DSM 5 Definition of a
“A syndrome characterized by clinically significant disturbance in …cognition, emotion regulation, or behavior that reflects a dysfx in the psychological, biological, or developmental processes underlying mental Fx” (APA, 2013, p. 20)
Other Specified Disorder Category
Used when the clinician wants to report the specific reason why a client's presentation does not met the criteria for any specific category within a diagnostic class. This is done by recording the name of the category, followed by the reason. Ex: A CT w/clinically significant depressive Sx's lasting 4 weeks but whose symptomatology doesn't reach the diagnostic threshold for a major depressive episode. The clinician would record "other specified depressive disorder, depressive episode with insufficient symptoms."
Unspecified Disorder Category
Used when the clinician chooses NOT to record a specific reason why a client's symptoms don't meet the criteria for a specific disorder and includes presentation for which there is insufficient information to make a more specific diagnosis.
DSM 5's Outline for Cultural Formulation
Encourages systematic assessment of the following categories: The individual's cultural identity Cultural conceptualizations of distress Psychosocial stressors & cultural features of vulnerability a& resilience Cultural features of the relationship between the individual and the clinician Overall cultural assessment
The Cultural Formulation Interview (CFI)
A brief, semistructured interview (16 questions) that may be used to gather information about the impact of culture on key aspects of a client's clinical presentation and care. The CFI focuses on 4 domains of assessment: 1. Cultural Definition of the Problem 2. Cultural Perceptions of Cause, Context, and Support 3. Cultural Factors Affecting Self-Coping and Past Help Seeking 4. Cultural Factors Affecting Current Help Seeking This information should be integrated with all other available clinical material. An informant version of the CFI can be used to collect collateral information on the CFI domains from family members or caregivers.
DSM 5's Appendix
Provides a glossary for cultural concepts of distress
Cultural Concepts of Distress
DSM 5 Appendix provides a glossary for cultural concepts of distress, which are ways that cultural groups experience, understand, & convey distress, behavioral problems, or troubling thoughts & emotions. Ex: Ataque de Nervios = Attack of nerves Susto = Fright Taijin Kyofusho = Interpersonal fear disorder These are important to psychiatric diagnosis for several reasons, including to avoid misDx, to obtain valuable clinical info., to improve rapport & engagement, & to enhance therapeutic efficacy. There are different types of cultural concepts in the following ways: 1. Cultural Syndromes 2. Cultural Idioms of Distress 3. Cultural Explanations
Different types of Cultural Concepts of Distress
DSM 5 defines different types of cultural concepts in the following ways:
1. Cultural Syndromes: "Clusters of Sx's & attributions that tend to co-occur among indiv. in specific cultural groups, communities, or contexts and that are recognized locally as coherent patterns of experiences."
2. Cultural Idioms of Distress: "Ways of expressing distress that may not involve specific Sx's or syndromes, but that provide collective, shared ways of experiencing & talking about personal or social concerns."
3. Cultural Explanations (perceived causes): "Labels, attributions, or features of an explanatory model that indicate culturally recognized meaning or etiology for SX's, illness, or distress." For Ct's presenting with these cultural concepts, clinical assessment should include determining whether they meet DSM 5 criteria for a specified mental D/O or an "other specified" or "unspecified" Dx. After Dx is made, the cultural terms and explanations should be included in case formulations.
(Intellectual Development Disorder)
DSM-IV-TR Diagnosis: Mental Retardation
Type of Change: Renamed; Diagnostic criteria modified
Dx Criteria: Intellectual deficits & deficits in adaptive Fx, both w/an onset during the developmental period.
- Intellectual deficits confirmed by both clinical assess. & individualized, standardized intelligence testing.
- Adaptive Fx deficits result in a failure to meet developmental & sociocultural standards for personal independence & social responsibility, & w/out ongoing support, they limit Fx'ing in 1 or more ADL's across multiple settings.
Specify Current Severity: Severity levels defined on the basis of adaptive Fx'ing rather than IQ scores. Adaptive Fx'ing determines the level of support the person requires & encompasses adaptive reasoning in 3 domains:
- Conceptual (academic skills, memory, problem solving, judgement in unfamiliar situations, etc.,)
- Social (empathy, interpersonal communication skills, friendship abilities, social judgment, etc.)
