DSM-5 Friend or Foe?

A Comprehensive Breakdown of Changes and Controversies

Part II
4. Highlights of Changes from DSM-IV-TR to DSM-5
Improvements
Overall Changes
-

Organization of the Manual

Coding of Disorders
Cross-cultural Application

Neurodevelopmental Disorders
Schizophrenia Spectrum and Other Psychotic Disorders
Bipolar and Related Disorders
Depressive Disorders
Anxiety Disorders
Obsessive-Compulsive and Related Disorders
Trauma- and Stressor-Related Disorders
Dissociative Disorders
Somatic Symptom and Related Disorders
Feeding and Eating Disorders
Sleep-Wake Disorders
Sexual Dysfunctions
Gender Dysphoria
Disruptive, Impulse-Control, and Conduct Disorders
Substance-Related and Addictive Disorders
Neurocognitive Disorders
Personality Disorders
Paraphilic Disorders

Changes of Specific Disorders

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

Improvements
The creators of the DSM-5 see the following improvements in the new manual:

The DSM-5 is a more user-friendly document compared with the DSM-IV.

(Brunk, 2013)

The DSM-IVs organizational structure failed to reflect shared features or

symptoms of related disorders and diagnostic groups, like psychotic
disorders and bipolar disorders or internalizing and externalizing disorders.
DSM-5 is constructed in a way that better reflects these interrelationships,
within and across diagnostic chapters. (Brunk, 2013)

The DSM-IV was limited because it promoted a strict categorical approach to

making diagnoses. This tends to not capture the variations of disorders
that are seen in real life. As a consequence, more not otherwise specified
diagnoses were used than were necessary. (Brunk, 2013) Most DSM-5
disorder categories incorporate dimensional (e.g., quantitative) assessments
that supports appraisal of symptom severity for each individual client. The
clinician can now identify the severity of symptoms on a scale of 3 or more
ordinal-level points, emphasizing patient self-assessment of symptom severity
(Narrow & Kuhl, 2011).

The DSM-5 integrates cross-cutting symptomatic descriptions without

regard to a specific diagnosis (Kuhl, Kupfer, & Regier, 2011), which better
reflects the true presentation of disorders and may further reduce reliance
on not otherwise specified diagnoses. It is well known that some symptoms
(e.g., sleep deprivation) are present across numerous disorders. Detailed,
clinically significant assessments will prompt more in-depth follow up of the
initial clinician-administered assessments. (Halter et al., 2013)

The DSM-IV did not adequately address lifespan perspective, including

variations of symptom presentation across the developmental trajectory, or
cultural perspectives. The chapter structure, criteria revisions, and text
outline of the DSM-5 actively address age and development as part of
diagnosis and classification. This reflects the manual's developmental
emphasis, rather than the previous edition's sequestering of all childhood
disorders to a separate chapter. Culture is similarly discussed more explicitly
to bring greater attention to cultural variations in symptom presentations.
(Kupfer et al., 2013)

As a "living document," the DSM-5 will be more amenable to updates and

therefore able to incorporate advances in the neuroscience and genetics of
psychiatric illness. It will be less susceptible to becoming outdated, compared
with its predecessors. The APA wants to take advantage of improvements in
knowledge about characteristics of psychiatric problems and approaches to
their management. The resulting advances in certain areas of diagnostic

nomenclature can be put into the evolving DSM and provide more objective
criteria than previously available for most disorders. (Kupfer et al., 2013)

An e-version of the DSM-5 makes updates possible as new information

becomes available. Revisions may become an ongoing process rather than a
periodic event. As a consequence, the Roman numeral format (e.g., DSM-IVTR) that was previously used to indicate the manuals updates was
abandoned in favor of the Arabic numeral 5. Subsequent revisions will be
referred to as version 5.1, 5.2, etc., which will be easier to track over time.
Ongoing revisions to individual diagnoses and diagnostic categories are
planned to be based on current evidence. If changes are made electronically,
as they are in the Oxford English Dictionary and in course catalogs in many
universities, regular and frequent updates will become more feasible and
affordable. (Halter et al., 2013)
The 20 diagnostic categories in the revised manual are purported to be
evidence-based (i.e., built on current best evidence informing decisions
about care for individual patients). Although research-based diagnosis is not a
new concept in the development of diagnoses and criteria, the emphasis in
this manual was planned to be hard-hitting. The leadership at APA sought to
provide diagnoses based on scientific evidence developed within the past two
decades. (Halter et al., 2013)

Many of the revisions in DSM-5 help psychiatry better resemble the rest of
medicine, including the use of dimensional approaches. Disorder boundaries
were often unclear to even the most seasoned clinicians and underscore the
proliferation of residual diagnoses (i.e., not otherwise specified disorders). A
large proportion of DSM users are primary care physicians. The use of
definable thresholds that exist on a continuum of normality is already present
throughout much of general medicine, such as in blood pressure and
cholesterol measurement, and these thresholds aid physicians in more
accurately detecting pathology and determining appropriate intervention.
Thus DSM-5 provides a model that should be recognizable to
nonpsychiatrists and should facilitate better diagnosis and follow-up care by
such clinicians. (Kupfer et al., 2013)

Diagnostic categories and diagnoses included in the new edition of the DSM
incorporate objective measures based on knowledge emerging from recent
advancements in neurodiagnostics, including measurements available
through genetic work-ups, neuroimaging, or neurochemistry. Some sleep
disorders categorized in the DSM-5 include a requirement for
polysomnography prior to formal diagnosis (Gever, 2012).
Narcolepsy/hypocretin deficiency (formerly known as narcolepsy) requires
measurement of hypocretin in the cerebrospinal fluid. Such techniques may
represent the dawn of a new era through which objective measurements
validate the existence of underlying causes, illuminating previously
unrecognized physical pathology. The potential for stigma reduction as a
consequence of more exacting diagnostic criteria is an exciting prospect
emerging from the changes in the DSM-5. (Halter et al., 2013)

Overall Changes
There are few notable differences from the DSM-IV. One distinction is DSM-5's
emphasis on numerous issues important to diagnosis and clinical care, including
the influence of development, gender, and culture on the presentation of
disorders. This is present in select diagnostic criteria, in text, or in both, which
include variations of symptom presentations, risk factors, course, comorbidities,
or other clinically useful information that might vary depending on a patient's
gender, age, or cultural background. (Kupfer et al., 2013)
In the earlier versions of DSM, disorders were described and arranged by
category, with a specific list of symptoms for each mental illness. In this
categorical system, a person either had a symptom or they didn't, and having a
certain number of symptoms was required to receive a diagnosis. If this number
was not met, the disorder could not be diagnosed.
There has not been much evidence that disorders are categorical, both in terms
of being categorically distinct from each other and from normal behavior. The
categorical syndromes did not always fit the range of symptoms that individuals
experience. (Apple, 2013) The reason so many people have more than one
psychiatric disorder is because many disorders reflect problems in the same
dimension or system. This new approach means thinking about what disorders
have in common instead of what makes them different. (Hopewood et al., 2011)
When the DSM-5 planning began in 1999 there was much written and speculated
about the magnitude of the changes through use of words like revolutionary
change to help the clinician capture the symptoms and severity of mental
illnesses, by using dimensional assessments. These would allow clinicians to
systematically evaluate patients on the full range of symptoms they may be
experiencing and rate both the presence and the severity of symptoms, such as
"very severe," "severe," "moderate" or "mild." (Apple, 2013)
Therefore a sweeping change based on using a manual-wide dimensional
model of diagnosis versus the historic traditional categorical model was
frequently discussed. (Beach et al., 2006 and Regier et al., 2011) The question
of whether mental disorders are discrete clinical conditions or arbitrary
distinctions along dimensions of functioning is a long-standing issue, but its
importance is escalating with the growing recognition of the frustrations and
limitations engendered by the categorical model. (Widiger & Samuel, 2005)
Although the revised manual represents the first substantial revision to its clinical
practice guidelines in more than 30 years, the categorical model has primarily
survived. While the DSM-5 still lists separate disorders, it also incorporates
dimensional measures of severity for many disorders. That shift is based on the
realization that the lines between many disorder categories blur over the life span

