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Britain - Trans people angry at being losers in gay marriage bill… [2013-05-23 GayStarNews]

http://tinyurl.com/podotve

Trans people angry at being losers in gay marriage bill

Trans campaigners highlight problems with England and Wales’ equal marriage bill saying they were betrayed by gay allies

23 MAY 2013

BY JANE FAE

Trans activists were left ‘despairing and angry’ at England and Wales’ equal marriage bill saying they have been betrayed by the British government and LGBT allies.

The Marriage (Same Sex Couples) Bill passed its third reading in Britain’s House of Commons last night with Members of Parliament voting 366 to 161 in favor of the legislation on Tuesday (21 May).

The bill now has to pass through the House of Lords where it will face opposition but the government appears determined to ensure it passes.

Trans activists say government proposals went a little way to fix what were widely seen as anomalies in the treatment of trans individuals when it came to marriage.

But plans were rejected to compensate trans people for ‘stolen marriages’, where a husband and wife in a loving relationship are forced to divorce when one transitions.

And the government failed to use the bill to rectify other aspects of already existing marriage law that trans people see as ‘offensive’.

This includes allowing husbands or wives to void marriages if their partner fails to reveal part of their gender history when they wed.

The ‘stolen marriage’ issue arose in respect of the granting of gender recognition certificates (GRC’s) in line with the Gender Recognition Act 2004.

This allowed an individual for the first time to amend their birth certificate to align all aspects of their gender history for official purposes.

But since equal marriage was not available in 2004, an absolute requirement for obtaining a GRC was that individuals first divorce. They could then have a civil partnership, offering marriage rights to gay couples since 2005, if they wished.

This caused significant grief to those who had managed to hold on to their partner through the transition journey.

There was, too, an added practical problem: where an individual traded marriage for civil partnership, their spouse would lose all ‘survivor’s benefits’ – the bit of pension they would obtain by out-living their partner – accrued during the marriage.

So obtaining a GRC could cost a spouse tens of thousands of pounds in pension.

If the new marriage bill completes its progress through parliament, that anomaly will be cleared. Divorce will not be required to obtain a GRC. And couples translating an existing marriage to a new ‘protected’ marriage will not lose any pension rights.

However, as junior Equalities Minister, Helen Grant told the Commons on Tuesday night, no compensation would be paid to those individuals who had been forced to choose between marriage and GRC in the years since the passing of the Gender Recognition Act.

In addition the new bill means that, before obtaining a GRC, trans individuals in a marriage must obtain the consent of their spouse.

One trans activist has already said this breaches human rights.

According to Helen Belcher, a member of the UK Parliamentary Forum on Gender Identity: ‘Above anything else that can happen in a marriage – bankruptcy, life-changing surgery and name change – gender change alone will require spousal consent.

‘This is deeply troubling because abstract objections are put ahead of an individual’s human rights. It also ignores the reality of obstructive spouses which will leave some trans people stranded for years without gender recognition and nothing they can do about it.’

The government also refused to remove from marriage law the option for a partner to have their marriage declared void if their spouse failed to disclose the fact that they possessed a GRC.

This is not, technically, the same as failure to disclose other material facts relating to gender history, which would continue to be covered by other sections of matrimonial law.

Trans campaigners say this undermines the utility of the GRC, itself already under fire. The main reason for obtaining a certificate is to tidy up the past, to remove from the records any trace of gender inconsistency.

But if its possession remains, also, grounds for dissolving a marriage, then the arguments against obtaining one grow stronger.

Concerns have grown further after the police and Crown Prosecution Service (CPS) to prosecute for trans people for assault when they don’t tell their lover about their gender history before sex.

Authorities have not taken any comparable action in respect of individuals who had failed to disclose their past history as sex offenders or child abusers.

Trans campaigners say the CPS will not engage with them on the issue.

But they feel this sends out a very clear message that failure to disclose ‘real gender’ is viewed as a more serious criminal act than being a rapist, thereby encouraging and providing mitigation for transphobic assault.

Government insistence on keeping special provisions for trans divorce within current matrimonial law is viewed as adding considerably to this impression.

In the United States, campaigns for equal marriage have frequently fractured, with trans groups accusing LGB activists of focusing primarily on gay issues with only vague promises to follow through on issues that affect the trans community after. The outcome of this week’s debates make it increasingly likely similar fault lines opening up in the UK.

GSN is awaiting a response from the UK government’s Equalities Department.

A separate legislative process is being pursued to introduce equal marriage in Scotland.

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Comments:   

Indi Kelly Edwards

we been screaming it from the rooftops since forever but as per usual we are ignored by our gay sisters and brothers as "those noisy annoying trans people". This is the result. We are supposed to lift each other up but you continue with your "gay marriage" tropes and completely ignore our appeals for "marriage equality". Its the GLBTI not the GL its about time yall started to listen to us and support and respect our needs instead of kicking us to the curb all the time. There is no excuse. We are not an accessory or a tokenistic tag on. Personally myself and many trans people are very disappointed but not surprised.

4 hours ago

   …..

   Korhan Erel

   One should never forget that gays and lesbians are also human beings... being gay or lesbian does not make you a nicer human being.

   4 hours ago

   …..

   Jani McCauley ·

   There are also some in the community who need to remember that we are human as well and being trans does not make us less worthy, which sadly seems to be one school of thought.

   4 hours ago

   …..
   
   Indi Kelly Edwards

   its sad that this will be systematically repeated all over the world.

   4 hours ago

…..

Princess Layla · Bredbury Comprehensive

1, I really don't know why we bother to have anything to do with the LGB community, we are like apples and oranges, I feel we may do better without them.
2, Regarding the subject of having to disclose gender history before sex, whilst I understood the reason behind the comparison I'm not sure comparing us to rapists and child abusers actually helps our public perception.

4 hours ago

   …..
   
   Donald Perry · Johns Hopkins University

   LGB people would probably be better off without trans people also. Do you really feel you can marry someone as one gender and then change genders without consideration of the spouse;s feeling on the matter? I marry a woman and she alone deciides to become a man and I am stuck with her new new person whether I want to not? That's really buying a pig in a poke.

   4 hours ago

   …..

   Jane Fae

   So what else should your partner be legally required to seek your permission on? Getting a second mortgage? Obtaining medical treatment? Opening a bank account?

   This is dinosaur stuff...

   2 hours ago

   …..

   Darren Sanderson

   Donald if you married a woman, and in a car accident she was horribly disformed you'd stand by her, right? You wouldn't want to divorce her despite her being less physically attractive would you? Or am I right in thinking that you're a despicable person who WOULD divorce a wife in that situation? Physical attraction is important to a marriage but it should never be the reason you decide to give up on someone you love, especially in their time of need

   about an hour ago

…..

Gerry Leddy · Holywood

Voicing their anger publicly does the issue no favours at all. to the outsiders especially the homophobic and antihomotic they can say, Look they cant even agree among themselves'. The outsiders haven't appreciated that LGBT is not based on a common identity. LGB has a common identity based on 'sexuality'. The T is an identity based on 'gender'. If the Trans anger spills into a derailment of the progress made so far, than it is time the gay group went back to being just LGB with the common sexuality identity.

6 hours ago

   …..

   Dana Taylor

   Aren't the trans community angry just like gays were way back when?

   5 hours ago

   …..

   Jane Fae ·

   Privilege? Much.

   4 hours ago
   
   …..

   Darren Sanderson

   It was never "just LGB". Ever. It has never ever been "just LGB". People of all the sexual minorities and gender identities have always been together because we're viewed by the rest of society that way. The haters don't see gender or sexuality they just see "freak" and we all fit that bill in their eyes. Wikipedia credits a transwoman with inciting the mob at Stonewall into rioting with a cry for help when she was being arrested and beaten, without which we may be in very different and more unforgiving circumstances today.

   Telling them to "shut the **** up" because they're not doing themselves any favours is a ridiculous notion. Nobody ever credited social change to silence because it never happens. It's disgusting to see LGB's defending heterosexual and cisgendered lawmakers who still wrongly persecute T's.

   about an hour ago

…..

Darren Sanderson

To all the T's out there angry at the LGB's. Please realise that it wasn't LGB's who wrote and passed this broken law. Both of our fates still lie almost entirely in the hands of heterosexual cisgendered lawmakers. Those are the same lawmakers who decided unfairly that it would be easier to pass the bill by excluding trans issues from the changes.

about an hour ago

—

© 2011-2012 Gay Star News.

Any IT guys on this forum that might have some advice?

Or IT gals.   

Any IT guys on this forum that might have some advice?

Thanks Wiki.  BAMZ is one of the under-rated places on the Island.  Well worth checking out.   

BAMZ (for you newbies, that's the Bermuda Aquarium, Museum & Zoo aka the Bermuda Zoological Society) needs towels for animal rehabilitation...they do a lot of conservation and rescue work on the island.

If you have any used or unwanted towels hanging around collecting mildew (heh heh) just drop them off at the aquarium to be put to good use!

THANKS!

US - DSM-5 "Highlights of Changes from DSM-IV-TR to DSM-5…" [2013-05-17 APA]

BLS 2013-05-22 OCR'd http://www.psychiatry.org/dsm5 downloaded .pdf text: changes-from-dsm-iv-tr--to-dsm-5.pdf Hhlights o

Changes made to the DSM-5 diagnostic criteria and texts are outlined in this chapter in the same order in which they appear in the DSM-5 classification. This is not an exhaustive guide; minor changes in text or wording made for clarity are not described here. It should also be noted that Section I of DSM-5 con- tains a description of changes pertaining to the chapter organization in DSM-5, the multiaxial system, and the introduction of dimensional assessments (in Section III).

