Dsm5primer 197499 PDF

Lynne M.
Kemen
Hunter College
INSTRUCTORʼS
DSM-5
TEACHING PRIMER
An instructorʼs resource on
teaching the changes to the DSM
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Copyright © 2014 Pearson Education, Inc. All rights reserved.

DSM-5 PRIMER – 3
INTRODUCTION
The new changes to the DSM-5 are evolving even as recently as a few weeks ago. The changes
made the front page of the New York Times and their placement there confirms that the subject is of
interest to the general public as well as to the medical community. Almost daily, I read articles
about the revised DSM-5 and how it is predicted to affect patients. Physicians, clinicians, patients,
families are all writing from their particular points of view. It’s really too early to know all of the
ramifications of the changes.
So the question of how we are to teach these changes is important and not precisely clear-cut. I
think it is important to realize that the various editions of the DSM are evolving and reflect changes
in our understanding of the importance of cultural as well as medical perspectives. What we
understand and accept in this decade may well change by the time the next DSM is written. This is
not a perfect manual and there are many who do not agree with everything written in it. For now, it
is what we have and I believe we should frame our teaching of the changes in this manner.
When I teach Abnormal Psychology, I always include an early lecture on how views of psychiatric
conditions are very much influenced by the times, belief systems and cultures of the communities
that are operating at that time. That lecture contains several examples of such a dynamic. My
students alternately are amused and horrified by the idea of trephination. But without an
understanding of causes, without our ability to image the brain, and in a culture where a fear of
spirits is prevalent, it makes sense to try to treat the patient by releasing the spirits in this manner.
Looking at evidence of the skulls found, this method was used in many different areas of the world
and ranged from single borings to multiple ones in a pattern. We do not know precisely why this
was used, but there have been many guesses that it was used to treat convulsions, head injuries or
swelling of the brain.
In a period when the Catholic Church had its nuns and priests getting up to pray every few hours
(sleep deprivation), fasting and doing purification rituals, many individuals had religious visions. In
a current context, we would probably prescribe medications and not see their experiences in a
religious light. At the time that it was happening, however, there was a very different interpretation,
and the individuals were praised for their religious fervor.
During Victorian times, sexuality was very repressed. Even pianos had limbs rather than legs and
furniture and extremities were covered. As sexual desires, masturbation and homosexuality were
abhorred in upper- and middle-class families, the repression created other outlets. In 1887, The
Lancet, the British medical journal, estimated that in London, 3% of the population were prostitutes
during this time. Sigmund Freud’s case studies involved a large number of upper middle-class
women in Vienna who were suffering from hysteria. This is a diagnosis no longer used and the
condition seems to have disappeared, as well.
And it took the DSM until 1972 to remove homosexuality as a psychiatric condition. In other times
and other cultures, same-sex relationships were not considered abnormal. Thanks to psychologist
Dr. Evelyn Hooker, who matched straight and gay men and then asked a panel of psychiatrists to
determine the sexual preference of the person, the idea that a homosexual could be diagnosed or
recognized in some way was disproven. Prior to Dr. Hooker’s work, all studies of homosexual men

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were drawn from cases of individuals who were already diagnosed with a psychiatric disorder.
Once Dr. Hooker did her work on homosexuals who were not suffering from a psychiatric disorder,
the old views were disproven.
I am certain that the DSM will continue to evolve and change as our culture evolves and changes.
As instructors of abnormal psychology, it is our job to prepare our students for an understanding of
what has been, what is, and to anticipate what will be.
The major changes in the DSM-5 represent a different way of looking at many of the diagnoses
from previous manuals. The order of the chapters is supposed to reflect related diagnoses.
The prior DSM versions used a multi-axial approach to a diagnosis, but the APA noted that it was
not really necessary to make a diagnosis based on this, so this version has changed and is now
using a non-axial approach. Axes I, II and III will be combined, and there will be separate notations
for psychosocial/contextual factors (previously Axis IV) and General Ability to Function (GAF),
which was Axis V.
The new chapters represent more of a longitudinal view of a condition. A child born with
developmental problems does not stay a child forever. A baby with Down syndrome can now live
into her late fifties or early sixties. Previously, one of the chapters was written as Childhood
Disorders, but this manual recognizes that this is not totally appropriate and has changed the title to
Neurodevelopmental Disorders.
In the earlier manuals, there was a distinction made between Asperger’s Syndrome and Autism
Spectrum Disorder. These topics have been merged.
The Bipolar and Depressive Disorders—among the most common diagnoses in psychiatry—have
been simplified in terms of diagnosing.
The Substance Use Disorders chapter has eliminated substance abuse and substance dependence
language.
The Major and Mild Cognitive Disorders chapter has replaced the dementias, and the
improvements in knowledge based on imaging technology are reflected in this change.
The Personality Disorders chapter has the standard classification model seen in earlier editions, but
there is also a new hybrid model that is unveiled in Section III of the DSM-5. This alternative
model reflects the changes that are happening in how this category is being diagnosed.
Section III: New Disorders and Features has been added to include new diagnoses that the editors
feel require further study but which are not yet ready to be formally classified.
Throughout the manual, there is heightened sensitivity to cultural aspects of how a patient presents,
and there is also more material on gender differences in diagnoses. There is increased recognition
that “normal” has a wide range of meaning depending on culture, education, and situation.

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The DSM-5 chapters are listed in the following order:
1. Neurodevelopmental Disorders
2. Schizophrenia Spectrum and Other Psychotic Disorders
3. Bipolar and Related Disorders
4. Depressive Disorders
5. Anxiety Disorders
6. Obsessive-Compulsive and Related Disorders
7. Trauma- and Stressor-Related Disorders
8. Dissociative Disorders
9. Somatic Symptom Disorders
10. Feeding and Eating Disorders
11. Elimination Disorders
12. Sleep-Wake Disorders
13. Sexual Dysfunctions
14. Gender Dysphoria
15. Disruptive, Impulse Control, and Conduct Disorders
16. Substance Use and Addictive Disorders
17. Neurocognitive Disorders
18. Personality Disorders
19. Paraphilic Disorders
20. Other Disorders

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1. NEURODEVELOPMENTAL DISORDERS
The proposed group of Neurodevelopmental Disorders has combined diagnoses that were
previously categorized under several different groups. There are several changes that are
significant.
First, a language change has been made under the first subcategory of mental retardation in the
DSM-IV to Intellectual Development Disorder. Originally this was classed under dementia, and
most abnormal psychology books placed this discussion in the disorders of childhood and
adolescence since it was a condition that began with birth. The argument about not placing it within
the category of dementia is that dementia is normally something that occurs as a patient ages and
there is a loss that occurs, rather than a deficit at birth.
The second subgroup of Communication Disorders did not previously exist under the DSM-IV.
Language, speech and social communication were not included in earlier versions of the DSM and
are now addressed. There is acknowledgement that this is often combined with the autism spectrum
disorders.
The third subgroup of Autism Spectrum Disorder has generated much interest on the part of health
professionals, educators and the public. Basically, the term spectrum addresses the wide range of
abilities of the patient. Under the new spectrum, autistic disorder (autism), Asperger’s disorder,
childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified are
included in this grouping.
The fourth subgroup is Attention Deficit/Hyperactivity Disorder. Significant changes are moving
the age of onset of ADHD to age 12 (from age 7). The DSM-5 also has proposed changes regarding
removal of PDD (pervasive developmental disorder including autism) from the exclusion criteria.
Many mental health experts now believe that ADHD and Autism Spectrum Disorder often co-exist.
The fifth subcategory is Specific Learning Disorder. This placement contrasts with the general
communication disorders of subcategory two (specific types of difficulty with math problems, for
example).
The sixth subcategory is Motor Disorders. Here, the major changes seem to be to bring consistency
to disorders such as tics and to take away such subjective terms as “non-functional” for repetitive
movement disorders. “Non-functional” can be viewed as a pejorative term. Not understanding
something is not the same as judging that it has no function.
Discussion Starters
1. The DSM-5 has made some rather major changes in the way certain diagnoses are viewed. The
decision to make a category of neurodevelopmental disorders and to make it a broader
category has great implications for diagnosing and treating the autism spectrum. The autism
spectrum now envelops Asperger’s syndrome. Think about how this might affect children as
they begin school.

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2. How might this change affect patients who are older, both teens and adults?
3. The addition of communication disorders (which did not previously exist) has been included
within the autism spectrum disorder. Do you think that co-morbidity is a good reason for
putting conditions together?
Lecture Ideas
1. There are some excellent videos from Autism Speaks. These show a therapist working with
patients and giving them the same activities. This is a great way for students who may not
have encountered autistic children to see the differences in how they react to objects, their
parents, and to the therapist.
2. Show a video clip of Temple Grandin, who was diagnosed as autistic as a child. She was
unable to speak until she was older than 3, and then hummed, screamed, and did not use words
until much later. She later went on to earn a Ph.D. and is a tireless spokesperson for those who
are not articulate.
3. Show a video of patients with ADHD and discuss similarities of autism and ADHD.
Student Activities
1. Ask students to visit the websites of Wrong Planet, Autism Speaks, and Asperger’s Parent to
read about the concerns and comments of these organizations to the DSM-5 changes.
2. Have students read about first-hand accounts of individuals with autism/Asperger’s, such as
The Way I See It, Revised and Expanded 2nd Edition: A Personal Look at Autism and
Asperger’s by Temple Grandin, or Look Me in the Eye: My Life with Asperger’s by John Elder
Robinson. Think about how these individuals perceive their world and how they have learned
to integrate their differences.
3. Ask students to think of fictional characters who might be on the Autism Spectrum: Spock in
Star Trek, Sherlock Holmes, Sheldon from The Big Bang Theory, the son in Parenthood, the
title character in Bones. Then ask them to read the brief article in The Guardian about the
dangers of diagnosing fictional characters. How does it help/harm the public’s awareness of
autism?
http://www.guardian.co.uk/books/booksblog/2007/apr/04/dontdiagnosefictionalcharac

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2. SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC

DISORDERS
The first change is the description of the category. Formerly, it was Schizophrenia and Other
Psychotic Disorders. This change in language indicates that there is a gradient of severity of the
conditions discussed.
Other important changes are adding Attenuated Psychosis Syndrome in Section 3 of the DSM-5.
This is the group that needs further consideration and is directed at making sure that patients who
have this diagnosis are identified because of their increased likelihood of eventually having a
diagnosis of schizophrenia.
The discussion and inclusion of Schizotypal Personality Disorder being co-morbid with another
Personality Disorder is high and the APA is recognizing that it is almost impossible to have a
single clear diagnosis in such cases. The Group of Personality Disorders is separate and explored at
length later.
Finally, the separation of catonia from schizophrenia allows for the inclusion of catatonia to be
included for Brief Psychotic Disorder, Schizophreniform Disorder, Schizoaffective Disorder,
Substance-induced Psychotic Disorder as well as Neuro-Developmental Disorders.
Sub-group 1. Attenuated Psychosis Syndrome (APS) in Section 3 (Appendix) of DSM-5
“Psychosis Risk Syndrome” or “Attenuated Psychosis Syndrome” seeks to identify patients who
are at risk for full-blown psychosis before it becomes such—i.e., the patients in this group are not
yet diagnosed as schizophrenics but are more likely than the general population to develop
schizophrenia in the future. Identifying these patients can be helpful in making sure that they are
more closely monitored.
Schizotypal Personality Disorder
Important issues that are discussed here are the extensive co-morbidity of PD (Personality
Disorder). The Personality Disorder is felt to be constant or trait-like over time and across
situations. This is discussed at greater length in the section on PD itself.
Delusional Disorder
There are several subtypes suggested:
Erotomanic Type: Delusions that another person, usually of higher status, is in love with the
individual.
Grandiose Type: Delusions of inflated worth, power, knowledge, identity, or special relationship to
a deity or famous individual.