and that symptoms attributed to a single disorder may also appear in other
disorders, just with different levels of severity.
Across diagnostic groups, the use of functional impairment as a criterion for
diagnosis has been reduced, but not eliminated. For example, autism and other
disorders involving neuropsychiatric deficits retain functional diagnostic criteria,
because functional impairment is considered a cornerstone of these disorders.
(Gever, 2012) For other conditions, functionality has been removed from
diagnostic criteria and included in the dimensional assessments.
In previous editions of the DSM, the not otherwise specified (NOS) diagnoses
tended to be catchall categories. For example, more than half of all eating
disorders were listed in the Eating Disorder NOS diagnostic classification.
(Gever, 2012)
In the new manual, NOS have been replaced with not elsewhere classified
(NEC). Although this sounds similar to the previous system, the inclusion of a
requisite list of specifiers, each with a specific diagnostic code, refines and
streamlines the process and conveys important, distinct clinical information. For
example, depressive disorder NEC may involve any one or any combination of
five specifiers, such as short duration, that indicate the patients clinical
condition and provide rationale as to why the presenting condition does not meet
criteria for one of the main depressive syndromes. (Halter et al., 2013)
Organization of the Manual
The DSM-5 lists approximately the same number of disorders as the DSM-IVTR, roughly 300 across 20 diagnostic categories. Some diagnoses were
eliminated, others were regrouped.
Beginning in 1980, the DSM-III (American Psychiatric Association, 1980) created
a multiaxial system to organize diagnostic conceptualization. DSM-5 authors
concluded that there was no scientific basis for these categories. Therefore, the
new edition of the DSM retired the five axes and replaced them by a non-axial
documentation of diagnosis. The categories in the DSM-5 are at once simpler
and more complex. (Halter et al., 2013 a)
The former Axes I, II, and III are collapsed into a single axis. This is largely due
to its incompatibility with diagnostic systems in the rest of medicine, as well as
the result of a decision to place personality disorders and intellectual disability at
the same level as other mental disorders. (Kupfer et al., 2013)
There are separate notations for psychosocial and contextual factors
(formerly Axis IV) and disability (formerly Axis V). The DSM-5 incorporates a 15page ICD checklist (World Health Organization, 2010 b) for assessment of
psychosocial and contextual factors previously assessed on Axis IV. They are
5

represented through an expanded selected set of ICD-9-CM V-codes and the

forthcoming ICD-10-CM Z-codes. (American Psychiatric Association, n. d. b)
The traditional Axis V Global Assessment of Functioning (GAF) score, that
combined assessment of symptom severity, suicide risk, and social functioning
into a single global assessment, has been criticized for mixing symptom
severity with functional severity. Therefore it was replaced by the WHO
Disability Assessment Schedule (WHODAS) (World Health Organization, 2010 a)
WHODAS is a 36-item measure that addresses six domainscognition,
mobility, self-care, getting along with others, life activities, and participation. Selfadministration takes 5 to 10 minutes, and clinician administration takes 20
minutes. (Halter et al., 2013)
The chapter structure of the DSM-5 generally follows a neurodevelopmental life
span approach, as do the disorders identified within category listings. In other
words, categories generally follow a sequence from problems that typically are
diagnosed in childhood through those typical of adolescents, adults, and finally,
older adults. Because this approach is congruent with the system used by the
ICD (World Health Organization, 2010 b), this restructuring brings greater
alignment of DSM-5 to the structuring of disorders in the future ICD-11. (Kupfer
et al., 2013)
The DSM-5 authors also sought to arrange disorders by relatedness, taking into
account similar vulnerabilities and characteristic symptoms for disorders listed
within individual categories. For example, schizophrenia and bipolar disorder are
listed in succession, as individuals affected by one of these two disorders may
share common genetic variations and overlapping manifestations (Craddock,
ODonovan, & Owen, 2005). Likewise, depression is listed immediately before
anxiety, reflecting the long-recognized interrelationship of these two disorders.
(Halter et al., 2013)
The manual is composed of three sections:

Section I: DSM-5 Basics contains an introduction to the DSM-5 to and

information on how to use the updated manual.

Section II: Essential Elements: Diagnostic Criteria and Codes lists

categorical diagnoses using a significantly-revised chapter organization with
an increase from 16 in the DSM-IV-TR to 22 categories of disorders in the
revised manual:
1. Neurodevelopmental Disorders
Includes Autism Spectrum Disorder
2. Schizophrenia Spectrum and other Psychotic Disorders
3. Bipolar Disorders
4. Depressive Disorders
Includes Disruptive Mood Dysregulation Disorder

Includes Premenstrual Dysphoric Disorder

5. Anxiety Disorders
6. Obsessive-Compulsive and Related Disorders
Includes Excoriation
Includes Hoarding Disorder
7. Trauma- and Stressor- Related Disorders
8. Dissociative Disorders
9. Somatic Symptom Disorders
Includes Complex Somatic Symptom Disorder
Includes Simple Somatic Symptom Disorder
10. Feeding and Eating Disorders
Includes Binge eating disorder
Includes Avoidant/Restrictive Food Intake Disorder
11. Elimination Disorders
12. Sleep-Wake Disorders
Includes Klein-Levin Syndrome
Includes Central Sleep Apnea
Includes Confusional Arousals
Rapid Eye Movement Behavioral Disorder
13. Sexual Dysfunctions
Includes Delayed Ejaculation
14. Gender Dysphoria
15. Disruptive, Impulse Control and Conduct Disorders
16. Substance Use Disorders and Addictive Disorders
17. Neurocognitive Disorders
18. Personality Disorders (least changed from DSM-IV-TR)
19. Paraphilic Disorders
20. Other Mental Disorders
21. Medication-Induced Movement Disorders and Other Adverse Effects
of Medication
22. Other Conditions That May Be a Focus of Clinical Attention (V and Z
codes)

Section III includes conditions that require further research before they
can be considered as formal disorders, a glossary, cultural concepts of
distress, and the names of individuals involved in the manuals development
These conditions include:
o
o
o
o

Assessment Measures
Cultural Formulation
Alternative DSM-5 Model for Personality Disorders
Conditions for Further Study
Attenuated Psychosis Syndrome
Depressive Episodes With Short-Duration Hypomania
Persistent Complex Bereavement Disorder
Caffeine Use Disorder
Internet Gaming Disorder

Neurobehavioral Disorder Due to Prenatal Alcohol Exposure (NDPAE)

Suicidal Behavior Disorder

Appendix
Highlights of Changes From DSM-IV to DSM-5
Glossary of Technical Terms
Glossary of Cultural Concepts of Distress
Alphabetical Listing of DSM-5 Diagnoses and Codes (ICD-9-CM and ICD10-CM)
o Numerical Listing of DSM-5 Diagnoses and Codes (ICD-9-CM)
o Numerical Listing of DSM-5 Diagnoses and Codes (ICD-10-CM)
o DSM-5 Advisors and Other Contributors
o
o
o
o

(American Psychiatric Association, 2013 and Peele, R., 2013)

Coding of Disorders
Diagnoses that were not changed in the revision process have the same codes
as in the DSM-IV-TR. The DSM-5 contains both ICD-9-CM codes for
immediate use and ICD-10-CM codes in parentheses. The inclusion of ICD10-CM codes facilitates a cross-walk to the new coding system that is to be
implemented on October 1, 2014. This change will result in the use of a sevendigit code that replaces the current five-digit coding system. This feature will
eliminate the need for separate training on ICD-10-CM codes for mental
disorders that is now being offered for all other diseases/disorders by other
medical societies and vendors to prepare for the 2014 implementation.
DSM-5 and the ICD should be thought of as companion publications. DSM-5
contains the most up-to-date criteria for diagnosing mental disorders, along with
extensive descriptive text, providing a common language for clinicians to
communicate about their patients. The ICD contains the code numbers used in
DSM-5 and all of medicine, needed for insurance reimbursement and for
monitoring of morbidity and mortality statistics by national and international
health agencies.
Because the DSM-5 diagnostic codes are limited to those contained in the ICD,
some disorders must share codes for recording and billing purposes. For a few
new disorders, such as Disruptive Mood Dysregulation Disorder (DMDD), the
only ICD-9-CM code available for DSM-5 was a Not Otherwise Specified (NOS)
code from DSM-IV (Mood Disorder NOS 296.99). For ICD-10-CM the code will
be F34.8, which is now Mood Disorder, Other Specified. (American Psychiatric
Association, n. d. b)
The ICD-10-CM will become the official health classification of the U.S.
government and for all electronic health care transactions, such as billing and

reimbursement on October 1, 2014. Information about the ICD-10-CM is

available at the National Center for Health Statistics website
(http://www.cdc.gov/nchs/icd/icd10cm.htm#10update).
There may be another alteration of the codes again when the ICD-11 is released.
In an e-version of the DSM-5, the manual can be updated. An open revision
process might present new opportunities and challenges for users of the DSM at
that time. (Munson, 2013)