- Practical (personal care, task organization, job responsibilites, money management, self-management of behavior, reaction, etc.)
- 4 Severity levels:
On an individually administered intelligence test, and indiv. w/intellectual disability socre 2 SD's or more below the population mean, including a margin for error (usually 5 pts). On test w/SD of 15 & mean of 100, reflects a score of 65-75 (70 +/- 5).
DDX's: Neurocognitive D/O's involve a loss of cognitive Fx.
Ex: if Dx of intellectial disability loses addl. cog. Fx (e.g., due to Alzheimer's disease) the Dx of intellectual disability & neurocognitive disorder may both be given.
The prevalence rate of intellectual disability is est. at about 1%
Indiv. w/intellectual disability have 3 to 4 times more comorbid mental D/O's compared to the general population
- Most commonly associated mental disorders include: ADHD, depressive and bipolar disorders, autism spectrum disorder, impulse-control disorders, stereotypic movement disorder
-The male-to-female ratio is 1.5: 1
Global Developmental Delay
DSM-IV-TR DX: New Dx in DSM 5
Dx Criteria: A failure to meet expected developmental milestones in several areas of intellectual Fx'ing. Dx is for children under 5 years of age when severity level of dysfx cannot be reliably assessed (e.g., the child is too young to participate in standardized testing).
Once this Dx has been given, reassessment is required after a period of time.
Unspecified Intellectual Disability
(Intellectual Developmental Disorder)
DSM-IV-TR Dx: In DSM 5 a new category (used when the clinician chooses not to specify a reason)
Dx Criteria: For person over 5 years of age when assess of the level of intellectual disability using locally available procedures is made difficult or impossible bc of assoc. physical or sensory impairments (e.g., locomotor disability, blindness, severe problem behaviors). (Should only be used in exceptional circumstances)
-Once this Dx has been given, reassess after a period of time required.
DSM-IV-TR DX: Expressive Language D/O & Mixed Expressive-Receptive Language D/O
Dx Criteria: Difficulties in acquiring & using language due to deficits in the comprehension or production of vocabulary, sentence structure, & discourse, and with an onset in the early developmental period.
Language abilities are significantly & quantifiably below those expected for age and result in Fx limitations in effective communication, social participation, academic achievement, and/or occupational performance.
The difficulties are not attributable to sensory impairment, motor dysFx, or another medical or neurological contiton and are not better explained by intellectual disability or global developmental delay.
Speech Sound Disorder
DSM-IV-TR Dx: Phonological D/O
Dx Criteria: Difficulty w/speech sound production that interferes w/intelligibility or prevents verbal communication of messages, & interferes w/social perticipation, academic achievement, or occupational performance.
Onset is in the early developmental period, & the difficultiees are not attributable to congenital or acquired conditions (e.g., cerebral palsy, hearing loss) or other medical or neurological conditions.
Childhood-Onset Fluency Disorder
DSM-IV-TR Dx: Stuttering
1. A disturbance in the normal fluency & time patterning of speech that is inappropriate for the person's age & language skills; persists over time; causes anxiety about speaking or limits effective communication, social participation, or academic or occupational performance; and has an onset in the early developmental period. (Note: Late-onset cases are diagnosed as adult-onset fluency disorder [307.0])
2. At least one of the following occurs frequently: Sound and syllable repetitions; sound prolongations of consonants and vowels; broken words; audible or silent blocking; circumlocutions (word substitutions to avoid problematic words); words produced with an excess of physical tension; and/or monosyllabic whole-word repititions (e.G., "you-you-you").
3. The disturbance is not attributable to a speech-motor or sensory deficit, dysfluency associated neurological injury (Tumor, trauma, etc.), or another medical condition and is not better explained by another mental disorder.
Note: Normal dysfluencies are fairly common in young children. If these increase in frequency or complexity as the child grows older, then this diagnosis is appropriate.
Social (Pragmatic) Communication Disorder
DSM-IV-TR Dx: New Dx's
1. Persistent difficultiesin the social use of verbal and nonverbal communication that have an onset in the early developmental period; limit effective communication, social participation, social relationships, academic achievement, or work performance; and are demonstrated by all of the following: Deficits in using communication for social purposes in a way that's appropriate for the social context; impairmant of the ability to adjust communication to match the context or the listener's needs; difficulties following rules for conversation and storytelling; and difficulties in understanding what is not explicitly stated and nonliteral or ambiguous meanings of language.