Terminology

The phrase “general medical condition” is replaced in DSM-5 with “another medical condition” where relevant across all disorders.


Neurodevelopmental Disorders

Intellectual Disability (Intellectual Developmental Disorder)

Diagnostic criteria for intellectual disability (intellectual developmental disorder) emphasize the need for an assessment of both cognitive capacity (IQ) and adaptive functioning. Severity is determined by adaptive functioning rather than IQ score. The term mental retardation was used in DSM-IV. However, intellectual disability is the term that has come into common use over the past two decades among medical, educational, and other professionals, and by the lay public and advocacy groups. Moreover, a federal statue in the United States (Public Law 111-256, Rosa’s Law) replaces the term “mental retarda- tion with intellectual disability. Despite the name change, the deficits in cognitive capacity beginning in the developmental period, with the accompanying diagnostic criteria, are considered to constitute a mental disorder. The term intellectual developmental disorder was placed in parentheses to reflect the World Health Organization’s classification system, which lists “disorders” in the International Classifica- tion of Diseases (ICD; ICD-11 to be released in 2015) and bases all “disabilities” on the International Classification of Functioning, Disability, and Health (ICF). Because the ICD-11 will not be adopted for several years, intellectual disability was chosen as the current preferred term with the bridge term for the future in parentheses.

Communication Disorders

The DSM-5 communication disorders include language disorder (which combines DSM-IV expressive and mixed receptive-expressive language disorders), speech sound disorder (a new name for phono- logical disorder), and childhood-onset fluency disorder (a new name for stuttering). Also included is social (pragmatic) communication disorder, a new condition for persistent difficulties in the social uses of verbal and nonverbal communication. Because social communication deficits are one component of autism spectrum disorder (ASD), it is important to note that social (pragmatic) communication disorder cannot be diagnosed in the presence of restricted repetitive behaviors, interests, and activities (the oth- er component of ASD). The symptoms of some patients diagnosed with DSM-IV pervasive developmen- tal disorder not otherwise specified may meet the DSM-5 criteria for social communication disorder.

Autism Spectrum Disorder

Autism spectrum disorder is a new DSM-5 name that reflects a scientific consensus that four previously separate disorders are actually a single condition with different levels of symptom severity in two core

domains. ASD now encompasses the previous DSM-IV autistic disorder (autism), Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified. ASD is characterized by 1) deficits in social communication and social interaction and 2) restricted repetitive behaviors, interests, and activities (RRBs). Because both components are required for diagnosis of ASD, social communication disorder is diagnosed if no RRBs are present.

Attention-Deficit/Hyperactivity Disorder

The diagnostic criteria for attention-deficit/hyperactivity disorder (ADHD) in DSM-5 are similar to those in DSM-IV. The same 18 symptoms are used as in DSM-IV, and continue to be divided into two symp- tom domains (inattention and hyperactivity/impulsivity), of which at least six symptoms in one domain are required for diagnosis. However, several changes have been made in DSM-5: 1) examples have been added to the criterion items to facilitate application across the life span; 2) the cross-situational requirement has been strengthened to “several” symptoms in each setting; 3) the onset criterion has been changed from “symptoms that caused impairment were present before age 7 years” to “several inattentive or hyperactive-impulsive symptoms were present prior to age 12”; 4) subtypes have been replaced with presentation specifiers that map directly to the prior subtypes; 5) a comorbid diagnosis with autism spectrum disorder is now allowed; and 6) a symptom threshold change has been made for adults, to reflect their substantial evidence of clinically significant ADHD impairment, with the cutoff for ADHD of five symptoms, instead of six required for younger persons, both for inattention and for hyperactivity and impulsivity. Finally, ADHD was placed in the neurodevelopmental disorders chapter to reflect brain developmental correlates with ADHD and the DSM-5 decision to eliminate the DSM-IV chapter that includes all diagnoses usually first made in infancy, childhood, or adolescence.

Specific Learning Disorder

Specific learning disorder combines the DSM-IV diagnoses of reading disorder, mathematics disorder, disorder of written expression, and learning disorder not otherwise specified. Because learning deficits in the areas of reading, written expression, and mathematics commonly occur together, coded speci- fiers for the deficit types in each area are included. The text acknowledges that specific types of read- ing deficits are described internationally in various ways as dyslexia and specific types of mathematics deficits as dyscalculia.

Motor Disorders

The following motor disorders are included in the DSM-5 neurodevelopmental disorders chapter: devel- opmental coordination disorder, stereotypic movement disorder, Tourette’s disorder, persistent (chron- ic) motor or vocal tic disorder, provisional tic disorder, other specified tic disorder, and unspecified tic disorder. The tic criteria have been standardized across all of these disorders in this chapter. Stereotypic movement disorder has been more clearly differentiated from body-focused repetitive behavior disor- ders that are in the DSM-5 obsessive-compulsive disorder chapter.



Schizophrenia Spectrum and Other Psychotic Disorders

Schizophrenia

Two changes were made to DSM-IV Criterion A for schizophrenia. The first change is the elimination of the special attribution of bizarre delusions and Schneiderian first-rank auditory hallucinations (e.g., two or more voices conversing). In DSM-IV, only one such symptom was needed to meet the diagnostic requirement for Criterion A, instead of two of the other listed symptoms. This special attribution was removed due to the nonspecificity of Schneiderian symptoms and the poor reliability in distinguishing bizarre from nonbizarre delusions. Therefore, in DSM-5, two Criterion A symptoms are required for any diagnosis of schizophrenia. The second change is the addition of a requirement in Criterion A that the individual must have at least one of these three symptoms: delusions, hallucinations, and disorganized speech. At least one of these core “positive symptoms” is necessary for a reliable diagnosis of schizophrenia.

Schizophrenia subtypes

The DSM-IV subtypes of schizophrenia (i.e., paranoid, disorganized, catatonic, undifferentiated, and residual types) are eliminated due to their limited diagnostic stability, low reliability, and poor validity. These subtypes also have not been shown to exhibit distinctive patterns of treatment response or lon- gitudinal course. Instead, a dimensional approach to rating severity for the core symptoms of schizo- phrenia is included in Section III to capture the important heterogeneity in symptom type and severity expressed across individuals with psychotic disorders.

Schizoaffective Disorder

The primary change to schizoaffective disorder is the requirement that a major mood episode be pres- ent for a majority of the disorder’s total duration after Criterion A has been met. This change was made on both conceptual and psychometric grounds. It makes schizoaffective disorder a longitudinal instead of a cross-sectional diagnosis—more comparable to schizophrenia, bipolar disorder, and major depres- sive disorder, which are bridged by this condition. The change was also made to improve the reliability, diagnostic stability, and validity of this disorder, while recognizing that the characterization of patients with both psychotic and mood symptoms, either concurrently or at different points in their illness, has been a clinical challenge.

Delusional Disorder

Criterion A for delusional disorder no longer has the requirement that the delusions must be non- bizarre. A specifier for bizarre type delusions provides continuity with DSM-IV. The demarcation of delusional disorder from psychotic variants of obsessive-compulsive disorder and body dysmorphic disorder is explicitly noted with a new exclusion criterion, which states that the symptoms must not be better explained by conditions such as obsessive-compulsive or body dysmorphic disorder with absent insight/delusional beliefs. DSM-5 no longer separates delusional disorder from shared delusional dis- order. If criteria are met for delusional disorder then that diagnosis is made. If the diagnosis cannot be made but shared beliefs are present, then the diagnosis “other specified schizophrenia spectrum and other psychotic disorder” is used.

Catatonia

The same criteria are used to diagnose catatonia whether the context is a psychotic, bipolar, depres- sive, or other medical disorder, or an unidentified medical condition. In DSM-IV, two out of five symp- tom clusters were required if the context was a psychotic or mood disorder, whereas only one symp- tom cluster was needed if the context was a general medical condition. In DSM-5, all contexts require three catatonic symptoms (from a total of 12 characteristic symptoms). In DSM-5, catatonia may be diagnosed as a specifier for depressive, bipolar, and psychotic disorders; as a separate diagnosis in the context of another medical condition; or as an other specified diagnosis.



Bipolar and Related Disorders

Bipolar Disorders

To enhance the accuracy of diagnosis and facilitate earlier detection in clinical settings, Criterion A for manic and hypomanic episodes now includes an emphasis on changes in activity and energy as well as mood. The DSM-IV diagnosis of bipolar I disorder, mixed episode, requiring that the individual simulta- neously meet full criteria for both mania and major depressive episode, has been removed. Instead, a new specifier, “with mixed features,” has been added that can be applied to episodes of mania or hy- pomania when depressive features are present, and to episodes of depression in the context of major depressive disorder or bipolar disorder when features of mania/hypomania are present.

Other Specified Bipolar and Related Disorder

DSM-5 allows the specification of particular conditions for other specified bipolar and related disorder, including categorization for individuals with a past history of a major depressive disorder who meet all criteria for hypomania except the duration criterion (i.e., at least 4 consecutive days). A second condi- tion constituting an other specified bipolar and related disorder is that too few symptoms of hypoma- nia are present to meet criteria for the full bipolar II syndrome, although the duration is sufficient at 4 or more days.

Anxious Distress Specifier

In the chapter on bipolar and related disorders and the chapter on depressive disorders, a specifier for anxious distress is delineated. This specifier is intended to identify patients with anxiety symptoms that are not part of the bipolar diagnostic criteria.



