An official website of the United States government
NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.
Substance Abuse and Mental Health Services Administration. DSM-5 Changes: Implications for Child Serious Emotional Disturbance [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2016 Jun.
The Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) includes changes to some key disorders of childhood. Two new childhood mental disorders were added in the DSM-5: social communication disorder (or SCD) and disruptive mood dysregulation disorder (or DMDD). There were age-related diagnostic criteria changes for two other mental disorder categories particularly relevant to the definition of serious emotional disturbance (SED): attention-deficit/hyperactivity disorder (ADHD) and post-traumatic stress disorder (PTSD). An ADHD diagnosis now requires symptoms to be present prior to the age of 12 (rather than 7, the age of onset from the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. [DSM-IV]). PTSD includes a new subtype specifically for children younger than 6 years of age.
Sections 3.1 and 3.2 provide detailed descriptions of these disorders as well as summaries of the research that has been conducted around their impact on the prevalence of childhood mental disorders. Other disorders did not have specific DSM-5 changes related to childhood, but these changes would be relevant to both adults and children (e.g., major depressive disorder [MDD], generalized anxiety disorder [GAD]). Section 3.3 provides a brief overview of DSM-5 changes to these remaining disorders. In the report sections that follow we reference prevalence rates found in studies of community samples using the DSM-5. For some disorders, we also reference prevalence rates in clinical samples where direct comparisons were performed between DSM-IV and DSM-5 ratings. The prevalence rates from clinical samples are relevant to this report in demonstrating the magnitude of change that might be expected in prevalence rates from DSM-IV to DSM-5.
Description. The DSM-5 communication disorders include a new condition for persistent difficulties in the social uses of verbal and nonverbal communication: social (pragmatic) communication disorder or SCD. SCD is characterized by a primary difficulty with pragmatics—the social use of language or communication—resulting in functional limitations in effective communication, social participation, development of social relationships, and academic achievement (see Table 5 for a description of DSM-5 SCD diagnostic criteria). Symptoms of SCD include difficulties in the acquisition and use of spoken language and inappropriate responses in conversation. Although diagnosis is rare for children younger than 4 years old, symptoms must be present in early childhood even if not recognized until later. Individuals with SCD have never had effective social communication. This new disorder cannot be diagnosed if social communication deficits are part of the two main characteristics of the new autism spectrum disorder (ASD). 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 an ASD diagnosis, SCD is diagnosed if no RRBs are present or there is no past history of RRBs. As described by the American Psychiatric Association (APA), the symptoms of some patients diagnosed with DSM-IV pervasive developmental disorder not otherwise specified (PDD-NOS) may meet the DSM-5 criteria for SCD (American Psychiatric Association, 2013c).
DSM-IV Pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS) to DSM-5 Social (Pragmatic) Communication Disorder (SCD) Comparison.
Estimated Prevalence. Although a few studies have reported empirical support for a conceptualization of SCD distinguishable from ASD (Gibson, Adams, Lockton, & Green, 2013) and ADHD (St Pourcain et al., 2011), there is one practitioner review publication describing concern that the inclusion/exclusion criteria and differential diagnosis with ASD, ADHD, social anxiety disorders, intellectual disabilities, and developmental delays, may mean that very few individuals will meet diagnostic criteria for SCD (Norbury, 2014).
No study was found on the general population’s prevalence of SCD. In one study that analyzed three datasets (1) data from the Simons Simplex Collection, a genetic consortium study focusing on families having just one child with an ASD; (2) the Collaborative Programs of Excellence in Autism, a multicenter study of ASD; and (3) the University of Michigan Autism and Communication Disorders Center data bank that included a total of 4,453 children with DSM-IV clinical PDD diagnoses and 690 with non-PDD diagnoses (e.g., language disorder), the proposed ASD DSM-5 criteria identified 91 percent of children with clinical DSM-IV PDD diagnoses (Huerta, Bishop, Duncan, Hus, & Lord, 2012). In this samples of children with DSM-IV diagnosis for PPD (86.6 percent of the pooled sample) and non-PPD (13.4 percent of the pooled sample), only 75 of 5,143 (1.5 percent) met social communication criteria for ASD, but did not meet threshold criteria for RRBs. This study concluded that few children with ASD are likely to be misclassified as having SCD or will be reclassified as SCD under the DSM-5 (Huerta et al., 2012). In contrast, a second study based on the multisite field trial of the DSM-IV of adults and children (mean age 9 years old), of which 657 had a clinical diagnosis of PDD and 276 had a diagnosis other than PDD (mental retardation, language disorders, childhood schizophrenia), almost 40 percent of cases with a clinical diagnosis of PDD and 71.7 percent of those with PDD-NOS did not met revised DSM-5 diagnostic criteria for ASD, concluding that proposed DSM-5 criteria could substantially alter the composition and estimate of the autism spectrum (McPartland, Reichow, & Volkmar, 2012). In the DSM-5 field trials in the United States and Canada based on child clinical populations (general child psychiatry outpatient services), one of the sites (Baystate Medical Center, Springfield, MA) found the DSM-IV and DSM-5 prevalence of ASD was almost the same (23 percent and 24 percent), but a second site (Stanford University Hospital, Palo Alto, CA) found the prevalence of ASD decreased from 26 percent to 19 percent. A review of the data (no tables provided in the publication) showed that the decrease at Stanford was offset by movement into the new SCD diagnosis (Regier et al., 2013).