Cross-cultural Application
The DSM-IV-TR had the first official recognition of the role of culture in
diagnosing mental illness in its Appendix I, which contained an abbreviated list of
Culture-Bound Syndromes and an Outline of Cultural Formulation. This
provided a method of categorizing and normatively defining culturally bound
disorders that parallel, but did not precisely fit, defined disorders.
Building on evidence, the DSM-5 aimed for increased cross-cultural application.
(Halter et al., 2013) Therefore the previous cultural formulation was replaced with
the Cultural Formulation Interview (CFI) (Brnhielm & Scarpinati-Rosso,
2009), a standard method for simple and efficient cultural assessment, into
criteria for diagnosis. The structured clinical interview with 14 questions is to be
administered during a patients initial assessment. The CFI is designed to make
cultural formulation quicker and easier and improve patient-centered care while
reducing racial and ethnic disparities in treatment. Furthermore, it may help
providers screen and identify individuals who would benefit from the presence of
language translators. (Halter et al., 2013)

Changes of Specific Disorders

The changes made to the DSM-5 diagnostic criteria of specific disorders that are
most relevant for mental health practitioners are outlined in this section. They
are listed in the same order in which they appear in the DSM-5 classification.

Neurodevelopmental Disorders
Neurodevelopmental disorders were formerly identified as disorders usually first
evident in infancy, childhood, and adolescence. The DSM-5 adds a specifier for
all neurodevelopmental disorders associated with known medical or genetic
conditions, or environmental factors. Specifiers are also included for specific
learning disorders in reading, writing, and mathematics. (Brunk, 2013)
Intellectual Disability (Intellectual Developmental Disorder)

In the DSM-IV-TR, intellectual developmental disorder was called mental

retardation. The revised name aligns the DSM-5 with federal legislative language
(Moran, 2013b). Impairment in adaptive functioning was coupled with intelligence
quotient to serve as the dual bases for diagnosis (Sederer, 2011). Severity
measures for mild, moderate, severe, and profound intellectual disability are now
included. (Halter et al., 2013)
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 Organizations classification
system, which lists disorders in the International Classification of Diseases
(ICD) and bases all disabilities on the International Classification of Functioning,
Disability, and Health (ICF). (American Psychiatric Association, 2013 b)
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 phonological disorder),

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 other component of ASD). The symptoms of some
patients diagnosed with DSM-IV pervasive developmental disorder not otherwise
specified may meet the DSM-5 criteria for social communication disorder.
(American Psychiatric Association, 2013 b)
Autism Spectrum Disorder
Autism spectrum disorder (ASD) is a new DSM-5 name that reflects a scientific
consensusbased on evidence from clinical field trialsthat four previously
separate disorders are actually a single condition with different levels of symptom
severity in two core domains. These conditions fall on a continuum of mild to
severe.
The new autism criteria combine Aspergers disorder, childhood
disintegrative disorder, and pervasive developmental disorder (not

10

otherwise specified) into the one diagnosis. (American Psychiatric Association,

2012) Therefore these previous diagnoses relinquish their separate identity.
This change grew out of the concern within the clinical and research field that it
was not possible to consistently break out autism, Aspergers disorder, and
pervasive developmental disorder not otherwise specified (Scrowley, 2013). The
Neurodevelopmental Disorders Work Group concluded that distinctions between
the disorders tend to be in terms of overall severity rather than in terms of
symptoms. (Moran, 2013b) For the clinician, it should be easier to diagnose
ASD than trying to distinguish between high-functioning autism and Aspergers
disorder. (Lohr & Tanguay, 2013)
The new criteria are intended to lead to more accurate diagnoses and, as a
result, more focused treatment. (American Psychiatric Association, 2012 f)
The hope is that mental health professionals can better address the needs of
people with autism spectrum disorders of all developmental levels and ages
including girls, who were not represented as well as they should be in DSM-IVTR. (Scrowley, 2013)
The DSM-IV-TR criteria included three separate behavioral dimensionssocial
impairment, deficits in communication, and restricted, repetitive behaviors and
interests. An individual qualified for a diagnosis by exhibiting six of the 12
identified deficits in these three domains, including two deficits in socialization
and one deficit in each of the other two domains.
The DSM-5 recognizes autism spectrum disorder on the basis of only two
domains: one is impaired social communication, and the other is restrictive
or repetitive behaviors that may be current or historical. To qualify for a
diagnosis, an individual must exhibit three social communication deficits and at
least two deficits in the category of restricted interests/repetitive behaviors.
This builds on the DSM-IV by adding information about sensory interests and
aversions. (Scrowley, 2013) Further, the symptoms must affect the childs
functioning in daily life/activities, and the diagnostic criteria more clearly reflect
those impacts on function.
The DSM-5 workgroup considered ranking people on the basis of their
impairment in those two domains to be much more informative for guiding
treatment and educational programs. (Brunk, 2013) Scientific American found
that the DSM-IV offered 2,027 different ways to be diagnosed with autism; the
DSM-5 provides just 11. (Jabr, 2012) The APA argued that past criteria were too
loose: some people who received a diagnosis probably did not have autism, and
this misdiagnosis has surely contributed to skyrocketing rates of autism
diagnoses worldwide since the 1980s. (Jabr, 2013)

11

Another change is removing the requirement of symptom onset before age

3. The DSM-IV required that a child exhibit symptoms before the age of 3. The
DSM-5 criteria indicate that symptoms must present in early childhood, and go
on to add that these symptoms may not fully manifest until the child is in a
situation where demands exceed his or her capabilities. Therefore, older children
may receive a diagnosis, and patient history may play a bigger role. (American
Psychiatric Association, 2012 f)
Rett's Disorder continues to be a separate disorder, and no longer considered
part of the autism spectrum (which makes sense due to its unique symptoms,
including deceleration of head growth between 5-48 months of age, and loss of
purposeful hand movements, replaced by repetitive, "stereotyped" hand
movement [hand washing or wringing motions]). (Hill, 2013)
If a child exhibits symptoms in the domain of social communication impairments,
but not in the domain of restricted interests/repetitive behaviors, he or she may
qualify for a diagnosis of Social Communication Disorder. (Autism Speaks, n.
d.)
Attention-Deficit/Hyperactivity Disorder (ADHD)
The DSM-5 eliminated the DSM-IV chapter that included all diagnoses usually
first made in infancy, childhood, or adolescence. Therefore, ADHD was placed in
the neurodevelopmental disorders chapter to reflect brain developmental
correlates with ADHD.
The diagnostic criteria for attention-deficit/hyperactivity disorder (ADHD) in DSM5 are similar to those in DSM-IV. The same primary 18 symptoms are used as in
DSM-IV, 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 following changes have been made:
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
6. A symptom threshold change has been made for adults, to reflect their
substantial evidence of clinically significant ADHD impairment, with the cutoff

12

for ADHD of five symptoms, instead of six required for younger persons, both
for inattention and for hyperactivity and impulsivity.
(American Psychiatric Association, 2013 b)
The DSM-5 extended diagnostic inclusion criteria to age 12 because many
reports have shown symptom onset among children older than 7 (American
Psychiatric Association, 2010).
Specific learning disorder
This disorder broadens the DSM-IV criteria to represent distinct disorders, which
interfere with the acquisition and use of one or more of the following academic
skills: oral language, reading, written language, or mathematics. (American
Psychiatric Association, 2013 b) Because learning deficits in the areas of
reading, written expression, and mathematics commonly occur together, coded
specifiers for the deficit types in each area are included. The text acknowledges
that specific types of reading deficits are described internationally in various ways
as dyslexia and specific types of mathematics deficits as dyscalculia. (American
Psychiatric Association, 2013 b)
Motor Disorders
The following motor disorders are included in the DSM-5: developmental
coordination disorder, stereotypic movement disorder, Tourettes disorder,
persistent (chronic) 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 disorders that are in the DSM-5 obsessivecompulsive disorder chapter. (American Psychiatric Association, 2013 b)

