• Some split (e.g., anxiety disorders).• Some renamed (e.g., neurodevelopmental

disorders).• Some new (e.g., Trauma- & Stressor-

Related Disorders)RO

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22 Chapters:1. Neurodevelopmental

Disorders2. Schizophrenia Spectrum &

Other Psychotic Disorders3. Bipolar & Related Disorders4. Depressive Disorders5. Anxiety Disorders6. Obs-Compulsive & Related 7. Trauma- & Stressor-Related 8. Dissociative Disorders9. Somatic Symptom Disorders10.Feeding & Eating Disorders11.Elimination Disorders12.Sleep/Wake Disorders

13. Sexual Dysfunctions14. Gender Dysphoria15. Disruptive, Impulse-Control

& Conduct Disorders16. Substance Related &

Addictive Disorders17. Neurocognitive Disorders18. Personality Disorders19. Paraphilic Disorders20. Other Mental Disorders21. Medication-induced

Movement…Med Effects22. Other Conditions (v codes)

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Neurodevelopmental • Not just a rename – – Etiology important;–Disorders here are considered genetic/biochemical; –Not responses to environment.

• Eliminated Rett’s Disorder (genetic).• Includes: ADHD, ID, ASD, Communication

Disorders, Global Developmental Delay, Motor (Tic) Disorders, Specific LD.

• May include specifier: “associated with known med/genetic condition or environmental factor.”• NO: Sensory Processing Disorder (SID)

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p. 31

MR Intellectual Disability (ICD-11: Int Dev Dis.)– PL 111-256, 2010, “ID.”– 3 criteria: Deficits in (a) intellectual functions, (b) adaptive

functioning, (c) onset during develop. period. – Code 319 with severity specifier: Mild (F70), Moderate

(F71), Severe (F72), Profound (F73). (Table for severity)– Severity is based on adaptive functioning, not IQ scores. – Functioning in Conceptual Domain, Social Domain,

Practical Domain.– Usually IQ scores 70 + 5 (Mean = 100; s.d. = 15). – Requires testing with instruments “normed for individual’s

sociocultural background and native language.” (p. 37)

Neurodevelopmental

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Autism Spectrum Disorder (ASD): (p. 50)

–Now included as ASD: Autism, Aspergers, PDD NOS, Disintegrative Disorder. –2 areas of disturbance:

• Social Communication & Social Interaction;• Restricted repetitive patterns of behavior.

–Diagnostic criteria are “illustrative, not exhaustive.”–Table for severity level, requiring: 1-support; 2-

substantial support; 3-very substantial support. –M:F = 4:1

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Neurodevelopmental

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NeurodevelopmentalCommunication Disorders:•Social Communication Disorder (new):•Language Disorders•Speech Disorders•Unspecified Communication Disorder•All of the following DSM IV disorders are subsumed under above: Language Emergence; Specific Language Impairment; Social Communication Disorder; Voice Disorder; Speech-Sound Disorder; Motor Speech Disorder; Child Onset Fluency Disorder.

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Social Communication Disorder:•Must have all of A.•A. Persistent difficulties in social use of verbal and nonverbal communication:– Social purposes: (greeting, sharing info).– Changing communication to match listener or context.– Difficulties following rules for conversation or

storytelling (taking turns).– Difficulties understanding what is not explicitly stated,

and nonliteral or ambiguous meanings (idioms, humor, metaphors).

Neurodevelopmental

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DSM-IV-TRAutism

AspergersOverlap

DSM 5

Autism Spectrum Disorder

Social Communication Disorder

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ADHD (p. 59)

• Inattention (>6/9) and/or hyperactivity-impulsivity (>6/9) that interferes with functioning or development.

• Prior to age 12 (instead of 7).• 2 or more settings. • Specify: Combined (314.01), Predominantly

inattentive presentation (314.00), Predominantly hyper/impulsive presentation (314.01). (Typo?)

• Specify: Mild, moderate, Severe. • Prevalence: About 5% of children, 2.5% of adults.• M:F 2:1R

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Neurodevelopmental

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Specific Learning Disorder: (p. 66)

–Difficulties despite “provision of interventions” in:–A. 6 areas (no specified # to be met).–Specify and code: Reading; Written expression;

Mathematics. –Specify: Mild, Moderate, Severe.

Neurodevelopmental

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Motor Disorders (p. 74)

–Developmental Coordination Disorder.–Stereotypic Movement Disorder.–Tic Disorders (specify: Tourette’s; Persistent

Motor or Vocal Tic disorder; Provisional Tic Disorder.)