Depressive Disorders

DSM-5 contains several new depressive disorders, including disruptive mood dysregulation disorder and premenstrual dysphoric disorder. To address concerns about potential overdiagnosis and overtreat- ment of bipolar disorder in children, a new diagnosis, disruptive mood dysregulation disorder, is includ- ed for children up to age 18 years who exhibit persistent irritability and frequent episodes of extreme behavioral dyscontrol. Based on strong scientific evidence, premenstrual dysphoric disorder has been moved from DSM-IV Appendix B, “Criteria Sets and Axes Provided for Further Study,” to the main body of DSM-5. Finally, DSM-5 conceptualizes chronic forms of depression in a somewhat modified way. What was referred to as dysthymia in DSM-IV now falls under the category of persistent depressive dis- order, which includes both chronic major depressive disorder and the previous dysthymic disorder. An inability to find scientifically meaningful differences between these two conditions led to their combi- nation with specifiers included to identify different pathways to the diagnosis and to provide continuity with DSM-IV.

Major Depressive Disorder

Neither the core criterion symptoms applied to the diagnosis of major depressive episode nor the req- uisite duration of at least 2 weeks has changed from DSM-IV. Criterion A for a major depressive episode in DSM-5 is identical to that of DSM-IV, as is the requirement for clinically significant distress or impair- ment in social, occupational, or other important areas of life, although this is now listed as Criterion

B rather than Criterion C. The coexistence within a major depressive episode of at least three manic symptoms (insufficient to satisfy criteria for a manic episode) is now acknowledged by the specifier “with mixed features.” The presence of mixed features in an episode of major depressive disorder in-

4 • Highlights of Changes from DSM-IV-TR to DSM-5

creases the likelihood that the illness exists in a bipolar spectrum; however, if the individual concerned has never met criteria for a manic or hypomanic episode, the diagnosis of major depressive disorder is retained.

Bereavement Exclusion

In DSM-IV, there was an exclusion criterion for a major depressive episode that was applied to depres- sive symptoms lasting less than 2 months following the death of a loved one (i.e., the bereavement exclusion). This exclusion is omitted in DSM-5 for several reasons. The first is to remove the implication that bereavement typically lasts only 2 months when both physicians and grief counselors recognize that the duration is more commonly 1–2 years. Second, bereavement is recognized as a severe psy- chosocial stressor that can precipitate a major depressive episode in a vulnerable individual, generally beginning soon after the loss. When major depressive disorder occurs in the context of bereavement, it adds an additional risk for suffering, feelings of worthlessness, suicidal ideation, poorer somatic health, worse interpersonal and work functioning, and an increased risk for persistent complex bereavement disorder, which is now described with explicit criteria in Conditions for Further Study in DSM-5 Section III. Third, bereavement-related major depression is most likely to occur in individuals with past personal and family histories of major depressive episodes. It is genetically influenced and is associated with similar personality characteristics, patterns of comorbidity, and risks of chronicity and/or recurrence

as non–bereavement-related major depressive episodes. Finally, the depressive symptoms associated with bereavement-related depression respond to the same psychosocial and medication treatments as non–bereavement-related depression. In the criteria for major depressive disorder, a detailed footnote has replaced the more simplistic DSM-IV exclusion to aid clinicians in making the critical distinction be- tween the symptoms characteristic of bereavement and those of a major depressive episode. Thus, al- though most people experiencing the loss of a loved one experience bereavement without developing a major depressive episode, evidence does not support the separation of loss of a loved one from other stressors in terms of its likelihood of precipitating a major depressive episode or the relative likelihood that the symptoms will remit spontaneously.

Specifiers for Depressive Disorders

Suicidality represents a critical concern in psychiatry. Thus, the clinician is given guidance on assess- ment of suicidal thinking, plans, and the presence of other risk factors in order to make a determination of the prominence of suicide prevention in treatment planning for a given individual. A new specifier to indicate the presence of mixed symptoms has been added across both the bipolar and the depressive disorders, allowing for the possibility of manic features in individuals with a diagnosis of unipolar de- pression. A substantial body of research conducted over the last two decades points to the importance of anxiety as relevant to prognosis and treatment decision making. The “with anxious distress” specifier gives the clinician an opportunity to rate the severity of anxious distress in all individuals with bipolar or depressive disorders.



Anxiety Disorders

The DSM-5 chapter on anxiety disorder no longer includes obsessive-compulsive disorder (which is included with the obsessive-compulsive and related disorders) or posttraumatic stress disorder and acute stress disorder (which is included with the trauma- and stressor-related disorders). However, the sequential order of these chapters in DSM-5 reflects the close relationships among them.

Agoraphobia, Specific Phobia, and Social Anxiety Disorder (Social Phobia)

Changes in criteria for agoraphobia, specific phobia, and social anxiety disorder (social phobia) include deletion of the requirement that individuals over age 18 years recognize that their anxiety is excessive or unreasonable. This change is based on evidence that individuals with such disorders often overesti- mate the danger in “phobic” situations and that older individuals often misattribute “phobic” fears to aging. Instead, the anxiety must be out of proportion to the actual danger or threat in the situation, af- ter taking cultural contextual factors into account. In addition, the 6-month duration, which was limited to individuals under age 18 in DSM-IV, is now extended to all ages. This change is intended to minimize overdiagnosis of transient fears.

Panic Attack

The essential features of panic attacks remain unchanged, although the complicated DSM-IV terminol- ogy for describing different types of panic attacks (i.e., situationally bound/cued, situationally predis- posed, and unexpected/uncued) is replaced with the terms unexpected and expected panic attacks. Panic attacks function as a marker and prognostic factor for severity of diagnosis, course, and comor- bidity across an array of disorders, including but not limited to anxiety disorders. Hence, panic attack can be listed as a specifier that is applicable to all DSM-5 disorders.

Panic Disorder and Agoraphobia

Panic disorder and agoraphobia are unlinked in DSM-5. Thus, the former DSM-IV diagnoses of panic disorder with agoraphobia, panic disorder without agoraphobia, and agoraphobia without history of panic disorder are now replaced by two diagnoses, panic disorder and agoraphobia, each with separate criteria. The co-occurrence of panic disorder and agoraphobia is now coded with two diagnoses. This change recognizes that a substantial number of individuals with agoraphobia do not experience panic symptoms. The diagnostic criteria for agoraphobia are derived from the DSM-IV descriptors for agora- phobia, although endorsement of fears from two or more agoraphobia situations is now required, be- cause this is a robust means for distinguishing agoraphobia from specific phobias. Also, the criteria for agoraphobia are extended to be consistent with criteria sets for other anxiety disorders (e.g., clinician judgment of the fears as being out of proportion to the actual danger in the situation, with a typical duration of 6 months or more).

Specific Phobia

The core features of specific phobia remain the same, but there is no longer a requirement that indi- viduals over age 18 years must recognize that their fear and anxiety are excessive or unreasonable, and the duration requirement (“typically lasting for 6 months or more”) now applies to all ages. Although they are now referred to as specifiers, the different types of specific phobia have essentially remained unchanged.

Social Anxiety Disorder (Social Phobia)

The essential features of social anxiety disorder (social phobia) (formerly called social phobia) remain the same. However, a number of changes have been made, including deletion of the requirement that individuals over age 18 years must recognize that their fear or anxiety is excessive or unreasonable, and duration criterion of “typically lasting for 6 months or more” is now required for all ages. A more sig- nificant change is that the “generalized” specifier has been deleted and replaced with a “performance only” specifier. The DSM-IV generalized specifier was problematic in that “fears include most social situ- ations” was difficult to operationalize. Individuals who fear only performance situations (i.e., speaking or performing in front of an audience) appear to represent a distinct subset of social anxiety disorder in terms of etiology, age at onset, physiological response, and treatment response.

Separation Anxiety Disorder

Although in DSM-IV, separation anxiety disorder was classified in the section “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence,” it is now classified as an anxiety disorder. The core features remain mostly unchanged, although the wording of the criteria has been modified to more adequately represent the expression of separation anxiety symptoms in adulthood. For example, at- tachment figures may include the children of adults with separation anxiety disorder, and avoidance behaviors may occur in the workplace as well as at school. Also, in contrast to DSM-IV, the diagnostic criteria no longer specify that age at onset must be before 18 years, because a substantial number of adults report onset of separation anxiety after age 18. Also, a duration criterion—“typically lasting for 6 months or more”—has been added for adults to minimize overdiagnosis of transient fears.

Selective Mutism

In DSM-IV, selective mutism was classified in the section “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence.” It is now classified as an anxiety disorder, given that a large majority of children with selective mutism are anxious. The diagnostic criteria are largely unchanged from DSM-IV.



Obsessive-Compulsive and Related Disorders

The chapter on obsessive-compulsive and related disorders, which is new in DSM-5, reflects the in- creasing evidence that these disorders are related to one another in terms of a range of diagnostic validators, as well as the clinical utility of grouping these disorders in the same chapter. New disorders include hoarding disorder, excoriation (skin-picking) disorder, substance-/medication-induced obses- sive-compulsive and related disorder, and obsessive-compulsive and related disorder due to another medical condition. The DSM-IV diagnosis of trichotillomania is now termed trichotillomania (hair-pull- ing disorder) and has been moved from a DSM-IV classification of impulse-control disorders not else- where classified to obsessive-compulsive and related disorders in DSM-5.