Schizophrenia Spectrum and Other Psychotic Disorders

Schizophrenia

Previously listed under the category of schizophrenia, disorders sharing

schizophrenia-like symptoms and underlying causes are now listed in the
schizophrenia spectrum disorders, roughly arranged from least to most
severe. This change is one of the least controversial in the new manual. (Halter,
et al., 2013 a)
Two changes were made to the primary symptom criteria for schizophrenia:
1. Bizarre delusions and special hallucinations in criterion A (characteristic

13

symptoms) and the Schneiderian first-rank auditory hallucinations (e.g., two or

more voices conversing) have been eliminated. With the DSM-IV, diagnosis of
schizophrenia was given if a patient just had bizarre delusions. Research showed
that there is very poor reliability in separating bizarre and non-bizarre delusions.
(American Psychiatric Association, 2013 b) The DSM-IV required only one
psychotic symptom for a diagnosis of schizophrenia. In the DSM-5, two
Criterion A symptoms are required for any diagnosis of schizophrenia.
2. The second change is the requirement for a person to now have at least one
of three positive symptoms of schizophrenia:
delusions,
hallucinations, and
disorganized speech.
The APA believes this helps increase the reliability of a schizophrenia
diagnosis.
Catatonic, disorganized, paranoid, residual, and undifferentiated have been
removed as subtypes of schizophrenia. These schizophrenia subtypes have
been eliminated in the DSM-5 because of their limited diagnostic stability, low
reliability, poor validity, and because they didnt appear to help with providing
kbetter targeted treatment, or predicting treatment response. The APA proposes
that clinicians instead use a dimensional approach to rating severity for the core
symptoms of schizophrenia. (American Psychiatric Association, 2013 b)
However, catatonia is retained as a specifier for depressive, bipolar, and
psychotic disorders or as a separate diagnosis in the context of another medical
condition.
Schizoaffective Disorder
The primary and biggest change to schizoaffective disorder is the requirement
that a major mood episode be present for a majority of the disorders 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 diagnosismore comparable to
schizophrenia, bipolar disorder, and major depressive 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.
(American Psychiatric Association, 2013 b)
Delusional Disorder
Mirroring the change in the schizophrenia diagnostic criteria, delusions in

14

delusion disorder are no longer required to be of the non-bizarre type. A

person can now be diagnosed with delusional disorder with bizarre delusions, via
a new specifier in the DSM-5.
The differential diagnosis of delusional disorder from psychotic variants of
obsessive-compulsive disorder and body dysmorphic disorder is explicitly noted
with a new exclusion criterion. This criterion states that the symptoms must not
be better explained by conditions such as obsessive-compulsive or body
dysmorphic disorder with absent insight/delusional beliefs. (American
Psychiatric Association, 2013 b)
DSM-5 no longer separates delusional disorder from shared delusional
disorder. 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.
(American Psychiatric Association, 2013 b)

Bipolar and Related Disorders

Bipolar Disorders
Bipolar disorders are now given a section separate from depressive or
unipolar disorders. They were previously listed under mood disorders along
with major depressive disorder.
In order to enhance the accuracy of diagnosis and facilitate earlier detection in
clinical settings, the primary criteria for manic and hypomanic episodes (Criterion
A) now includes an emphasis on changes in activity and energy as well as
mood: the DSM-5 mentions core symptoms of increased energy/activity for both
hypomanic and manic episodes. The diagnosis can be made on the basis of a
set of criteria that is consistent across the life span, despite arguments that the
criteria are too stringent for children and adolescents. (Kaplan, 2012).
The DSM-IV diagnosis of bipolar I disorder, mixed episode, requiring that the
individual simultaneously 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 hypomania when
depressive features are present. It can also be applied to episodes of
depressionsuch as in the context of major depressive disorder or bipolar
disorderwhen features of mania/hypomania are present.
Thirty years of data indicating that comorbid severe anxiety is a risk factor for
suicide across depression and bipolar disorders led to the addition of an anxiety
specifier: anxious distress (Moran, 2013 a). This specifier is intended to
identify patients with anxiety symptoms that are not part of the bipolar diagnostic

15

criteria. (American Psychiatric Association, 2013 b) The rationale for this

addition is that anxiety is a serious complication of bipolar disorder and must be
addressed.
Also, a mixed state specifier replaces the fully mixed type of bipolar disorder,
which was rarely seen. The mixed state specifier applies to individuals who have
major depression along with three manic symptoms, and to individuals who have
mania along with three depressive symptoms. (Halter et al., 2013 a)
The areas on the anxiety scale of the DSM-5 are: feeling keyed up, feeling
unusually restless, difficulty concentrating because of worries, dread, and an
acute fear of loss of control. Two or more of these symptoms on most days
are considered anxious distress.
Bipolar disorder should not be used as a diagnosis, when a manic or hypermanic
episode appears to result from ECT or antidepressant treatment, has been
reversed.

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 condition
constituting an other specified bipolar and related disorder is that too few
symptoms of hypomania are present to meet criteria for the full bipolar II
syndrome, although the duration is sufficient at 4 or more days. (American
Psychiatric Association, 2013 b)

Depressive Disorders
In the chapter on depressive disorders, a new specifier for anxious distress is
delineated. (American Psychiatric Association, 2013 b)
Disruptive Mood Dysregulation Disorder
Disruptive mood dysregulation disorder (DMDD) is a newcomer that addresses
presentations of persistent, severe, and non-episodic irritability and frequent
episodes of extreme behavioral dyscontrol, that has contributed to an
upsurge of pediatric bipolar disorders (Brunk, 2013).
For most of the DSM's existence, bipolar disorder was considered primarily an
illness of adulthood, but over the past two decades there has been a 40-fold
increase in the diagnosis of childhood bipolar disorder (Tracy, 2013). Persistent
foul temper punctuated by bursts of rage was considered diagnostic of bipolar
16

disorder (onset before age 10). This new trend outraged a large segment of the
psychiatric community. Most of the so-called bipolar kidssome of whom
subsequently took mood stabilizers and antipsychotics with serious side effects
did not have a form of bipolar disorder, many psychiatrists argued. (Jabr, 2013)
Therefore disruptive mood dysregulation disorder is viewed as an alternative to
assigning a lifelong diagnosis of bipolar disorder, which often was
accompanied by early and powerful treatment prescriptions of untested and
unapproved medications. (Margulies, Weintraub, Basile, Grover, & Carlson,
2012)
To meet the criteria of DMDD, a child between six and 18 must "exhibit
persistent irritability and frequent episodes of behavior outbursts three or
more times a week for more than a year." The diagnosis applies to 6- to 18year-olds who have outbursts that are out of proportion to what is happening in
the environment. Symptoms overlap with oppositional defiance disorder but are
considered more severe.
Major Depressive Disorder
Neither the core criterion symptoms applied to the diagnosis of major
depressive episode nor the requisite 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 impairment 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 increases 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. (American Psychiatric Association, 2013 b)
Persistent Depressive Disorder (Dysthymia)
What was referred to as dysthymia in DSM-IV now falls under the category of
persistent depressive disorder, 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
combination with specifiers included to identify different pathways to the
diagnosis and to provide continuity with DSM-IV. (American Psychiatric
Association, 2013 b)
Premenstrual Dysphoric Disorder