Overall, these studies suggest that between 1.5 percent to 40 percent or more of children who would have been classified as PDD before, will not meet diagnostic criteria of ASD under the DSM-5 and some of them would likely be reclassified as SCD and be included in the SED estimate, if SCD is part of the SED definition (McPartland, Reichow, & Volkmar, 2012). It should be noted that there is concern in the field that SCD could be over diagnosed by speech-language pathologists. If SCD is treated as a residual category (like the previous PDD-NOS) for communication disorders diagnosed by speech-language pathologists, children who should be diagnosed as ASD would be classified as SCD since identifying ASD may prove challenging for speech-language pathologists (Norbury, 2014).
Implications for Estimate of SED. As SCD would be under the purview of speech-language pathology, the inclusion/exclusion of SCD on the Federal Register definition of SED needs to be determined. If SCD is included in the definition of SED, some increase can be expected in the estimate of SED from the reclassification of children previously classified as PDD and PDD-NOS to SCD. An additional increase in the SED estimate can be expected from the diagnoses of SCD by speech-language pathologists if they are not obtaining differential diagnosis from other professionals.
Description. DMDD is a new addition to DSM-5 that aims to combine bipolar disorder that first appears in childhood with oppositional behaviors (Axelson, 2013). DMDD is characterized by severe and recurrent temper outbursts that are grossly out of proportion in intensity or duration to the situation. These occur, on average, three or more times each week for 1 year or more (see Table 6 for a description of DSM-5 DMDD diagnostic criteria). The key feature of DMDD is chronic irritability that is present in between episodes of anger or temper tantrums. A diagnosis requires symptoms to be present in at least two settings (at home, at school, or with peers) for 12 or more months, and symptoms must be severe in at least one of these settings. Onset of DMDD must occur before age 10, and a child must be at least 6 years old to receive a diagnosis of DMDD. The main driver behind the conceptualization of DMDD was concern that diagnosis of bipolar disorder was being applied inconsistently across clinicians because of the disagreement about how to classify irritability in the DSM-IV. In addition, chronic childhood irritability has not been shown to predict later onset of bipolar disorder, suggesting that irritability may be best contained within a separate mood dysregulation category (Leigh, Smith, Milavic, & Stringaris, 2012).
DSM-IV Bipolar Disorder-Manic Episode and Oppositional Defiant Disorder to DSM-5 Disruptive Mood Dysregulation Disorder (or DMDD) Comparison.
Estimated Prevalence. A study combining data from three community surveys: (1) a representative sample of 918 preschoolers (aged 2–5) attending a large primary care pediatric clinic in central North Carolina; (2) a representative sample of 1,420 children aged 9, 11, and 13 years in 11 predominantly rural counties of North Carolina; and (3) representative study of 920 children aged 9 to 17 years from four rural counties in North Carolina, found that prevalence of DMDD ranges from less than 1 percent to 3.3 percent depending on child age. DMDD is most prevalent among young children (aged 2 to 5) whose parents report high rates of temper tantrums and irritable moods (Copeland, Angold, Costello, & Egger, 2013). However, according to DSM-5, DMDD cannot be diagnosed in children under 6 years old; therefore, the real DSM-5 prevalence in the population will be closer to 1 percent. In the DSM-5 field trials in the United States and Canada based on child clinical populations (general child psychiatry outpatient services), estimates for DSM-IV were considered “not applicable because the diagnosis is new to DSM-5,” and the DSM-5 prevalence was 5 percent for Baystate Medical Center, 8 percent for Columbia, and 15 percent for Colorado (Regier et al., 2013). Importantly, estimates for ODD in Columbia decreased from 22 percent using DSM-IV to 17 percent using DSM-5, but no additional analyses were reported to determine if children with ODD under the DSM-IV were reclassified as DMDD under DSM-5 (Regier et al., 2013).
Implications for Estimate of SED. The comorbidity of DMDD with other disorders is extremely high as described in the DSM-5, indicating that the prevalence increase in the SED estimates, if DMDD is included, will not increase as “it is rare to find individuals whose symptoms meet criteria for DMDD alone” (American Psychiatric Association, 2013b, p. 160). However, if children have symptoms that meet criteria for ODD or intermittent explosive disorders and DMDD, only DMDD should be assigned. Thus with this new diagnosis, children will be reclassified. When all symptom, severity, and frequency criteria are applied, DMDD is only present in roughly 1 percent of school-aged children (Copeland et al., 2013). DMDD should include many of the children who would have been diagnosed with bipolar disorder using the DSM-IV. Because these children would receive the new diagnosis of DMDD instead of ODD or bipolar disorder, the addition of DMDD to the DSM-5 should not affect prevalence estimates of SED.