2. The symptoms are not attributable to another medical or neurological condition or to low abilities in the areas of word structure and grammar, and are not better explained by another mental disorder (e.g., autism spectrum disorder, intellectual disability).
1. AUTISM SPECTRUM D/O includes similar social communication deficits. If such deficits are present, a diagnosis of social (pragmatic) communication disorder should be considered only if the developmental history fails to show any evidence of restricted/repetative patterns of behavior, interests or activities.
2. In SOCIAL ANXIETY D/O, the person's social communication skills have developed appropriately, but he/she doesn't use them because of anxiety or fear about social interactions. In social (pragmatic) communication disorder, the person has never had effective social communication.
Unspecified Communication Disorder
DSM-IV-TR DX: New Dx in DSM 5 a new category (used when the clinician chooses not to specify a reason)
Dx Criteria: Clinically significant Sx’s of a communication D/O, but fails to meet the full criteria for any of the communication or neurodevelopmental D/O and the clinician does not specify the reason.
Autism Spectrum Disorder (ASD)
DSM-IV-TR DX: Autistic D/O, Asperger’s D/O, Pervasive Developmental D/O NOS, Childhood Disintegrative D/O, & Rett’s D/O
Type of Change: Renamed; Dx’s combined; Dx criteria modified; severity & feature specifiers (e.g., w/or w/out accompanying intellectual impairment) added
1.Pervasive and sustained deficits in social communication and social interaction and restricted repetitive patterns of behavior, interests, and activities.
a.Deficits in social communication and social interaction are demonstrated by the following, currently or by history:
i.Deficits in social-emotional reciprocity (e.g., rarely initiates or responds to social interactions; doesn't share emotions; uses language to request or label rather than to converse; has difficulty understanding and responding to social cues; rarely imitates others’ behavior).
ii.Deficits in nonverbal communicative behaviors used for social interaction (e.g., abnormalities in the use of eye contact, gestures, facial expressions, or speech intonation; poorly integrated verbal and nonverbal communicative behaviors; difficulty understanding nonverbal communications).
iii.Deficits in developing, maintaining, and understanding relationships (e.g., a lack of shared social play and imagination; no, reduced, or atypical social interest; difficulty adjusting behavior to suit the social context).
b.Restricted, repetitive patterns of behavior, interests, or activities are demonstrated by 2 or more of the following, currently or by history:
i.Stereotyped or repetitive motor movements, use of objects, or speech (e.g., simple motor stereotypies, lining up toys, echolalia).
ii.Insistence on sameness, inflexible adherence to routines, or ritualized patterns of verbal or nonverbal behavior (e.g., greeting rituals, extreme distress at small changes).
iii.Highly restricted, fixated interests that are abnormal in focus or intensity (e.g., strong attachment to unusual objects, highly circumscribed or perseverative interests).
iv.Over-or under-reactivity to sensory input or unusual interest in sensory aspects of the env. (e.g., apparent indifference to pain, adverse response to certain sounds, visual fascination with lights).
Sx’s begin in the early developmental period (but may not be fully apparent until social demands exceed capacities, or may be masked by strategies learned in adolescence or adulthood); cause clinically significant impairment in important areas of Fx’ing; and are not better explained by an intellectual disability.
Specify Current Severity: Severity of social communication deficits and of restricted, repetitive behaviors should be separately rated. Severity levels include:
Level 1 - "Requires Support"
Level 2 - "Requires Substantial Support"
Level 3 - "Requires Very Substantial Support on both social communication & repetitive behaviors."
Severity may vary by context and fluctuate over time.
-Specify if: Assoc. w/a known medical or genetic condition or env. factor; assoc. w/another neurodevelopmental, mental, or behavioral disorder.
-Specify if: W/or w/out accompanying intellectual impairment; w/or w/out accompanying language impairment; with catatonia.
1.A co-Dx’s of autism spectrum disorder in someone w/INTELLECTUAL DISABILITY is appropriate when his/her social communication and interaction are substantially impaired relative to the developmental level of his/her nonverbal skills,
2.LANGUAGE D/O’s may include communication probs that result in social difficulties but is not usually assoc. w/abnormal nonverbal communication or restricted, repetitive patterns of behavior, interests, or activities.