Other childhood disorders:–See other chapters.

Neurodevelopmental

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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. DZ

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• Fear (fight or flight) + Anxiety (hyper-vigilance) + Behavior (avoidance).

• Separation Anxiety.• Selective Mutism. • Specific Phobias (more specifiers). • Social Anxiety Dis. (in chldrn, not just w adults). • Panic Disorder (4/12 symptoms + worry + behav.).• Agoraphobia. • GAD (3/6 sxs for adults, 1/6 for children). • Substance/medication induced; Anxiety due to AMC• Also Panic Attack Specifier (p. 214)

Anxiety Disorders

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Obsessive-Compulsive & Related Disorders

OCD. Hoarding Disorder. Excoriation (Skin Picking Disorder). Hair Pulling Disorder. Substance/Medication Induced. Due to Another Medical Condition.

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Obsessions vs Compulsions

Obsessions: Recurrent & persistent thoughts, urges, or images that are experiences as intrusive and unwanted.

Compulsions: Repetitive behaviors or mental acts that an individual feels driven to perform in response to an obsession or according to rules that must be rigidly applied.

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Trauma- & Stressor-RelatedExposure to traumatic or stressful event. New grouping of disorders from various places in DSM Adjustment Disorder.Acute Stress Disorder. PTSD.– 4 clusters of symptoms: Intrusion, Avoidance, Negative

mood/cognitions, Arousal & reactivity. – Children: expanded definition; section for < 6 yo.– Specifiers: (a) dissociative sxs (depersonalizationor derealization); (b) delayed expression.

Attachment disorders (next slide).

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p. 265

Attachment related disorders: Common etiology: Absence of adequate caregiving

during childhood. Reactive Attachment Disorder: Internalizing disorder: depression, withdrawal. New criteria (4/5 sxs; onset between 9 mos. & 5

yrs.) Disinhibited Social Engagement: (NEW). Externalizing disorder: disinhibition, externalizing

behavior. 2/4 sxs; onset > 9 mos.

Trauma- & Stressor-Related

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5 Pathogenic Realms

Some disorders are considered to arise from one or more of five pathogenic realms. This distinguishes them from disorders that are thought to be biochemical (e.g., bipolar disorder).

1. Persistent disregard of child’s emotional needs; &/or2. Persistent disregard of child’s physical needs; &/or3. Repeated changes in primary caregivers; &/or4. Raised in settings with limited opportunities for

stable attachments; &/or5. Persistent harsh punishment or other types of grossly

inept parenting. RO

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Bipolar Disorders

• 1974: Increased focus on distinguishing BP from schizophrenia.

• Mid-1980s: Broadening the “BP spectrum”–Avoid antidepressant-induced mania–Treat the spectrum properly

• Mid-1990s: Pediatric BD–Catch it early, avoid kindling

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• Late 1990s: Increased use of 2nd generation antipsychotics for BD.• Now: Narrowing the gate on Pediatric

BD.

Bipolar Disorders

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• Bipolar I: no change (> 1 episode mania). (NB: suicide risk 15 x’s greater)

• Bipolar II: no change (hypomania & MDD) (Lethality of suicide methods greater than Bipolar I)

• Cyclothymia: (hypomanic episodes below criteria for hypomania + depression below threshold for MD); (minimum of 2 years for adults, 1 year in children/adolescents).

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Bipolar Disorders

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Bipolar Disorders

Specifiers:oAnxious distress (mild, moderate, moderate-severe, severe).oMixed features.oRapid cycling (4 mood episodes in 12/ months. oWith melancholic features.oWith atypical features.

What about Pediatric Bipolar?• Increasing diagnosis, over-diagnosis, wrong medication

interventions, inaccurate prediction, heterogenous disorder. • There may be two types of currently diagnosed PBD:

– a narrow definition that looks like adult BD > still BD.– a different form that includes explosive emotional outbursts that don’t

look like mania (no grandiosity, delusions) and are not so cyclical. • Looks a little like ADHD, but there may be more aggression.

Looks like disruptive behavior disorder, but more emotional lability.

• Believed that they will not grow up with BD and should perhaps be treated with antidepressants and/or Ritalin.