DSM-5 PRIMER – 9
Jealous Type: Delusions that the individual’s sexual partner is unfaithful.
Persecutory Type: Delusions that the individual (or someone to whom the individual is close) is
being malevolently treated in some way.
Somatic Type: Delusions that the individual has some general medical condition.
Mixed Type: Delusions characteristic of more than one of the above types, but in which no one
theme predominates.
Unspecified Type
• Specify if delusions are bizarre.

• Specify if delusions are shared.
The APA recommends three changes:
1. Dropping the requirement that the delusion be non-bizarre

2. Clarifying the body dysmorphic delusion from somatic type delusion
3. Indicating if the delusion is shared with another, and discarding the Folie a Deux diagnosis
Brief Psychotic Disorder
No substantial changes from DSM-IV.
Substance-Induced Psychotic Disorder
Psychotic Disorder Associated with Another Medical Condition
No changes recommended.
Catatonic Disorder Associated with Another Medical Condition
Recommendations include: Catatonia should be a specifier and not a subtype of schizophrenia in

DSM-5. By making it a standalone diagnosis, it can be used for other conditions such as Brief
Psychotic Disorder, Schizophreniform Disorder, Schizoaffective Disorder, or Substance-induced
Psychotic Disorder. It can also be then used for Autistic Disorders and Neurodevelopmental
Disorders.
Schizophreniform Disorder

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Schizoaffective Disorder
“Major mood episode” has been replaced with “Major depressive episode or a manic episode.”
Schizophrenia
Most of the major parts of the DSM-IV diagnosis will be kept. It is, however, proposed that the
sub-types of schizophrenia (Paranoid Type, Disorganized Type, Catatonic Type, Undifferentiated
Type, and Residual Type) be eliminated.
Exclusions from the diagnosis of schizophrenia will include:
Schizoaffective and Mood Disorder Exclusion: Schizoaffective Disorder and Mood Disorder With
Psychotic Features have been ruled out because either (1) no Major Depressive or Manic Episodes
have occurred concurrently with the active phase symptoms; or (2) if mood episodes have occurred
during active-phase symptoms, their total duration has been brief relative to the duration of the
active and residual periods.
Substance/General Medical Condition Exclusion: The disturbance is not due to the direct physiological
effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.
Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder,

another Pervasive Developmental Disorder, or other communication disorder of childhood onset,
the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are
also present for at least a month.
Psychotic Disorder Not Elsewhere Classified
Catatonic Disorder Not Elsewhere Classified
This category includes individuals who develop catatonia in the context of rare autoimmune and
cancer disorders in which the cancer is a consequence but not a cause of the symptoms. It will also
include patients on the Autism Spectrum or with Neurodevelopmental Disorders.
Discussion Starters
1. The stigma of labeling is especially strong with schizophrenia. There have been studies that
indicate that physicians who are treating patients with this diagnosis for regular physical issues
do not give the same level of care (http://www.psychiatrictimes.com/apa2013/bias-against-
schizophrenic-patients-seeking-medical-care). It has been suggested that the term
schizophrenia be replaced with another term, salience syndrome, to reduce the stigma of the
diagnosis. Do you believe that this change would achieve its goal? Possible answers could
range from affirmative to negative. The class could be asked if they believe this this newer
term would also become stigmatized over time.

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2. Should a Risk Syndrome for First Episode Psychosis be included in the DSM-5? Discuss the
pros and cons. Would this actually help identify someone, or exacerbate a situation, by use of a
label?
3. Catatonia should be a specifier and not a subtype of schizophrenia in DSM-5. Again, the
question of co-morbidity arises. Should this be a separate diagnosis with other conditions?
How do you think this categorization improves the ability to diagnose the condition?
Lecture Ideas
1. Compare the progression of various editions of the DSM as a reflection of the cultural times
and how medicine and psychiatry operate. There are those who feel that schizophrenia was
being overdiagnosed in the period from 1960–1970, during the DSM-II era. The next version
of the DSM added a length of time of six months of continuous illness for it to receive the
diagnosis of schizophrenia and it was thought that this would distinguish this condition from
affective psychoses that were more transitory. This time factor has been continued in
subsequent editions of the DSM.
2. Look at cultural changes over even greater time periods and look at how societies have dealt
with this condition. For example, schizophrenia does not appear to be a recently developed
condition. There are descriptions of patients with schizophrenia-like symptoms in ancient
India and Rome. During Victorian times, the number of admissions to asylums rose
precipitously. This may have been due to a growing recognition of patients in need of
commitment, or it may have been due to a change in the way families dealt with family
members who were ill. Similarly, there are differences in cultural ways of viewing
schizophrenia. Individualism and collectivism are two very different ways of viewing how a
person fits into his/her society. In the individualistic cultures, the needs of a person are more
important than in the collectivistic society, which emphasizes conformity and being part of a
homogenous group. Discuss how these themes are reflected in the DSM-5.
Student Activities
1. Visit the website artwithimpact.org. Have the students watch one of the suggested films and
write a reflection piece of 3–5 pages on the portrayal of the schizophrenic character in terms of
the new DSM-5 criteria.
2. Have students read novels in which a character has schizophrenia. Having discussed how the
understanding of schizophrenia has varied historically, look at the time setting of the novel and
write a paper discussing how it fits into the societal theories of that time (suggest 3–5 pages).
3. Ask students to watch videos of patients with schizophrenia and of patients with autism and
decide if there is comorbidity. What factors are the same, what are different? Have them write
a brief paper (1–2 pages) about what they notice. You can use the videos in the MyPsychLab
or find others on YouTube.

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3. BIPOLAR AND RELATED DISORDERS
This section was not as changed as extensively as many others.
Important changes in this section: Bipolar I Disorder & Bipolar II Disorder and Bipolar Disorder
Not Elsewhere Classified, Bipolar I Disorder & Bipolar II Disorder have some changes with the
bereavement exclusion in Major Depressive Episode. Along with removing the exclusion, the work
group is proposing the addition of a footnote to accompany the diagnostic criteria for Major
Depressive Episode that would help clinicians differentiate bereavement and other loss reactions
from Major Depression.
Furthermore, increased energy/activity has been added as a core symptom of Manic Episodes and
Hypomanic Episodes.
Bipolar I Disorder
Requires a history or the presence of a manic episode. It also requires ruling out other diagnoses
such as Schizoaffective Disorder, Schizophreniform Disorder, Delusional Disorder, or Psychotic
Disorder NEC. The diagnosis also requires that the health care professional specify if the current
episode is manic, hypomanic or depressive. In the DSM-5, there is a mixed bipolar criteria that
serves as an indicator that the condition of either mania or depression is beginning to include at
least 3 factors from the opposite condition. For example, if the patient is depressed, but has 3
indicators of mania, this means the patient may be likely to move to a bipolar diagnosis. Early
recognition of this change is the reason for this change.
Bipolar II Disorder
Requires a history or the presence of a depressive and hypomanic episode. It also requires ruling
out other diagnoses such as Schizoaffective Disorder, Schizophreniform Disorder, Delusional
Disorder, or Psychotic Disorder NEC. The diagnosis also requires that the health care professional
specify if the current episode is hypomanic or depressive.
Cyclothymic Disorder
No significant changes from DSM-IV.
Substance-Induced Bipolar Disorder
No changes.
Bipolar Disorder Associated with Another Medical Condition
Still being reviewed by the APA.

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Bipolar Disorder Not Elsewhere Classified
The significant note here is that NOS does not give clinical information and is felt to be used too
frequently. The APA urges clinicians to specify threshold symptoms indicating bipolarity.
Discussion Starters
1. Bipolar disorder has differences in cultures, genders and history in terms of how it is
considered. Discuss how the changes in the new DSM-5 might influence how this condition is
recognized.
2. The diagnosis of bipolar disorder has changed significantly in the last several years and
younger patients are being diagnosed with this condition. Discuss this.
3. By making the diagnosis criteria for BP I less rigorous, do you think that there will be more
individuals with this diagnosis?
Lecture Ideas
1. Show videos from MyPsychLab on bipolar disorder and ask students to observe the
characteristics of bipolar behavior and to think about how the DSM-5 changes might affect
who is diagnosed with this condition.
2. Many children and teens who are prone to explosive anger are now being labeled bipolar. In
the past decade alone, diagnoses of the disorder in children have increased by 40 percent, with
some estimates putting the prevalence rate as high as 3 percent in adolescents. Prior to the
1990s, almost no one diagnosed bipolar disorder in children or adolescents. Discuss how this
change has come about and the implications of such.
3. The danger of suicidal ideation is particularly high with patients with a bipolar diagnosis.
Some feel that it is essential to screen for those who may be at risk. The DSM-5 addresses this
issue by including an earlier diagnosis if a patient is depressed but shows some signs of mania.
Do you believe this will make a difference?
Student Activities
1. Watch Boy Interrupted (http://www.hbo.com/documentaries/boy-interrupted/index.html) and

write a reflection piece on it. This should be a 1–2 page paper. Include how you think the
DSM-5 changes would impact this situation.
2. Listen to Mental Health Day Podcast #14: Dr. Ellen Leibenluft on DMDD (Disruptive Mood
Dysregulation Disorder) and Bipolar Kids in DSM-5. Write a 1–2 page reflection on her
comments.
http://www.mentalhealthday.org/show/mental-health-day-podcast-14-dr-ellen-leibenluft-on-
dmdd-and-bipolar-kids-in-dsm-5/

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3. Watch Silver Linings Playbook and comment on how the main character Pat’s diagnosis of
bipolar disorder is portrayed in the film. Look at the DSM-5 criteria and describe how you feel
this film fits, or doesn’t fit, into the DSM-5 model.

DSM-5 PRIMER – 15
4. DEPRESSIVE DISORDERS
Depressive Disorders
Here are the important changes in this group: Disruptive Mood Dysregulation Disorder, Major
Depressive Disorder Single Episode, Premenstrual Dysphoric Disorder (see below).
Disruptive Mood Dysregulation Disorder
This section notes that in the case of children, with the DMDD diagnosis there is closely
overlapping criteria for Oppositional Defiant Disorder. This is not the case for ODD diagnosis
always having similarities with DMDD. The APA notes that DMDD is more severe and urges that
in cases with both diagnoses present, only DMDD be used.
Major Depressive Disorder, Single Episode
This section acknowledges that bereavement symptoms can be extremely close to MDDSE. If
symptoms such as suicidal ideas, feelings of worthlessness, and psychomotor impairment are
present, this may be beyond the scope of “normal” grieving and should be considered as MDDSE.
Major Depressive Disorder, Recurrent Episodes
This section does not have significant changes from the previous DSM.
Dysthymic Disorder
May be combined with MDD since it is self-reported and difficult for a patient to remember over a
period of time the differences between lesser and greater depression. This is still being discussed.
Premenstrual Dysphoric Disorder
Previously in the Appendix, APA is recommending that it be moved to Depressive Disorder. It is

felt that unless there are clear diagnostic differences between PMDD and MDD or dysthymia, the
wrong diagnosis and treatment could be given.
Substance-Induced Depressive Disorder
No proposed changes.
Depressive Disorder Associated with Another Medical Condition
Still being considered.