3.When a person has impairment in social communication and social interactions but does not show restricted and repetitive interests or behavior, criteria for SOCIAL (PRAGMATIC) COMMUNICATION D/O, instead of autism spectrum D/O, may be met.
4.SCHIZOPHRENIA W/CHILDHOOD ONSET usually develops after a period of normal, or near normal, development. In addition, hallucinations and delusions are not features of autism spectrum disorder.
5.In SELECTIVE MUTISM, early development is usually normal, the child usually displays appropriate communication skills in some settings, and, even in settings where the child doesn't speak, social reciprocity is not impaired and restricted or repetitive patterns of behavior are not present.
Attention-Deficit/Hyperactivity Disorder (ADHD)
DSM-IV-TR DX: Attention-Deficit/ Hyperactivity Disorder
Type of Change: Diagnostic criteria modified; Severity specifiers added (Mild, Moderate, Severe) & Specifiers added ("In partial Remission")
1.At least 6 Sx’s of inattention and/or 6 Sx’s of hyperactivity-impulsivity (or 5 Sx’s of inattention and/or 5 Sx’s of hyperactivity-impulsivity for persons age 17 years and older).
1.Often fails to pay close attention to details or makes careless mistakes;
2.Has trouble sustaining attention;
3.Doesn't seem to listen when spoken to directly;
4.Doesn't follow through on instructions and fails to finish tasks;
5.Has difficulty organizing tasks and activities;
6.Avoids, dislikes, or is reluctant to perform tasks that require sustained mental effort;
7.Loses things needed for tasks or activities;
8.Is easily distracted by irrelevant stimuli (for people age 17 and up, may include unrelated thoughts);
9.Is forgetful in daily activities.
1.Often fidgets with or taps hands or feet or squirms in seat;
2.Leaves seat when staying seated is expected;
3.Runs about or climbs in situations where it is inappropriate;
4.Is unable to play or engage in leisure activities quietly;
5.Is "on the go";
7.Blurts out answers before questions are completed;
8.Has difficulty waiting his/her turn;
9.Interrupts or intrudes on others.
2.Sx’s have been present for at least 6 months to an extent that is inconsistent w/developmental level and that negatively impacts on social and school or work activities.
3.Onset of some Sx’s is before age 12 and several Sx’s are present in at least 2 settings (e.g., home, school, work, with friends or family).
4.SX’s don't occur solely during the course of a psychotic D/O, are not better explained by another mental D/O, and are not just a manifestation of oppositional behavior, defiance, hostility, or failure to understand directions.
1.Combined presentation: At least 6 (or 5) inattention Sx’s and at least 6 (or 5) hyperactivity-impulsivity Sx’s during the past 6 months.
2.Predominantly inattentive presentation: At least 6 (or 5) inattention Sx’s and fewer than 6 (or 5) hyperactivity-impulsivity Sx’s during the past 6 months.
3.Predominantly hyperactive/impulsive presentation: At least 6 (or 5) hyperactivity-impulsivity Sx’s and fewer than 6 (or 5) inattention Sx’s during the past 6 months.
Specify current severity:
1.Mild: Few, if any, Sx’s beyond those required for Dx & the Sx’s cause minor impairments in Fx’ing.
2.Moderate: Sx’s or functional impairment btwn "mild" and “severe.”
3.Severe: Many Sx’s in excess of those needed for Dx, or several Sx’s are especially severe, or Sx’s cause significant impairment in functioning.
Specify if: In partial remission (after full criteria were met before, fewer than the full criteria have been met for the past 6 months and symptoms still produce impairment in functioning).
1.While children w/AUTISM SPECTRUM D/O may misbehave during transitions bc they can't tolerate change from their usual routine, children w/ADHD may misbehave during transitions bc of impulsivity or poor self-control.
2.In individuals w/a SPECIFIC LEARNING D/O who do not have ADHD, inattention is not impairing outside of schoolwork.
3.In BIPOLAR I D/O, poor concentration, increased activity, & increased impulsivity are episodic (i.e., only present during mood episodes) & accompanied by an elevated mood and other bipolar symptoms.