17

Premenstrual dysphoric disorder is formally listed as a mood disorder for the

first time. Based on strong scientific evidence, this disorder has been elevated
from DSM-IV Appendix B to the depressive disorders section of DSM-5. (Brunk,
2013)
Its symptoms, including mood disturbance, are more severe than those identified
in the previous manual. According to the DSM-5, a diagnosis of premenstrual
dysphoric disorder should only be considered in women whose symptoms cause
clinically significant distress, or interfere with work, school, usual activities
and relationships.
Controversy about this diagnosis 20 years ago was heated. Opponents
suggested womens hormones were being blamed for mental illness and that the
social implications were dangerous (Tavris, 1993). For this revision, controversy
has been nearly absent. (Halter et al., 2013 b)
Removal of bereavement exclusion
If a person displays 5 out of the 9 symptoms of major depressive disordersuch
as low mood and energy, insomnia, feelings of worthlessness, loss of pleasure
and change in weightmost of the time, for 2 weeks or longer, they meet the
criteria for this diagnosis.
Earlier editions of DSM stipulated that someone who has lost a loved one should
not receive a diagnosis of depression unless the relevant symptoms last longer
than one year (DSM-III) or longer than two months (DSM-IV) following the
death. The idea was that, in these cases, what looks like major depression is
probably bereavement, a typical and transient response to loss that does not
require medication. (Jabr, 2013)
In the DSM-5, the bereavement provision has been replaced by several
footnotes describing the differences between grief and depression as well as an
admonition to clinicians that careful examination and clinical judgment is
required to differentiate bereavement from a bereavement-induced major
depressive disorder. This reflects the recognition that bereavement is a severe
psychosocial stressor that can precipitate a major depressive episode beginning
soon after the loss of a loved one. (American Psychiatric Association, 2012 a)
This essentially requires providers to diagnose a grieving individual with
major depression 2 weeks after the loss.
The American Psychiatric Association omitted this exclusion in the 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 12 years.

Second, bereavement is recognized as a severe psychosocial stressor that

18

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, detailed footnotes have replaced the more
simplistic DSM-IV exclusion to aid clinicians in making the critical distinction
between the symptoms characteristic of bereavement and those of a major
depressive episode. (American Psychiatric Association, 2013 b)

"The basic message in the bereavement exclusion from DSM-IV was that we
as clinicians could not diagnose major depression during the first 2
months following a bereavement. This would be independent of how the
person might be suffering during that 2-month period.

The other thing that seemed to be implied, which was very unfortunate, was
that a number of people concluded that bereavement may only last 2
months, when in fact all of us know that bereavement often lasts a lot longer
than 2 months. The DSM-5 includes a criteria note that allows one to think
about the presence of major depression while someone is also experiencing a
significant loss." (Brunk, 2013)

According to two 2007 reviews and one 2010 review, bereavement-related

depression is similar to other depression in their severity and duration and
long-term outcomes. (Wakefield & First, 2012)

The ICD makes no such exceptions.

It does not make sense to make an exception of grief following the death of a
loved one, but not of any other kinds of loss or psychosocial stress such
as divorce, unemployment, financial failure or romantic rejection. (Jabr, 2013)

Specifiers for Depressive Disorders

People who are suicidal are a public mental health concern. Therefore a new
specifier is available that helps shed light on suicidality factors in someone who
is depressed. (Grohol, 2013 b)
Suicidality represents a critical concern in psychiatry. Thus, the clinician is given
19

guidance on assessment 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 depression.
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. (American Psychiatric Association, 2013 b)

Anxiety Disorders
In the DSM-5, obsessive-compulsive disorder and posttraumatic stress
disorder are set off into their own diagnostic categories, removing them from
the family of anxiety disorders. Longitudinal outcomes, comorbidities, familial
aggregations, and underlying biology suggest the conditions are different from
anxiety disorders. However, the sequential order of these chapters reflects the
close relationships among them. (American Psychiatric Association, 2013 b)
This new approach also makes sense because the disorders that are left in the
anxiety categorygeneralized, social, separation, panic, and phobic anxieties
are pretty much treated the same way. (Otto, 2013).
Anxiety disorders are now organized in a dedicated chapter separate from other
anxiety-related disorders. "With panic attacks" is a specifier for any mental
disorder, and panic disorder and agoraphobia have become unlinked. (Brunk,
2013)
Separation Anxiety Disorder
Separation anxiety disorder now includes adults. Adults may be at greater risk
than children for the disorder, with a lifetime prevalence estimate of 6.6%
compared to 4.1% for children (Shear, Ruscio, Walters, & Kessler, 2006).
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, attachment 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 criteriontypically

20

lasting for 6 months or morehas been added for adults to minimize

overdiagnosis of transient fears. (American Psychiatric Association, 2013 b)
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.
(American Psychiatric Association, 2013 b)
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
overestimate 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, after 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. (American
Psychiatric Association, 2013 b)
The anxiety must be out of proportion to the actual threat or danger the
situation poses, after taking into account all the factors of the environment and
situation. The symptoms must also last at least 6 months for all ages. This
change is intended to help minimize the over-diagnosis of occasional fears.
Besides the above-mentioned changes, the generalized specifier has been
deleted for social anxiety disorder and replaced with a performance only
specifier. The DSM-IV generalized specifier was problematic in that fears
include most social situations 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.
(American Psychiatric Association, 2013 b)
Agoraphobia is now a freestanding disorder and not necessarily a subset of
panic disorder.
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 agoraphobia, although

21

endorsement of fears from two or more agoraphobia situations is now required,

because 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). (American Psychiatric Association, 2013 b)
Panic Attack
The essential features of panic attacks remain unchanged, although the
complicated DSM-IV terminology for describing different types of panic attacks
(i.e., situationally bound/cued, situationally predisposed, 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 comorbidity 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. (American Psychiatric Association, 2013 b)
Obsessive-Compulsive and Related Disorders
Since the DSM-5 chapter on anxiety disorder no longer includes obsessivecompulsive disorder, this disorder is now included with the obsessivecompulsive and related disorders.
The chapter on obsessive-compulsive and related disorders, which is new in
DSM-5, reflects the increasing 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. (American Psychiatric
Association, 2013 b)
In previous editions of the DSM, some of the disorders within this new obsessivecompulsive and related disorders category were listed across several other
diagnostic groups. While obsessive-compulsive disorder was formerly included in
anxiety disorders, body dysmorphic disorder was a somatoform disorder, and
hair-pulling disorder (previously trichotillomania) was listed under impulse control
disorders not elsewhere classified.
New disorders include hoarding disorder, excoriation (skin-picking) disorder,
substance/medication-induced obsessive-compulsive and related disorder, and
obsessive-compulsive and related disorder due to another medical condition. All
disorders in this category have the core symptom of abnormal and obsessive
fixations.

22

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 beliefs.
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. (American Psychiatric Association, 2013 b)
Body Dysmorphic Disorder
For DSM-5, body dysmorphic disorder, a diagnostic criterion describing
repetitive behaviors or mental 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 clinical utility of making this distinction in
individuals with body dysmorphic disorder. The delusional variant 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 disorder, 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. (American Psychiatric
Association, 2013 b)
Hoarding disorder
The addition hoarding disorder to the DSM-5 is supported by extensive scientific
research on this disorder. This devastating problem has been showcased on
prime-time television and become part of common language. People who amass
huge quantities of belongings and have extreme and persistent problems in
parting with or discarding them regardless of their actual value may receive
this diagnosis. Typically, the individual and the family suffer from chronic
emotional, social, physical, financial, and even legal problems as a result of
the hoarding. (American Psychiatric Association, 2012 b)

23

The DSM-IV listed hoarding as one of the possible symptoms of obsessivecompulsive personality disorder and noted that extreme hoarding may also occur
in obsessive-compulsive disorder. However, available data do not indicate that
hoarding is a variant of obsessive-compulsive disorder or another mental
disorder. (American Psychiatric Association, 2013 b)
Consequently, many hoarders do not have any other symptoms of OCD and
hoarding may be more common than OCD in the general population.
Investigations have also suggested that although OCD and hoarding can cooccur, they are genetically and neurologically distinct. Parents and siblings of
hoarders show higher rates of hoarding than do first-degree relatives of people
with OCD, for instance, and hoarding seems to be inherited as a recessive trait,
whereas the compulsive checking and organizing that characterizes OCD is
dominant. (Jabr, 2013)
Neuroimaging studies have revealed that when hoarders make decisions about
what to keep and what to throw out, their brain activity is markedly different from
that of people with OCD and people without a mental disorder. (Jabr, 2013)
Therefore, there is evidence for the diagnostic validity and clinical utility of a
separate diagnosis of hoarding disorder. Hoarding disorder may have unique
neurobiological correlates, is associated with significant impairment, and may
respond to clinical intervention. (American Psychiatric Association, 2013 b)
The official recognition of hoarding as an important neuropsychic disorder will
increase screening, detection, diagnosis, and treatment. This diagnosis is
one of major public health significance, because every department of public
health in every county in the country has to deal with a hoarding issue, whether
its animal-related or other forms of excessive acquisition. (Brunk, 2013) The new
diagnosis is already inspiring pharmaceutical companies to think about doing
trials specifically for hoarding disorder. (Krumboltz, 2013)
Excoriation (skin-picking) disorder
This disorder is new to DSM-5 and results in noticeable physical damage,
emotional distress, and attempts to conceal the behavior (Odlaug & Grant,
2010)
Substance/Medication-Induced Obsessive-Compulsive and Related
Disorder and Obsessive-Compulsive and Related Disorder Due to Another
Medical Condition
DSM-IV included a specifier with obsessive-compulsive symptoms in the
diagnoses of anxiety disorders due to a general medical condition and
substance-induced anxiety disorders.
Given that obsessive-compulsive and related disorders are now a distinct