Description. ADHD is a chronic neurodevelopmental disorder according to DSM-5 that is characterized by a persistent and pervasive pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development. 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. The diagnostic criteria for ADHD in DSM-5 are similar to those in DSM-IV. The same 18 symptoms noted in the DSM-IV are used, and continue to be divided into two symptom domains (inattention and hyperactivity/impulsivity), of which at least six symptoms in one domain are required for diagnosis. The majority of ADHD criteria changes were geared toward improving detection of ADHD among adults. However, one change may have relevance to the estimation of SED: 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.” Table 7 shows a comparison between DSM-IV and DSM-5 diagnostic criteria for ADHD.
DSM-IV to DSM-5 Attention-Deficit/Hyperactivity Disorder Comparison.
Estimated Prevalence. In the DSM-5 field trials in the United States and Canada based on child clinical populations (general child psychiatry outpatient services), using DSM-IV, ADHD prevalence at Baystate Medical Center was 59 percent and at Columbia it was 55 percent. Applying the DSM-5 criteria, the prevalence of ADHD was 69 percent at Baystate and 58 percent at Columbia, representing a 10 percent and 3 percent absolute difference, respectively (Regier et al., 2013). In a birth cohort study of 2,232 British children who were prospectively evaluated at ages 7 and 12 years for ADHD, the outcome of extending the age-of-onset criterion to age 12 resulted in the increase in ADHD prevalence by age 12 years by only 0.1 percent (Polanczyk et al., 2010). This negligible increase is in line with previous findings indicating that 95 percent of adults with a diagnosis of ADHD recall their symptoms starting before age 12 (R. C. Kessler et al., 2005).
Implications for Estimate of SED. Some increase can be expected in the SED estimate based on expanding ADHD criteria in the DSM-5 and more cases might be diagnosed. Based on studies from community samples comparing DSM-IV and DSM-5 criteria, ADHD is expected to have a modest increase (under 10 percent absolute difference).
Description. DSM-5 criteria for PTSD differ significantly from those in DSM-IV for children and adolescents. The arousal cluster will now include irritability or angry outbursts and reckless behaviors. PTSD in the DSM-5 is more developmentally sensitive in that diagnostic thresholds have been lowered for children and adolescents.
Separate criteria have been added for children aged 6 years or younger. These criteria have been designed to be more developmentally appropriate for young children by including caregiver-child–related losses as a main source of trauma and focus on behaviorally expressed PTSD symptoms. According to the DSM-5, PTSD can develop at any age after 1 year of age. Clinical re-experiencing can vary according to developmental stage, with young children having frightening dreams not specific to the trauma. Young children are more likely to express symptoms through play, and they may lack fearful reactions at the time of exposure or during re-experiencing phenomena. It is also noted that parents may report a wide range of emotional or behavioral changes, including a focus on imagined interventions in their play. The preschool subtype excludes symptoms such as negative self-beliefs and blame, which are dependent on the ability to verbalize cognitive constructs and complex emotional states. The developmental preschool PTSD subtype lowers the Cluster C threshold from three to one symptom.
The new criteria were based on Scheeringa and colleagues’ proposed alternative algorithm, which was derived from studies performed in young children using modified DSM-IV PTSD criteria (Scheeringa, Zeanah, & Cohen, 2011). These studies showed that children’s loss of a parent/caregiver through death, abandonment, foster care placement, and other main caregiver-related events can be experienced as traumatic events. Given young children’s need for a parent/child relationship to feel safe, caregiver loss may be perceived as a serious threat to a child’s own safety and psychological/physical survival, which is part of the criteria defining a traumatic event. The relevance of caregiver loss as a source of trauma also applies among older children, since the loss of parents/caregivers is more associated with trauma than high-magnitude events, like a motor vehicle crash. One report of children in foster care found that the most common trauma identified by children aged 6 to 12 to their therapists was “placement in foster care” (Scheeringa et al., 2011). Table 8 shows a comparison between DSM-IV and DSM-5 diagnostic criteria for PTSD.
DSM-IV to DSM-5 Post-traumatic Stress Disorder Comparison Children 6 Years and Younger.
Estimated Prevalence. Rates of PTSD in preschool children diagnosed with DSM-IV criteria have been lower than in other age groups. This was in part related to DSM-IV language stipulating that a child must have an intense response to the event—intense fear, helplessness, or horror—that in children could be expressed by disorganized or agitated behavior. This language has been deleted from the DSM-5, because the criterion proved to have no utility in predicting the onset of PTSD and because the diagnostic criteria were not developmentally informed (American Psychiatric Association, 2013d). With DSM-IV criteria, even in severely traumatized young children, the frequencies of PTSD ranged only between 13 percent and 20 percent. With the new algorithm proposed for DSM-5, 44 percent to 69 percent of children in the same studies would be diagnosed with PTSD (Scheeringa et al., 2011).