• Many will now be diagnosed with Disruptive Mood Dysregulation Disorder (under Depression). D

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Depressive DisordersDisruptive Mood Dysregulation Disorder:– New disorder.– Older than 5 yrs;– Persistent irritability;– Frequent episodes of behavior outbursts > 3 a

week for more than 1 year; – Intended to address concerns about potential over-

dx & over-trmnt of bipolar disorder in children; – First diagnosis between ages 6-18;onset <10.– Cannot coexist with ODD or bipolar disorder.– Children with this dx typically develop unipolardepression or anxiety, not bipolar disorder.R

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p. 155

Depression DisordersMajor Depressive Episode – –Need 5/9 symptoms.– In children/adol mood may be irritable.– Table of codes for severity and single vs recurrent

Dysthymia Persistent Depressive Disorder– Still 2 years (adults); 1 yr children/adol– Five specifiers. (p. 169)

o Nixed Mixed Anxiety Depression Section 3.RO

Premenstrual Dysphoric Disorder•5 sxs in week before menses.•Improvement few days after onset of menses. •A: 1/4 mood symptoms + B: 1/7 behavior symptoms = combined to equal 5 sxs.

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Depression Disorders

Bereavement“Responses to a significant loss (e.g., bereavement…) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in the Criterion A [for MDE], which may resemble a depressive episode. Although such symptoms may be understandable or considered appropriate to the loss, the presence of a MDE in addition to the normal response to a significant loss should also be carefully considered. This decision inevitably requires the exercise of clinical judgment based on the individual’s history and cultural norms for the expression of distress in the context of loss.” (p. 125-126) {V Code}•See footnote p. 126; same footnote p. 161 43

Schizophrenia & Other Psychotic Disorders

• Schizophrenia:– Eliminated subtypes (paranoid, hebephrenic,

disorganized, residual, catatonic).– 2/5 sxs (a. delusions, b. hallucinations, c.

disorganized speech, d. disorganized or catatonic behavior, e. negative symptoms); 1 sx must be a, b, or c; 1 month.

–What are negative sxs? “diminished emotional expression or avolition”).

– Functional impairment. –Disturbance persist for > 6 months.

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p. 87

Schizophrenia & Other Psychotic Disorders

Delusional Disorders: Few changes. •Subtypes: erotomanic, grandiose, jealous, persecutory, somatic, mixed, unspecified. •Specifier: w. bizarre content (implausible, not within ordinary experience).Brief Psychotic Disorder: – 1 day to 1 month.– Specifiers: w./w-o stressors; postpartum; with

catatonia, severity (0-4 for each symptom). RO

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Schizophrenia & Other Psychotic Disorders

• Schizophreniform Disorder.– 1 to 6 months.– Specifiers: good/w-o good prognostic features, with

catatonia, each sxs severity 0-4 • Schizoaffective Disorder: • Major Mood Episode + Criterion A of

schizophrenia.• >2 weeks of delusions or hallucinations w-o mood.

• Some discussion of Schizotypal PD here. 46

Substance-Related & Addictive Disorders

• No “abuse” or “dependence”; now “use.” • Chapter reorganized by substance.–10 classes of drugs:Alcohol; Caffeine; Cannabis; Hallucinogens;

Inhalants; Opioids; Sedatives, hypnotics & anxiolytics; Stimulants; Tobacco; Other.

• Two groups of disorders: (a) Substance use disorders, (b) Substance-induced disorders.

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• Substance use disorder: continued use of substance despite significant substance-related problems. 4 sets of criteria:– Impaired control (4 criteria).–Social impairment (3 criteria).–Risky use (2 criteria).–Pharmacological criteria (2 criteria:

tolerance & withdrawal). 48

Substance-Related & Addictive Disorders

• Severity levels:–Mild (2-3 symptoms)–Moderate (4-5 symptoms)–Severe (> 6 symptoms)

• Remission: –Early vs Sustained; –Maintenance therapy–Controlled environment

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Substance-Related & Addictive Disorders

Example: Moderate Valium use disorder; Mild alcohol use disorder; Secobarbital withdrawal.

• New language:“All drugs that are taken in excess have in common direct activation of the brain reward system…. Individuals with lower levels of self-control, which may reflect impairments of brain inhibitory mechanisms, may be particularly predisposed to develop substance use disorders, suggesting that the roots of substance use disorders for some persons can be seen in behaviors long before the onset of actual substance use itself.” (p. 481)

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Substance-Related & Addictive Disorders

• “This chapter also includes gambling disorder, reflecting evidence that gambling behaviors activate reward systems similar to those activated by drugs of abuse, and produce some behavioral symptoms that appear comparable to those produced by the substance use disorders.” (p. 481)

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Substance-Related & Addictive Disorders

• Controversy about other behavioral “addictions” to be included here/elsewhere.–Gambling is here.