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Depressive Disorder Not Elsewhere Classified
Noted as being an extremely common diagnosis that may be too broad to be useful (except for
billing practices) and may reflect an effort to avoid the stigma of a psychiatric label. In the future,
short-term depression of a few days’ length may be used here.
Discussion Starters
1. The recognition that grieving is a part of depression, and that it has different lengths of time
for different people, is a significant change from the DSM-IV. How do you think this impacts
patient care? Possible answers have to do with insurance coverage for the emotional aspects of
grieving, medications dispensed, etc.
2. Prior to the 1970s, depression was not generally accepted as being possible for children.
Multiple researchers in the 1970s showed this to be false. The latest research suggests that
children may begin to show symptoms of depression as early as 3 years of age. There are
psychiatrists such as Joan Luby who advocate that children should be screened for depression
when they enter pre-school. Will we be over-diagnosing children by using the DSM-5, as
some mental health experts fear? And with that, will there be over-medication?
3. The idea of “mixed diagnosis” for a patient who is depressed, but who exhibits 3 symptoms of
mania, is new to DSM-5. Is this something that is going to blur diagnoses? Since many
healthcare providers are not trained in psychology/psychiatry and yet may be the first or only
person to diagnose the patient, will we be missing co-morbidity?
Lecture Ideas
1. Discuss different cultures and how they deal with bereavement. What are some of the
differences in terms of how grief is expressed and/or signified (wearing black, wearing white,
covering mirrors, not shaving, etc.)? How can psychologists be more culturally sensitive?
2. Show a video of a patient with depression and compare it to a patient with Attention Deficit.
Discuss how a mental health professional might diagnose them using the DSM-5 criterion.
You can use MyPsychLab videos.
3. There are two new diagnoses in the DSM-5 Depressive Disorders section: Disruptive Mood
Dysregulation Disorder and Premenstrual Dysphoric Disorder. Discuss how this may change
patient care. In particular, how will disruptive mood dysregulation fit with bipolar or
oppositional defiant diagnoses?
Student Activities
1. Read Catcher in the Rye and comment on the character from the DSM-5 perspective. Write a
paper 3–5 pages in length.

DSM-5 PRIMER – 17
2. One of the DSM-5 changes that is receiving the most attention and controversy is diagnosing
as major depression the extreme sadness, weight loss, fatigue and trouble sleeping some
people experience after a loved one’s death. Major depression is typically treated with
antidepressants. Write a reflection piece of 1–2 pages.
3. Dr. Allen Frances, who co-authored the DSM-IV, charges that we are over-treating people in
the United States who are “basically well” and are “shamefully neglecting” people with mental
disorders who are really sick, including one million people in prison with psychiatric
disorders.
He further charges that a primary care physician, not a psychiatrist, is giving the diagnosis, and
that the length of time the patient is seen averages less than 10 minutes.
“People who are basically normal are getting all kinds of medicine that they don’t need that
makes them worse and it is a terrible drain on the economy,” Frances said. Write a 1–2 page
reflection piece on what that could mean in terms of medications prescribed, particularly to
children.

18 – DSM-5 PRIMER
5. ANXIETY DISORDERS
Within the general grouping, there has been an effort to make the wording more consistent across
the diagnoses. For example, the terms “fear” or “anxiety” are used consistently across the criteria
within Specific Phobia and across anxiety disorders. The term “almost always provokes” is
intended to simplify the criteria in place of “almost invariably provokes an immediate anxiety
response” and is consistent with new phrasing for Social Anxiety Disorder and Agoraphobia.
Generally, there is more sensitivity to cultural aspects of a reaction.
Perhaps the most significant changes within Anxiety Disorders occur in Separation Anxiety. The
age of onset is no longer there and the duration is now at least 6 months to differentiate from a
transient event. With children, the anxiety about not having an adult, per se, is omitted since
significant others may not be adults.
In the category of Generalized Anxiety Disorder, the number of symptoms has been reduced from
6 to 2.
Agoraphobia
Agoraphobia will now be a codable disorder (no longer a syndrome) and will no longer have a
separate diagnosis of Panic Disorder with Agoraphobia. Agoraphobia will be a standalone
condition and may be comorbid with Panic Disorder.
Social Phobia/Social Anxiety Disorder
Social Phobia has been renamed Social Anxiety Disorder. Among other changes are the duration of
at least 6 months to distinguish from a transient situation and the inclusion of children being
uncomfortable with all people, not simply unknown people.
Substance-Induced Anxiety Disorders
Section represents a large grouping, but basically there are no substantial wording changes from
DSM-IV to the current issues.
Anxiety Disorder Attributable to Another Medical Condition
No substantial revisions.
Anxiety Disorder Not Elsewhere Classified
No substantial rewording.
There are now separate categories for Obsessive-Compulsive and Related Disorders and Trauma-
and Stressor-Related Disorders (#6 and #7 in the APA list).

DSM-5 PRIMER – 19
NOTE: Because there are so few changes to this category, I would suggest that the instructor point
out the separation anxiety changes to reflect that the significant other need not be a parent and that
there is no onset or duration reflected.

20 – DSM-5 PRIMER
6. OBSESSIVE-COMPULSIVE AND RELATED DISORDERS
This category contains diagnoses that were listed in DSM-IV under the chapter of Anxiety
Disorders as well as the chapters of Somatoform Disorders and Impulse-Control Disorders Not
Elsewhere Classified. The important changes mostly deal with a change of language that makes
diagnoses less negative/prejudicial. “Mania” is replaced with “condition” and “inappropriate” is
replaced with “unwanted.”
Obsessive Compulsive Disorder
The major changes involve replacing certain words—“impulse” with “urge” and “inappropriate”
with “unwanted.” This does two things. In the former case, it clarifies that this is not an impulse
control issue, and in the latter, it is less judgmental.
Body Dysmorphic Disorder
Not changed diagnostically, but there is increased emphasis on the fact that the source of BDD may
be apparent only to the patient. Nevertheless, the discomfort is certainly experienced by the patient.
Hoarding Disorder
This is being made a separate diagnosis, and the APA feels that it is important to note that hoarding
can create a danger to the hoarder.
Hair-Pulling Disorder (Trichotillomania)
The APA feels that the term “mania” is inappropriate to this condition, but has recommended using
the term “trichotillomania” in parentheses to not confuse clinicians. It is their intention to drop the
term “mania” in later versions of the DSM.
Skin Picking Disorder
Considered to be a condition that warrants its own diagnosis and should not be confused with BDD
or with tactile hallucinations.
Substance-Induced Obsessive-Compulsive or Related Disorders
There are no significant changes from the DSM-IV.
Obsessive-Compulsive or Related Disorder Attributable to Another Medical Condition
There are no significant changes from the DSM-IV.

DSM-5 PRIMER – 21
Obsessive-Compulsive or Related Disorder Not Elsewhere Classified
The DSM-5 diagnostic criteria for this disorder are similar to those in the analogous DSM-IV-TR
section on Anxiety Disorders.
Discussion Starters
1. In the past, this category was listed under Anxiety Disorders. In the DSM-5, it now has its own
category. Within the new grouping are Body Dysmorphia, Hoarding, as well as Obsessions.
How do you think these topics are related?
2. The awareness of the patient of the behavior has also changed. In the DSM-IV, the awareness
level of the patient was indicated as present or not. Now there is a range of patient insight from
present to delusional (i.e., the patient totally believes something that is not true to be true).
How does this change impact a diagnosis?
3. The problem of hoarding is now a subcategory of OCD. In particular, the potential harm that
this kind of behavior could do to either the patient or others is noted. How would hoarding fit
into this category and how do you think someone could be harmed by this condition?
Lecture Ideas
1. Show video of Dave from MyPsychLab and discuss how his condition impacts his life.
Discuss how his behavior fits into Anxiety (from the previous DSM-IV) and how the newer
classification might be an improvement.
2. Discuss Body Dysmorphia and show photos of individuals who have had repeated surgeries to
change their appearance. The evolution of Michael Jackson’s face over several years is a good
starting point. You can also reference Jocelyn Wildenstein (the “cat woman”) or Joan Rivers.
How does our society feed into this disorder and how does it relate to OCD?
3. Excoriation or excessive skin picking is included in this category. How is this different from
cutting, which is listed under Borderline Personality Disorder?
Student Activities
1. Have students watch Hoarders and comment on how this behavior affects the individual and
how it fits into this category of the DSM-5. Write a 1-page reflection paper.
2. Have students select a film about obsessional jealousy (Sleeping with the Enemy, Heat and
Sunlight) and write short paper (3–5 pages) about how the character’s behavior fits with the
DSM-5 description of this condition.
3. Compare behavior from the Autism Spectrum category with OCD behavior and write a brief
paper about any differences.

22 – DSM-5 PRIMER
7. TRAUMA- AND STRESSOR-RELATED DISORDERS
There are some major changes in this category.
This category contains diagnoses that were listed in DSM-IV under the chapter of Anxiety
Disorders and the chapter of Adjustment Disorders. The Anxiety, Obsessive-Compulsive
Spectrum, Posttraumatic, and Dissociative Disorders Work Group has been responsible for
addressing these revisions. Many of the disorders that were previously listed in the Anxiety
Disorders chapter in DSM-IV have been distributed throughout this chapter as well as separate
chapters on Obsessive-Compulsive and Related Disorders and Anxiety Disorders.
One of the most interesting additions in this discussion is the proposed disorder, Persistent
Complex Bereavement Disorder. This is being proposed for Section III, a section of DSM-5 in
which conditions that require further research will be included. Posttraumatic Stress Disorder now
has a subtype for PTSD in preschool children rather than having this subtype exist as a separate
diagnosis. A dissociative symptoms subtype has also been added to this disorder. Under
Adjustment Disorders, a 6-month requirement for children for the bereavement-related subtype has
been added, and the disorder includes minor wording changes, including changes to the
bereavement-related subtype. Finally, the work group has proposed criteria for Trauma- or
Stressor-Related Disorder Not Elsewhere Classified.
Reactive Attachment Disorder
The APA notes that almost all RAD is a result of extremely negligent and inadequate childcare, but
notes that not every abused child exhibits RAD. It is described as a pattern of disturbed and
developmentally-inappropriate attachment behaviors that a child manifests before the age of 5 in
which the child stays emotionally unengaged with any adult caregiver.
Disinhibited Social Engagement Disorder
Like the RAD diagnosis, DSED is a variant of pathological attachment disorder, and the opposite
of RAD. In this case, this new diagnosis will fall into the broad category of Trauma- and Stressor-
Related Disorders. Children diagnosed with DSED display behavior in which the child is extremely
attached to any adult whether or not the child knows the adult. To receive this diagnosis, the child
must have experienced some form of pathogenic care that is responsible for this behavior.
Pathogenic care can include persistent exposure to unsafe environments, frequently unmet basic
needs, overly harsh punishment, and more.
Acute Stress Disorder
The definition of traumatic event is made more general. The symptoms exhibited are made more
consistent with those of Posttraumatic Stress Disorder, which is the next category.

