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NEURODEVELOPMENTAL DISORDERS

DSM-5 replaces the chapter on disorders first diagnosed in infancy, childhood, or adolescence with a new chapter, Neurodevelopmental Disorders. These disorders first appear in the early developmental period, generally before a child first starts school. The resulting deficits cause difficulties in personal, social, and academic functioning. Some disorders are discrete (e.g., specific learning disorder), whereas some disorders involve global deficits or delays (e.g., autism spectrum disorders). A few new disorders have been added to the Neurodevelopmental Disorders chapter, and some changes have been made to existing conditions.

The above list encompasses all of the neurodevelopmental disorders in DSM-5. Disorders that in the past would also have been first diagnosed in childhood (e.g., elimination disorders, reactive attachment disorder) have been relocated to relevant chapters.

We turn now to a more detailed look at each of the neurodevelopmental disorders.

Intellectual Disability (Intellectual Developmental Disorder), Formerly Mental Retardation

Mental retardation has been renamed Intellectual Development Disorder (IDD) in DSM-5 to reflect changes in U.S. federal law (Public Law 111-256), which replaced the term mental retardation with intellectual disability. The criteria for IDD has changed, and people with IDD are no longer categorized solely on the basis of IQ, although IQ must be at least two standard deviations from the mean (70 or less).

IDD is characterized by deficits in cognitive abilities (e.g., problem solving, planning, reasoning, judgment) and adaptive functioning. Diagnostic criteria emphasize the importance of assessing both cognitive abilities and adaptive functioning. The severity level (mild, moderate, severe, or profound) of the intellectual disability is determined by the person’s ability to meet developmental and sociocultural standards for independence and social responsibility, not by the IQ score. To help determine a diagnosis, a table listing IDD severity levels (mild, moderate, severe, or profound) across three different domains (conceptual, social, and practical) is included on pages 34–36 of DSM-5.

A great deal of comorbidity exists among the neurodevelopmental disorders. For example, children born with neurobehavioral disorder due to prenatal alcohol exposure (ND-PAE; formerly fetal alcohol syndrome) often develop mild intellectual developmental disorders (see Seligman & Reichenberg, 2012, p. 51).

Global developmental delay is diagnosed if the severity level cannot be accurately determined. This diagnosis is restricted to children under the age of 5. If the degree of intellectual disability cannot be determined, unspecified intellectual disability would be the diagnosis.

Communication Disorders

The communication disorders begin in childhood and generally follow a steady course, with possible lifelong functional impairment. In most cases, the functions affected involve speech, language, and social communication. The criteria remain the same for the communication disorders in DSM-5, with the exception of language disorder, which combines expressive and mixed-expressive language disorders from DSM-IV into one disorder and the addition of social (pragmatic) communication disorder, which is discussed next. Overall, DSM-5 includes the following communication disorders:

• Language
  
• Speech sound disorder (formerly phonological disorder)
  
• Childhood-onset fluency disorder (stuttering)
  
• Social (pragmatic) communication disorder
  
• Unspecified communication disorder

Social (pragmatic) communication disorder is a new condition. Children who are diagnosed with this disorder have deficits in the social use of verbal and nonverbal communication, including the following:

• Using communication appropriately for social purposes
  
• Matching communication to the needs of the situation (e.g., speaking differently in a library than at home)
  
• Understanding rules for conversing (e.g., using nonverbal signals to regulate interaction)
  
• Difficulty making inferences, if something is not stated explicitly

If restricted repetitive behaviors, interests, and activities (RRBs) are present, then social communication disorder cannot be diagnosed. Some children who are diagnosed with pervasive developmental disorder—not otherwise specified (PDD-NOS) under DSM-IV may now meet the criteria for social communication disorder in DSM-5. Also, those who meet only the social communication criteria for ASD, but not the other criteria, may be considered for this disorder.

Autism Spectrum Disorder

With the publication of DSM-5 comes the integration of four disorders into the broad category of Autism Spectrum Disorder. Autistic disorder, Asperger’s disorder, childhood disintegrative disorder, and PDD-NOS have been combined into a single category in recognition of the fact that reliability of distinguishing among these groups had been poor, and there is insufficient research to support maintaining them as separate and distinct disorders. The following new diagnostic criteria are intended to improve reliability and decrease the complexity of diagnosis (e.g., DSM-5 has 11 different ways to meet the diagnostic criteria, whereas DSM-IV reportedly allowed 2,027 diagnostic possibilities).