24

category, DSM-5 includes new categories for substance/medication-induced

obsessive-compulsive and related disorder and for obsessive-compulsive and
related disorder due to another medical condition. This change is consistent with
the intent of the new manual, because it reflects the recognition that substances,
medications, and medical conditions can present with symptoms similar to
primary obsessive-compulsive and related disorders. (American Psychiatric
Association, 2013 b)

Trauma- and Stressor-Related Disorders

This category is new and all disorders share abnormal responses to external
trauma and stress. (Friedman et al., 2011) Posttraumatic stress disorder and
acute stress disorder are now included with the trauma- and stressor-related
disorders.
Reactive Attachment Disorder and Disinhibited Social Engagement
Disorder
The DSM-IV childhood diagnosis reactive attachment disorder had two
subtypes: emotionally withdrawn/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
childs 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
resembles 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 established or even secure attachments. The two disorders differ in other
important ways, including correlates, course, and response to intervention, and
for these reasons are considered separate disorders. (American Psychiatric
Association, 2013 b)
The diagnosis of disinhibited social engagement disorder is used when children
demonstrate no normal fear of strangers, seem unfazed in response to
separation from a primary caregiver, and are unusually willing to go off with
people who are unknown to them.
Posttraumatic stress disorder (PTSD)
Moved from anxiety disorders to this new chapter in the DSM-5 on trauma- and
25

stressor-related disorders, criteria for posttraumatic stress disorder differ

significantly from those in the DSM-IV. (American Psychiatric Association, 2013
b)
One change is the removal of the A2 criteria, which was that an individual not
only has to be exposed to an overwhelming stress but they have to react with
horror or disgust. What was happening is that soldiers who are trained to
immediately deal with horrendous experiences would say that their training
kicked in. They didnt have the reaction the A2 criteria yet they subsequently
would have clear criteria for PTSD. There was a need to eliminate that criteria."
(Brunk, 2013)
The exposure to actual or threatened death, serious injury or sexual violation is
central to the definition of PTSD, with media exposure being explicitly excluded
unless it is work-related.
The revised manual pays more attention to the behavioral symptoms that
accompany PTSD than the DSM-IV. Because the avoidance/numbing cluster has
been divided into two distinct clusters, avoidance and persistent negative
alterations in cognition and mood, four (instead of three) clusters of symptoms
now define posttraumatic stress disorder:
1. intrusion (re-experiencing),
2. persistent avoidance,
3. alterations in arousal and reactivity (includes irritable or aggressive
behavior and reckless or self-destructive behavior, and
4. persistent negative alterations in cognitions and mood (includes new or
re-conceptualized symptoms, such as persistent negative emotional states).
The new cluster of negative cognitions and mood includes estrangement from
others, a persistent and distorted sense of blame of self/others, diminished
interest in activities, and inability to remember key aspects of the event. The
arousal cluster includes more aggression-related symptoms than it did in the
DSM-IV.
Three symptoms are new:
1. specious (misleading or nearly believable) self- or other-blame in regard
to the trauma,
2. negative mood states, and
3. reckless or maladaptive behavior.
Direct exposure or exposure of a close friend or relative to a traumatic event,
or repeated exposure to the aversive details of trauma, such as that
experienced by disaster workers or first responders, meets the criteria for a
PTSD diagnosis.

26

Because small children develop PTSD at the same rate as adults, a

developmental subtype of PTSD was added to address the needs of children
younger than 6 who have been subjected to traumatic events. (Jagodzinski,
2011) Previous criteria for PTSD aren't appropriate for children, no matter how
bright or verbally expressive a young child may be. Therefore, diagnostic
thresholds have been lowered for children and adolescents. New research
details what PTSD looks like in young children and finds that treatment for these
young sufferers can be effective. (Psychiatry 'Bible' DSM-5 to Add PTSD
for Preschoolers, 2013)
Another subtype for individuals with prominent dissociative symptoms is called
dissociative.
Acute Stress Disorder
In the DSM-5, the stressor criterion (Criterion A) for acute stress disorder is
changed from the 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 persons response involved intense
fear, helplessness, or horror) has been eliminated.
Based on evidence that acute posttraumatic reactions are very heterogeneous
and that the DSM-IVs emphasis on dissociative symptoms was overly restrictive,
individuals may meet diagnostic criteria in the DSM-5 for acute stress disorder if
they exhibit any 9 of 14 listed symptoms in these categories: intrusion,
negative mood, dissociation, avoidance, and arousal. (American Psychiatric
Association, 2013 b)
Adjustment Disorders
The DSM-IV saw adjustment disorders as a residual category for individuals
who exhibit clinically significant distress without meeting the criteria for a more
discrete disorder.
In the DSM-5, adjustment disorders are re-conceptualized as a heterogeneous
array of stress-response syndromes that occur after exposure to a
distressing (traumatic or non-traumatic) event. The DSM-IV subtypes
marked by depressed mood, anxious symptoms, or disturbances in conduct have
been retained, unchanged. (American Psychiatric Association, 2013 b)

Dissociative Disorders

27

Dissociative disorders are purposefully listed immediately after Trauma and

Stressor-Related Disorders due to the link with trauma and disorganized
attachment (Boysen, 2011). The manual maintains the two disorders as
separate categories because research indicates that patients with dissociative
disorders do not respond well to standard exposure-based treatments designed
for PTSD and that they leave treatment prematurely. (Bland et al., 2012).
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. (American Psychiatric Association, 2013 b)
Dissociative Identity Disorder
Several changes to the criteria for dissociative identity disorder have been made
in the DSM-5.
1. Criterion A has been expanded to include certain possession-form
phenomena in some cultures and functional neurological symptoms to
account for more diverse presentations of the disorder.
2. Criterion A now specifically states that disruptions or transitions in identity
may be observable by others or self-reported.
3. According to Criterion B, individuals 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.
(American Psychiatric Association, 2013 b)

Somatic Symptom and Related Disorders

Somatic symptom and related disorders were formerly known as somatoform
disorders. Diagnoses of somatization disorder, hypochondriasis, the 3
variants of pain disorder, and undifferentiated somatoform disorder were
regrouped into somatic symptom disorder and illness anxiety disorder.
(Dimsdale, 2013)
Since the word somatization refers to psychological stress that manifests in the
form of physical symptoms, a persons physical symptoms are traceable to a
mental or emotional cause rather than to a physical one. DSM-IV criteria
overemphasized the importance of an absence of a medical explanation for
the somatic symptoms. The DSM-5 classification defines disorders on the
basis of positive symptoms (i.e., distressing somatic symptoms plus abnormal
28