DSM-5 PRIMER – 23
Posttraumatic Stress Disorder
Note: The following criteria apply to adults, adolescents, and children older than six. There is a
Pre-school Subtype for children ages six and younger.
The subtype applies not only to those who are directly affected, or who have family or friends who
are affected, but also caretakers such as those who repeatedly deal with trauma professionally
(police officers, members of Child Protective Care, etc.). “Sexual assault is specifically included,
for example, as is a recurring exposure that could apply to police officers or first responders,” notes
the APA. “Language stipulating an individual’s response to the event—intense fear, helplessness or
horror, according to DSM-IV—has been deleted because that criterion proved to have no utility in
predicting the onset of PTSD.”
Subtype: Posttraumatic Stress Disorder in Preschool Children
In children (under the age of 6), involves exposure to one or more of the following events: death or
threatened death, actual or threatened serious injury, or actual or threatened sexual violation, in one
or more of the following ways: direct experience, witnessing in-person traumatic events occurring
to others, learning that traumatic events occurred to a primary caretaker.
The child may experience persistent distressing memories of the event, keep re-enacting the event
in play or have recurrent nightmares of the event. The child’s behavior may include dissociation of
the event. The child may also avoid any reminders of the event and exhibit hyper-vigilance,
angry/aggressive behavior, and show problems with concentration. Note the duration of these
behaviors should exceed one month for the diagnosis. Also, a child can have comorbidity of
preschool and dissociative subtypes if symptoms for both are exhibited.
Subtype: Posttraumatic Stress Disorder with Prominent Dissociative (Depersonalization/

Derealization) Symptoms
Depersonalization: Often described as feeling that an experience is happening to someone else, like
watching a film rather than being directly involved.
Derealization: Often described as feeling that what is happening is not real or like being in a
dream.
Note: The Dissociative and Preschool Subtypes are not mutually exclusive.
Adjustment Disorders
Criterion unchanged from DSM-IV except for the addition of Bereavement-Related Subtype.
Elimination of Bereavement Exclusion
Addition of ASD/PTSD Subtype

24 – DSM-5 PRIMER
Addition of Bereavement-Related Subtype
The concept of bereavement being a culturally varied issue is critical to the DSM-5. The
differences in cultures concerning what is considered “appropriate behavior” is specifically noted.
Twelve months of emotional or behavioral stress for adults and 6 months for children is considered
to be the norm for grieving.
In this category, the individual is exhibiting discomfort for a longer period that is significantly
impacting that individual’s ability to work or take part in social activities. The specific
manifestations are broken down as follows:
• With Depressed Mood

• With Anxiety
• With Mixed Anxiety and Depressed Mood
• With Disturbance of Conduct
• With Mixed Disturbance of Emotions and Conduct
• With Features of Acute Stress Disorder or Posttraumatic Stress
Related to Bereavement
Following the death of a family member or close friend, the individual exhibits difficulty moving
forward. Intense preoccupation with the loss that exceeds expected cultural, religious and age-
appropriate responses.
Unspecified
For maladaptive reactions that are not classifiable as one of the specific subtypes of Adjustment
Disorder.
Trauma- or Stressor-Related Disorder Not Elsewhere Classified
The DSM-5 diagnostic criteria for this disorder are similar to those in DSM-IV-TR, with very
minor wording changes being proposed.
Discussion Starters
1. There has been a blending of this category from several other categories previously used in the
DSM-IV, specifically Anxiety and Obsessive-Compulsive Disorders. The Dissociative
Disorder category was previously in its own category. The decision to make the DSM-5 a
lifespan approach may have been the reason for this change.
2. The inclusion of those caretakers including police and those involved in violent crime and the
aftermath are specifically included in the PTSD section. This indicates an awareness that it
does not have to happen directly to someone to be traumatic.

DSM-5 PRIMER – 25
3. The language has changed in the area of posttraumatic disorders and there is more awareness
that different individuals may show the effects of trauma at different time intervals. This
condition has moved from the DSM-IV category of Anxiety to Trauma- and Stressor-Related
Disorders. Do you think that this means that it is given more importance?
Lecture Ideas
1. The DSM-5 changes will have repercussions for veterans. National estimates of PTSD
prevalence suggest that DSM-5 rates were slightly lower than DSM-IV. Discordant findings in
diagnostic prevalence were attributable to three major changes in the DSM-5 criteria for PTSD:
a. The revision of Criterion A1 in DSM-5 narrowed qualifying traumatic events such that
the unexpected death of family or a close friend due to natural causes is no longer
included. Research suggests this is the greatest contributor (> 50%) to the discrepancy for
meeting DSM-IV but not DSM-5 PTSD criteria.
b. Splitting DSM-IV Criterion C into two criteria in DSM-5 now requires that a PTSD
diagnosis must include at least one avoidance symptom.
c. Criterion A2, response to traumatic event involving intense fear, hopelessness, or horror,
was removed from DSM-5.
http://www.ptsd.va.gov/professional/pages/diagnostic_criteria_dsm-5.asp
Discuss how these changes might affect veterans.
2. Abused children can react to the abuse in several ways. In one, they fail to form attachment to
anyone, and in the other, they may exhibit disinhibited social engagement disorder. In the first
case, the symptoms may at first appear to be an autistic spectrum disorder and in the second,
they may appear to be ADHD and have impulsivity problems. Discuss how someone who is
observing a child could distinguish these.
3. The rates of prevalence for PTSD using DSM-IV criteria at age 75 years is 8.7%. Twelve-
month prevalence among U.S. adults is about 3.5% (DSM-5, page 276). Lower rates are found
in most other countries including those in Europe, Asia, Africa and Latin America. Discuss
why this might be and think about how the DSM-5 criteria might change this.
Student Activities
1. Read the Time magazine article about PTSD in which the author states that he believes the
DSM-5 version of the diagnosis will make it easier for veterans to receive this diagnosis and
summarize how this might happen (http://nation.time.com/2013/05/14/an-easier-ptsd-
diagnosis/) in a 1-page paper.
2. Watch a film about PTSD such as The Best Years of Our Lives (1946) or Jarhead (2005) and
comment on how you believe the characters in these dramas would benefit from the DSM-5’s
evaluation of their situation. Write a 1–2 page paper on this.

26 – DSM-5 PRIMER
3. Read Still Here With Me: Teenagers and Children on Losing a Parent by Suzanne Sjöqvist
(2007) and apply it to Acute Stress Disorder as described by the DSM-5. How many of the
symptoms in the diagnostic criteria are the children describing? Write a 1-page paper.

DSM-5 PRIMER – 27
8. DISSOCIATIVE DISORDERS
Among the most recent revisions to these disorders include changes to Dissociative Identity
Disorder.
The changes in this category are interesting and important because they reflect a change in
acknowledging cultural differences (trance states are common in some societies and would not be
considered abnormal behavior in that context).
Depersonalization-Derealization
Here it is necessary that two conditions be met:
1. The disturbance is not caused by substance abuse or another medical condition.
2. That other conditions such as schizophrenia, panic disorder, major depressive disorder or
another dissociate disorder are not the cause of the diagnosis. This change allows for comorbid
diagnoses to exist.
Dissociative Amnesia
Minor wording changes for clarity.
Dissociative Identity Disorder
This is the interesting section where the possibility of an experience of possession is addressed. As
noted above, this makes this diagnosis more culturally useful.
Dissociative Identity Disorder Not Otherwise Classified
Only minor changes to make for consistency with DDI.
Discussion Starters
1. How do you differentiate between depersonalization and derealization? Do you think that the
DSM-5 changes were useful?
2. The DSM-5 is making some important cultural changes in considering the concept of
possession. How do you think this fits into medicine and science?
3. The DSM-5 is now including self-reporting as well as observation of others in this general
category. Do you think a patient can be objective if this is a mental disorder?

28 – DSM-5 PRIMER
Lecture Ideas
1. Read students segments of this article about 3 patients who believe they have been possessed.
Discuss in terms of the DSM-5.
http://www.hindawi.com/crim/psychiatry/2012/232740/
2. Compare Dissociative Fugue and Dissociative Amnesia. Both are types of dissociative
disorders. Given that the new DSM-5 combines these two, does this make sense?
In both instances, the patient has a severe loss of personal memory. Fugue is characterized by
the individual’s search for a new identity. They tend to leave their home and become
somebody else. In Dissociative Amnesia, individuals are not driven to seek a new identity.
Student Activities
1. Ask students to read an article about a man who disappeared: “The man with no memory:
Navy vet wakes up, speaks only Swedish” (http://www.cnn.com/2013/07/16/health/amnesia-
swedish/index.html). Address the issues described in the DSM-5 about lack of memory of
normal things (playing tennis). Why can’t he speak English? Thoughts about the trauma?
Write a 1-page paper about this.
2. Assign an article about placebos, “Placebo Effect Works Both Ways: Beliefs About Pain
Levels Appear to Override Effects of Potent Pain-Relieving Drug,” and ask them to relate this
to the concept of possession (i.e., how the power of belief can “trick” the brain). Write a 1–2
page paper on this concept and apply it to the DSM-5.
http://www.sciencedaily.com/releases/2011/02/110226212356.htm
3. Ask students to read a paper about the concept of possession and functional neurological
symptoms (“Investigation of the cerebral blood flow of an Omani man with supposed ‘spirit
possession’ associated with an altered mental state: a case report” at
http://www.jmedicalcasereports.com/content/3/1/9325). Discuss how the DSM-5 would
interpret this in a 2–3 page paper.

DSM-5 PRIMER – 29
9. SOMATIC SYMPTOM DISORDERS
This is a new category in the DSM and includes diagnoses of Somatic Symptom Disorder, Illness
Anxiety Disorder, Conversion Disorder and Factitious Disorder. What these diagnoses share in
common are somatic symptoms associated with significant distress and impairment. The patient
who is seen with these conditions is more likely to be seen in primary care settings than in
psychiatric or mental health settings.
The previous category in DSM-IV closest to this one is Somatoform Disorders. The editors of
DSM-5 said that there was often confusion and overlap in the older version, and so the number of
disorders has been reduced, as have the number of subcategories.
There is specific acknowledgement that somatic symptom disorders can accompany diagnosed
medical disorders and they note “it is not appropriate to give an individual a mental order diagnosis
simply because a cause cannot be demonstrated” (page 309).
It is noted that many patients who are given a somatic symptom diagnosis feel that their distress is
being marginalized and that these diagnoses are pejorative and demeaning.
Contributing factors to these conditions can include increased sensitivity to pain (genetic or
biological), trauma, learning and culture.
Somatic Symptom Disorder
The patient has somatic symptoms that are distressing and result in significant disruption of daily
life. These include excessive thoughts, feelings, behaviors related to the somatic symptoms or
associated health concerns. Their duration is six or more months.
Illness Anxiety Disorder
Currently, there are two populations of patients subsumed under the disorder. The first group of
hypochonriasis patients—approximately 75%—has somatic symptoms and is concerned about that.
The second group—approximately 25%—has minimal somatic symptoms but is concerned about
having a mysterious and serious illness. Group 1 will be classified as having a new diagnosis of
Somatic Symptom Disorder (SSD). Group 2 will remain in Illness Anxiety Disorder (IAD).
Conversion Disorder: Functional Neurological Symptom Disorder
The major change is the name change. Most patients with this disorder are seen by neurologists and
the name is preferred by patients. While it is noted that it would be impossible to prove a patient
were feigning the disorder, it is also noted that it is no more likely that the patient with this
diagnosis is deliberately pretending to have the problem.
Psychological Factors Affecting Medical Condition
Only minor wording changes.