The new diagnostic criteria for autism spectrum disorder are characterized by the presence of the following:

Deficits in social communication and interaction, in multiple domains, including:

• Deficits in social interactions (e.g., lack of reciprocity in conversation)
  
• Problems with nonverbal communication skills (e.g., lack of eye contact, body language)
  
• Difficulty understanding relationships (e.g., creating, maintaining, and understanding nuances in behavior)

Restricted repetitive behaviors, interests, and activities (RRBs), such as:

• Repetitive motor movement (head banging, flapping, or rocking)
  
• Ritualized behavior (verbal or nonverbal)
  
• Unusually strong interests in unusual objects or perseveration
  
• Heightened sensitivity to sensory stimulation (wind, pain, sound, smell, touch)

Severity level for autism spectrum disorder is determined along a continuum, on the basis of degree of impairment for social communication impairments and RRBs separately, according to the following degree:

• Level 1 (requiring support)
  
• Level 2 (requiring substantial support)
  
• Level 3 (requiring very substantial support)

Under this new dimensional approach to diagnosis, some people on the autism spectrum show mild symptoms, whereas others have much more severe symptoms (indicated by documentation of Level 3). Interested readers should refer to DSM-5 for a matrix of severity for autism spectrum disorder (APA, 2013a, p. 52).

A note about Asperger’s: The DSM-5 Childhood and Adolescent Disorders Work Group recommended the use of dimensions of severity instead of a separate diagnosis for Asperger’s disorder. Subsuming Asperger’s disorder into the overall autism spectrum has been one of the most, if not the most, controversial change in DSM-5. According to the American Psychiatric Association, the decision was made after conducting considerable research on diagnostic criteria, outcomes, course, etiology, neurocognitive profile, and treatment, among others. Concerns raised by this change include the possibility of increased stigma as people with Asperger’s are conceptualized as being on the autism spectrum. Conversely, increased services may now be available to meet the needs of children and adults who in the past may have been denied services because they did not meet the diagnostic criteria set down in DSM-IV. The complete impact of the change to a dimensional assessment approach based on verbal language abilities, social interaction, intelligence, and independent living capacity may prove to be a positive change, particularly for children. It seems possible that adults who were previously diagnosed with Asperger’s may not benefit as much, although the DSM-5 also clearly states that “Individuals with a well-established DSM-IV diagnosis of autistic disorder, Asperger’s disorder, or pervasive developmental disorder not otherwise specified should be given the diagnosis of autism spectrum disorder” (APA, 2013a, p. 51). (See also DSM-5 Childhood and Adolescent Disorders Work Group, 2010; Frazier et al., 2012; Mao & Yen, 2010.) The grandfathering clause, however, will not help those who are diagnosed in the future. Recent research indicates that the new ASD criteria tends to underdiagnose individuals with symptoms in the milder range of the spectrum.

Following is an example of how an autism spectrum disorder might be coded:

The differential diagnosis for autism spectrum disorder rules out Rett syndrome, which may share some of the same symptoms as autism spectrum disorder, but not all. If RRBs are absent, social communication disorder would be diagnosed rather than autism spectrum disorder.

Attention-Deficit/Hyperactivity Disorder (ADHD)

The DSM-5 diagnostic criteria for ADHD recognizes lifespan differences in presentation of ADHD among adults and children and adolescents. Twenty years of research indicates that many adults have the symptoms of ADHD, even though they might not have been diagnosed in childhood. The criteria are calibrated somewhat differently for adults, with the cutoff for symptoms for adult diagnosis of ADHD set at five symptoms rather than the six symptoms required for a younger person. The requirement for onset of symptoms prior to the age of 7 has been loosened to require that five impulsive, inattentive, or hyperactive symptoms were present before the age of 12 (APA, 2013a). Other changes in the DSM-5 section on ADHD include the provision of adult examples and the requirement that several symptoms must be found in each setting. Eighteen symptoms are provided, along with the requirement that at least six symptoms in either inattention or hyperactivity/impulsivity must be observed for diagnosis. Additional changes include the following:

• ADHD subtypes are now referred to as specifiers.
  
• A co-occurring diagnosis with autism spectrum disorder is now allowed.
  
• The cutoff for symptoms for adult diagnosis of ADHD is set at five symptoms rather than the six symptoms required for a younger person.

The prevalence of ADHD in adults is 4.4%. A recent longitudinal study published in the journal Pediatrics found that 30% of adults who were diagnosed with ADHD as children continued to have the disorder at the age of 27. Other studies have found the rate to be as high as 50%. In addition, the suicide rate for adults who had childhood ADHD was 5 times higher than for adults who did not have childhood ADHD (Barbaresi et al., 2013).

Assessment and treatment options for adult ADHD include cognitive therapy in conjunction with medication management, when ADHD symptoms are in the moderate to severe range (Montano, 2004).