–Other behavioral patterns are not: Internet gaming, shopping, sex, exercise addiction.

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Substance-Related & Addictive Disorders

Disruptive, Impulse Control, & Conduct Disorders

• Some childhood disorders went here.• These disorders share symptom of problems of

self-control of emotions and behaviors.• Unique in that they violate the rights of others

or brings person into conflict with authority. • Typical onset is in childhood or adolescence.

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Disruptive, Impulse Control, & Conduct Disorders

• Oppositional defiant disorder.• Intermittent explosive disorder.• Conduct disorder.• Antisocial PD (see PD chapter)• Pyromania.• Kleptomania.• Other.

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Disruptive, Impulse Control, & Conduct Disorders

Conceptualizing the relationship across ODD, CD, & Antisocial PD:

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ODD

CD APD

ANXIETY

DEPRESSION

Oppositional Defiant Disorder: o4/7 symptoms• Angry/Irritable Mood (3) • Argumentative/Defiant Behavior (4)

oPlus has been spiteful or vindictive > x2 in past 6 months.

o6 months; not just with sibling.oMild (1 setting); Moderate (2 settings); Severe (>3

settings)

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Disruptive, Impulse Control, & Conduct Disorders

Intermittent Explosive Disorder–Either verbal aggression 2/week for 3 mos., or

behavioral outbursts resulting in damage of property or assault on animals or person, 3 xs in 12 mos. –Minimum age of 6. (For ages 6-18 is not part

of Adjustment Disorder.)

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Disruptive, Impulse Control, & Conduct Disorders

Conduct Disorder (minor wording changes)o 3/15 criteria in 12 mos, from any category:•Aggression to people and animals (7)•Destruction of property (2)•Deceitfulness or theft (3)•Serious violation of rules (3)o Subtypes: Age of onset (<10, >10, unspecified)o Specifier: With limited prosocial emotions (use

multiple sources of information). (see p. 470)

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Disruptive, Impulse Control, & Conduct Disorders

Disruptive, Impulse Control, & Conduct Disorders

• Pyromania and Kleptomania remained. • All disorders in this chapter:

Are correlated with substance abuse. Prognosis guarded.

• Not included: Nonsuicidal self-injury (see proposed criteria in Section 3).

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Gender Dysphoria• Different criteria for children, & adoles. & adults. • 6/8 symptoms over 6 mos (must include strong desire

to be other gender)• Language: – Sex = biology; Gender = social role/identity; – Transgender = identify with other gender; – Transexual = seeks/has undergone social transition to other

gender.– Gender dysphoria = distress that may accompany the

incongruience between assigned and expressed gender. – Thus dysphoria, not identity, is key to this diagnosis.

• Specifier: With disorder of sex development (for children & adults); post-transition (adolescents & adults).

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p. 451

Gender Dysphoria• Less pathologizing term than Disorder.• Balancing Needs:–Not a Mental Disorder per se.–How to get insurance coverage?

• Imperfect compromise.• Other dysphorias?• Keeping pathology in gender identity?• No “Discrimination Disorder” A new V

code?

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Other Disorders: V codes!

Relational problems (7) [uncomplicated bereavement] Abuse & Neglect (approximately 48) Educational Problems (1) Occupational Problems (2) Housing & Economic Problems (9) Other problems related to social environment (6) [discrimination] Problems related to crime or interaction w legal system (5) Other health srvc encounters for counseling & medical advice (2) Problems related to other psychosocial, personal, &

environmental circumstances (7) Other circumstances of personal history (7) Problems related to access to medical & other health care (2) Nonadherence to medical treatment (5) [malingering]

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p. 715

Re Suicidal Behaviors• Kapusta, N. (2012). Non-suicidal self-

injury and suicide risk assessment, quo vadis DSM-V? Suicidology Online, 3, 1-3.

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Diagnosing Personality Disorders

What is a “personality” and how can it be “disordered”?

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Where Are We?Where were we?

Where did we go wrong? Where should we go?

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Personality TraitsPreviously:

Gordon Allport: 4,000 personality traitsUnmanageable.

Raymond Cattell: 16 personality factorsStill too complex.

Hans Eysenck: 3-factor theoryToo simplistic.

Then: D. W. Fiske (1949); Norman (1967); Smith (1967); Goldberg (1981); and McCrae & Costa (1987): THE BIG FIVE –Studied in over 50 cultures; remarkably consistent.