Specifiers for Obsessive-Compulsive and Related Disorders

The “with poor insight” specifier for obsessive-compulsive disorder has been refined in DSM-5 to allow a distinction between individuals with good or fair insight, poor insight, and “absent insight/delusional” obsessive-compulsive disorder beliefs (i.e., complete conviction that obsessive-compulsive disorder beliefs are true). Analogous “insight” specifiers have been included for body dysmorphic disorder and hoarding disorder. These specifiers are intended to improve differential diagnosis by emphasizing that individuals with these two disorders may present with a range of insight into their disorder-related be- liefs, including absent insight/delusional symptoms. This change also emphasizes that the presence of absent insight/delusional beliefs warrants a diagnosis of the relevant obsessive-compulsive or related disorder, rather than a schizophrenia spectrum and other psychotic disorder. The “tic-related” specifier for obsessive-compulsive disorder reflects a growing literature on the diagnostic validity and clinical utility of identifying individuals with a current or past comorbid tic disorder, because this comorbidity may have important clinical implications.

Body Dysmorphic Disorder

For DSM-5 body dysmorphic disorder, a diagnostic criterion describing repetitive behaviors or mental

Highlights of Changes from DSM-IV-TR to DSM-5 • 7

acts in response to preoccupations with perceived defects or flaws in physical appearance has been added, consistent with data indicating the prevalence and importance of this symptom. A “with muscle dysmorphia” specifier has been added to reflect a growing literature on the diagnostic validity and clini- cal utility of making this distinction in individuals with body dysmorphic disorder. The delusional vari- ant of body dysmorphic disorder (which identifies individuals who are completely convinced that their perceived defects or flaws are truly abnormal appearing) is no longer coded as both delusional disor- der, somatic type, and body dysmorphic disorder; in DSM-5 this presentation is designated only as body dysmorphic disorder with the absent insight/delusional beliefs specifier.

Hoarding Disorder

Hoarding disorder is a new diagnosis in DSM-5. DSM-IV lists hoarding as one of the possible symptoms of obsessive-compulsive personality disorder and notes that extreme hoarding may occur in obsessive- compulsive disorder. However, available data do not indicate that hoarding is a variant of obsessive- compulsive disorder or another mental disorder. Instead, there is evidence for the diagnostic validity and clinical utility of a separate diagnosis of hoarding disorder, which reflects persistent difficulty dis- carding or parting with possessions due to a perceived need to save the items and distress associated with discarding them. Hoarding disorder may have unique neurobiological correlates, is associated with significant impairment, and may respond to clinical intervention.

Trichotillomania (Hair-Pulling Disorder)

Trichotillomania was included in DSM-IV, although “hair-pulling disorder” has been added parentheti- cally to the disorder’s name in DSM-5.

Excoriation (Skin-Picking) Disorder

Excoriation (skin-picking) disorder is newly added to DSM-5, with strong evidence for its diagnostic validity and clinical utility.

Substance/Medication-Induced Obsessive-Compulsive and Related Disorder and Obsessive-Compul- sive and Related Disorder Due to Another Medical Condition DSM-IV included a specifier “with obsessive-compulsive symptoms” in the diagnoses of anxiety disor- ders due to a general medical condition and substance-induced anxiety disorders. Given that obses- sive-compulsive and related disorders are now a distinct category, DSM-5 includes new categories for substance-/medication-induced obsessive-compulsive and related disorder and for obsessive-compul- sive and related disorder due to another medical condition. This change is consistent with the intent of DSM-IV, and it reflects the recognition that substances, medications, and medical conditions can pres- ent with symptoms similar to primary obsessive-compulsive and related disorders.

Other Specified and Unspecified Obsessive-Compulsive and Related Disorders

DSM-5 includes the diagnoses other specified obsessive-compulsive and related disorder, which can include conditions such as body-focused repetitive behavior disorder and obsessional jealousy, or unspecified obsessive-compulsive and related disorder. Body-focused repetitive behavior disorder is characterized by recurrent behaviors other than hair pulling and skin picking (e.g., nail biting, lip biting, cheek chewing) and repeated attempts to decrease or stop the behaviors. Obsessional jealousy is char- acterized by nondelusional preoccupation with a partner’s perceived infidelity.



Trauma- and Stressor-Related Disorders

Acute Stress Disorder

In DSM-5, the stressor criterion (Criterion A) for acute stress disorder is changed from DSM-IV. The criterion requires being explicit as to whether qualifying traumatic events were experienced directly, witnessed, or experienced indirectly. Also, the DSM-IV Criterion A2 regarding the subjective reaction to the traumatic event (e.g., “the person’s response involved intense fear, helplessness, or horror”) has been eliminated. Based on evidence that acute posttraumatic reactions are very heterogeneous and that DSM-IV’s emphasis on dissociative symptoms is overly restrictive, individuals may meet diagnostic criteria in DSM-5 for acute stress disorder if they exhibit any 9 of 14 listed symptoms in these catego- ries: intrusion, negative mood, dissociation, avoidance, and arousal.

Adjustment Disorders

In DSM-5, adjustment disorders are reconceptualized as a heterogeneous array of stress-response syndromes that occur after exposure to a distressing (traumatic or nontraumatic) event, rather than as a residual category for individuals who exhibit clinically significant distress without meeting criteria for a more discrete disorder (as in DSM-IV ). DSM-IV subtypes marked by depressed mood, anxious symp- toms, or disturbances in conduct have been retained, unchanged.

Posttraumatic Stress Disorder

DSM-5 criteria for posttraumatic stress disorder differ significantly from those in DSM-IV. As described previously for acute stress disorder, the stressor criterion (Criterion A) is more explicit with regard to how an individual experienced “traumatic” events. Also, Criterion A2 (subjective reaction) has been eliminated. Whereas there were three major symptom clusters in DSM-IV—reexperiencing, avoid- ance/numbing, and arousal—there are now four symptom clusters in DSM-5, because the avoidance/ numbing cluster is divided into two distinct clusters: avoidance and persistent negative alterations in cognitions and mood. This latter category, which retains most of the DSM-IV numbing symptoms, also includes new or reconceptualized symptoms, such as persistent negative emotional states. The final cluster—alterations in arousal and reactivity—retains most of the DSM-IV arousal symptoms. It also includes irritable or aggressive behavior and reckless or self-destructive behavior. Posttraumatic stress disorder is now developmentally sensitive in that diagnostic thresholds have been lowered for children and adolescents. Furthermore, separate criteria have been added for children age 6 years or younger with this disorder.

Reactive Attachment Disorder

The DSM-IV childhood diagnosis reactive attachment disorder had two subtypes: emotionally with- drawn/inhibited and indiscriminately social/disinhibited. In DSM-5, these subtypes are defined as distinct disorders: reactive attachment disorder and disinhibited social engagement disorder. Both of these disorders are the result of social neglect or other situations that limit a young child’s opportunity to form selective attachments. Although sharing this etiological pathway, the two disorders differ in important ways. Because of dampened positive affect, reactive attachment disorder more closely re- sembles internalizing disorders; it is essentially equivalent to a lack of or incompletely formed preferred attachments to caregiving adults. In contrast, disinhibited social engagement disorder more closely resembles ADHD; it may occur in children who do not necessarily lack attachments and may have es- tablished or even secure attachments. The two disorders differ in other important ways, including cor- relates, course, and response to intervention, and for these reasons are considered separate disorders.



Dissociative Disorders

Major changes in dissociative disorders in DSM-5 include the following: 1) derealization is included in the name and symptom structure of what previously was called depersonalization disorder and is now called depersonalization/derealization disorder, 2) dissociative fugue is now a specifier of dissociative amnesia rather than a separate diagnosis, and 3) the criteria for dissociative identity disorder have been changed to indicate that symptoms of disruption of identity may be reported as well as observed, and that gaps in the recall of events may occur for everyday and not just traumatic events. Also, experi- ences of pathological possession in some cultures are included in the description of identity disruption.

Dissociative Identity Disorder

Several changes to the criteria for dissociative identity disorder have been made in DSM-5. First, Criterion A has been expanded to include certain possession-form phenomena and functional neurological symp- toms to account for more diverse presentations of the disorder. Second, Criterion A now specifically states that transitions in identity may be observable by others or self-reported. Third, according to Criterion B, in- dividuals with dissociative identity disorder may have recurrent gaps in recall for everyday events, not just for traumatic experiences. Other text modifications clarify the nature and course of identity disruptions.



Somatic Symptom and Related Disorders

In DSM-5, somatoform disorders are now referred to as somatic symptom and related disorders. In DSM-IV, there was significant overlap across the somatoform disorders and a lack of clarity about their boundaries. These disorders are primarily seen in medical settings, and nonpsychiatric physicians found the DSM-IV somatoform diagnoses problematic to use. The DSM-5 classification reduces the number of these disorders and subcategories to avoid problematic overlap. Diagnoses of somatization disorder, hypochondriasis, pain disorder, and undifferentiated somatoform disorder have been removed.

Somatic Symptom Disorder

DSM-5 better recognizes the complexity of the interface between psychiatry and medicine. Individu- als with somatic symptoms plus abnormal thoughts, feelings, and behaviors may or may not have a diagnosed medical condition. The relationship between somatic symptoms and psychopathology exists along a spectrum, and the arbitrarily high symptom count required for DSM-IV somatization disorder did not accommodate this spectrum. The diagnosis of somatization disorder was essentially based on a long and complex symptom count of medically unexplained symptoms. Individuals previously diag- nosed with somatization disorder will usually meet DSM-5 criteria for somatic symptom disorder, but only if they have the maladaptive thoughts, feelings, and behaviors that define the disorder, in addition to their somatic symptoms.

In DSM-IV, the diagnosis undifferentiated somatoform disorder had been created in recognition that somatization disorder would only describe a small minority of “somatizing” individuals, but this disor- der did not prove to be a useful clinical diagnosis. Because the distinction between somatization disor- der and undifferentiated somatoform disorder was arbitrary, they are merged in DSM-5 under somatic symptom disorder, and no specific number of somatic symptoms is required.