Specific Learning Disorder

DSM-5 broadens the DSM-IV criteria to embrace distinct disorders that impede the acquisition of one or more of the following academic skills: oral language, reading, written language, or mathematics. For each disorder, the severity level of mild, moderate, or severe must be specified.

Motor Disorders

Developmental coordination disorder, stereotypic movement disorder, and tic disorders have been subsumed under the broader category of Motor Disorders in DSM-5. Coded specifiers for each type of disorder are included, along with diagnostic criteria, prevalence rates, and differential diagnosis. The tic criteria have been standardized across all of the disorders in the DSM-5 chapter on neurodevelopmental disorders. Stereotypic movement disorder has been more clearly differentiated from body-focused repetitive behavior disorders that are listed in the DSM-5 chapter on obsessive-compulsive disorders.

We now move from the neurodevelopmental disorders to a new chapter in DSM-5, Schizophrenia Spectrum and Other Psychotic Disorders.

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SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDERS

DSM-5 takes a spectrum approach to schizophrenia and other psychotic disorders, with all of the disorders being defined by the presence of one or more of the following five domains: (1) delusions, (2) hallucinations, (3) disorganized thinking (or speech), (4) disorganized or abnormal motor behavior, and (5) negative symptoms. Persons are diagnosed on the spectrum according to the number and degree of deficits, ranging from schizotypal personality disorder characterized by odd and eccentric symptoms but without breaks with reality, to schizophrenia, in which hallucinations and delusions are prominent. The presence or absence of mood symptoms along with psychosis informs the diagnosis and has prognostic value in terms of course and treatment considerations.

The relocation of these disorders near the beginning of the DSM-5 indicates the strong relationships with neurocognitive disorders and the likelihood of a strong genetic link among the psychotic disorders. Readers need to be aware of some small changes that impact the diagnosis of psychotic disorders in the schizophrenia spectrum, although treatment recommendations remain the same.

The following list provides an outline for the new DSM-5 chapter on Schizophrenia Spectrum and Other Psychotic Disorders. For consistency throughout the text, the ICD-9 codes are listed first, followed by the diagnosis, and ending with the ICD-10 codes (which often begin with the letter F). A detailed explanation of changes and the implications for assessment, diagnosis, and treatment follows.

Schizotypal (Personality) Disorder

Considered to be on the mild side of the schizophrenia spectrum, schizotypal personality disorder is listed in this chapter in DSM-5, although the criteria and text remain in the chapter on personality disorders. No changes have been made to the criteria for schizotypal personality disorder from DSM-IV.

Delusional Disorder

A hallmark of this disorder is the presence of a delusion without marked impairment in areas of functioning. Indeed, persons with delusional disorder may appear to be quite normal in appearance and behavior, until they begin to discuss their delusional ideas. In DSM-5, “with bizarre content” is now a course specifier, and the requirement that delusions must be nonbizarre has been lifted. Differential diagnosis is aided by new exclusion criteria stating that symptoms must not be better explained by conditions such as an obsessive-compulsive disorder or body dysmorphic disorder with absent insight/delusional beliefs (APA, 2013a). Shared delusional disorder (pas de deux) has been eliminated from DSM-5. If the diagnosis meets the criteria for delusional disorder, then that diagnosis is made. If the criteria for delusional disorder are not met but shared beliefs are present, then the diagnosis would be other specified schizophrenia spectrum and other psychotic disorder.

Brief Psychotic Disorder and Schizophreniform Disorder

Sudden onset of psychotic symptoms with return to normal within a month is considered to be a brief psychotic disorder. If the disorder continues for 1 month or longer, another schizophrenia spectrum disorder should be considered such as schizophreniform disorder or delusional disorder. Both disorders share the same diagnostic criteria as schizophrenia and generally differ only in terms of duration.

Schizophrenia

Two major changes have been made in the criteria for the diagnosis of schizophrenia. The first is the elimination of two symptoms in Criterion A that were found to have poor reliability and nonspecificity (e.g., bizarre delusions and Schneiderian first-rank auditory hallucinations). Instead, DSM-5 now requires two symptoms from Criterion A to be present for the diagnosis of schizophrenia. In addition, the person must have at least one of the following core positive symptoms: delusions, hallucinations, or disorganized speech.

The subtypes of schizophrenia have also been removed. It is no longer necessary to distinguish among the paranoid, disorganized, undifferentiated and residual, or catatonic types. These distinctions were found to be lacking in diagnostic stability, reliability, and validity, and were not predictive of treatment response or longitudinal course. Instead, DSM-5 offers a dimensional approach to schizophrenia and the psychotic disorders that allows clinicians to rate severity of core symptoms and discern client behavior on a spectrum (see rating scale on pages 742–744 of DSM-5).