Based on a total of 1,073 parents of children attending a large pediatric clinic that completed the Child Behavior Checklist Age 1.5–5 Years and a new interviewer-based psychiatric diagnostic measure (the Preschool Age Psychiatric Assessment), 0.1 percent of 2 to 5 year olds in one study qualified for PTSD under DSM-IV and 0.6 percent qualified with the new algorithm proposed for DSM-5 (Egger et al., 2006). In other community studies of children 1 to 6 years old recruited after mixed-traumatic events, the estimate for PTSD was 0 to 1.7 percent using DSM-IV criteria and 10 percent to 26 percent with the proposed DSM-5 algorithm (Scheeringa et al., 2011).
A study based on a representative population sample of 1,420 children aged 9 to 13 at baseline and followed annually through age 16 (Great Smoky Mountains Study) found that less than 0.5 percent met the criteria for full-blown DSM-IV PTSD (lifetime prevalence was 0.1 percent, while the 3-month prevalence was 0.03 percent) (Copeland, Keeler, Angold, & Costello, 2007). Other studies with clinical populations of school-age children exposed to traumatic events have shown between 4 percent and 52 percent estimates of DSM-IV PTSD, but there is no equivalent work using these studies to estimate PTSD based on DSM-5 proposed criteria as it was done for younger children (Scheeringa et al., 2011). It is unknown how the changes proposed by Scheeringa et al. (2011) on PTSD criteria for school children will impact the estimate, since some changes will improve applicability, while others may limit it.
Implications for Estimate of SED. Some increase can be expected in the SED estimate from the inclusion of PTSD criteria in the DSM-5, particularly for younger children.
Several minor changes have been made to other mental disorders sometimes assessed in psychiatric epidemiological studies of children and adolescents. These changes are summarized below, but are largely expected to have little to no impact on SED estimates either because of minimal DSM-5 changes or their very low base rate in children and adolescents.
A major depressive episode (MDE) is characterized by the combination of depressed mood or loss of interest or pleasure lasting for most of the day, nearly every day for 2 weeks or more (American Psychiatric Association, 2013b). The primary symptom (depressed mood or loss of interest/pleasure) must be accompanied by four or more additional symptoms and must cause clinically significant distress or impairment. The primary difference between MDE and MDD is that MDD includes all of the criteria for MDE as well as MDE exclusionary criteria for mania and hypomania.
Changes in the MDE/MDD criteria from DSM-IV to DSM-5 have been minimal. There have been some changes in the way that “mixed states” are described for diagnostic coding (mixed states now fall under the specifier “with mixed features”). In addition, the examples provided to describe a depressed mood have been expanded in DSM-5 from “e.g., feels sad or empty” (American Psychiatric Association, 1994, p. 327) to “e.g., feels sad, empty, hopeless” (American Psychiatric Association, 2013b, p. 160). This change in wording has not received much attention (Uher, Payne, Pavlova, & Perlis, 2013). However, the wording change has the possibility of increasing the prevalence of MDE/MDD if survey respondents and clinicians were not already equating feeling hopeless with feeling sad, empty, or depressed.
The more substantive change is that the formal bereavement exclusion for MDE/MDD in DSM-IV has been removed from DSM-5. The bereavement exclusion criterion has been a longstanding feature of MDE/MDD, designed to allow clinicians to distinguish between normal grieving and a mental illness (Fox & Jones, 2013). It has been replaced with text noting that MDE/MDD should not be confused with normal and appropriate grief but that the presence of bereavement is not prohibitive of an MDE/MDD diagnosis. All MDE/MDD changes are expected to have minimal impact on the estimation of SED in children and adolescents. Table 9 shows a comparison between DSM-IV and DSM-5 diagnostic criteria for MDE/MDD.
DSM-IV to DSM-5 Major Depressive Episode/Disorder Comparison.
Dysthymic disorder is a disorder characterized by a persistently depressed mood that occurs most of the day, for more days than not, for a period of at least 2 years. In children and adolescents, mood can be irritable and duration must be at least 1 year (American Psychiatric Association, 2013b). In the DSM-5 it has been re-named persistent depressive disorder. This name change reflects the consolidation of DSM-IV chronic MDD and dysthymic disorder. Previously, in DSM-IV, a diagnosis of dysthymic disorder was contraindicated if the patient met criteria for MDD in the first 2 years after the symptoms arose. In DSM-5 this exclusion has been removed. This change should have no impact on the estimation of SED because most if not all adolescents with chronic major depression would be classified as having MDE/MDD, and therefore would be counted as having SED already. Table 10 shows a comparison between DSM-IV and DSM-5 diagnostic criteria for dysthymic disorder/persistent depressive disorder.
DSM-IV to DSM-5 Dysthymic Disorder/Persistent Depressive Disorder Comparison.