Medically Unexplained Symptoms

DSM-IV criteria overemphasized the importance of an absence of a medical explanation for the somatic symptoms. Unexplained symptoms are present to various degrees, particularly in conversion disorder,

10 • Highlights of Changes from DSM-IV-TR to DSM-5

but somatic symptom disorders can also accompany diagnosed medical disorders. The reliability of medically unexplained symptoms is limited, and grounding a diagnosis on the absence of an explana- tion is problematic and reinforces mind -body dualism. The DSM-5 classification defines disorders on the basis of positive symptoms (i.e., distressing somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to these symptoms). Medically unexplained symptoms do remain a key fea- ture in conversion disorder and pseudocyesis because it is possible to demonstrate definitively in such disorders that the symptoms are not consistent with medical pathophysiology.

Hypochondriasis and Illness Anxiety Disorder

Hypochondriasis has been eliminated as a disorder, in part because the name was perceived as pejora- tive and not conducive to an effective therapeutic relationship. Most individuals who would previously have been diagnosed with hypochondriasis have significant somatic symptoms in addition to their high health anxiety, and would now receive a DSM-5 diagnosis of somatic symptom disorder. In DSM-5, indi- viduals with high health anxiety without somatic symptoms would receive a diagnosis of illness anxiety disorder (unless their health anxiety was better explained by a primary anxiety disorder, such as gener- alized anxiety disorder).

Pain Disorder

DSM-5 takes a different approach to the important clinical realm of individuals with pain. In DSM-IV, the pain disorder diagnoses assume that some pains are associated solely with psychological factors, some with medical diseases or injuries, and some with both. There is a lack of evidence that such distinctions can be made with reliability and validity, and a large body of research has demonstrated that psycho- logical factors influence all forms of pain. Most individuals with chronic pain attribute their pain to a combination of factors, including somatic, psychological, and environmental influences. In DSM-5, some individuals with chronic pain would be appropriately diagnosed as having somatic symptom disorder, with predominant pain. For others, psychological factors affecting other medical conditions or an ad- justment disorder would be more appropriate.

Psychological Factors Affecting Other Medical Conditions and Factitious Disorder

Psychological factors affecting other medical conditions is a new mental disorder in DSM-5, having formerly been included in the DSM-IV chapter “Other Conditions That May Be a Focus of Clinical Atten- tion.” This disorder and factitious disorder are placed among the somatic symptom and related disor- ders because somatic symptoms are predominant in both disorders, and both are most often encoun- tered in medical settings. The variants of psychological factors affecting other medical conditions are removed in favor of the stem diagnosis.

Conversion Disorder (Functional Neurological Symptom Disorder)

Criteria for conversion disorder (functional neurological symptom disorder) are modified to emphasize the essential importance of the neurological examination, and in recognition that relevant psychologi- cal factors may not be demonstrable at the time of diagnosis.



Feeding and Eating Disorders

In DSM-5, the feeding and eating disorders include several disorders included in DSM-IV as feeding and eating disorders of infancy or early childhood in the chapter “Disorders Usually First Diagnosed in In- fancy, Childhood, or Adolescence.” In addition, brief descriptions and preliminary diagnostic criteria are provided for several conditions under other specified feeding and eating disorder; insufficient information about these conditions is currently available to document their clinical characteristics and validity or to provide definitive diagnostic criteria.

Pica and Rumination Disorder

The DSM-IV criteria for pica and for rumination disorder have been revised for clarity and to indicate that the diagnoses can be made for individuals of any age.

Avoidant/Restrictive Food Intake Disorder

DSM-IV feeding disorder of infancy or early childhood has been renamed avoidant/restrictive food intake disorder, and the criteria have been significantly expanded. The DSM-IV disorder was rarely used, and limited information is available on the characteristics, course, and outcome of children with this disorder. Additionally, a large number of individuals, primarily but not exclusively children and adoles- cents, substantially restrict their food intake and experience significant associated physiological or psy- chosocial problems but do not meet criteria for any DSM-IV eating disorder. Avoidant/restrictive food intake disorder is a broad category intended to capture this range of presentations.

Anorexia Nervosa

The core diagnostic criteria for anorexia nervosa are conceptually unchanged from DSM-IV with one ex- ception: the requirement for amenorrhea has been eliminated. In DSM-IV, this requirement was waived in a number of situations (e.g., for males, for females taking contraceptives). In addition, the clinical characteristics and course of females meeting all DSM-IV criteria for anorexia nervosa except amenor- rhea closely resemble those of females meeting all DSM-IV criteria. As in DSM-IV, individuals with this disorder are required by Criterion A to be at a significantly low body weight for their developmental stage. The wording of the criterion has been changed for clarity, and guidance regarding how to judge whether an individual is at or below a significantly low weight is now provided in the text. In DSM-5, Criterion B is expanded to include not only overtly expressed fear of weight gain but also persistent behavior that interferes with weight gain.

Bulimia Nervosa

The only change to the DSM-IV criteria for bulimia nervosa is a reduction in the required minimum average frequency of binge eating and inappropriate compensatory behavior frequency from twice to once weekly. The clinical characteristics and outcome of individuals meeting this slightly lower thresh- old are similar to those meeting the DSM-IV criterion.

Binge-Eating Disorder

Extensive research followed the promulgation of preliminary criteria for binge eating disorder in Ap- pendix B of DSM-IV, and findings supported the clinical utility and validity of binge-eating disorder. The only significant difference from the preliminary DSM-IV criteria is that the minimum average frequency of binge eating required for diagnosis has been changed from at least twice weekly for 6 months to at least once weekly over the last 3 months, which is identical to the DSM-5 frequency criterion for buli- mia nervosa.

Elimination Disorders

No significant changes have been made to the elimination disorders diagnostic class from DSM-IV to DSM-5. The disorders in this chapter were previously classified under disorders usually first diagnosed in infancy, childhood, or adolescence in DSM-IV and exist now as an independent classification in DSM-5.



Sleep-Wake Disorders

Because of the DSM-5 mandate for concurrent specification of coexisting conditions (medical and mental), sleep disorders related to another mental disorder and sleep disorder related to a general medical condition have been removed from DSM-5, and greater specification of coexisting conditions is provided for each sleep-wake disorder. This change underscores that the individual has a sleep disorder warranting independent clinical attention, in addition to any medical and mental disorders that are also present, and acknowledges the bidirectional and interactive effects between sleep disorders and coex- isting medical and mental disorders. This reconceptualization reflects a paradigm shift that is widely ac- cepted in the field of sleep disorders medicine. It moves away from making causal attributions between coexisting disorders. Any additional relevant information from the prior diagnostic categories of sleep disorder related to another mental disorder and sleep disorder related to another medical condition has been integrated into the other sleep-wake disorders where appropriate.

Consequently, in DSM-5, the diagnosis of primary insomnia has been renamed insomnia disorder to avoid the differentiation of primary and secondary insomnia. DSM-5 also distinguishes narcolepsy, which is now known to be associated with hypocretin deficiency, from other forms of hypersomno- lence. These changes are warranted by neurobiological and genetic evidence validating this reorganiza- tion. Finally, throughout the DSM-5 classification of sleep-wake disorders, pediatric and developmental criteria and text are integrated where existing science and considerations of clinical utility support such integration. This developmental perspective encompasses age-dependent variations in clinical presentation.

Breathing-Related Sleep Disorders

In DSM-5, breathing-related sleep disorders are divided into three relatively distinct disorders: obstruc- tive sleep apnea hypopnea, central sleep apnea, and sleep-related hypoventilation. This change reflects the growing understanding of pathophysiology in the genesis of these disorders and, furthermore, has relevance to treatment planning.

Circadian Rhythm Sleep-Wake Disorders

The subtypes of circadian rhythm sleep-wake disorders have been expanded to include advanced sleep phase syndrome, irregular sleep-wake type, and non-24-hour sleep-wake type, whereas the jet lag type has been removed.

Rapid Eye Movement Sleep Behavior Disorder and Restless Legs Syndrome

The use of DSM-IV “not otherwise specified” diagnoses has been reduced by designating rapid eye movement sleep behavior disorder and restless legs syndrome as independent disorders. In DSM-IV, both were included under dyssomnia not otherwise specified. Their full diagnostic status is supported by research evidence.



Sexual Dysfunctions

In DSM-IV, sexual dysfunctions referred to sexual pain or to a disturbance in one or more phases of the sexual response cycle. Research suggests that sexual response is not always a linear, uniform process and that the distinction between certain phases (e.g., desire and arousal) may be artificial. In DSM-5, gender-specific sexual dysfunctions have been added, and, for females, sexual desire and arousal disor- ders have been combined into one disorder: female sexual interest/arousal disorder.

To improve precision regarding duration and severity criteria and to reduce the likelihood of overdiagnosis, all of the DSM-5 sexual dysfunctions (except substance-/medication-induced sexual dysfunction) now require a minimum duration of approximately 6 months and more precise severity criteria. These changes provide useful thresholds for making a diagnosis and distinguish transient sexual difficulties from more persistent sexual dysfunction.

Genito-Pelvic Pain/Penetration Disorder

Genito-pelvic pain/penetration disorder is new in DSM-5 and represents a merging of the DSM-IV cat- egories of vaginismus and dyspareunia, which were highly comorbid and difficult to distinguish. The di- agnosis of sexual aversion disorder has been removed due to rare use and lack of supporting research.