A note about Attenuated Psychosis Syndrome: It is a well-known fact that early diagnosis and treatment of symptoms of psychosis improve long-term prognosis. To encourage earlier identification, Attenuated Psychosis Syndrome was considered for inclusion in the manual. However, the benefits of adding a disorder like this must be balanced with consideration of any possible negative effects of early treatment, such as stigma or overprescription of antipsychotics. DSM-5 Section III, subsection: Conditions for Further Study includes conditions that, with further research, may become full-blown disorders in future updates of the DSM-5. One of the proposed criteria sets provides symptoms and diagnostic features of attenuated psychosis, which usually first appears in adolescents and young adults.

Schizoaffective Disorder

This disorder has long been considered to be a bridge between a bipolar or mood disorder and schizophrenia, with people having symptoms of depression or mania as well as psychotic symptoms. These symptoms may occur concurrently or at different points in the duration of the disorder. DSM-5 now looks at schizoaffective disorder longitudinally, across the course and duration of the disorder, and clarifies that a mood disorder must remain for “most of the time” after Criterion A of schizophrenia (e.g., negative symptoms, delusions, hallucinations) has been met. This new criteria in DSM-5 should improve the clinician’s ability to make an accurate differential diagnosis that rules out schizophrenia or a bipolar or depressive disorder.

Catatonia

Although catatonia is no longer a subtype of schizophrenia, DSM-5 allows for catatonia to be included as a specifier for any psychotic, bipolar, or depressive disorder; as a separate diagnosis in the context of another medical condition; or as another unspecified disorder. The criteria remain the same as in DSM-IV. A major difference in DSM-5 is that all contexts require the presence of three catatonic symptoms out of a total of 12 possible symptoms (e.g., waxy flexibility, negativism, posturing, mimicking others’ speech or movements, lack of response, agitation, grimacing, repetitive movements, catalepsy, stupor).

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BIPOLAR AND RELATED DISORDERS

The diagnosis and treatment of mood disorders has been refined in DSM-5 by dividing the mood disorders into two distinct chapters: a chapter on bipolar and related disorders (bipolar I and II, cyclothymic disorder, and four new disorders) and a chapter on depressive disorders. Disruptive mood dysregulation disorder (DMDD) is a new diagnosis for children under the age of 18 who present with extreme emotional and behavioral dysregulation. Its description is included in the chapter on depressive disorders, since most children with this symptom profile do not go on to develop bipolar disorder. Rather, a depressive disorder or anxiety disorder is more likely to develop in adulthood.

We now turn to a detailed look at each of the bipolar disorders.

Bipolar I, Bipolar II, and Cyclothymia

DSM-5 includes six pages of course specifiers for bipolar and related disorders. Many specifiers are the same as in DSM-IV (e.g., “with rapid cycling,” “with seasonal pattern”). New specifiers have been made in the bipolar disorders in DSM-5 to facilitate earlier and more accurate diagnosis. Diagnosis of mania has been enhanced with the inclusion of changes in “activity and energy level,” not just changes in mood. A new specifier “with mixed features” replaces the mixed episode criterion that was found in DSM-IV. The specifier can be applied to episodes of depression (in either MDD or bipolar disorders) when features of mania or hypomania are present, or to hypomania or mania when depressive features are present. The distinction is that the “mixed episode” specifier in DSM-IV required the person to meet the full criteria for both mania and a major depressive episode concurrently. That is no longer the case.

Other Bipolar Disorders

There are many variations of bipolar disorder, in addition to bipolar I, bipolar II, and cyclothymia. Bipolar disorder NOS was a frequently used diagnosis in DSM-IV that has been replaced with the following four diagnoses to specify the appropriate type of bipolar disorder that is being presented:

• Substance/medication-induced bipolar and related disorder
  
• Bipolar and related disorder due to another medical condition
  
• Other specified bipolar and related disorder
  
• Unspecified bipolar and related disorder

Readers are reminded that, in children, a diagnosis of disruptive mood dysregulation disorder (which is discussed later) is generally more appropriate than the diagnosis of bipolar disorder.

Substance/medication-induced bipolar and related disorder would be the appropriate diagnosis if evidence suggests that the symptoms of bipolar disorder occurred during or soon after substance intoxication or withdrawal, or after the exposure to a medication that is known to produce the symptoms of bipolar disorder. In such situations, the substance ingested would be listed, along with a specifier indicating whether onset was during intoxication or during withdrawal.

Bipolar and related disorder due to another medical condition would be the appropriate diagnosis if the manic, hypomanic, or mixed symptoms occur as a direct pathophysiological result of another medical condition. The medical conditions most commonly associated with the development of a bipolar disorder are Cushing’s disease, hyperthyroidism, lupus, multiple sclerosis, stroke, and traumatic brain injury (APA, 2013a).