thoughts, feelings, and behaviors in response to these symptoms). (American

Psychiatric Association, 2013 b)
Medically unexplained symptoms do remain a key feature in conversion disorder
and pseudocyesis because it is possible to demonstrate definitively in such
disorders that the symptoms are not consistent with medical pathophysiology.
(American Psychiatric Association, 2013 b)
Somatic Symptom Disorder (SSD)
Somatic symptom disorder has been added to the DSM-5 to better recognize the
complexity of the interface between psychiatry and medicine. These
disorders are primarily seen in medical settings. Non-psychiatric physicians
found somatoform diagnoses problematic to use. (American Psychiatric
Association, 2013 b)
The DSM-IV emphasized medically unexplained symptoms as the key feature
of somatoform disorders. The Somatic Symptoms Workgroup stated that patients
feel that their complaints are viewed as inauthentic, doctors cant agree about
what is or is not medically unexplained, and that the reliability of medically
unexplained symptoms is limited. Grounding a diagnosis on the absence of an
explanation is problematic and reinforces mind-body dualism, which is more
consonant with the 17th century than the 21st.
Psychiatric symptoms and general medical symptoms can and do coexist.
Patients think and feel with their brains and are affected by life experience and
the cellular milieu that they live in. (American Psychiatric Association, 2013 b)
The DSM-5 diagnosis of somatic symptom disorder represents an attempt to
correct these problems in DSM IV. The DSM-5 diagnosis does not question the
reality of patients suffering and emphasizes instead that psychiatric disorders
are more properly diagnosed on the basis of features such as disproportionate
and excessive thoughts, feelings, and behaviors, rather than by negative features
like medically unexplained symptoms. (Dimsdale, et al., 2013 b) In other words,
a patients suffering is now considered authentic, whether or not it is
medically explained. (Tagore, 2013)
The diagnosis of somatic symptom disorder subsumes the former diagnoses of
somatization disorder, hypochondriasis, undifferentiated somatoform disorder,
and pain disorder. There was significant problematic overlap across the
somatoform disorders and a lack of clarity about their boundaries. (American
Psychiatric Association, 2013 b)
People can be diagnosed with SSD if, for at least six months, they have had
one or more physical symptoms that are distressing and/or disruptive to their
daily life, and if they have one of the following three reactions:

29

1. disproportionate thoughts about the seriousness of their symptom(s),

2. a high level of anxiety about their symptoms or health, or
3. devoting excessive time and energy to their symptoms or health concerns.
Individuals with somatic symptoms plus abnormal thoughts, feelings, and
behaviors may or may not have a diagnosed medical condition.
Individuals previously diagnosed with somatization disorder usually meet the
DSM-5 criteria for somatic symptom disorder if they have the above-mentioned
criteria that define the disorder, in addition to their somatic symptoms. (American
Psychiatric Association, 2013 b)
Hypochondriasis and Illness Anxiety Disorder
Hypochondriasis has been eliminated as a disorder, in part because the name
was perceived as pejorative 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 therefore receive now a DSM-5 diagnosis of somatic
symptom disorder. In the DSM-5, individuals with high health anxiety without
somatic symptoms receive a diagnosis of illness anxiety disorder (unless their
health anxiety was better explained by a primary anxiety disorder, such as generalized anxiety disorder). (American Psychiatric Association, 2013 b)
Pain Disorder
In the 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. Somatic Symptom Disorder Workgroup saw a lack
of evidence that such distinctions can be made with reliability and validity,
because a large body of research has demonstrated that psychological 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 the DSM-5, some individuals with chronic pain
should therefore be appropriately diagnosed as having somatic symptom
disorder, with predominant pain. For others, psychological factors affecting other
medical conditions or an adjustment disorder are more appropriate. (American
Psychiatric Association, 2013 b)
Psychological Factors Affecting Other Medical Conditions and Factitious
Disorder
The DSM-IV included Psychological Factors Affecting Medical Condition
(PFAMC) in the part of the manual reserved for conditions that may be of interest
to clinicians, even though they are explicitly not to be considered mental
disorders (Other Conditions That May Be a Focus of Clinical Attention).
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In the DSM-5, this disorder and factitious disorder are placed among the
somatic symptom and related disorders because somatic symptoms are
predominant in both disorders, and both are most often encountered in medical
settings. (American Psychiatric Association, 2013 b) The variants were reduced
from 2 to 1. The 6 subtypes were entirely eliminated in favor of one diagnosis.
PFAMC might describe someone's stress precipitating a stroke, a patient's
noncompliance with treatment, type A personality traits that are a risk factor for
heart attack, a sedentary lifestyle predisposing to obesity, or unsafe sexual
practices. (Frances, 2013 c)
Conversion Disorder (Functional Neurological Symptom Disorder)
Criteria for conversion disorder (functional neurological symptom disorder) have
been modified to emphasize the essential importance of the neurological
examination, and in recognition that relevant psychological factors may not
be demonstrable at the time of diagnosis.

Feeding and Eating Disorders

This category was formerly known as Eating Disorders. It includes several
problems originally listed among Disorders of Infancy, Childhood, or
Adolescence. These include pica, rumination disorder, and
avoidant/restrictive food intake disorder.
Symptoms of anorexia nervosa traditionally have included amenorrhea and a
fear of gaining weight. New criteria include menstruating women along with
individuals who are not fixated on weight gain.
The twice-weekly binge and purge criterion previously required for a diagnosis
of bulimia nervosa has been reduced to once per week.
Binge Eating Disorder
Binge eating disorder is moved from the DSM-IVs Appendix B: Criteria Sets and
Axes Provided for Further Study to the DSM-5 Section 2 as an actual disorder.
The change is intended to better represent the symptoms and behaviors of
people with this condition. (American Psychiatric Association, 2012 b)
Criteria for binge-eating disorder are:
1. one binge per week for 3 months,
2. feeling out of control, and
3. being distressed by the behavior.

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Affected individuals report that they eat too rapidly, feel too full, and eat when
they are not hungry. Eating alone is common due to embarrassment. (Halter et
al., 2013 a)
Avoidant/Restrictive Food Intake Disorder
This disorder describes people who are particularly uninterested in eating or
are restrictive or phobic in their food choices. They must also suffer resulting
weight loss, nutritional deficiency, or social problems. (Frances, 2013 e)

Sleep-Wake Disorders
This category, formerly known as Sleep Disorders, has had a nearly complete
overhaul in the DSM-5. The reworking of this category will make sleep problems
easier for professionals to diagnose and discriminate between different sleep
disorders. The term primary was dropped, with the previously named primary
insomnia disorder listed simply as insomnia disorder (Reynolds, 2011)
Dimensional measures gauge severity and identify other contributing factors.
(Halter et al., 2013 a)
Primary and commonly diagnosed sleep disorders are now organized into three
major categories:
insomnia disorder,
hypersomnolence disorder, and
narcolepsy.
The DSM-5 allows professionals to choose among sub-types in each category,
as can be done with many other major disorders in the manual.

Sexual Dysfunctions
Sexual dysfunctions were formerly classified along with Sexual and Gender
Identity Disorders.

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Gender Dysphoria
This category was also formerly listed under the category of Sexual and Gender
Identity Disorders. This meant, for example, that a man who believed he was
destined to be a woman was considered mentally ill.
The DSM-5 eliminated the term gender identity disorder, long considered
stigmatizing by mental health specialists and lesbian, gay, bisexual and
transgender activists. For years, advocates lobbied the APA to redefine or
remove gender identity disorder as a psychiatric diagnosis. Their work has been
rewarded. To receive the new diagnosis and qualify for insurance coverage, one
must experience a sense of mismatch between biological gender and
personal gender identification and must experience related distress
(dysphoria). (Halter et al., 2013 a)
In other words: when the new manual refers to gender dysphoria, it focuses the
attention on only those who feel distressed by their gender identity.