30 – DSM-5 PRIMER
Factitious Disorder
Factitious Disorder, which once had its own category, is now grouped here. The APA notes that
there is often diagnostic overlap with Conversion Disorders and other Somatic Disorders and feels
it is appropriate to move it to this group.
Somatic Symptom Disorder Not Otherwise Classified
This is the category where patients exhibiting pseudocyesis (false pregnancy) are placed.
Discussion Starters
1. This category is one of the most controversial of the DSM-5 groups. There is concern on the
part of many that medical problems will be diagnosed as mental problems and that there will
be many conditions mislabeled. What kinds of problems can you imagine happening and do
you think that people will be at risk due to confusion of symptoms?
2. The body-mind dualism factor is directly addressed here. How do you think this fits with the
DSM-5 approach to health?
3. Do you think that a psychiatric diagnosis is necessarily demeaning or pejorative?
Lecture Ideas
1. This category is among the most hotly-contested groups. How does the DSM-5’s contention
that just because a medical diagnosis is not easily determined, it may be inappropriate?
2. Look at Anxiety Disorders and see if some of the somatic symptom disorders seem to fit better
in that category.
3. Some families have a higher than average number of diagnoses (cancer, Alzheimer’s,
Parkinson’s, schizophrenia, etc.). Are patients who are preoccupied with having or acquiring a
serious illness of this type justified (i.e., is this a healthy concern)?
Student Activities
1. Under Culture-Related Diagnostic Issues is the statement that changes resembling conversion
are common in certain culturally-sanctioned disorders. Ask students to find 3 of these changes
and to write a 1–2 page paper about their findings.
2. Ask students to watch the Hypochondriasis video and then write a 1-page reflection showing
how their observations compare with the DSM-5 criteria.
3. Have students watch the YouTube video on Conversion Disorder and write a 1-page reflection
paper on how their observations compare with the DSM-5 criteria.
http://www.youtube.com/watch?v=6xhypWbI0bk

DSM-5 PRIMER – 31
10. FEEDING AND EATING DISORDERS (REPLACES EATING

DISORDERS IN THE DSM-IV)
This new category allows clinicians to include infants, children and adolescents in addition to
adults.
Among the significant changes in this section is the addition of Binge Eating Disorder.
It is noted at the start of this chapter that sometimes individuals with feeding and eating disorders
behave in a way, or report experiencing behavior, that is similar to substance-abuse disorders
(craving, compulsion). The authors note that while the same neural systems are involved in both
types of disorders, there is not yet enough understanding to combine the groups.
Obesity is not included in the DSM-5 as a mental disorder. The opening notes to this chapter state
that “a range of genetic, physiological, behavioral and environmental factors that vary across
individuals contributes to the development of obesity” (page 329).
Pica
This disorder was originally in Disorders Usually First Diagnosed in Infancy, Childhood, or
Adolescence. The recommendation has been to move it since this condition can occur at any age.
This diagnosis can also be given in combination with other eating disorders, unlike those eating
disorders that do not become combined with each other.
Rumination Disorder
Avoidant/Restrictive Food Intake Disorder
Further, the APA notes that there are 3 distinct categories: individuals who do not eat enough/show
little interest in feeding or eating; individuals who accept only a limited diet in relation to sensory
features; and, individuals whose food refusal is related to aversive experience.
Anorexia Nervosa
The major shift here is not using the word “refusal” since it is judgmental and indicates intention.
This clarification may help the patient.
Similarly, deletion of the term “fear of weight gain” is proposed since many patients deny this.
Instead, the concept of behavioral change is recommended.

32 – DSM-5 PRIMER
Amenorrhea as a condition has been deleted since many patients do not manifest this problem.
The subtype of Binge Eating/Purging or Restricting is inserted here with a clarification of 3 months
duration.
Bulimia Nervosa
The important change is that this behavior occurs once rather than twice a week for a period of 3
months.
Binge Eating Disorder
Binge Eating Disorder is one of the disorders in the DSM-IV Appendix. It has now been moved to
this section.
Feeding or Eating Disorder Not Elsewhere Classified
It is noted that there is not sufficient data available at present to justify designating these conditions
as disorders. However, these conditions may be associated with levels of distress and/or
impairment similar to those associated with the recognized Feeding and Eating Disorders, and may
require intensive clinical intervention.
Atypical Anorexia Nervosa
All of the criteria for Anorexia Nervosa are met, except that, despite significant weight loss, the
individual’s weight is within or above the normal range.
Subthreshold Bulimia Nervosa (Low Frequency or Limited Duration)
All of the criteria for Bulimia Nervosa are met, except that the binge eating and inappropriate
compensatory behaviors occur, on average, less than once a week and/or fewer than 3 months.
Subthreshold Binge Eating Disorder (Low Frequency or Limited Duration)
All of the criteria for Binge Eating Disorder are met, except that the binge eating occurs, on
average, less than once a week and/or fewer than 3 months.
Other specific syndromes not listed in DSM-5:
Purging Disorder
Recurrent purging behavior to influence weight or shape, such as self-induced vomiting, misuse of
laxatives, diuretics, or other medications, in the absence of binge eating.

DSM-5 PRIMER – 33
Night Eating Syndrome
The patient repeatedly consumes a large amount of food after the evening meal or after awakening.
The patient is aware and remembers the behavior. It is not due to drugs or substance abuse, or other
medical problems.
Insufficient information:
Other Feeding or Eating Condition Not Elsewhere Classified
This is a residual category for clinically significant problems meeting the definition of a Feeding or
Eating Disorder but not satisfying the criteria for any other disorder or condition.
Discussion Starters
1. How do you think the decision to remove the category of disorders first appearing in infancy
or childhood affects the diagnoses of pica, rumination, and avoidant/restrictive food intake?
2. The removal of obesity as a mental disorder is important. In every class I have taught about
eating disorders, someone brings up the issues of anorexia and bulimia being overemphasized,
while those who have weight problems in the other direction are not discussed.
3. The issue of substance abuse disorders mimicking those of feeding and eating disorders has
been brought up, but then not dealt with, in this new version of the DSM. Why do you think
they did this?
Lecture Ideas
1. Discuss how the avoidant/restrictive food intake disorder compares with a child who only eats
hot dogs for several years. Do you think the child should be diagnosed with this condition
according to the DSM-5?
2. Pica and autism have been discussed as being comorbid. Having already learned about the
autism spectrum, how do you think these conditions work together?
3. The DSM-5 has changed the language in the section regarding anorexia so that refusal has
been omitted. The change is supposed to indicate that the intention of the patient to not eat is
no longer a factor. How do you think this reflects how culture and society has changed since
the last DSM?
Student Activities
1. Read a book about eating disorders (suggestions include Running on Empty: A Diary of
Anorexia and Recovery by Carrie Arnold or Wasted: A Memoir of Anorexia and Bulimia by
Marya Hornbacher) and write a brief paper of 1–2 pages about anorexia and bulimia in the
context of the DSM-5.

34 – DSM-5 PRIMER
2. An article in Psychology Today by Allen Frances, M.D. states: “Excessive eating 12 times in 3
months is no longer just a manifestation of gluttony and the easy availability of really great
tasting food. DSM-5 has instead turned it into a psychiatric illness called Binge Eating
Disorder” (http://www.psychologytoday.com/blog/dsm5-in-distress/201212/dsm-5-is-guide-
not-bible-ignore-its-ten-worst-changes). Do you agree or disagree? Write a 1–2 page opinion
piece on this.
3. Psychiatric Annals published an article by B. Timothy Walsh, M.D. discussing his opinion of
the DSM-5 chapter on eating disorders. Read the article and write a 1–2 page reflection on
this.
http://www.healio.com/psychiatry/journals/psycann/%7Bee1f3f3b-291d-4066-8826-
e83fd6a01687%7D/this-issue-eating-disorders-in-dsm-5

DSM-5 PRIMER – 35
11. ELIMINATION DISORDERS
This category contains diagnoses that were listed in DSM-IV under the chapter of Disorders
Usually First Diagnosed in Infancy, Childhood, or Adolescence.
Enuresis
No revisions are being recommended for this disorder at the current time.
Encopresis
No revisions are being recommended for this disorder at the current time.

36 – DSM-5 PRIMER
12. SLEEP-WAKE DISORDERS
This category contains diagnoses that were listed in DSM-IV under the chapter Sleep Disorders.
There is a greater inclusion of disorders not listed in the mental disorder section of the International
Classification of Diseases. This has been proposed primarily as a way to educate non-expert sleep
clinicians (such as psychiatrists and general medical physicians) about Sleep-Wake Disorders that
have mental as well as medical/neurological aspects. The opening discussion states that what all of
these disorders share in common is “daytime distress and impairment” (page 361). The comorbidity
of depression, anxiety and cognitive changes is discussed.
Insomnia Disorder
1. Replaces the terms “Primary Insomnia” and “Insomnia Related to Another Mental/Medical
Disorder” with Insomnia Disorder, with specification of clinically comorbid conditions.
2. Integrates the construct of sleep dissatisfaction to the definition of insomnia.
3. Adds early morning awakening as a separate symptom.
4. Adds a minimum frequency criterion (i.e., 3 nights per week) with sleep disturbance.
5. Raises the minimum duration threshold from 1 to 3 months for chronic insomnia.
6. Provides specific examples of daytime impairments (fatigue and daytime sleepiness).
7. Specifies that sleep disturbance occurs despite adequate opportunity for sleep.
Hypersomnolence Disorders
Includes the Hypersomnolence Disorder diagnostic criteria for consideration in DSM-5:
1. Replaces the term “Hypersomnia” with “Hypersomnolence.”

2. Replaces “Primary Hypersomnia” and “Hypersomnia Related to Another Mental/Medical
Disorder” with Major Somnolence Disorder, with specification of clinically comorbid
conditions.
3. Criterion A: Increases precision in the definition of excessive sleepiness symptoms.
4. Criterion A: Adds sleep inertia as a symptom.
5. Criterion B: Adds a minimum frequency criterion (i.e., 3 days per week) with excessive
sleepiness.
6. Criterion B: Raises the minimum duration threshold from 1 to 3 months for excessive
sleepiness.
7. Divides Hypersomnolence Disorders into 4 subtypes.
Narcolepsy/Hypocretin Deficiency
Major suggested change: Replacing “narcolepsy” with “narcolepsy/hypocretin deficiency.”
Obstructive Sleep Apnea Hypopnea Syndrome
Two substantial changes were made:

DSM-5 PRIMER – 37
1. Provides specific diagnostic criteria for Obstructive Sleep Apnea Hypopnea, Central Sleep
Apnea, and Sleep-Related Hypoventilation, rather than using only one set of criteria for
“Breathing Related Sleep Disorder.”
2. Includes polysomnographic criteria in the diagnostic criteria.
Central Sleep Apnea
The same substantial changes as for OSAHS were made:
Sleep-Related Hypoventilation
The same substantial changes as for OSAHS are made:
Circadian Rhythm Sleep-Wake Disorder (formerly Circadian Rhythm Sleep Disorders)
1. The name change encompasses all aspects of circadian rhythm.
2. The inclusion of subtypes of circadian subtypes to include: 1) Advanced Sleep Phase Type, 2)
Irregular Sleep-Wake Type, and 3) Non-24 Hour Sleep-Wake Type, while removing Jet Lag
Type and Unspecified Type, which were included in the DSM-IV.
Disorder of Arousal
Disorders of Arousal (Confusional Arousals, Sleepwalking, and Sleep Terrors) are considered to be
variations of a single neurophysiologic phenomenon—namely the simultaneous mixture of
elements of both wakefulness and NREM sleep—thereby resulting in the appearance of complex
motor behavior without conscious awareness (sometimes termed “state dissociation”).
Nightmare Disorder
The changes are mostly alterations in terminology—i.e., changing “repeated awakenings” to

“repeated occurrences”; replacing “extended and extremely frightening dreams, usually involving
threats to survival, security, or self-esteem” with “extremely dysphoric and well-remembered

38 – DSM-5 PRIMER
dreams that usually involve efforts to avoid threats to survival, security or physical integrity.”
Remove “(in contrast to the confusion and disorientation seen in Sleep Terror Disorder and some
forms of epilepsy).”
Remove “The dysphoric dreams do not occur exclusively during the course of another mental
disorder (e.g., a delirium, Posttraumatic Stress Disorder).” Change phrase “due to the direct
physiological effects of a substance” to “attributable to the direct physiological effects of a
substance.” Since Posttraumatic Stress Disorder is now a diagnosis, this allows for comorbidity
with this disorder.
Rapid Eye Movement Sleep Behavior Disorder
Emphasis on the possibility of injury to the patient or bed partner during these episodes.
Restless Legs Syndrome
Has been put into its own category.
Substance-Induced Sleep Disorder
Changes are primarily in terminology: “medication” is replaced by “substance.”
Nicotine is included as a substance that may cause a sleep disorder.
Sleep-Wake Disorders Not Elsewhere Classified
Insomnia Disorder Not Elsewhere Classified
Shorter than 3 months but also causing disruption of sleep for the patient.
Major Somnolence Disorder (Hypersomnia Not Elsewhere Classified)
All other sleep disorders responsible for excessive sleepiness must have been eliminated.
Discussion Starters
1. The idea behind this particular chapter has been termed by its creators as “splitting and
lumping” different sleep and wake disorders into the most logical type of reorganization. How
do you think this approach has worked out?
2. The age range of these disorders now goes from infancy to old age. Does this kind of
longitudinal approach make sense?
3. In addition to the cognitive influence, mood can also be greatly affected by sleep-wake
disorders. Do you think the DSM-5 has placed enough emphasis on this factor?