Other specified and unspecified bipolar and related disorder refers to the presentation of symptoms of a bipolar disorder that do not meet the full criteria, but in which distress in social, occupational, or other areas of functioning is present. Insufficient information may be available, or the clinician may choose not to specify the reason why the criteria were not met.

Anxious Distress Specifier

Anxious distress is a new specifier to be considered in all mood disorders, including bipolar and related disorders. Anxious distress refers to persons exhibiting anxiety symptoms beyond the diagnostic criteria for a mood episode (manic, hypomanic, or depressed). Following is a description of the anxious distress specifier that is applicable to bipolar disorders and depressive disorders.

To qualify for the anxious distress specifier, a minimum of two of the following anxiety symptoms must be present most days during the current or most recent mood episode of mania, hypomania, or depression (APA, 2013a):

• tension or feeling wound up
  
• restlessness
  
• inability to concentrate
  
• dread of something terrible happening
  
• fear of losing control

Severity levels—mild (two symptoms), moderate (three symptoms), moderate-severe (four or five symptoms), or severe (four or five symptoms with motor agitation)—should be assessed for anxious distress.

A great deal of research indicates that the presence of anxiety in conjunction with depression can be destabilizing and may potentially increase the risk of suicidality, longer duration of illness, or lack of response to treatment. Thus, the anxious distress specifier must be accurately assessed, along with additional assessment of suicidal risk factors, including potential plans, thoughts, or history, in persons who exhibit moderate to severe levels of anxious distress. Suicide assessment should also be kept in mind when making a diagnosis of major depressive disorder, to which we now turn.

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DEPRESSIVE DISORDERS

The DSM-5 chapter on depressive disorders includes two new disorders: (1) premenstrual dysphoric disorder (previously in the Appendix of DSM-IV) and (2) disruptive mood dysregulation disorder (DMDD), which is specific to children who present with extreme irritability and emotional dysregulation. Depression is conceptualized in a new way. Dysthymia has been combined with chronic major depressive disorder and is now referred to as persistent depressive disorder. Also new in DSM-5 is the elimination of the bereavement exclusion criterion from the diagnosis of major depressive disorder. Following is a list of depressive disorders, and their codes, followed by a more detailed explanation of specific changes from DSM-IV to DSM-5.

Disruptive Mood Dysregulation Disorder

Temper or anger outbursts with underlying persistent irritability disproportionate to the situation and unrelenting over a 12-month period is the hallmark feature of disruptive mood dysregulation disorder, a new DSM-5 disorder that affects children over the age of 6.

The intent of this disorder is to distinguish children with the milder DMDD from the diagnosis of childhood-onset bipolar disorder. Overall, research does not indicate that the preponderance of children diagnosed and treated for bipolar disorder actually go on to develop bipolar disorder as adults. In fact, longitudinal studies indicate that the majority of children treated for symptoms of intense irritability and disruptive behavior actually develop unipolar depression or anxiety disorders as young adults. In effect, bipolar disorder occurs in less than 1% of children before the onset of puberty. Because little research is available on the long-term effects of psychotropic medications on young brains that are not fully developed, the intent of identifying this disorder is to reduce the number of such prescriptions that are given to young children. For a complete discussion of both sides of the controversy surrounding the diagnosis of bipolar disorder in children, refer to Leibenluft (2011) and Washburn, West, and Heil (2011).

The symptoms of DMDD include the following:

• Severe chronic temper outbursts, verbal aggression, or emotional storms that are out of proportion to the situation.
  
• The outbursts occur an average of three or more times per week.
  
• They occur for a period of 12 or more months.
  
• Persistent irritability does not remit when stressors go away, or between episodes, and is observable by others (e.g., friends, family, teachers).
  
• Irritability is observed in at least two out of three settings (home, school, with peers) and is severe in at least one of these locations.
  
• The diagnosis can not be made prior to the age of 6, nor after the age of 18.
  
• Historical assessment finds that these symptoms were present prior to the age of 10.
  
• There has been no prior diagnosis of a mania or euphoric mood lasting longer than 1 day.
  
• The behaviors do not occur as a result of a major depressive or other disorder, such as anxiety, persistent depressive disorder, or posttraumatic stress disorder.
  
• The disorder is not better accounted for by a bipolar disorder, a substance, or a medical or neurological condition (APA, 2013a).

DMDD is a severe disorder. Approximately 50% of children who present with these symptoms will continue to have chronic irritability 1 year later. The behavior is extreme enough to cause disruption in peer and family relationships, difficulties in school, and problems maintaining relationships. Dangerous behaviors such as aggression, suicide attempts, and self-harming are common, as is hospitalization. The presence of co-occurring disorders is also high, so careful assessment is necessary to distinguish DMDD from childhood-onset bipolar disorder, oppositional defiant disorder, ADHD, and intermittent explosive disorder. Oppositional defiant disorder is most frequently comorbid with DMDD. Intermittent explosive disorder, which has a duration of 3 months, with remittance between episodes, should not be diagnosed concurrently with DMDD, which has a 12-month minimum duration and remains persistent over the 12-month period.