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The Big Five(OCEAN)

Openness: This trait features characteristics such as imagination and insight, and those high in this trait also tend to have a broad range of interests.

Conscientiousness: Common features of this dimension include high levels of thoughtfulness, with good impulse control and goal-directed behaviors. Those high in conscientiousness tend to be organized and mindful of details.

Extraversion: This trait includes characteristics such as excitability, sociability, talkativeness, assertiveness and high amounts of emotional expressiveness.

Agreeableness: This personality dimension includes attributes such as trust, altruism, kindness, affection, & other pro-social behaviors.

Neuroticism: Individuals high in this trait tend to experience emotional instability, anxiety, moodiness, irritability, and sadness.

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Dimensional Scale Based on Big Five

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Big 5 vs DSM-IVThe five personality dimensions were not

the building blocks for the personality disorders in DSM-IV.

Instead, 10 PD were put into three clusters.

The characterization of the clusters did not coincide with the Big 5.

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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

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The Categorical System

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Personality DisordersStudy on clients diagnosed with PD who were in treatment, conducted by DSM TF, 1999-2007:–Rediagnosed using RDC on 5,000 clients 75%

false positives. – Those with “BPD” 85% false positives.–After 1 yr most no longer meet criteria.

Therefore, workgroup considered:– Eliminating some PD.– Elevating criteria for PD.–Making process of dx more daunting.

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From DSM-IV to DSM 5• Erase all PD?

• Recluster?

• Redefine?

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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."

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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)RO

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Personality Disorders – The way it almost was

More emphasis on process of PD diagnosis:1.Does person have a personality problem (self, interpersonal)2.Determine if it matches 1 of the 6 personality types (former PD’s)3.If it does, describe using domains and their facets4.If it doesn’t PD-trait specified (PDTS) category: you can describe people even if they don’t have a trait diagnosis.5.Would require knowing more about a client, increase involvement of psychotherapist in diagnosis, reduce use of PD diagnosis. 6.Sequestered to Section 3 as of December 2012

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Personality DisordersSuggested process of diagnosis:1.Documented observations over 12 months of impairments in core functioning (self, interpersonal, empathy, intimacy).2.Personally observed pathological traits over 12 months.3.Recognized overall severity level of 3 over 12 months.

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Personality Disorders Pathological traits seen in 5 realms, as seen in relationship with therapist over 12 months:1.Negative affectivity:

Lability, anxiety, separation insecurity, hostility, perseveration, submissiveness, suspiciousness, dysphoric attitudes, emotional dysregulation.

2.Detachment: Emotional constriction, anhedonia, withdrawal, intimacy avoidance.

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Personality Disorders

3. Antagonism:Manipulative, deceitful, attention seeking, grandiose, callous.

4. Disinhibition or compulsivity:Perfectionism, controlling, impulsive, risk taking, distancing, emotionally inaccessible.

5. Psychoticism:Unusual beliefs, eccentric, cognitive dysregulation.

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Personality Disorders• Considered eliminating:–Schizotypal (to be moved to Schiz.)–Schizoid (to be moved to Schiz.)–Histrionic PD–Dependent PD

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Personality Disorders

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All 10 PDs

The cluster system

What did they change? Removed lower age limit (except

Antisocial PD).

See also Section 3

Instead, retained:

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CultureDSM-IV: Culture bound syndromes.APA Multicultural Guidelines: How

social, cultural, political, and historical contexts manifest in clinical presentations.

DSM 5: More in text; Cultural formulation chapter (p. 749-759) w CF Interview (16 Qs).

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Good Article re Culture:Dadlani, Overtree, & Perry-Jenkins (2012). Culture at the center: A reformulation of diagnostic assessment. Professional Psychology: Research & Practice, 43(3), 175-182.

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Good Books re Diagnosis Beach, Wamboldt, Kaslow, Heyman, First, Underwood,

& Reiss (Eds.) (2006). Relational processes and DSM-V: Neuroscience, assessment, prevention, and treatment. Arlington, VA: American Psychiatric Association.

Garcia, B., & Petrovich, A. (2011). Strengthening the DSM: Incorporating resilience and cultural competence. NY: Springer Publishing Co.

Frances, A. (2013). Saving normal: An insider’s revolt against out-of-control psychiatric diagnosis, DSM 5, big pharma, & the medicalization of ordinary life. NY: William Morrow.

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Questions?

Answers?

Thank you!85