Subtypes

DSM-IV included the following subtypes for all sexual disorders: lifelong versus acquired, generalized versus situational, and due to psychological factors versus due to combined factors. DSM-5 includes only lifelong versus acquired and generalized versus situational subtypes. Sexual dysfunction due to a general medical condition and the subtype due to psychological versus combined factors have been deleted due to findings that the most frequent clinical presentation is one in which both psychological and biological factors contribute. To indicate the presence and degree of medical and other nonmedical correlates, the following associated features are described in the accompanying text: partner factors, relationship factors, individual vulnerability factors, cultural or religious factors, and medical factors.



Gender Dysphoria

Gender dysphoria is a new diagnostic class in DSM-5 and reflects a change in conceptualization of the disorder’s defining features by emphasizing the phenomenon of “gender incongruence” rather than cross-gender identification per se, as was the case in DSM-IV gender identity disorder. In DSM-IV, the chapter “Sexual and Gender Identity Disorders” included three relatively disparate diagnostic classes: gender identity disorders, sexual dysfunctions, and paraphilias. Gender identity disorder, however, is neither a sexual dysfunction nor a paraphilia. Gender dysphoria is a unique condition in that it is a diagnosis made by mental health care providers, although a large proportion of the treatment is endocrinological and surgical (at least for some adolescents and most adults). In contrast to the dichotomized DSM-IV gender identity disorder diagnosis, the type and severity of gender dysphoria can be inferred from the number and type of indicators and from the severity measures.

The experienced gender incongruence and resulting gender dysphoria may take many forms. Gender dysphoria thus is considered to be a multicategory concept rather than a dichotomy, and DSM-5 ac- knowledges the wide variation of gender-incongruent conditions. Separate criteria sets are provided for gender dysphoria in children and in adolescents and adults. The adolescent and adult criteria include a more detailed and specific set of polythetic symptoms. The previous Criterion A (cross-gender identification) and Criterion B (aversion toward one’s gender) have been merged, because no support- ing evidence from factor analytic studies supported keeping the two separate. In the wording of the criteria, “the other sex” is replaced by “some alternative gender.” Gender instead of sex is used system- atically because the concept “sex” is inadequate when referring to individuals with a disorder of sex development.

In the child criteria, “strong desire to be of the other gender” replaces the previous “repeatedly stated desire” to capture the situation of some children who, in a coercive environment, may not verbalize the desire to be of another gender. For children, Criterion A1 (“a strong desire to be of the other gender or an insistence that he or she is the other gender . . .)” is now necessary (but not sufficient), which makes the diagnosis more restrictive and conservative.

Subtypes and Specifiers

The subtyping on the basis of sexual orientation has been removed because the distinction is not considered clinically useful. A posttransition specifier has been added because many individuals, after transition, no longer meet criteria for gender dysphoria; however, they continue to undergo various treatments to facilitate life in the desired gender. Although the concept of posttransition is modeled on the concept of full or partial remission, the term remission has implications in terms of symptom reduction that do not apply directly to gender dysphoria.



Disruptive, Impulse-Control, and Conduct Disorders

The chapter on disruptive, impulse-control, and conduct disorders is new to DSM-5. It brings together disorders that were previously included in the chapter “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence” (i.e., oppositional defiant disorder; conduct disorder; and disruptive be- havior disorder not otherwise specified, now categorized as other specified and unspecified disruptive, impulse-control, and conduct disorders) and the chapter “Impulse-Control Disorders Not Otherwise Specified” (i.e., intermittent explosive disorder, pyromania, and kleptomania). These disorders are all characterized by problems in emotional and behavioral self-control. Because of its close association with conduct disorder, antisocial personality disorder has dual listing in this chapter and in the chapter on personality disorders. Of note, ADHD is frequently comorbid with the disorders in this chapter but is listed with the neurodevelopmental disorders.

Oppositional Defiant Disorder

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 vindictive- ness. 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 behav- iors 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 symp- toms across settings is an important indicator of severity.

Conduct Disorder

The criteria for conduct disorder are largely unchanged from DSM-IV. A descriptive features specifier has been added for individuals who meet full criteria for the disorder but also present with limited pro- social emotions. This specifier applies to those with conduct disorder who show a callous and unemo- tional interpersonal style across multiple settings and relationships. The specifier is based on research showing that individuals with conduct disorder who meet criteria for the specifier tend to have a rela- tively more severe form of the disorder and a different treatment response.

Intermittent Explosive Disorder

The primary change in DSM-5 intermittent explosive disorder is the type of aggressive outbursts that should be considered: physical aggression was required in DSM-IV, whereas verbal aggression and non- destructive/noninjurious physical aggression also meet criteria in DSM-5. DSM-5 also provides more specific criteria defining frequency needed to meet criteria and specifies that the aggressive outbursts are impulsive and/or anger based in nature, and must cause marked distress, cause impairment in oc- cupational or interpersonal functioning, or be associated with negative financial or legal consequences. Furthermore, because of the paucity of research on this disorder in young children and the potential difficulty of distinguishing these outbursts from normal temper tantrums in young children, 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 further clarified.



Substance-Related and Addictive Disorders

Gambling Disorder

An important departure from past diagnostic manuals is that the substance-related disorders chapter has been expanded to include gambling disorder. This change reflects the increasing and consistent evidence that some behaviors, such as gambling, activate the brain reward system with effects similar to those of drugs of abuse and that gambling disorder symptoms resemble substance use disorders to a certain extent.

Criteria and Terminology

DSM-5 does not separate the diagnoses of substance abuse and dependence as in DSM-IV. Rather, cri- teria are provided for substance use disorder, accompanied by criteria for intoxication, withdrawal, sub- stance/medication-induced disorders, and unspecified substance-induced disorders, where relevant. The DSM-5 substance use disorder criteria are nearly identical to the DSM-IV substance abuse and de- pendence criteria combined into a single list, with two exceptions. The DSM-IV recurrent legal problems criterion for substance abuse has been deleted from DSM-5, and a new criterion, craving or a strong desire or urge to use a substance, has been added. In addition, the threshold for substance use disorder diagnosis in DSM-5 is set at two or more criteria, in contrast to a threshold of one or more criteria for a diagnosis of DSM-IV substance abuse and three or more for DSM-IV substance dependence. Canna- bis withdrawal is new for DSM-5, as is caffeine withdrawal (which was in DSM-IV Appendix B, “Criteria Sets and Axes Provided for Further Study”). Of note, the criteria for DSM-5 tobacco use disorder are the same as those for other substance use disorders. By contrast, DSM-IV did not have a category for tobacco abuse, so the criteria in DSM-5 that are from DSM-IV abuse are new for tobacco in DSM-5. Severity of the DSM-5 substance use disorders is based on the number of criteria endorsed: 2–3 criteria indicate a mild disorder; 4–5 criteria, a moderate disorder; and 6 or more, a severe disorder. The DSM- IV specifier for a physiological subtype has been eliminated in DSM-5, as has the DSM-IV diagnosis of polysubstance dependence. Early remission from a DSM-5 substance use disorder is defined as at least 3 but less than 12 months without substance use disorder criteria (except craving), and sustained re- mission is defined as at least 12 months without criteria (except craving). Additional new DSM-5 speci- fiers include “in a controlled environment” and “on maintenance therapy” as the situation warrants.


Neurocognitive Disorders

Delirium

The criteria for delirium have been updated and clarified on the basis of currently available evidence.

Major and Mild Neurocognitive Disorder

The DSM-IV diagnoses of dementia and amnestic disorder are subsumed under the newly named entity major neurocognitive disorder (NCD). The term dementia is not precluded from use in the etiological subtypes where that term is standard. Furthermore, DSM-5 now recognizes a less severe level of cogni- tive impairment, mild NCD, which is a new disorder that permits the diagnosis of less disabling syn- dromes that may nonetheless be the focus of concern and treatment. Diagnostic criteria are provided for both major NCD and mild NCD, followed by diagnostic criteria for the different etiological subtypes. An updated listing of neurocognitive domains is also provided in DSM-5, as these are necessary for establishing the presence of NCD, distinguishing between the major and mild levels of impairment, and differentiating among etiological subtypes.

Although the threshold between mild NCD and major NCD is inherently arbitrary, there are important reasons to consider these two levels of impairment separately. The major NCD syndrome provides consistency with the rest of medicine and with prior DSM editions and necessarily remains distinct to capture the care needs for this group. Although the mild NCD syndrome is new to DSM-5, its presence is consistent with its use in other fields of medicine, where it is a significant focus of care and research, notably in individuals with Alzheimer’s disease, cerebrovascular disorders, HIV, and traumatic brain injury.

Etiological Subtypes

In DSM-IV, individual criteria sets were designated for dementia of the Alzheimer’s type, vascular dementia, and substance-induced dementia, whereas the other neurodegenerative disorders were classified as dementia due to another medical condition, with HIV, head trauma, Parkinson’s disease, Huntington’s disease, Pick’s disease, Creutzfeldt-Jakob disease, and other medical conditions specified. In DSM-5, major or mild vascular NCD and major or mild NCD due to Alzheimer’s disease have been re- tained, whereas new separate criteria are now presented for major or mild NCD due to frontotemporal NCD, Lewy bodies, traumatic brain injury, Parkinson’s disease, HIV infection, Huntington’s disease, prion disease, another medical condition, and multiple etiologies. Substance/medication-induced NCD and unspecified NCD are also included as diagnoses.

