                Synopsis of Final DSM-IV Changes
 
 
A few weeks ago, I received the final issue of the "DSM-IV Update" 
newsletter published by the American Psychiatric Association (APA).  
This newsletter (available from APA; 800-368-5777) briefly describes  
changes in the new DSM-IV.
 
This post summarizes their summary, selectively emphasizing changes 
in DSM disorders that interest me. Although the APA's DSM-IV Manual, 
to be published by APA in June or so and available from them, is 
obviously the official reference for all such changes, this synopsis 
highlights some of what to expect.

[I originally posted this to the sci.psychology newsgroup, and now 
belatedly here on the psychiatry mailing-list.]

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