The behavior must also be inconsistent with the child’s age and developmental level and cannot be better explained by autism spectrum disorder, PTSD, or pervasive developmental disabilities. If the child has already been diagnosed with bipolar disorder, intermittent explosive disorder, or oppositional defiant disorder, a diagnosis of DMDD would not be appropriate (APA, 2013a).

Major Depressive Disorder

With two exceptions, the diagnosis and treatment of the classic major depressive disorder remains the same as described in DSM-IV. The exceptions are the addition of new specifiers (described later) and the elimination of the bereavement exclusion, which we address next.

The Bereavement Exclusion

A major change in the diagnosis of major depressive disorder is the removal of the bereavement exclusion, which prevented a person who was grieving from being diagnosed with major depressive disorder in the first 2 months following the death of a loved one. Under the old DSM-IV criteria, a person would have been considered to be grieving rather than depressed. APA research teams discovered, however, that persons who had experienced a major depressive episode prior to a major loss were far more likely to have a recurrent depressive episode after a loss, and the bereavement exclusion was preventing them from being accurately diagnosed and receiving the appropriate care. Second, removal of the bereavement exclusion is an acknowledgment of the fact that grief does not end after only 2 months. Grief is a far more complicated process that must take into account multiple factors, including relationship, age, and cause of death. Grieving the loss of a spouse after 50 years of marriage, for example, may never be resolved, and certainly not within the 2-month period allotted for grief.

DSM-5 actually expands the caution about diagnosing MDE to include any significant loss (e.g., divorce, financial ruin, natural disasters, loss of children through custody disputes) that causes intense sadness, insomnia, inability to eat, and rumination. Even though the symptoms may be appropriate to the loss, the presence of a major depressive episode must still be ruled out, especially in individuals with a prior history of a depressive disorder. When making a diagnosis, clinicians should also consider cultural norms related to the expression of grief and loss.

DSM-5 includes a comprehensive footnote (APA, 2013a, p. 161) to clarify the purpose of the bereavement exclusion and to help clinicians distinguish between symptoms of grief and loss and the presence of a major depressive episode (MDE), while also understanding that both may be present. When grief occurs in conjunction with an MDE, symptoms may be more severe and poorer outcomes may result, including increased risk for suicidality and risk of developing persistent complex bereavement disorder, a Condition for Further Study, which can be found in DSM-5 Section III: Emerging Measures and Models.

New Specifiers

As described earlier in the bipolar disorders section, an “anxious distress” specifier has been added in DSM-5 for all depressive disorders, and the specifier “with mixed features” allows for the possibility of manic features in a person who has been diagnosed with unipolar depression.

Persistent Depressive Disorder (Dysthymia)

Dysthymic disorder, which appeared in DSM-IV, has been combined with chronic major depressive disorder to create this broader category of persistent depressive disorder. The hallmark of this disorder is a depressed mood that lasts most of the day, for most days, over a 2-year period (1 year for children and adolescents). The chronicity of this disorder can be identified through the use of course specifiers, which are similar to those for major depressive disorder. Risk factors for childhood-onset PDD include parental loss or separation. The early-onset specifier is given if the disorder is diagnosed prior to the age of 21.

Premenstrual Dysphoric Disorder

Decades of research have confirmed that premenstrual dysphoric disorder (PMDD) is a specific and treatment-responsive form of depressive disorder that occurs in a small number of women. Specifically, it has been estimated that 75% of women experience minor symptoms premenstrually, with 20% to 30% experiencing the less severe premenstrual syndrome, which does not require the presence of five criteria or changes in affect. Only 2% to 10% of premenopausal women, however, are expected to meet the criteria for the more severe PMDD (Epperson et al., 2012). Research indicates that PMDD is separate from a mood disorder (although it can occur in conjunction with one). Mood lability and irritability are the primary symptoms, and must be present most months in the previous 12-month period, appearing in the week before the onset of menses, start to improve after menses begins, and recede postmenses. Criterion D requires clinically significant distress. The criteria for PMDD are slightly more stringent than those that appeared in the Appendix to DSM-IV, requiring 5 of the following 11 symptoms to be necessary for diagnosis:

Symptoms may be as severe as major depressive disorder, although lasting for less than a week. The symptoms must cause clinically significant distress or marked disruption in relationships and/or social or occupational functioning during the affected week.