Bipolar I disorder, at one time referred to as manic-depressive disorder, is defined by the occurrence of at least one manic episode, which is a period of abnormally and persistently elevated, expansive, or irritable mood that is accompanied by increased energy or activity, which results in clinically significant impairment in functioning or the need for hospitalization (American Psychiatric Association, 2013b). The prevalence rate of child/adolescent mania and/or bipolar disorder is extremely rare. In the DSM-5 field trials in the United States and Canada based on child clinical populations (general child psychiatry outpatient services), the combined bipolar I and II prevalence was 6 percent using DSM-IV and 5 percent using DSM-5. Bipolar I disorders are characterized by one or more manic episodes or mixed episodes and one or more MDEs; bipolar II disorders are characterized by one or more MDEs and at least one hypomanic episode (Regier et al., 2013).
The diagnostic criteria for manic episodes have undergone several changes between DSM-IV and DSM-5. Criterion A now requires that mood changes are accompanied by abnormally and persistently goal-directed behavior or energy. Second, wording has been added to clarify that (1) symptoms must represent a noticeable change from usual behavior, and (2) these changes have to be present most of the day, nearly every day during the minimum 1-week duration.
Exclusion criteria for manic episodes have also changed, mania that emerges after antidepressant treatment can be classified as bipolar I disorder diagnosis in the DSM-5, whereas this was a substance-induced manic disorder in DSM-IV. The criteria for bipolar I disorder have also undergone a slight change. However, in DSM-5, these subtypes were converted to specifiers instead (i.e., specify most recent episode type according to its features).
In addition to the changes in manic episode criteria, there have been changes to the overall diagnostic criteria for bipolar I disorder. In DSM-IV, bipolar I disorder was diagnosed by “type,” which was characterized by the nature of the most recent episode (bipolar I disorder, single manic episode; bipolar I disorder, most recent episode hypomanic; bipolar I disorder, most recent episode manic; bipolar I disorder, most recent episode mixed; bipolar I disorder, most recent episode depressed; and bipolar I disorder, most recent episode unspecified). Each of these “types” had slightly varying criteria. In DSM-5, the diagnostic description has been simplified and these “types” have been relegated to the role of specifiers. Diagnostic procedure indicates that clinicians should first provide the bipolar I diagnosis then specify the characteristics of the most recent episode, in addition to several other specifiers. Although important to understanding the general change in diagnostic approach, these changes are geared toward communicating a more streamlined diagnostic description rather than reflecting a change in the diagnostic criteria and will not have an impact on SED prevalence estimates. Table 11 shows a comparison between DSM-IV and DSM-5 diagnostic criteria for manic episode, and Table 12 shows a comparison between DSM-IV and DSM-5 diagnostic criteria for bipolar I.
DSM-IV to DSM-5 Manic Episode Criteria Comparison.
DSM-IV to DSM-5 Bipolar I Disorder Comparison.
Generalized anxiety disorder (GAD) is an anxiety disorder characterized by excessive anxiety and worry that is not focused on a single trigger (e.g., fear of social situations, fear of having a panic attack, or fear of a specific event/situation). There have been very few changes made to GAD criteria in DSM-5. The DSM-IV criteria for GAD included that the anxiety and worry does not occur exclusively during PTSD, a mood disorder, a psychotic disorder, or PDD. In DSM-5, this has been replaced with text indicating that “the disturbance is not better explained by another mental disorder.” This will have no impact on any estimate of SED prevalence. Table 13 shows a comparison between DSM-IV and DSM-5 diagnostic criteria for generalized anxiety disorder.
DSM-IV to DSM-5 Generalized Anxiety Disorder Comparison.
Panic disorder is an anxiety disorder characterized by panic attack(s) and the ongoing concern about experiencing additional panic attacks (American Psychiatric Association, 2013b). A panic attack is an abrupt, but quickly peaking, surge of intense fear or discomfort, accompanied by a series of physical symptoms. In DSM-IV, panic disorder and agoraphobia were conceptually linked. Agoraphobia is an anxiety disorder characterized by an intense fear or anxiety triggered by the real or anticipated exposure to a number of situations (i.e., using public transportation, being in open spaces), which causes clinically significant distress or impairment. The diagnoses in DSM-IV included panic disorder with agoraphobia, panic disorder without agoraphobia, and agoraphobia without history of panic disorder. In DSM-5, however, panic disorder and agoraphobia have been separated and individuals meeting criteria for both disorders are considered to have comorbid mental disorders. Examining the comparison of panic disorder criteria specifically (Table 14), with the exception of the disaggregation of agoraphobia, the criteria are similar between DSM-IV and DSM-5. There are minor wording changes to the description of panic attacks that may have slight implications to the prevalence of panic disorder under DSM-5. Under DSM-IV, the specification was made that panic attacks were discrete periods of intense fear or discomfort that peaked within 10 minutes. In DSM-5, panic attacks are described as an abrupt surge of intense fear or intense discomfort that peak within a few minutes. The wording changes reflect two conceptual issues. First, the change in wording from a discrete event to an abrupt surge broadens criteria based on evidence that panic attacks do not necessarily arise “out of the blue” but can arise during periods of anxiety or other distress and that it is the sudden increase in fear/discomfort that is the hallmark of a panic attack. In addition, they have removed the 10-minute criterion, in favor of the less precise but implicitly shorter descriptive of “within minutes” (American Psychiatric Association, 2013b, p. 214). This was only a change in classification and is expected to have no impact on overarching prevalence estimates of SED. Table 14 shows a comparison between DSM-IV and DSM-5 diagnostic criteria for panic disorder and agoraphobia.