Personality Disorders

The criteria for personality disorders in Section II of DSM-5 have not changed from those in DSM-IV. An alternative approach to the diagnosis of personality disorders was developed for DSM-5 for further study and can be found in Section III. For the general criteria for personality disorder presented in Sec- tion III, a revised personality functioning criterion (Criterion A) has been developed based on a litera- ture review of reliable clinical measures of core impairments central to personality pathology. Further- more, the moderate level of impairment in personality functioning required for a personality disorder diagnosis in DSM-5 Section III was set empirically to maximize the ability of clinicians to identify per- sonality disorder pathology accurately and efficiently. With a single assessment of level of personality functioning, a clinician can determine whether a full assessment for personality disorder is necessary. The diagnostic criteria for specific DSM-5 personality disorders in the alternative model are consis- tently defined across disorders by typical impairments in personality functioning and by characteristic pathological personality traits that have been empirically determined to be related to the personality disorders they represent. Diagnostic thresholds for both Criterion A and Criterion B have been set em- pirically to minimize change in disorder prevalence and overlap with other personality disorders and to maximize relations with psychosocial impairment. A diagnosis of personality disorder—trait specified, based on moderate or greater impairment in personality functioning and the presence of pathologi- cal personality traits, replaces personality disorder not otherwise specified and provides a much more informative diagnosis for patients who are not optimally described as having a specific personality dis- order. A greater emphasis on personality functioning and trait-based criteria increases the stability and empirical bases of the disorders.

Personality functioning and personality traits also can be assessed whether or not an individual has a personality disorder, providing clinically useful information about all patients. The DSM-5 Section III ap- proach provides a clear conceptual basis for all personality disorder pathology and an efficient assess- ment approach with considerable clinical utility.



Paraphilic Disorders

Specifiers

An overarching change from DSM-IV is the addition of the course specifiers “in a controlled environment” and “in remission” to the diagnostic criteria sets for all the paraphilic disorders. These specifiers are added to indicate important changes in an individual’s status. There is no expert

US - DSM5 - New Gender Dysphoria Criteria Replace GID… [2013-04-11 APA]

http://www.transyouthequality.org/documents/gender_dysphoria.pdf

Psychiatric News - April 05, 2013 Volume 48 Number 7 page 9-14 10.1176/appi.pn.2013.4a19 American Psychiatric Association

Professional News

New Gender Dysphoria Criteria Replace GID

Mark Moran

New criteria for gender dysphoria will emphasize the individual’s felt sense of “incongruence” with natal gender, rather than cross-gender behavior. This article is part of a series on the differences between DSM-IV and DSM-5. The series will run through May, when the manual will be published.

Gender dysphoria is a new diagnostic class in DSM-5—and a chapter unto itself—replacing the DSM-IV diagnosis of gender identity disorder and reflecting a new conceptualization of individuals who seek treatment for problems related to gender.

Criteria for the new category emphasize the phenomenon of “gender incongruence” rather than cross-gender identification, as was the case in DSM-IV. By separating it from sexual dysfunctions and paraphilias (with which it had previously been included in DSM-IV in a chapter titled “Sex and Gender Identity Disorders”), work group members said they hope to diminish stigma attached to a unique diagnosis that is used by mental health professionals but for which treatment often involves endocrinologists, surgeons, and other professionals.

(The chapter devoted to gender dysphoria follows the chapter titled “Sexual Dysfunctions.” That chapter is marked by the addition of gender-specific sexual dysfunctions and the combination of female sexual desire and arousal disorders into a new disorder, female sexual interest/arousal disorder. Additionally, the paraphillic disorders that had previously appeared with gender identity disorder (GID) in the DSM-IV chapter titled “Sex and Gender Identity Disorders” have been split off into a separate chapter that appears later in the manual. And to improve precision regarding duration and severity and to reduce the likelihood of overdiagnosis, all of the DSM-5 sexual dysfunctions except substance-/medication-induced sexual dysfunction now require a minimum duration of approximately six months.)

Meanwhile, refinements to intermittent explosive disorder, conduct disorder, and oppositional defiant disorder mark the major changes to the chapter titled “Disruptive, Impulse-Control, and Conduct Disorders.” The chapter, bringing together disorders marked by problems in emotional and behavioral self-control, combines disorders previously classified in DSM-IV under disorders of infancy, childhood, and adolescence, along with other impulse control disorders—pyromania and kleptomania—not confined by age.

The three chapters—”Sexual Dysfunctions,” “Gender Dysphoria,” and “Disruptive, Impulse-Control and Conduct Disorders”—are the 12th, 13th, and 14th chapters that will appear in Section II of DSM-5, to be published in May. While the new manual includes much that is familiar, important differences—not only in criteria for individual disorders, but in the organization of the text—will be readily apparent. The changes reflect an effort begun more than a decade ago to respond to challenges posed by research and clinical experience to previous editions of the manual including high rates of comorbidity within and across DSM chapters, an excessive use of and reliance on “not otherwise specified” (NOS) criteria, and a growing inability to integrate DSM disorders with the findings from genetic and other research.

Some of the overarching conceptual ideas that have informed the development of diagnostic criteria and the organization of the text include incorporation of a developmental approach to psychiatric disorders, recognition of the influence of culture and gender on how psychiatric illness presents in individual patients, a move toward the use of dimensional measures to rate severity and disaggregate symptoms that tend to occur across multiple disorders, harmonization of the text with ICD, and integration of genetic and neurobiological findings by grouping clusters of disorders that share genetic or neurobiological substrates.

DSM-5 consists of three sections: Section I gives an introduction to DSM-5 with instructions on how to use the manual; Section II outlines the categorical diagnoses according to a revised chapter organization that eliminates the multiaxial system; and Section III includes conditions that require further research before their consideration as formal diagnoses, as well as cultural formulations and other information.

Jack Drescher, M.D., a member of a subgroup that helped formulate criteria for gender dysphoria, explained that a central tension in discussions about the diagnosis was between the possibly stigmatizing effect of retaining a category for gender conflicts among a list of mental disorders and the need to maintain access to care for individuals who do experience distress or impairment in function with regard to gender conflicts.

“We decided the access-to-care issue was very important,” Drescher told Psychiatric News. “If you take out the diagnosis, you don’t have a code for treatment.”

But Drescher said the removal of the diagnosis from the chapter including sexual dysfunctions—and the separation of paraphillic disorders into its own chapter in DSM-5—should serve to lessen stigma associated with the diagnosis. Also, he said the name change to “gender dysphoria” is an effort to reflect the individual’s felt sense of incongruence with natal gender, as opposed to pathologizing gender-atypical behavior.

Drescher said the category is reconceptualized as one diagnosis with separate developmentally appropriate criteria sets for children and for adolescents and adults.

For both groups, the criteria include a specifier to indicate whether the individual’s condition is related to a disorder of sex development (DSD) such as congenital adrenal hyperplasia; this is in contrast to DSM-IV in which the presence of a DSD or intersex condition was an exclusionary criterion for the diagnosis of GID.

The criteria for adolescents and adults also include a specifier to indicate whether the individual has transitioned to full-time living in the desired gender.

And for children, Criterion A1 (“a strong desire to be of the other gender or an insistence that he or she is the other gender...)” is now necessary but not sufficient to meet the diagnosis, which makes the diagnosis more restrictive and conservative.

“It’s really a narrowing of the criteria because you have to want the diagnosis,” Drescher said. “It takes psychiatrists out of the business of labeling children or others simply because they show gender-atypical behavior.” ■

A fact sheet on gender dysphoria is posted at http://www.psychiatry.org/dsm5.



Key PointsGender Dysphoria

   • A new category—and separate chapter—for gender dysphoria emphasizes the phenomenon of “gender incongruence” rather than cross-gender identification.

   • Gender dysphoria is now separate from the chapters on sexual dysfunctions and on paraphillic disorders.

   • The category is reconceptualized as one overarching diagnosis with separate developmentally appropriate criteria sets for children and for adolescents and adults.

   • For children, adolescents, and adults, a specifier is included for individuals whose condition is related to a disorder of sex development (DSD) such as congenital adrenal hyperplasia; in DSM-IV the presence of a DSD or intersex condition was exclusionary for diagnosis of gender identity disorder.

   • For adolescents and adults, a specifier is also included for individuals who have transitioned to full-time living in the desired gender.

For children, “a strong desire to be of the other gender or an insistence that he or she is the other gender” is now necessary but not sufficient to meet the diagnosis, making the diagnosis more restrictive and conservative.


Sexual Dysfunctions



   • The chapter on sexual dyfunctions will include gender-specific sexual dysfunctions.

    • Female sexual desire and arousal disorders have been combined into one disorder: female sexual interest/arousal disorder.

   • Paraphillic disorders (previously included in the DSM-IV chapter titled “Sex and Gender Identity Disorders”) have been split off into a separate chapter.

   • All of the DSM-5 sexual dysfunctions except substance-/medication-induced sexual dysfunction now require a minimum duration of approximately six months to improve precision regarding duration and severity criteria and to reduce the likelihood of overdiagnosis.

American Psychiatric Association

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END

US - DSM-5 "Autism Spectrum Disorder Fact Sheet…" [2013-05-22 dsm5.org]

BLS 2013-05-22 OCR'd .pdf text http://www.dsm5.org/Documents/Autism%20Spectrum%20Disorder%20Fact%20Sheet.pdf

Autism Spectrum Disorder

One of the most important changes in the fifth edition of the Diagnostic and Statistical Manual of Men- tal Disorders (DSM-5) is to autism spectrum disorder (ASD). The revised diagnosis represents a new, more accurate, and medically and scientifically useful way of diagnosing individuals with autism-related disorders.

Using DSM-IV, patients could be diagnosed with four separate disorders: autistic disorder, Asperger’s disorder, childhood disintegrative disorder, or the catch-all diagnosis of pervasive developmental dis- order not otherwise specified. Researchers found that these separate diagnoses were not consistently applied across different clinics and treatment centers. Anyone diagnosed with one of the four pervasive developmental disorders (PDD) from DSM-IV should still meet the criteria for ASD in DSM-5 or another, more accurate DSM-5 diagnosis. While DSM does not outline recommended treatment and services for mental disorders, determining an accurate diagnosis is a first step for a clinician in defining a treatment plan for a patient.