DSM-5 PRIMER – 39
Lecture Ideas
1. Too much or too little sleep is not healthy. Go through some of the diagnoses and discuss how
they could impact a patient’s mental health.
2. Are sleep problems a possible precursor to more serious psychiatric problems?
3. Go through the longitudinal study of someone with sleep disorders and examine how early
sleep problems could lead to other sleep problems later in life.
Student Activities
1. Ask students to keep a sleep journal for 2 weeks and to write down any sleeping problems they
notice, in an attempt to account for differences in quality of sleep.
2. Sleepwalk With Me was written, directed, and acted by Mike Birbiglia, based on his true-life
journey as a comedian living with REM Sleep Behavior Disorder. Ask students to watch the
film and to compare it to the DSM-5 description of this disorder.
3. Ask students to read Wide Awake and Dreaming: A Memoir of Narcolepsy by Julie Flygare
and to comment on the author’s experiences as compared to the DSM-5 description (2–3
pages).

40 – DSM-5 PRIMER
13. SEXUAL DYSFUNCTIONS
This category contains diagnoses that were listed in DSM-IV under the chapter Sexual and Gender
Identity Disorders.
Sexual Dysfunctions
In all these diagnoses, the terms marked distress or interpersonal difficulty will be replaced with
clinically significant distress or impairment.
1. Erectile Dysfunction: In order to define homogenous groups for clinical research, a more
precise definition is needed. The terms marked distress or interpersonal difficulty have been
widely interpreted by various investigators and has led to inconsistent definitions of
syndromes. Separation of the reaction to a disorder from its definition should allow for more
precise definitions of the entities being studied.
2. Female Orgasmic Dysfunction: There is a suggested change to reflect more of a continuum

regarding orgasm sensitivity. The condition must occur 75% of the time or more over a 6-
month period. Cultural prohibition regarding orgasm is also considered as a factor.
3. Delayed Ejaculation replaces the term Inhibited Male Orgasm. As with Erectile Dysfunction,
the terms marked distress or interpersonal difficulty have been widely interpreted and this is
an attempt to make the definitions more clear and consistent.
4. Early Ejaculation replaces the term Premature Ejaculation. “Substitute descriptive

terminology for an inaccurate, pejorative term” shows increased sensitivity to these issues.
5. Female Sexual Interest/Arousal Disorder: “The word ‘desire’ is changed to ‘interest.’ Desire
connotes a deficiency and often implies a biological urge.” The APA also notes “There is no
such thing as ‘spontaneous’ sexual desire.”
6. Male Hypoactive Sexual Desire: The APA is recommending that the term Hypoactive Sexual
Desire Disorder be switched to Male Hypoactive Sexual Desire Disorder.
7. Genito-Pelvic Pain/Penetration Disorder replaces Vaginismus and Dyspareunia. The APA

notes that it has been difficult to differentially diagnose these conditions and feels that it is
important that the disorder be so reflected in the DSM-5.
8. Substance/Medication Induced Sexual Dysfunction: All of these have been synched with the
Substance Use and Addictive Disorders Category.
9. Sexual Dysfunction Not Otherwise Classified is still being worked on as of this writing.
The sexual disorders have all been changed in terms of length of time. It is now 6 months duration
or longer for all cases. This is supposed to avoid over-diagnosis of these conditions.

DSM-5 PRIMER – 41
Genito-Pelvic Pain/Penetration Disorder is a new diagnosis and is a combination of two previous
disorders: Vaginismus and Dysperunia. The authors of this version point out that there is much co-
morbidity and difficulty separating these conditions and that it is simpler to combine them.
Both culture and the effects of aging are considered in this section and there is more sensitivity to
religious upbringing as a factor in sexual difficulties in this newer edition.
The section entitled Substance/Medication-Induced Sexual Dysfunction is considered to be a

temporal effect of the substance/medication.
Discussion Starters
1. Allen J. Frances, M.D. has made several comments about how he feels that this particular
chapter has made serious errors. “Sexuality is an inherently difficult arena for psychiatric
diagnosis because: 1) the field has generated remarkably little research and few researchers; 2)
there are no consensus norms in sexual behavior to provide a useful boundary in deciding what
constitutes a sexual mental disorder; 3) individual and cultural biases play a large and difficult
to sort out role, and; 4) decisions regarding the diagnosis of sexual disorders can have
profound and unanticipated forensic and societal implications.” How would you respond to
these charges? (http://www.psychologytoday.com/blog/dsm5-in-distress/201003/dsm5-sexual-
disorders-make-no-sense)
2. There are many changes in terminology in the DSM-5 version of this section. Do you think
that the renaming will be helpful to patients?
3. The effects of culture may have stronger effects for this section than most others. How do you
think a health care provider could be more sensitive to these issues if it is not immediately
apparent what background the patient has?
Lecture Ideas
1. Discuss how sexual expectations have changed from when the DSM-III (1980) and DSM-IV
(1994) were written.
2. The idea of lifetime/acquired and generalized/situational issues is receiving more attention

than in previous editions. Discuss how this affects the way diagnoses are given.
3. As the chapter specifically states, sexual response has a requisite biological underpinning, but
is also experienced within a context that may include social and cultural factors. Devise a
discussion around how this change in the DSM-5 might be interpreted.
Student Activities
1. Have students examine how sexuality is viewed in different cultures and write a brief 1–2 page
paper about how this would fit into the cultural sensitivities discussed in the DSM-5.

42 – DSM-5 PRIMER
2. Have students examine how sexuality has changed over different periods and write a 1–2 page
paper relating this to the DSM-5.
3. The DSM-5 notes that if the sexual dysfunction is mostly explainable by another nonsexual
mental disorder, then only that other diagnosis should be made. Write a brief 1–2 page paper
agreeing or disagreeing with this and explain why.

DSM-5 PRIMER – 43
14. GENDER DYSPHORIA
This chapter is going to be an extremely controversial one. Recognizing this, the APA notes that
even the chapter terminology may be stigmatizing and has suggested that Gender Incongruence
might be a more appropriate term. There is not always distress involved in this diagnosis.
Gender Dysphoria occurs in two sub-groups:
• Children
• Adolescents and adults
The changes are that the child must have a minimum of 6 months of feeling that he/she is assigned
the wrong sex. This is a must for this diagnosis, with several other combinations that may also add
to the diagnosis.
The APA realizes that Gender Identity Disorder (GID) may be a stigmatizing diagnosis and has
proposed that the term be changed to Gender Incongruence. This change will most likely appear in
the next DSM manual. Also of note, the committee discussed the issue of whether this was a
psychiatric or medical condition and decided to leave that open in an attempt to help patients obtain
insurance coverage for cross-gender hormones, sexual reassignment and other therapies.
Gender Dysphoria involves a marked incongruence between one’s experienced/expressed gender

and assigned gender, of at least 6 months duration. The issue of medical vs. psychiatric diagnosis
was also raised here. It was noted that many of the individuals with Gender Incongruence ceased
having distress once they were on cross-gender hormones or had had sexual reassignment. Ceasing
the treatment would cause the individual to again experience distress.
Overall, there is an increased sensitivity to not stigmatizing the patient. There are many who feel
that this is not a psychiatric condition at all and that it should not be listed as such.
Discussion Starters
1. Many have said that the progression of Gender Dysphoria is reminiscent of the progression of
homosexuality in that it is changing as society changes and that it should no longer be
considered a mental health issue.
2. How should this condition be considered and do you believe that it is a choice?
3. Many trans people disagree with the idea of distress being part of the diagnosis. What is your
view?
Lecture Ideas
1. Watch YouTube video “16x9: Inside the Wrong Body: Gender Identity Disorder at a young
age”: http://www.youtube.com/watch?v=cE3YMMOs4LY

44 – DSM-5 PRIMER
2. Watch “Gender Identity Disorder Debate”

http://www.youtube.com/watch?v=nVuVEXiFsW8
3. Watch “TransByDef Monday: Cadence Jean on Gender Dysphoria!”

http://www.youtube.com/watch?v=Rh994_rkWsY
Use any of the above videos to encourage conversation regarding this category and make sure that
it is clear that the individuals have been screened for any other physical or psychological problems
and that those have been ruled out.
Student Activities
1. Have students read Annabel by Kathleen Winter. Write a 3-page paper on how the book
matches or doesn’t match DSM-5.
2. Ask students to watch Ma Vie En Rose and write a 2-page paper on how it relates to the DSM-
5 chapter.
3. Have students watch Boys Don’t Cry and write a 2-page reflection paper on how the lead
character fits the DSM-5 criteria. You could also ask them to address the changes from the
time the film was made (1999) to present.

DSM-5 PRIMER – 45
15. DISRUPTIVE, IMPULSE CONTROL, AND CONDUCT

DISORDERS (PREVIOUSLY UNDER DISORDERS OF
CHILDHOOD AND ADOLESCENCE)
This category contains diagnoses that were listed in DSM-IV under the chapter Disorders Usually
First Diagnosed in Infancy, Childhood, or Adolescence and Impulse Control Disorders Not
Elsewhere Classified. Please note that the proposed criteria and rationale for Disruptive Mood
Dysregulation Disorder can be found in the Depressive Disorders section.
Among the most recent revisions are changes in the frequency criterion for Oppositional Defiant
Disorder and the addition of an age requirement (18 years) for the diagnosis of Intermittent
Explosive Disorder. The Callous and Unemotional Specifier now includes clarified wording and
some additional guidance on use. Finally, the work group has proposed criteria for Disruptive
Behavior Disorder Not Elsewhere Classified.
These disorders all share problems in emotional and behavioral self-control. Because of its close
association with conduct disorder, antisocial personality disorder has a dual listing in this chapter
and in the chapter on Personality Disorders. Although ADHD is frequently comorbid with the
disorders in this chapter, it is listed under Neurodevelopmental Disorders.
Oppositional Defiant Disorder
Four recommendations were made by the APA for changes in this diagnosis:
1. The major symptoms for ODD should remain the same.