Panic Disorder and Agoraphobia Criteria Changes from DSM-IV to DSM-5.
Separation anxiety disorder (SAD) is a psychological condition in which an individual experiences excessive anxiety, fear, or distress regarding separation from home or from people to whom the individual has a strong emotional attachment (e.g., a parent, grandparents, or siblings; Table 15). SAD is the inappropriate and excessive display of fear and distress when faced with situations of separation from the home or from a specific attachment figure. The anxiety that is expressed is categorized as being atypical of the expected developmental level and age. The severity of the symptoms ranges from anticipatory uneasiness to full-blown anxiety about separation. SAD may cause significant negative effects within a child’s everyday life, as well. These effects can be seen in areas of social and emotional functioning, family life, physical health, and within the academic context. The duration of this problem must persist for at least 4 weeks and must present itself before a person is 18 years of age to be diagnosed as SAD (American Psychiatric Association, 2013b).
DSM-IV to DSM-5 Separation Anxiety Disorder Comparison.
The primary change from DSM-IV to DSM-5 has been the reclassification of SAD from the disorders usually diagnosed in infancy, childhood, and adolescence section to anxiety disorders. Criteria changes from DSM-IV to DSM-5 are largely wording changes rather than major conceptual differences. The largest differences are related to broadening the criteria to better align with the presentation of SAD among adults; consequently, this should have minimal impact on childhood estimates.
Social anxiety disorder is an anxiety disorder characterized by fear of social situations wherein the individual may be exposed to scrutiny by others (American Psychiatric Association, 2013b). In children, the anxiety must occur in peer settings and not just during interactions with adults. In addition, for children, the fear or anxiety may be expressed by crying, tantrums, freezing, clinging, shrinking, or failing to speak in social situations.
Diagnostic criteria for social phobia have undergone several minor wording changes from DSM-IV to DSM-5 (Table 16). One additional change is anticipated to have a broader impact on estimates of social phobia. In DSM-IV, criteria for social phobia required that an individual “recognizes that the fear is excessive or unreasonable.” In DSM-5 this has been changed to note that “the fear or anxiety is out of proportion to the actual threat posed by the social situation and to the sociocultural context.” This means that the patient does not need to recognize that their fear is unreasonable, so long as the clinician can determine that the fear is unreasonable.
DSM-IV to DSM-5 Social Phobia/Social Anxiety Disorder Comparison.
For the new social anxiety disorder, which replaces social phobia, the “generalized” (if the fears include most social situations) specifier has been deleted and replaced with a “performance only” specifier (if the fear is restricted to speaking or performing in public). The rationale is that the DSM-IV generalized specifier was difficult to operationalize. The DSM-5 describes that 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.
Epidemiological work in the U.S. population using data from the National Comorbidity Survey-Adolescent Supplement found that only 0.7 percent of adolescents meeting criteria for social anxiety disorder could be classified as having the performance-only social anxiety disorder (Burstein et al., 2011). Subsequent work based on a clinical sample in Boston of 204 youth seeking treatment for anxiety disorders at a university-affiliated center, found that no children endorsed discrete fear in performance situations only in the absence of fear in other social situations (Kerns, Comer, Pincus, & Hofmann, 2013). No impact in the prevalence of SED is expected from the new social anxiety disorder specifier when applied to youth.
Conduct disorder (CD) is usually first diagnosed in childhood and was categorized in DSM-IV under the category of the same name. Conduct disorder is characterized by a repetitive and persistent pattern of behavior that violates either the rights of others or major age appropriate societal norms or rules. People with CD often show aggression to people and animals, destruction of property, deceitfulness or theft, and/or serious violations of rules. At least 3 symptoms out of 15 must be present in the past 12 months with 1 symptom having been present in the past 6 months. To be diagnosed with CD, the symptoms must cause significant impairment in social, academic, or occupational functioning. The disorder is typically diagnosed prior to adulthood (American Psychiatric Association, 2013a).
The main change to the diagnostic criteria for CD is the addition of a subtype grouping around callous and unemotional traits. The callous–lack-of-empathy trait is defined as a disregard and lack of concern about the feelings of others and more concerned about the effects of his or her actions on himself/herself than their effects on others even when they may result in substantial harm to others (American Psychiatric Association, 2013a). The purpose of this change was to better account for heterogeneity within CD. As such, this change is not expected to impact prevalence estimates of CD. In the DSM-5 field trials in the United States and Canada based on child clinical populations (general child psychiatry outpatient services), CD prevalence was the same (8 percent) using DSM-IV and DSM-5. The estimated prevalence using DSM-5 for the new callous/unemotional specifier for CD was 5 percent (Regier et al., 2013). Table 17 shows a comparison between DSM-IV and DSM-5 diagnostic criteria for CD.