Disruptive, Impulse Control, and Conduct Disorders

This category now contains disorders that previously were included across
diagnostic categories. Oppositional defiant disorder and conduct disorder
were formerly classified alongside attention-deficit/hyperactivity disorder as
disruptive behavior disorders. Intermittent explosive disorder was classified as
an impulse control disorder NEC (not elsewhere classified), and antisocial
personality disorder was classified exclusively under personality disorders
where it remains as a cross-listed diagnosis in the DSM-5. (Halter et al., 2013 a)

Substance-Related and Addictive Disorders

The DSM-5 is the first to include the word addiction. But this change is largely
cosmetic, appearing only in the title of the section Addiction and Related
Disorders. Previous versions shied away from this charged word. (Dahr, 2013).
In the new category of behavioral addictions, gambling is the sole disorder,
which was previously called "pathological gambling" and listed under "ImpulseControl Disorder Not Elsewhere Classified. The APA based its decision in part
on recent evidence that compulsive behaviors and compulsive substance use
create similar subjective experiences, follow the same clinical pattern, may derive
from the same neural network, and respond to similar treatments. The brains of
people who are addicted to gambling change in similar ways to the brains of drug
addicts and that both drug addicts and pathological gamblers benefit from group
therapy and gradual weaning. (Jabr, 2013)

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Addiction is a disorder of the brain reward system, and it doesnt matter whether
the system is repeatedly activated by gambling or alcohol or another substance.
In functional brain imagingwhether with gamblers or drug addictswhen
they are showed video or photograph cues associated with their addiction, the
same brain areas are activated. (Moran, 2013)
Internet addiction was considered for this category, but work group members
decided there was insufficient research data to do so. Therefore Internet gaming
disorder is included in the manuals appendix instead, with a goal of encouraging
additional study. (Nauert, 2010)
Substance Use Disorder
The previous manual discussed substance abuse and substance
dependence. Many critics contended that this was a poor choice. (Jabr, 2013)
The distinction between abuse and dependence has never made much clinical
sense and did little to enhance understanding or guide treatment. (Lembke,
2013) To many clinicians, they appeared to be the same disorder but on a
continuum of abuse. The APA agreed and considered the term abuse as
clinically meaningless. (Moran, 2013) They also pointed out the misuse of the
term dependence to describe the normal withdrawal patterns that can occur
during appropriate medication use. (Kupfer et al., 2013) Therefore, substancerelated and addictive disorders combine the DSM-IV categories of substance
abuse and substance dependence.
There are two major changes to the new DSM-5 criteria for substance use
disorder:

Recurrent legal problems criterion for substance abuse has been

deleted

A new criterion has been added: craving or a strong desire or urge to

use a substance.

The threshold for substance use disorder diagnosis is set at two or more
criteria. This is a change from the DSM-IV, where substance abuse required a
threshold of one or more criteria be met, and substance dependence required a
threshold of three or more. (Grohol, 2013 c)
The severity of the diagnosis depends on how many of the six criteria apply.
More criteria means greater severity:
23 criteria indicate a mild disorder
45 criteria, a moderate disorder
6 or more, a severe disorder.
Rather than dividing the world into alcoholics and non-alcoholics, for example,
the new alcohol disorder spectrum includes everyone at levels from "mild" (your
"normal" college binge drinker) to "severe" (someone whose drinking is out of
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control and who meets all six criteria). One can even be almost alcoholic, with
four criteria. Previously, the milder substance use required only one symptom
while the DSM-5s mild alcohol use disorder disorder requires two to three
symptoms. (Dhar, 2013 a)
Since this change supports treatment according to severity, or stage, of illness,
people with different degrees of severity and treatment response are expected to
receive treatment specifically tailored to their needs. (Willenbring, 2013) The new
criteria are also expected to support early interventions in order to hinder the
addiction problem, to reduce or halt physical problems, and to save money by
reducing long-term disability. (Halter et al., 2013 a)
The introduction of the severity scale is meant to help addiction treatment fall in
line with physical medicine, with its numerically precise diagnostics like blood
pressure and cholesterol levels. (Dahr, 2013)
The DSM-5 removed the physiological subtype, as well as the diagnosis for
polysubstance dependence. Early remission from a 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 specifiers include in a
controlled environment and on maintenance therapy.
Cannabis withdrawal is new, as is caffeine withdrawal. These were previously
included only in the DSM-IV Appendix B, Criteria Sets and Axes Provided for
Further Study. The symptoms of withdrawal must be severe enough to cause
the person substantial problems with functioning at work or in social
situationsor significant impairment in functioning in other important areas.
These symptoms include:
Anger, irritability or feelings of aggression
Depressed mood
Feelings of restlessness
Loss of appetite (or weight loss)
Insomnia or other sleeping problems
Feelings of anxiety or nervousness
Physical symptoms of withdrawal include headache, stomach pains, increased
sweating, fever, chills or shakiness. At least one of these physical symptoms
must be present, and the severity of the symptom(s) must be great enough to
cause substantial discomfort.
The criteria for the DSM-5 tobacco use disorder are the same as those for
other substance use disorders. By contrast, the DSM-IV did not have a category
for tobacco abuse.

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Neurocognitive Disorders
Disorders listed in this category were formerly found under delirium, dementia,
and amnestic and other cognitive disorders. Major neurocognitive disorder now
subsumes dementia and the amenstic disorder. Although the problems that are
addressed in this revised category remain the same, using the term
neurocognitive was chosen to neutralize dementia-related stigma. (Halter et
al., 2013 a)
Neurocognitive disorders are divided into major and mild types. Major
neurocognitive disorders are characterized by substantial cognitive decline
that results in curtailed independence and functioning among affected
individuals.
Mild neurocognitive disorder was added as a new disorder. This diagnosis
identifies people whose symptoms place them somewhere in a gray zone
between normal cognition and those with noticeably significant cognitive
deterioration. Identifying early-presenting symptoms among those individuals
may aid in earlier interventions at a stage when some disease-modifying
therapies may be most effective (Sperling, 2011).
The workgroup for this disorder assumed that the DSM-5 can make a significant
contribution to assisting clinicians with diagnosing neurocognitive disorders. "An
enormous amount of information has emerged in the area of neurocognitive
disorders [in terms of] early differentiation of a probable Alzheimers disease
versus a frontal temporal dementia diagnosis and differentiating dementia with
Lewy bodies versus vascular dementia. (Brunk, 2013)

Personality disorders
In previous editions of the manual, personality disorders were listed on Axis II,
suggesting that they were unique from Axis I. The removal of the Axis system
eliminates the suggestion of a causal dichotomy between personality disorders
and all other psychiatric diagnoses. (Skodol, 2012).
The DSM-5 maintains the categorical model and criteria for the 10
personality disorders included in the DSM-IV. Originally, a hybrid categoricaldimensional model was proposed. It included not only core impairments in
personality functioning but also various combinations of pathological personality
traits associated with these conditions. Although this proposal was endorsed by
the DSM-5 Task Force, it was decided that the hybrid model required more
research support before being fully adopted. Therefore, this new model was
added in Section III to encourage study of how the methodology could be used
to clinically diagnose personality in clinical practice.

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Paraphilic disorders
Sex has a controversial history in the DSM. Therefore the manual has undergone
significant changes over the last 50 years in how it defines healthy and
unhealthy sexuality. For example, homosexuality was considered a mental
disorder until 1973. Up until 1986 the manual still gave clinicians the option of
declaring gay people mentally ill if their sexuality caused them distress.
The Paraphilic Disorders Section of the DSM-5 represents a significant
departure from DSM-IV-TR. Paraphilias (sexual masochism, fetishism,
voyeurism, transvestism, sadism, pedophilia, etc.) have been removed from the
DSM. They are disorders involving the patients need for unusual sexual
stimulation to achieve sexual arousal or orgasm. This group of disorders was
listed in the Sexual and Gender Identity section of earlier versions of the DSM.
The DSM-5 defines paraphilic disorders as: Any intense and persistent sexual
interest other than sexual interest in genital stimulation or preparatory fondling
with phenotypically normal, consenting human partners between the ages of
physical maturity and physical decline. The new manual added one criterion:
These disorders apply if an individual feels personal distress about their
interest. Remission is defined as having no distress, functional impairment, or
recurring behavior for 5 years in an uncontrolled environment.
The manual lists the following sexual disorders: Voyeuristic Disorder,
Exhibitionistic Disorder, Frotteuristic Disorder, Sexual Masochism Disorder,
Sexual Sadism Disorder, Pedophilic Disorder, Fetishistic Disorder, Transvestic
Disorder, Other Specified Paraphilic Disorder, or Unspecified Paraphilic Disorder.
The work group assigned to this category sought to distinguish the mild and
socially harmless paraphilias from the severe paraphilias, which are distressing
to those afflicted and/or are potentially dangerous to others (Dreger, 2010).
Therefore, risk-assessing specifiers have been developed to indicate level of
threat to others posed by individuals diagnosed with a paraphilic disorder,
designating whether the individual is in a controlled environment, and if the
individual is in remission.
Psychiatrists have argued that by including the paraphilic disorders in the DSM,
the door remains open for those individuals to seek treatment. (Keenan,
2013)

For Extended Bibliography and References, click here.

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