Synopsis of Final DSM-IV Changes A few weeks ago, I received the final issue of the "DSM-IV Update" newsletter published by the American Psychiatric Association (APA). This newsletter (available from APA; 800-368-5777) briefly describes changes in the new DSM-IV. This post summarizes their summary, selectively emphasizing changes in DSM disorders that interest me. Although the APA's DSM-IV Manual, to be published by APA in June or so and available from them, is obviously the official reference for all such changes, this synopsis highlights some of what to expect. [I originally posted this to the sci.psychology newsgroup, and now belatedly here on the psychiatry mailing-list.] David Baldwin, PhD Psychologist (OR #815) (503) 686 2598 The Multi-Axial System: Axis I will now include Pervasive Developmental Disorders, Learning Disorders, Motor Skills Disorders and Communications Disorders, formerly on Axis II. Only the Personality Disorders and Mental Retardation are now coded on Axis II. Axis IV is changed to now report psychosocial and environmental problems; it no longer rates the severity of stressors. Axis V is similar to before, but its scale has been expanded over 100 points to include higher levels of functioning. Disorders Usually First Diagnosed in Children & Adolescents: The criteria for Mental Retardation have been modified, now closer to those of the American Association of Mental Retardation. Learning Disorders, now on Axis I, are also somewhat easier to diagnose in the presence of sensory deficit or neurologic condition. The "developmental" prefix has been dropped. Autistic Disorder has been more strictly defined, and now must include onset of delayed or abnormal functioning in play or social interaction before age 3 years. Rett's Disorder, Childhood Disintegrative Disorder, and Aspergers's Disorder have been included for greater specificity (formerly coded as Pervasive Developmental Disorder, NOS). Disruptive and Attention Deficit Disorders: Attention-Deficit Hyperactivity Disorder is now one disorder (ADD and ADHD were separate disorders), with three subtypes: combined, predominantly inattentive, or predominantly hyperactive/impulsive. An additional criterion now requires symptoms in two or more situations (e.g., at school, work, and at home). Criteria for Conduct Disorder have been expanded (adding "staying out at night" and "intimidating others" ) to make it easier to diagnose females. New subtypes based on age of onset have been added -- since earlier onset has a worse prognosis and is more likely associated with aggressive behavior or antisocial personality disorder. The "uses obscene language" criterion has been dropped from Oppositional Defiant Disorder, because so many people swear nowadays. An impairment criterion is added. Communication Disorders: Expressive Language Disorder is no longer excluded in presence of speech-motor disorder, sensory deficit, or environmental deprivation, so long as the deficit is clear. Mixed Receptive-Expressive Language Disorder is also easier to diagnose (as above). It replaces developmental receptive language disorder, and now includes cluttering. Elimination Disorders: The duration requirement of Encopresis is reduced to 3 months (it was 6 months), and subtypes are added. Frequency and duration threshold for Enuresis is raised to twice a week for 3 months (from two a month), but there's leeway if clinically significant distress or impairment is seen. Other Disorders of Childhood or Adolescence: The Anxiety Disorders of Childhood subsection no longer exists, eliminating Avoidant Disorder of Childhood, and Overanxious Disorder. Separation Anxiety Disorder has been moved to a catch-all "other disorders" section. Among the (adult) anxiety disorders, criteria for Social Phobia and Generalized Anxiety Disorder have been modified so that they now may apply to children. Stereotypic Movement Disorder is the new name for Stereotypy/habit Disorder. Delirium, Amnestic and other Cognitive Disorders: The Organic Mental Disorders section is gone, as it implied other disorders weren't "organic". Definition of Amnestic Disorders is simplified; memory impairment criteria are sharpened. Substance-Related Disorders: This new section combines what were two sections: Psychoactive Substance Use Disorders, and Psychoactive Substance-Induced Organic Mental Disorders. The conceptualization of substance dependence and substance abuse is clarified. Schizophrenia