DSM-IV to DSM-5 Conduct Disorder Comparison.
Oppositional defiant disorder’s (ODD) is characterized by a frequent and persistent pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness that may significantly impair social functioning (American Psychiatric Association, 2013b). ODD is primarily viewed as a younger-child version of CD and it emerges mostly during the preschool years (before 5 years old), where symptoms of aggression and defiance are present but the acts committed by the child are less severe. Most research on changes to the categorization of ODD in DSM-5 have focused on understanding the underlying dimensions of ODD, towards the goal of being better able to predict different outcomes in later childhood (which children with ODD develop CD, which children develop other mental disorders, which children become nonsymptomatic) (Barry et al, 2013; Krieger et al., 2013). As such, there is no expectation that children previously diagnosed with something else will necessarily move into the ODD category in the DSM-5. However, some children previously diagnosed with ODD using DSM-IV criteria may move into the DMDD category under DSM-5 if their symptoms include chronic irritability along with anger and severe tantrums.
As described in the DSM-5 manual (American Psychiatric Association, 2013b, p, 64), cases with DMDD and ADHD should be diagnosed separately. In the DSM-5 field trials in the United States and Canada based on child clinical populations (general child psychiatry outpatient services), estimates for ODD were described for one of the sites (Columbia/Cornell Medical Centers-New York) as decreasing from 22 percent using DSM-IV to 17 percent using DSM-5 (Regier et al., 2013). Thus, the prevalence of ODD may decrease very slightly when DSM-5 criteria are applied, but given that DMDD only occurs in 1 percent of the school-age population, this effect is expected to be minimal. In terms of SED, DSM-5 recategorization of irritability from ODD to DMDD is expected to result in no difference in the SED prevalence estimate. Table 18 shows a comparison between DSM-IV and DSM-5 oppositional defiant disorder.
DSM-IV to DSM-5 Oppositional Defiant Disorder Comparison.
Anorexia Nervosa. Anorexia nervosa is an eating disorder characterized by an intense fear of gaining weight and the refusal to maintain a minimally normal body weight. Individuals with anorexia also exhibit a misperception of body shape and/or size. There have been several DSM-5 criteria changes. In DSM-IV, a diagnosis of anorexia nervosa was excluded if the patient maintained bodyweight at or above the 85th percentile for his or her height/age. In DSM-5 this criterion is similar, but adds sex, developmental norms, and physical health and uses body mass index data. The DSM-5 adds “persistent behavior that interferes with weight gain” as an added way to meet a criterion. The DSM-5 does not include criteria on menstruating females’ absence of three consecutive menses, as the DSM-IV does. The restrictive type and binge-eating/purging types differ in that DSM-IV specifies “during the current episode” and DSM-5 specifies “during the past 3 months.” The DSM-5 adds criteria for partial and full remission, while the DSM-IV does not include this information. Data from a U.S. sample of 215 youth 8 to 21 years enrolled as new patients with eating disorders in six clinics showed an increase from 30 percent to 40 percent in anorexia nervosa when comparing DSM-IV and DSM-5 criteria (Ornstein et al., 2013). Table 19 shows a comparison between DSM-IV and DSM-5 for anorexia nervosa.
DSM-IV to DSM-5 Anorexia Nervosa Comparison.
Bulimia Nervosa. Bulimia nervosa is an eating disorder characterized by binge eating followed by inappropriate compensatory behaviors designed to prevent weight gain. In addition, the self-evaluation of individuals with bulimia nervosa is excessively influenced by weight and body shape. The major change in criteria for diagnosis of bulimia nervosa is reducing the binge frequency threshold from twice per week in DSM-IV to once per week in DSM-5. The other differences include the DSM-IV differentiating between purging and nonpurging type (the DSM-5 does not) and the DSM-5 specifying criteria for partial remission, full remission, and severity, while the DSM-IV does not. DSM-IV to DSM-5 criteria changes may increase the prevalence rate. Data from an Australian cohort study of 2,822 adolescents and young adults (57.0 percent female) whose parents were recruited from antenatal clinics at a single hospital and followed through age 20, indicate that rates of bulimia nervosa are higher when applying the DSM-5 criteria versus the DSM–IV (Allen, Byrne, Oddy, & Crosby, 2013). Similarly, data from a U.S. sample of 215 youth 8 to 21 years enrolled as new patients with eating disorders in six clinics showed an increase in bulimia nervosa from 7.3 percent to 11.8 percent when comparing DSM-IV and DSM-5 criteria (Ornstein et al., 2013). Table 20 shows a comparison between DSM-IV and DSM-5 for bulimia nervosa.