4.DISRUPTIVE MOOD DYSREGULATION D/O is marked by pervasive irritability and intolerance of frustration; impulsiveness and inattention are not key features.
5.In DEPRESSIVE D/O’s, the inability to concentrate is significant only during a depressive episode,
6.In ANXIETY D/O’s, inattention results from worry and rumination; also, while restlessness occurs in both disorders, in people with ADHD restlessness is not associated with worry and rumination,
7.In OPPOSITIONAL DEFIANT D/O’s, resistance to tasks that require seIf-appIication is due to negativity, hostility, and defiance. In ADHD, resistance to tasks requiring prolonged mental effort is due to impulsivity, difficulty in sustaining attention, and forgetting instructions.
8.Inattention, hyperactivity, or impulsivity attributable to the use of medication is diagnosed as OTHER SPECIFIED or UNSPECIFIED OTHER (OR UNKNOWN) SUBSTANCE-RELATED DISORDER.
Specific Learning Disorder
DSM-IV-TR DX: Reading D/O, Mathematics D/O, D/O’s of Written Expression, Learning D/O’s NOS
Type of Change: Renamed; Dx combined; Dx criteria modified; severity (Mild, Moderate, Severe) & Type specifiers (e.g., with impairment in reading) added
One or more specific learning deficits (see below) have persisted for at least 6 months, despite intervention. Affected academic skills are significantly & quantifiably below those expected for age, & the deficits interfere w/school or work performance or ADL’s, as confirmed by both clinical assess and individually administered standardized achievement measures. (For persons age 17 and older, a documented Hx of learning difficulties may take the place of standardized assessment.)
The Sx’s begin during school-age yrs (but may not be fully apparent until demands for academic skills exceed the person's capacities) & are not better explained by intellectual disabilities, uncorrected vision or hearing deficits, other mental or neurological D/O’s, psychosocial adversity, lack of proficiency in the language used to teach, or inadequate academic instruction.
Difficulties in learning & using academic skills associated w/specific learning D/O may be manifested as inaccurate or slow, effortful word reading; difficulty understanding the meaning of what is read; difficulties with spelling; difficulties with written expression; difficulties mastering number sense, number facts, or calculation; and/or difficulties with mathematical reasoning.
W/impairment in reading;
W/impairment in written expression,"
W/impairment in mathematics.
If more than one domain is impaired (e.g., both reading & written expression), code each one individually.
Specify current severity:
Mild: Some difficulties in at least 1 academic domain but may be able to compensate or function well with accommodations or support services.
Moderate: Marked difficulties in at least 1 academic domain - i.e., is unlikely to become proficient w/out some intensive, specialized teaching during school years.
Severe: Severe difficulties in learning skills in several academic domains — i.e., is unlikely to learn those skills without ongoing intensive individualized and specialized teaching for most of the school years.
If INTELLECTUAL DISABILITY is present, specific learning D/O can be Dx’ed only when the learning difficulties are more severe than those usually associated w/the intellectual disability.
With ADHD, poor academic performance may not be due to difficulties in learning academic skills, but rather to difficulties in performing those skills. If criteria for both D/O’s are met both Dx’s can be given.
With learning difficulties due to NEUROLOGICAL or SENSORY D/O’s (hearing or vision impairment, traumatic brain injury, etc.), there are abnormal findings on neurological examination.
The learning difficulties found in specific learning D/O persist despite adequate educational opportunity, exposure to the same instruction as peers, and competency in the language used to teach.
Learning difficulties that include problems with word recognition, decoding, and spelling abilities are also called dyslexia," and learning difficulties characterized by problems processing numerical information, learning arithmetic facts, and performing accurate or fluent calculations are also referred to as dyscalculia.
Developmental Coordination Disorder
DSM-IV-TR DX: Developmental Coordination Disorder
Type of Change: Diagnostic criteria modified
Dx Criteria: The acquisition and execution of coordinated motor skills is substantially below that expected, given the person's chronological age and opportunity for learning and using the skills; and the motor skills deficit significantly and persistently interferes with ADL’s appropriate to chronological age (e.g., self-care) and impacts on academic productivity, prevocational and vocational activities, leisure, and play.
-The onset of Sx’s is in the early developmental period, and the deficits are not better explained by intellectual disability or visual impairment and are not attributable to a neurological condition affecting movement.