2. Remove exclusionary criteria for Conduct Disorder.
3. Organize emotional and behavioral symptoms so as to distinguish between them.
4. Develop a severity scale.
Four refinements have been made to the criteria for Oppositional Defiant Disorder. First, symptoms
are now grouped into three types: angry/irritable mood, argumentative/defiant behavior, and
vindictiveness. This change highlights that the disorder reflects both emotional and behavioral
symptomatology. Second, the exclusion criterion for Conduct Disorder has been removed. Third,
given that many behaviors associated with symptoms of Oppositional Defiant Disorder occur
commonly in normally developing children and adolescents, a note has been added to the criteria to
provide guidance on the frequency typically needed for a behavior to be considered symptomatic of
the disorder. Fourth, a severity rating has been added to the criteria to reflect research showing that
the degree of pervasiveness of symptoms across settings is an important indicator of severity.
Intermittent Explosive Disorder
This diagnosis can be made in older adolescents and young adults aged 18 or older in addition to
the diagnosis of Attention-Deficit/Hyperactivity Disorder, Oppositional Defiant Disorder, Conduct
Disorder, or Autistic Spectrum Disorder when recurrent impulsive aggressive outbursts warrant
independent clinical attention. In the DSM-IV, physical aggression was necessary for this

46 – DSM-5 PRIMER
diagnosis. Now, verbal aggression and non-destructive/noninjurious physical aggression also meet
criteria in the DSM-5.
To distinguish between “normal” temper tantrums, a minimum age of 6 years (or equivalent
developmental level) is now required. Finally, especially for youth, the relationship of this disorder
to other disorders (e.g., ADHD, disruptive mood dysregulation disorder) has been addressed.
Conduct Disorder
The criteria for conduct disorder are largely unchanged from DSM-IV. An additional specifier for
Callous and Unemotional Traits in Conduct Disorder has been proposed.
Dyssocial Personality Disorder (Antisocial Personality Disorder)
The name of the disorder has been changed to DPD. As in prior DSMs, there is a minimum age of
18 for this diagnosis and for those who previously had signs of Conduct Disorder prior to age 15.
Discussion Starters
1. How do you think the change of placement from the category of Childhood Disorders affects
the consideration of this spectrum of disorders?
2. Do you think that the changes to Intermittent Explosive Disorder might affect issues such as
bullying by including verbal and emotional abuse?
3. Do you think our culture has changed with respect to labeling individuals with these disorders?
How might receiving a label of Conduct Disorder before age 15 change a person’s life?
Lecture Ideas
1. Watch the “Ed: Impulse Control Disorder” video and compare how Ed’s gambling impulsivity
matches the DSM-5 criteria. Analyze how his condition fits in this group and also note that it
is under Non-Substance Related Disorders within Substance-Related and Addictive Disorders.
Discuss how they fit or don’t fit with each.
2. There can be cultural issues related to Conduct Disorders. The DSM-5 specifically cites
situations where patterns of disruptive behavior are seen as being near-normative (in especially
threatening situations, in war zones, in high crime areas). Discuss the role of context.
3. There appear to be gender-related diagnostic issues in Conduct Disorders and how behavior is
manifested (males tend to be more physical and relationally aggressive whereas females tend
to be more relationally aggressive). Discuss why these differences might exist and how it
relates to the condition as described in the DSM-5.

DSM-5 PRIMER – 47
Student Activities
1. Ask students to watch the sci-fi film Impulse Control and apply what they have learned about
this condition to the film. Write a 1–2 page reflection paper.
2. Ask students to watch “Dear Teacher, I Have Conduct Disorder.” Write a 1-page paper
discussing how this fits the DSM-5 description.
http://www.youtube.com/watch?v=pr5k_MEXz6E
3. Antisocial Personality Disorder is listed in the DSM-5 under this chapter, under Substance-
Related and Addictive Disorders and also under Personality Disorders. Watch this video and
write a 1–2 page paper on this personality type as it relates to the DSM-5.
http://www.youtube.com/watch?v=TCBSU7CsYcc

48 – DSM-5 PRIMER
16. SUBSTANCE USE DISORDERS (PREVIOUSLY

SUBSTANCE USE AND ADDICTIVE DISORDERS)
There are no major changes to the following. These disorders will be listed both in the Substance
Use and Addictive Disorders chapter and in the chapter containing the induced disorder. Please see
below for a list of these disorders.
• Substance-Induced Psychotic Disorder

• Substance-Induced Bipolar Disorder
• Substance-Induced Depressive Disorder
• Substance-Induced Anxiety Disorder
• Substance-Induced Obsessive-Compulsive or Related Disorders
• Substance-Induced Sleep-Wake Disorder
• Substance-Induced Sexual Dysfunction
• Substance-Induced Delirium
• Substance-Induced Neurocognitive Disorder
Important changes to this category are the addition of Gambling to Substance Use Disorders
(previously, this was in the OCD category).
This committee has also recommended that the following disorders be put into Category III, which
contains conditions that require further study:
• Neurobiologic Disorders Associated with Prenatal Alcohol Exposure

• Caffeine Use Disorder
• Internet Disorder
For the following substance problems, the APA has recommended combining Substance Abuse and
Dependence Into One Disorder.
• Alcohol-Related Disorders R
• Caffeine-Related Disorders
• Cannabis-Related Disorders
• Hallucinogen-Related Disorders
• Inhalant-Related Disorders
• Opioid-Related Disorders
• Sedative/Hypnotic-Related Disorders R 27–30
• Stimulant-Related Disorders
• Tobacco-Related Disorders
• Unknown Substance Disorders
• Gambling Disorder
Some of the most important changes to this group are the addition of gambling disorder as a non-
substance related disorder.

DSM-5 PRIMER – 49
The writers of the DSM-5 note that impulsivity or low self-control may be early predictors of
Substance Abuse Disorders (in fact these may be seen long before there is an actual substance
abuse problem).
Significantly, the previous distinctions between “abuse” and “dependence” have been removed
from this edition of the DSM-5. Now, rather than having two separate categories, this line is seen
as being part of a continuum.
The authors of the DSM-5 also note that the wiring of the brain changes whether or not the
individual is currently using a substance, and they use this as an explanation for high recidivity or
relapse.
Social impairment and a resultant deterioration of relationships, ability to work or function in

society are also addressed as factors that show up in any number of Substance Use Disorders.
They also address the creation of mental disorders through substance abuse when it did not
previously exist, and have added a clause that includes repeated problems with the legal system as
part of the entire picture.
Discussion Starters
1. Over time, the idea of Substance-Related and Addictive Disorders has become much more
neurologically-oriented. Talk about the addiction model as it has evolved for the DSM-5.
2. The concept of stimulating pleasure centers with addiction is a fairly new one. Discuss how
gambling fits into a Substance-Related and Addictive Disorder model.
3. The connection between impulsivity and addiction brings ADHD models into the arena.
Discuss how these comorbidities fit into the DSM-5 model.
Lecture Ideas
1. Watch MyPsychLab videos of Ed and Chris and discuss similarities and differences and how
they relate to the new DSM-5.
2. The gender differences of addiction are significant. Discuss this and relate it to the comments
made in the DSM-5.
3. The culture-related diagnostic issues mentioned in the DSM-5, particularly relating to “legal”
drugs such as alcohol and tobacco, have changed to reflect our changing society’s view of the
use of these substances. Discuss the changes and how you think they will affect diagnostic
choices.

50 – DSM-5 PRIMER
Student Activities
1. Have students watch Reefer Madness (1936) and write a 1–2 page paper about how views of
addiction and the use of this substance have changed.
2. Ask students to watch Flight (2012) and write a 1–2 page paper about alcoholism and the
DSM-5.
3. Beautiful Boy: A Father’s Journey Through His Son’s Addiction is a book by David Sheff
about crystal meth addiction. Ask students to read the book and to note the social and
physical/neurological changes as commented on in the DSM-5.

DSM-5 PRIMER – 51
17. NEUROCOGNITIVE DISORDERS
This category contains diagnoses that were listed in DSM-IV under the chapter of Delirium,
Dementia, Amnestic, and Other Cognitive Disorders. There has been a recommendation that the
category be divided into three broad syndromes: Delirium, Major Neurocognitive Disorder, and
Mild Neurocognitive Disorder. The APA has also modified the diagnostic criteria for
Neurocognitive Disorder due to Alzheimer’s disease to maintain consistency with newly published
consensus criteria. Finally, Neurocognitive Disorder Not Elsewhere Classified has been newly
added. The APA notes that while cognitive defects are noticeable in many mental disorders such as
schizophrenia or bipolar disorders, the NCD diagnosis is used only when cognition is the main
factor in the diagnosis.
Delirium
Terminology change—“Consciousness”—is too nebulous a term to describe the symptoms of

delirium. “Awareness” has been deemed a better term. Visuospatial impairment and impairment in
executive function are key symptoms of delirium; the group has also added a clarification that a
preexisting neurocognitive disorder does not account for the cognitive changes.
Substance-Induced Delirium
This diagnosis should be made instead of a diagnosis of Substance Intoxication or Substance

Withdrawal only when the symptoms fulfill full criteria for a DSM-5 delirium and when the
symptoms are sufficiently severe to warrant clinical attention.
Mild Neurocognitive Disorders
Minor Neurocognitive Disorder has been added to recognize the substantial clinical needs of
individuals who have mild cognitive deficits in one or more of the same domains but can function
independently (i.e., have intact instrumental activities of daily living), often through increased
effort or compensatory strategies. This syndrome, known in many settings as Mild Cognitive
Impairment, may be particularly critical, as it may be a focus of early intervention. Early
intervention efforts may enable the use of treatments that are not effective at more severe levels of
impairment and/or neuronal damage, and, in the case of neurodegenerative disease, may enable a
clinical trial to prevent or slow progression. This is perhaps the most important change to this
category.
Major Cognitive Disorder
Major Neurocognitive Disorder (including what was formerly known as Dementia) is a disorder
with greater cognitive deficits in at least one (typically two or more) of the following domains:
• Complex attention (sustained attention, divided attention, selective attention, processing

speed)
• Executive ability (planning, decision-making, working memory, responding to
feedback/error correction, overriding habits, mental flexibility)

52 – DSM-5 PRIMER
• Learning and memory (immediate memory, recent memory (including free recall, cued
recall, and recognition memory))
• Language (expressive language (including naming, fluency, grammar and syntax) and
receptive language)
• Visuoconstructional-perceptual ability (construction and visual perception)
• Social cognition (recognition of emotions, theory of mind, behavioral regulation)
The cognitive deficits must be sufficient to interfere with functional independence. Important
changes from the DSM-IV criteria include: change in nomenclature (MNCD or Dementia), not
necessarily requiring memory to be one of the impaired domains, allowing cognitive deficit limited
to one domain.
The term “Dementia” is replaced by Major Neurocognitive Disorder, which is conceptualized as

including what was formerly known as dementia as well as entities like amnestic disorder.
“Dementia” is an accepted term for older adults (e.g., with Alzheimer’s disease)—although even in
this setting it has acquired a pejorative or stigmatizing connotation. It is less well accepted among
younger adults with related deficits, e.g., HIV or head injury. The sensitivity to labeling is an
important change in this category.
Subtypes of Major and Mild Neurocognitive Disorders
There are 12 subtypes and there are some significant changes in the diagnoses and understanding of
these diseases. In all cases, the understanding of, and diagnostic tools available for, this category is
driving the changes suggested.
1. Neurocognitive Disorder Due to Alzheimer’s Disease: It is suggested that there be even more
specific diagnostic coding to include psychosis and depression. These may or may not be part
of the patient’s symptoms.
2. Vascular Neurocognitive Disorder: The old concept of Multi-infarct Dementia, which the
DSM-IV Vascular Dementia adhered to, has been replaced by a much broader concept of
dementia due to both small and large vessel disease.
3. Frontotemporal Neurocognitive Disorder: Frontotemporal degeneration can be difficult to

distinguish from primary psychiatric disorders, and including them in DSM-5 should help
clinicians make this distinction.
4. Neurocognitive Disorder Due to Traumatic Brain Injury: This subcategory is currently under
consideration.
5. Neurocognitive Disorder Due to Lewy Body Dementia: The importance of this disease has
increased (it is now the 2nd most common neurocognitive disorder).
6. Neurocognitive Disorder Due to Parkinson’s Disease
7. Neurocognitive Disorder Due to HIV Infection