DSM-IV to DSM-5 Bulimia Nervosa Comparison.
Binge Eating Disorder. Binge eating disorder had been included in DSM-IV as a “criteria set provided for further study,” and has been included in DSM-5 as a disorder. This disorder is characterized by binge or out of control eating accompanied by significant distress about eating. Binge eating disorder is differentiated from bulimia nervosa in that there are no inappropriate compensatory behaviors (e.g., purging or excessive exercise) seen in binge eating disorder. As noted previously, this disorder was added into DSM-5 because a significant subset of people presenting with an eating disorder had exhibited binge eating behaviors that were not accompanied by any behaviors intended to compensate for the binge eating (Call, Walsh, & Attia, 2013; Crow et al., 2012; Striegel-Moore & Franko, 2008). Changes between the criteria enumerated in DSM-IV and those in DSM-5 are minimal. The only change, which represents a less stringent requirement in DSM-5, reduces the minimum frequency/duration of the binge eating behavior to at least once a week for 3 months (it had been at least 2 days a week for 6 months). Table 21 shows a comparison between DSM-IV and DSM-5 for binge eating disorder.
DSM-IV to DSM-5 Binge Eating Disorder Comparison.
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 its course and outcome or the characteristics of children with this disorder. A large number of children and adolescents substantially restrict their food intake and experience significant associated physiological or psychosocial 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. In the DSM-5 field trials in the United States and Canada based on child clinical populations (general child psychiatry outpatient services), avoidant/restrictive food intake disorder prevalence was described for one site (Columbia/Cornell Medical Centers-New York) and it was 11 percent using DSM-5 (not applicable for DSM-IV) (Regier et al., 2013). Table 22 shows a comparison between DSM-IV and DSM-5 for avoidant/restrictive food intake disorder.
DSM-IV to DSM-5 Avoidant/Restrictive Food Intake Disorder Comparison.
Body dysmorphic disorder (BDD) is a mental illness characterized by an excessive preoccupation with a perceived physical defect or flaw that causes significant distress or functional impairment. There have been several important changes in BDD criteria from DSM-IV to DSM-5. First, BDD has been reclassified from somatoform disorders in DSM-IV to obsessive-compulsive and related disorders under DSM-5. Second, DSM-5 BDD has an added diagnostic criterion indicating that the patient must have had repetitive behaviors or mental acts that were in response to preoccupations with perceived defects or flaws in physical appearance. Third, a “with muscle dysmorphia” specifier has been added to reflect a growing literature on the diagnostic validity and clinical utility of making this distinction in individuals with BDD. Finally, the delusional variant of BDD (which identifies individuals who are completely convinced that their perceived defects or flaws are truly abnormal in appearance) is no longer coded as both a delusional disorder (somatic type) and BDD. Under DSM-5, this presentation is designated only as BDD with the “absent insight/delusional beliefs” specifier and not as a delusional disorder.
Under DSM-IV criteria, BDD was a fairly common disorder affecting approximately 2.4 percent of the general population at any time (point prevalence) as estimated by a random sample telephone survey conducted in 2004 among 2,513 adults residing in the United States (Keel, Brown, Holm-Denoma, & Bodell, 2011). As a comparison, this is similar to point prevalence estimates of DSM-IV defined GAD. Estimates under DSM-5 criteria are not currently available for children or adults. However, criteria-induced changes in the estimates are likely to be minor. Over 90 percent of people with BDD report repetitive behaviors or mental acts in response to their preoccupation with a perceived physical deficit (Able, Johnston, Adler, & Swindle, 2007), and this was the only restrictive change to diagnostic criteria. BDD affects both males and females and has been identified in children as young as age 5 and as old as age 80 (Able et al., 2007). Moreover, patients with BDD report that unwanted, anxiety provoking obsessions related to BDD cause significant distress (e.g., avoidance of social situations due to anxiety of being ridiculed) and the repetitive behaviors are time consuming, functionally impairing (e.g., being late for work due to compulsive compensatory behavior), and can be dangerous (e.g., skin picking leading to infection). Suicidal thoughts is a significant concern among people with BDD; suicidal ideation is as high as 80 percent in this population and one in four make a suicide attempt (Able et al., 2007). There are very few prospective studies of BDD, but retrospective studies suggest a mean onset of BDD around age 16 and indicate a chronic course with a low probability of remission without treatment (Able et al., 2007). Since approximately 75 percent of those with BDD meeting criteria for MDD as well, even if BDD was not assessed in a clinical instrument, the majority of the cases with BDD would be classified as having SED due to comorbidity. Table 23 shows a comparison between DSM-IV and DSM-5 for body dysmorphic disorder.
DSM-IV to DSM-5 Body Dysmorphic Disorder Comparison.
All material appearing in this report is in the public domain and may be reproduced or copied without permission from SAMHSA. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, SAMHSA, HHS.
Your browsing activity is empty.
Activity recording is turned off.
See more...