Assessment of PMDD begins by charting symptoms prospectively for a 2-month period to confirm the presence of a cyclical pattern. The chart should be maintained daily and may include self-report and/or input from a person who lives with the woman.

PMDD must be distinguished from mental disorders that are made worse premenstrually. The symptoms cannot be a result of medication or substance use, nor an exacerbation of a current medical condition (e.g., hyperthyroidism). If oral contraceptives are used, PMDD cannot be diagnosed unless symptoms continue, and are as severe, when contraceptives are removed. Most cases of PMDD worsen with age and then subside with the onset of menopause (APA, 2013a).

Treatment for PMDD focuses on controlling or minimizing symptoms. Women should not suffer because of fears about stigma. Research has validated that antidepressants and anxiolytics administered during the period between ovulation and onset of menses have been shown to reduce emotionality and other symptoms. Selective serotonin reuptake inhibitors are considered to be the first line of treatment for PMDD (Cunningham, Yonkers, O’Brien, & Eriksson, 2009). Medications that suppress ovulation have also been shown to be effective for some women, although they can have a rebound effect (Epperson et al., 2012). Vitamins and supplements such as vitamin B6, calcium, and magnesium have been shown to help in some studies, but more research is necessary. In general, treatments that help with other mood disorders can also be effective with PMDD: herbal remedies (to reduce irritability, mood swings, and headaches), aerobic exercise to improve mood and energy; lifestyle changes such as relaxation; and cognitive therapy to help reduce stress (Pearlstein & Steiner, 2008).

Substance/Medication-Induced Depressive Disorder

The use of alcohol or illicit drugs can result in the development of depression while using the substance or during the withdrawal period. Similarly, many medications prescribed to treat physical and psychological conditions, including antidepressants, may also have the untoward side effect of causing depression (APA, 2013a). Antidepressants are generally considered safe, but the suicide risk for young adults ages 18 to 24 who begin taking antidepressants was large enough for the Food and Drug Administration to issue a black-box warning to advocate careful monitoring of clients in this age group for treatment-emergent suicidal ideation (Friedman & Leon, 2007; Seligman & Reichenberg, 2012).

Depressive Disorder Due to Another Medical Condition

Stroke, Parkinson’s disease, Huntington’s disease, lupus, and Cushing’s disease are all illnesses that have been linked with depression. Some symptoms may be episodic and may go away after the medical disorder is treated. There is also a clear connection between some severe medical disorders and suicide, especially in the weeks following the initial diagnosis.

Other Specified Depressive Disorder

When criteria for a specific depressive disorder are not completely met, one of the following designations can be considered: recurrent brief depression (does not meet the duration criterion), short-duration depressive episode (in situations without a prior history of mood disorder), and depressive episode with insufficient symptoms (depressed affect and at least one other symptom). For example, a person who presents with a minimum of 2 weeks of clinically significant distress, depressed affect and at least one of the eight symptoms of a MDE would be coded as:

Unspecified Depressive Disorder

This diagnosis is given when depression is present and causes significant problems in social, occupational, or other important areas of functioning, but does not meet the full criteria for any of the depressive disorders listed earlier, and the clinician does not wish to specify or does not have enough information to give a more specific diagnosis.

Additional Specifiers for Depressive Disorders

DSM-5 maintains all of the specifiers for depressive disorder that were found in DSM-IV (e.g., “with melancholic features,” “with atypical features,” “with psychotic features,” “with catatonia,” “with paripartum onset,” “with seasonal pattern,” “in partial remission,” “in full remission,” and specifiers of severity. As mentioned earlier in the discussion of bipolar disorders, DSM-5 also adds an “anxious distress” specifier to all mood disorders, along with an assessment of current severity level.

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ANXIETY DISORDERS

The former Anxiety Disorders of DSM-IV have been redistributed into three consecutive classifications in DSM-5: Anxiety Disorders, Obsessive-Compulsive and Related Disorders, and Trauma- and Stressor-Related Disorders. The Anxiety Disorders section includes disorders that have the same shared features of excessive fear and anxiety along with behavioral disturbances. The creation of a new classification of Obsessive-Compulsive and Related Disorders reflects emerging evidence of the relatedness of disorders such as OCD, hoarding, and body dysmorphic disorder, among others. The third chapter, Trauma- and Stressor-Related Disorders, includes disorders that result from exposure to a stressful or traumatic event. More will be said about this later.

Now we turn to the DSM-5 chapter related to anxiety disorders, which now includes the following list of disorders. Readers will note that in keeping with the developmental lifespan approach of DSM-5, several disorders that were previously located in the children’s section of DSM-IV (e.g., separation anxiety disorder and selective mutism) have been reclassified as anxiety disorders, although the criteria remain much the same.