DSM-5 PRIMER – 53
8. Substance-Induced Neurocognitive Disorder
9. Neurocognitive Disorder Due to Huntington’s Disease
10. Neurocognitive Disorder Due to Prion Disease
11. Neurocognitive Disorder Due to Another Medical Condition
12. Neurocognitive Disorder Not Elsewhere Classified
As an important note, the term dementia is still retained in the DSM-5 with the explanation that this
preserves continuity and that physicians and patients both are accustomed to this term. It is
considered to still be appropriate for old age-related conditions, but the newer categorization of
Neurocognitive Disorder is now being used for younger patients who are exhibiting impairment as
a result of HIV infection or traumatic brain injury. The APA also notes that NCD is a broader term
and can be used for conditions that are due to another medical condition, as well.
Discussion Starters
1. The “Baby-Boomer Generation” is now reaching its sixties and seventies, so it makes sense
that the DSM-5 is placing more attention on Alzheimer’s and major and minor NCD. Discuss.
2. The public is becoming more and more aware of NCD from sports injuries. One insurance
company is sponsoring proper fitting of helmets and underwriting some of the cost of the
helmets themselves. How do you think this awareness is going to change NCD for younger
individuals?
3. As neuroimaging becomes progressively better, earlier diagnosis of many NCDs will be

earlier, and presumably, treatment can begin sooner. How do you think this will change the
next version of the DSM?
Lecture Ideas
1. Watch Alvin’s Alzheimer’s video from MyPsychLab and discuss how this video fits with the
DSM-5.
2. Watch the YouTube video “Lewy Bodies Dementia”:

http://www.youtube.com/watch?v=KG0VSZeYPHs
3. Watch the YouTube video “Arnold Palmer Hospital - Concussions & Head Injuries in Young
Athletes”: http://www.youtube.com/watch?v=bHDWAqX3MLU

54 – DSM-5 PRIMER
Student Activities
1. Have students read Still Alice by Lisa Genova (2009), a fictional work by a neuroscientist
describing early onset Alzheimer’s, and write a paper of 2–3 pages describing how this fits
with the DSM-5.
2. Assign either the book My Stroke of Insight by Jill Bolte Taylor (2009) or have students watch
the TEDtalk video of this neuroscientist describing her own journey and realizations as she
suffers and recovers from a debilitating stroke (2008).
http://www.ted.com/talks/jill_bolte_taylor_s_powerful_stroke_of_insight.html
3. Have students read The Wildness by Samantha Harvey (2009), another novel about a man
experiencing Alzheimer’s. Write a 1–2 page paper about this book and how it relates to the
disease as described in the DSM-5.

DSM-5 PRIMER – 55
18. PERSONALITY DISORDERS
This group has some of the most significant changes of any category. The problems of co-
morbidity and lack of agreement for many diagnoses is finally being addressed by the APA.
Despite this, none of the criteria for personality disorders have changed in the DSM-5. While
several proposed revisions were drafted that would have significantly changed the method by
which individuals with these disorders are diagnosed, the APA decided to retain the DSM-IV
categorical approach with the same 10 personality disorders. Personality Disorders is listed in both
Section II (Diagnostic Criteria and Codes) and in Section III (Emerging Measures and Models)
under the heading Alternative DSM-5 Model for Personality Disorders. The editors of this chapter
note that they hope that both versions will be helpful, with the first being used primarily for clinical
practice and the second for research initiatives.
As an overall change for this group, the APA is noting the comorbidity of conditions within this
category and the lack of agreement when assigning a diagnosis. Consequently, the APA is
suggesting a hybrid dimensional-categorical model for personality and PD assessment, and
diagnosis is proposed for DSM-5. Family history, personal history (abuse), medical history (suicide
attempts) and an assignment of the severity of the disorder seem to be more important than the
actual former diagnoses within PD.
The Clusters A, B & C are unchanged from DSM-IV. Other Personality Disorders listed in a
separate category are Personality Changes Due to Another Medical Condition, Other Specified
Personality Disorder (used when there are mixed personality features) and Unspecified Personality
Disorder (used when symptom characteristics are present but do not meet the full criteria used in
specific diagnoses).
Discussion Starters
1. Why did the DSM-5 take such a different approach with this category?
2. Why does the manual warn against making judgments about personality functioning without
taking into account culture of origin? Why would this category be any different from any other
disorders?
3. Under the differential diagnosis, for General Personality Disorder, there is a notation that “A
personality disorder should be diagnosed only when the defining characteristics appeared
before early adulthood.” Often a health professional does not meet the patient until he/she is an
adult, so how can this be done/ascertained?
Lecture Ideas
1. Watch the MyPsychLab video with Liz and Borderline Personality Disorder. How does the
video match what is described in the DSM-5?

56 – DSM-5 PRIMER
2. The actress Glenn Close, who portrayed a woman with a borderline personality in Fatal
Attraction, has formed an organization, Bring Change 2 Mind, to help reduce the stigma of
mental illness. Discuss the responsibility of entertainers to be responsible for the public’s
perception of mental disorders. How do the changes in the DSM-5 impact this?
3. Watch the YouTube video “Avoidant Personality Disorder” and discuss how this video shows
the DSM-5 diagnosis criteria. http://www.youtube.com/watch?v=vIsg2V0mf6Y
Student Activities
1. Have students watch Goodfellas (1990) and write a 1–2 page paper about antisocial
personality disorder as portrayed in film and as described in the DSM-5.
2. Have students watch A Streetcar Named Desire (1951) and write a 1–2 page paper about
narcissistic personality disorder as portrayed in the film and as described in the DSM-5.
3. Have students watch Beauty and the Beast (1991) and write a 1–2 page paper about schizoid
personality disorder as portrayed in the film and as described in the DSM-5.

DSM-5 PRIMER – 57
19. PARAPHILIC DISORDERS
The APA is changing the name of this category from Paraphilias to Paraphilic Disorders.
There are some important changes in the way these conditions are being viewed.
Changes Affecting the Diagnostic Criteria for All Paraphilic Disorders
The APA is now distinguishing between whether paraphilias are necessarily mental disorders. This
change is of major importance to this category. The entire category is retaining the distinction
between normative and non-normative sexual behaviour, but stops at the labeling of non-normative
sexual behaviour as being psychopathological. This is a huge shift. A diagnosis such as
transvestism no longer requires that the patient be either distressed or impaired by his behaviour—
i.e., the patient is neither harming, or being harmed by, his behavior.
Another change is the ability to note that the patient is in a controlled environment or that the
condition is in remission.
This applies to all of the following sub-categories:
• Exhibitionistic Disorder
• Fetishistic Disorder
• Frotteuristic Disorder
• Pedophilic Disorder
• Sexual Masochism Disorder
• Sexual Sadism Disorder
• Transvestic Disorder
• Voyeuristic Disorder
• Paraphilic Disorders Not Elsewhere Classified
Discussion Starters
1. There has been quite a bit of upset from members of the communities that are represented in
these groups that the paraphilias are not considered to be mental disorders as long as they do
not cause personal distress to the subject, but that they do qualify as mental disorders if the
person does express personal distress. This has been likened to the evolving diagnosis to non-
diagnosis of homosexuality.
2. In the past, paraphilic disorders were grouped with gender and sexual disorders. Obviously,
this is a huge change and one that reflects society’s changing attitudes. Comment on these
changes.
3. Have students watch the MyPsychLab video of Jocelyn and sadomasochistic disorder and
comment on how this fits with DSM-5 changes.
Lecture Ideas

58 – DSM-5 PRIMER
1. Have students watch “Paraphilias and Sexual Obsessions Talk w/ Rachael Bell”:
http://www.blogtalkradio.com/behindtheyellowtape/2012/03/10/paraphilias-and-sexual-
obsessions-talk-w-rachel-bell.
2. Discuss the idea of continuum of behavior for paraphilias and how this relates to the new
version of the DSM.
3. If the paraphilia is such that there is no victim, should it be considered a mental disorder?
Student Activities
1. Ask students to watch 9 1/2 Weeks (1986) and write a 1–2 page paper about sadomasochism
and how it relates to the DSM-5.
2. Ask students to watch Sliver (1993) and write a 1–2 page paper about exhibitionism and how it
relates to the DSM-5.
3. Ask students to read Hotel Honolulu by Paul Theroux (2001) and write a 1–2 page paper about
voyeurism and the DSM-5.

DSM-5 PRIMER – 59
20. OTHER DISORDERS
There are four disorders in this chapter: Other Specified Mental Disorder Due to Another Medical
Condition, Unspecified Mental Disorder Due to Another Medical Condition, Other Specified
Mental Disorder, and Unspecified Mental Disorder.
Other Specified Mental Disorders Due to Another Medical Condition
This was previously under Amnestic Disorder NOS or Demential NOS. This is to be used in cases
where symptoms are the result of a medical condition that is creating considerable distress in
social, occupational or other activities of daily living, but that does not meet the full criteria for any
specific mental condition. The diagnostic code for the specific medical condition is to be listed just
before this diagnosis. The example cited by the APA is Dissociative Symptoms in the context of
seizures.
Unspecified Mental Disorder Due to Another Medical Condition
This was previously listed under Cognitive Disorder NOS. This differs from the previous diagnosis
in that the person making the diagnosis does not have sufficient information to make a more
specific diagnosis. This would particularly be useful in emergency room settings where the
physician or diagnostician would not have a full complement of prior medical history or tests to
make a more specific diagnosis.
Other Specified Mental Disorder
This was previously listed under Unspecified Mental Disorder (nonpsychotic) and should be used
when the symptoms do not meet the full criteria for any specific mental disorder (as opposed to
medical disorder used in the first category).
Unspecified Mental Disorder
This was previously listed under Unspecified Mental Disorder (nonpsychotic), the same as Other
Specified Mental Disorder.
This diagnosis would be used when the symptoms do not meet the full criteria for any mental
disorder, but which result in the presentation of clinically significant distress or impairment. This
diagnosis would be appropriate for emergency room settings.
Because this is a category that is much less specific than other categories, I am not going to include
Lecture Ideas or Student Activities. It would be extremely difficult to illustrate any of these
diagnoses.
I do think it would be useful to have discussions about this category.

60 – DSM-5 PRIMER
Discussion Starters
1. Why do you think these diagnoses exist in this category?
2. Can you think of reasons why these particular diagnoses might be useful/used?
3. There are many other cases of comorbidity with diagnoses. Why might it be useful to
document the mental aspects in this way?

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2. SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC

Sub-group 1. Attenuated Psychosis Syndrome (APS) in Section 3 (Appendix) of DSM-5

Schizotypal Personality Disorder

There are several subtypes suggested:

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• Specify if delusions are bizarre.

The APA recommends three changes:

1. Dropping the requirement that the delusion be non-bizarre

Brief Psychotic Disorder

No substantial changes from DSM-IV.

Substance-Induced Psychotic Disorder

No substantial changes from DSM-IV.

Psychotic Disorder Associated with Another Medical Condition

Catatonic Disorder Associated with Another Medical Condition

Recommendations include: Catatonia should be a specifier and not a subtype of schizophrenia in

No substantial changes from DSM-IV.

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Exclusions from the diagnosis of schizophrenia will include:

Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder,

Psychotic Disorder Not Elsewhere Classified

No substantial changes from DSM-IV.

Catatonic Disorder Not Elsewhere Classified

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3. BIPOLAR AND RELATED DISORDERS

This section was not as changed as extensively as many others.

No significant changes from DSM-IV.

Substance-Induced Bipolar Disorder

Bipolar Disorder Associated with Another Medical Condition

Still being reviewed by the APA.

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1. Watch Boy Interrupted (http://www.hbo.com/documentaries/boy-interrupted/index.html) and

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Disruptive Mood Dysregulation Disorder

Major Depressive Disorder, Single Episode

Major Depressive Disorder, Recurrent Episodes

Premenstrual Dysphoric Disorder

Previously in the Appendix, APA is recommending that it be moved to Depressive Disorder. It is

Substance-Induced Depressive Disorder

Depressive Disorder Associated with Another Medical Condition

Still being considered.

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Depressive Disorder Not Elsewhere Classified

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Social Phobia/Social Anxiety Disorder

Substance-Induced Anxiety Disorders

Anxiety Disorder Attributable to Another Medical Condition

Anxiety Disorder Not Elsewhere Classified

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6. OBSESSIVE-COMPULSIVE AND RELATED DISORDERS

Obsessive Compulsive Disorder