The Neurodevelopmental Work Group, led by Susan Swedo, MD, senior investigator at the National Institute of Mental Health, recommended the DSM-5 criteria for ASD to be a better reflection of the state of knowledge about autism. The Work Group believes a single umbrella disorder will improve the diagnosis of ASD without limiting the sensitivity of the criteria, or substantially changing the number of children being diagnosed.

People with ASD tend to have communication deficits, such as responding inappropriately in conversa- tions, misreading nonverbal interactions, or having difficulty building friendships appropriate to their age. In addition, people with ASD may be overly dependent on routines, highly sensitive to changes in their environment, or intensely focused on inappropriate items. Again, the symptoms of people with ASD will fall on a continuum, with some individuals showing mild symptoms and others having much more severe symptoms. This spectrum will allow clinicians to account for the variations in symptoms and behaviors from person to person.

Under the DSM-5 criteria, individuals with ASD must show symptoms from early childhood, even if those symptoms are not recognized until later. This criteria change encourages earlier diagnosis of ASD but also allows people whose symptoms may not be fully recognized until social demands exceed their capacity to receive the diagnosis. It is an important change from DSM-IV criteria, which was geared toward identifying school-aged children with autism-related disorders, but not as useful in diagnosing younger children.

The DSM-5 criteria were tested in real-life clinical settings as part of DSM-5 field trials, and analysis from that testing indicated that there will be no significant changes in the prevalence of the disorder. More recently, the largest and most up-to-date study, published by Huerta, et al, in the October 2012 issue of American Journal of Psychiatry, provided the most comprehensive assessment of the DSM-5 criteria for ASD based on symptom extraction from previously collected data. The study found that DSM-5 criteria identified 91 percent of children with clinical DSM-IV PDD diagnoses, suggesting that most children with DSM-IV PDD diagnoses will retain their diagnosis of ASD using the new criteria. Several other studies, using various methodologies, have been inconsistent in their findings.

-

DSM is the manual used by clinicians and researchers to diagnose and classify mental disorders. The American Psychiatric Association (APA) will publish DSM-5 in 2013, culminating a 14-year revision process.

APA is a national medical specialty society whose more than 36,000 physician members specialize in the diagnosis, treat- ment, prevention and research of mental illnesses, including substance use disorders. Visit the APA at www.psychiatry.org. For more information, please contact Eve Herold at 703-907-8640 or press@psych.org.

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© 2013 American Psychiatric Association

US - DSM-5 "Autism Spectrum Disorder Fact Sheet…" [2013-05-22 dsm5.org]

BLS 2013-05-22 OCR'd .pdf text http://www.dsm5.org/Documents/Autism%20Spectrum%20Disorder%20Fact%20Sheet.pdf

Autism Spectrum Disorder

One of the most important changes in the fifth edition of the Diagnostic and Statistical Manual of Men- tal Disorders (DSM-5) is to autism spectrum disorder (ASD). The revised diagnosis represents a new, more accurate, and medically and scientifically useful way of diagnosing individuals with autism-related disorders.

Using DSM-IV, patients could be diagnosed with four separate disorders: autistic disorder, Asperger’s disorder, childhood disintegrative disorder, or the catch-all diagnosis of pervasive developmental dis- order not otherwise specified. Researchers found that these separate diagnoses were not consistently applied across different clinics and treatment centers. Anyone diagnosed with one of the four pervasive developmental disorders (PDD) from DSM-IV should still meet the criteria for ASD in DSM-5 or another, more accurate DSM-5 diagnosis. While DSM does not outline recommended treatment and services for mental disorders, determining an accurate diagnosis is a first step for a clinician in defining a treatment plan for a patient.

The Neurodevelopmental Work Group, led by Susan Swedo, MD, senior investigator at the National Institute of Mental Health, recommended the DSM-5 criteria for ASD to be a better reflection of the state of knowledge about autism. The Work Group believes a single umbrella disorder will improve the diagnosis of ASD without limiting the sensitivity of the criteria, or substantially changing the number of children being diagnosed.

People with ASD tend to have communication deficits, such as responding inappropriately in conversa- tions, misreading nonverbal interactions, or having difficulty building friendships appropriate to their age. In addition, people with ASD may be overly dependent on routines, highly sensitive to changes in their environment, or intensely focused on inappropriate items. Again, the symptoms of people with ASD will fall on a continuum, with some individuals showing mild symptoms and others having much more severe symptoms. This spectrum will allow clinicians to account for the variations in symptoms and behaviors from person to person.

Under the DSM-5 criteria, individuals with ASD must show symptoms from early childhood, even if those symptoms are not recognized until later. This criteria change encourages earlier diagnosis of ASD but also allows people whose symptoms may not be fully recognized until social demands exceed their capacity to receive the diagnosis. It is an important change from DSM-IV criteria, which was geared toward identifying school-aged children with autism-related disorders, but not as useful in diagnosing younger children.

The DSM-5 criteria were tested in real-life clinical settings as part of DSM-5 field trials, and analysis from that testing indicated that there will be no significant changes in the prevalence of the disorder. More recently, the largest and most up-to-date study, published by Huerta, et al, in the October 2012 issue of American Journal of Psychiatry, provided the most comprehensive assessment of the DSM-5 criteria for ASD based on symptom extraction from previously collected data. The study found that DSM-5 criteria identified 91 percent of children with clinical DSM-IV PDD diagnoses, suggesting that most children with DSM-IV PDD diagnoses will retain their diagnosis of ASD using the new criteria. Several other studies, using various methodologies, have been inconsistent in their findings.

-

DSM is the manual used by clinicians and researchers to diagnose and classify mental disorders. The American Psychiatric Association (APA) will publish DSM-5 in 2013, culminating a 14-year revision process.

APA is a national medical specialty society whose more than 36,000 physician members specialize in the diagnosis, treat- ment, prevention and research of mental illnesses, including substance use disorders. Visit the APA at www.psychiatry.org. For more information, please contact Eve Herold at 703-907-8640 or press@psych.org.

—

© 2013 American Psychiatric Association

US - DSM-5 Attention Deficit/Hyperactivity Disorder Fact Sheet… [2013-05-22 dsm5.org]

BLS 2013-05-22 OCR'd .pdf text http://www.dsm5.org/Documents/ADHD%20Fact%20Sheet.pdf

Attention Deficit/ Hyperactivity Disorder

The definition of attention-deficit/hyperactivity disorder (ADHD) has been updated in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) to more accurately characterize the experience of affected adults. This revision is based on nearly two decades of research showing that ADHD, although a disorder that begins in childhood, can continue through adulthood for some people. Previous editions of DSM did not provide appropriate guidance to clinicians in diagnosing adults with the condition. By adapting criteria for adults, DSM-5 aims to ensure that children with ADHD can con- tinue to get care throughout their lives if needed.

Changes to the Disorder

ADHD is characterized by a pattern of behavior, present in multiple settings (e.g., school and home), that can result in performance issues in social, educational, or work settings. As in DSM-IV, symptoms will be divided into two categories of inattention and hyperactivity and impulsivity that include behav- iors like failure to pay close attention to details, difficulty organizing tasks and activities, excessive talk- ing, fidgeting, or an inability to remain seated in appropriate situations.

Children must have at least six symptoms from either (or both) the inattention group of criteria and the hyperactivity and impulsivity criteria, while older adolescents and adults (over age 17 years) must present with five. While the criteria have not changed from DSM-IV, examples have been included to illustrate the types of behavior children, older adolescents, and adults with ADHD might exhibit. The descriptions will help clinicians better identify typical ADHD symptoms at each stage of patients’ lives. Using DSM-5, several of the individual’s ADHD symptoms must be present prior to age 12 years, com- pared to 7 years as the age of onset in DSM-IV. This change is supported by substantial research pub- lished since 1994 that found no clinical differences between children identified by 7 years versus later in terms of course, severity, outcome, or treatment response.

DSM-5 includes no exclusion criteria for people with autism spectrum disorder, since symptoms of both disorders co-occur. However, ADHD symptoms must not occur exclusively during the course of schizo- phrenia or another psychotic disorder and must not be better explained by another mental disorder, such as a depressive or bipolar disorder, anxiety disorder, dissociative disorder, personality disorder, or substance intoxication or withdrawal.

Care Beyond Childhood

The ADHD diagnosis in previous editions of DSM was written to help clinicians identify the disorder in children. Almost two decades of research conclusively show that a significant number of individuals diagnosed with ADHD as children continue to experience the disorder as adults. Evidence of this came from studies in which individuals were tracked for years or even decades after their initial childhood diagnosis. The results showed that ADHD does not fade at a specific age.

Studies also showed that the DSM-IV criteria worked as well for adults as they did for children but that a lower threshold of symptoms (five instead of six) was sufficient for a reliable diagnosis.

In light of the research findings, DSM-5 makes a special effort to address adults affected by ADHD to ensure that they are able to get care when needed.

-

DSM is the manual used by clinicians and researchers to diagnose and classify mental disorders. The American Psychiatric Association (APA) will publish DSM-5 in 2013, culminating a 14-year revision process.

APA is a national medical specialty society whose more than 36,000 physician members specialize in the diagnosis, treat- ment, prevention and research of mental illnesses, including substance use disorders. Visit the APA at www.psychiatry.org. For more information, please contact Eve Herold at 703-907-8640 or press@psych.org.

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© 2013 American Psychiatric Association