Minimal changes have been made to the criteria for the diagnosis of anxiety disorders, with the exception of separate criteria for agoraphobia and panic disorder and the addition of a “performance only” specifier for social anxiety disorder. The criteria for agoraphobia, specific phobia, and social anxiety disorder no longer require that the person recognize that the anxiety is unreasonable or excessive. Instead, and after accounting for cultural context, the anxiety must be out of proportion to the actual danger or threat imposed by the situation. The requirement of a 6-month duration is now extended to all ages in DSM-5, with the intent of reducing the overdiagnosis of short-lived fears or anxieties.

We turn now to a list of anxiety disorders and their codes followed by highlights of the changes included in DSM-5.

Separation Anxiety Disorder

The hallmark of separation anxiety disorder is the presence of excessive fear or anxiety regarding separation from attachment figures. Once considered the domain of childhood, separation anxiety disorder can now be coded in adults. Since the criteria for childhood onset of this disorder remains the same as DSM-IV, this section focuses specifically on adult presentation of this condition, which is frequently comorbid with generalized anxiety disorder and may severely limit a person’s ability to travel, or work outside of the home.

The prevalence rate of separation anxiety disorder decreases across the lifespan, from a high of 4% in childhood to 1% to 2% of adults. Symptoms also vary by developmental stage. Adults may be dependent and overprotective and may experience cardiovascular symptoms (e.g., palpitations, dizziness, feeling faint) that are rarely seen in children. Whereas children may express school refusal or concerns about leaving home, adults with the disorder tend to exhibit fear of change, or be overly concerned about being separated from their children or from significant others.

The duration criteria specifies that the anxiety must last a minimum of 4 weeks in children and adolescents, and 6 months or more in adults. It is also important to differentiate separation anxiety disorder from the high value some cultures place on interdependence among family members (APA, 2013a).

Selective Mutism

Selective mutism has been reclassified in DSM-5 as an anxiety disorder. The criteria for selective mutism remains the same; the only difference is its relocation to this chapter from the DSM-IV category of disorders that are first diagnosed in childhood and adolescence.

Specific Phobia

The core criteria of specific phobias remain largely unchanged, with the addition of the broadbrush criteria change for all anxiety disorders (i.e., minimum 6 months’ duration and the deletion of the requirement that the person must recognize that the anxiety is excessive). The specific types of phobias are now considered to be specifiers. Anxiety symptoms of specific phobia in children may include crying, tantrums, freezing, or clinging behaviors.

Social Anxiety Disorder

This was previously referred to as “social phobia.” The criteria for DSM-5 social anxiety disorder remain largely the same, with the adoption of the following changes:

Panic Disorder

Panic disorder and agoraphobia have been separated in DSM-5. Previous options for diagnosis in DSM-IV were: panic disorder without agoraphobia, panic disorder with agoraphobia, and agoraphobia without history of panic disorder. DSM-5 has replaced these diagnoses with two distinct disorders: (1) panic disorder and (2) agoraphobia. Persons with both panic disorder and agoraphobia will now receive two diagnoses. The change was made in recognition of the fact that many people with agoraphobia do not experience symptoms of panic. The diagnostic criteria for agoraphobia now require two or more agoraphobic situations prior to diagnosis, as well as the changes noted earlier (i.e., the anxiety must be of a minimum 6-month duration and determined by the clinician to be excessive).

The essential features of panic disorder remain largely the same, although type descriptions of situationally bound (in anticipation of a specific trigger), situationally predisposed (usually associated with a specific trigger), and unexpected/uncued (unrelated to any obvious trigger) have been simplified into two type descriptions: “unexpected” and “expected.” Recurrent panic attacks that occur in conjunction with a thunderstorm, for example, would be “expected.”

The feelings of panic are caused by fear and stress, and commonly co-occur in other DSM-5 disorders as well. Thus, panic attacks can serve as a diagnostic indicator of severity, course, and prognosis across a variety of disorders, and can be listed as a specifier for any DSM-5 disorder.

Agoraphobia

Agoraphobia has been unlinked from panic disorder and is now a separate diagnosis under DSM-5. The criteria for agoraphobia include fear and anxiety of being in public (closed spaces, public transportation), fear of being unable to escape, and avoidance of such situations or requiring a companion. The fear must be persistent (lasting 6 months or more), out of proportion to the danger that is present, and cannot be accounted for by another psychological or medical disorder. If both panic and agoraphobia are present, both would be listed.

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OBSESSIVE-COMPULSIVE AND RELATED DISORDERS

Following the list of disorders and codes for the new DSM-5 chapter Obsessive-Compulsive and Related Disorders, diagnostic criteria, specifiers, and other information new to DSM-5 will be provided.

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