and other Psychotic Disorders: The required active symptom duration in Schizophrenia is increased to 1 month (from 1 week); other criteria are simplified, and prodromal/residual symptom lists are dropped. Brief Psychotic Disorder now encompasses all psychotic "breaks" of less than 1 month. The severe stressor requirement is dropped. The minimum duration is 1 day (was a few hours). Mood Disorders: Major Depressive Episode drops the exclusion for symptoms due to physical condition, delusions, incoherence, etc. and adds a criterion to ensure clinical significance. The primary and secondary subtypes of Dysthymic Disorder are dropped. Criteria for Melancholic, Atypical, and Catatonic Features, and for the course-specifing subtypes, are broadened some. Organization of Bipolar Disorders is changed; there are now Bipolar I and Bipolar II (no history of manic episodes) types, with subtypes based on most recent episode. Anxiety Disorders: Criteria for Panic Attacks clarify that these can occur as a part of several anxiety disorders. Panic Disorder (with or without Agoraphobia) now requires recurrent unexpected panic attacks and 1 month or more of persistent concern about them, a slightly easier definition. Specific Phobia (was Simple Phobia) gives subtypes to describe the focus of the phobia. Social Phobia now subsumes Avoidant Disorder of Childhood. Obsessive-Compulsive Disorder now clarifies the distinction between its components, and a specifier is added to note "poor insight" regarding the "unreasonableness" criterion. Post-Traumatic Stress Disorder (PTSD) no longer requires that the stressor be "outside the range of normal human experience" -- this was unreliable and inaccurate. A new criterion requires symptoms must cause clinically significant distress or impairment. New acute and chronic subtypes are added. A new Acute Stress Disorder describes reactions to extreme stress lasting up to 1 month. Generalized Anxiety Disorder now subsumes Overanxious Disorder of Childhood. Its symptom list is simpler, and some "difficulty of controlling worry" is now required. Somatoform Disorders: The diagnostic items signifying Somatization Disorder are simplified and condensed. Dissociative Disorders: Dissociative Identity Disorder is the new name for MPD, to be more descriptive. A former requirement: "inability to recall important personal information", is reinstated. Dissociative Amnesia, and Dissociative Fugue, replace the comparable but former "psychogenic" disorders, as more descriptive names. Sexual and Gender Identity Disorders: Gender Identity Disorder now subsumes transsexualism, gender identity disorder of childhood (as well as of adolescence or adulthood), and accommodates both sexes. Sleep Disorders: This section has been re-organized; disorders are now grouped by etiology, (e.g., primary, substance-induced, etc.), not by presenting symptoms. Primary insomnia drops the old 3 times a week requirement, but must have a duration of at least 1 month. Insomnia or Hypersomnia Related to [Axis I or Axis II disorder] can be used if the sleep disorder is severe enough to warrant independent attention. Nightmare Disorder is the new name for Dream Anxiety Disorder. Impulse Control Disorders: Intermittent Explosive Disorder is no longer excluded when generalized impulsiveness or aggressiveness is seen between episodes. Adjustment Disorders: All the Adjustment Disorders can now last longer than 6 months: symptoms can last up to 6 months after termination of a stressor or its consequences. An acute/chronic specification can indicate even longer-lasting cases. Several old and peculiar subtypes are dropped. Personality Disorders (Axis II): Criteria for Antisocial Personality Disorder have been condensed, simplified, and altered: two adult irresponsibility items are dropped, and two work and debt-paying items combined. Borderline Personality Disorder now adds an additional item for transient, stress-related paranoid ideation or severe dissociative symptoms. Passive-Aggressive Personality Disorder has been dropped, and is now an undiagnosable "trait". A revised version lingers on in an Appendix. Other Conditions that May be a Focus of Clinical Attention (V-Codes): This is a new name for the section formerly called "Conditions Not Attributable to a Mental Disorder...", and the list of conditions is broadened to include relational problems, problems related to abuse or neglect, and medically-related issues.