Asian Journal of Psychiatry 11 (2014) 114118

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Asian Journal of Psychiatry

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DSM 5 and child psychiatric disorders:

What is new? What has changed?
Valsamma Eapen a,b,*, Rudi Crncec a,b
a
Academic Unit of Child Psychiatry, South Western Sydney Local Health District (AUCS), Liverpool Hospital, Mental Health Centre (Level 1: ICAMHS),
Locked Bag 7103, Liverpool BC, NSW 1871, Australia
b
School of Psychiatry & Ingham Institute, University of New South Wales, Sydney, Australia

A R T I C L E I N F O A B S T R A C T

Article history: The signicant changes in DSM 5 as these relate to a number of the child psychiatric disorders are
Received 29 March 2014 reviewed by several authors in this special issue: In this paper we address some of the changes in the
Accepted 22 April 2014 conceptual organisation of DSM 5 and specically focus on anxiety and related disorders. In the case of
child and adolescent psychiatry, the most notable feature is that the chapter on Disorders Usually First
Keywords: Diagnosed in infancy, Childhood or Adolescence has been deleted. Instead, a new chapter in DSM 5
DSM 5 describes Neurodevelopmental Disorders which typically manifest early in development. Further, an
Classication
expectation had been built that DSM would be based on the latest data in neuroscience and that a clear
Child and adolescent psychiatric disorders
direction towards a mixed dimensional and categorical approach would be evident. This has been the
Neurodevelopmental disorders
case with some disorders and a notable example is the removal of Obsessive Compulsive Disorder (OCD)
from the Anxiety Disorder chapter and placement with other related disorders that share similar
neurobiology and treatment response. In this regard, the addition in DSM 5 of a new specier tic-
related to OCD is worth noting as there is emerging evidence that differential treatment response exists
when tics are associated with OCD. The same situation applies to tics with ADHD, thus presenting the
argument for a dimensional approach to Tic Spectrum Disorder (TSD) incorporating categories such as
those with tics only, tics with OCD, tics with ADHD etc. to be given due consideration in the future.
Another important change that clinicians in the eld of child psychiatry will no doubt notice is the
demise of the multiaxial classication. Instead, DSM 5 has moved back to a nonaxial documentation of
diagnosis with separate notations for important psychosocial and contextual factors as well as level of
functioning and disability. Clinicians are urged, however, to continue to recognise the need to
understand how symptoms and behaviours might have arisen and assess relevant contextual factors
such as the family relationships, quality of care, any history of abuse, and so on. Further, the move to
harmonise DSM 5 with the structure of ICD 11 (scheduled for release in 2015) should make
understanding and familiarising oneself with the two major classicatory systems easier in the future.
2014 Elsevier B.V. All rights reserved.

Preface already been much debate and controversy. In this regard,

Twenty years after the last edition of the Diagnostic and
Statistical Manual (DSM) series, the DSM IV, was published and
after 13 years in the development, the publication of DSM 5 in May
2013 has been met with renewed optimism from some quarters
and disappointment from others. Since the publication there has
* Corresponding author at: Academic Unit of Child Psychiatry, South Western
Sydney Local Health District, Liverpool Hospital, Mental Health Centre (Level 1:
ICAMHS), Locked Bag 7103, Liverpool BC, NSW 1871, Australia.
Tel.: +61 2 96164205.
E-mail address: v.eapen@unsw.edu.au (V. Eapen).
concerns have been raised that some patients who need assistance
but fall short of fullling revised criteria under DSM 5, such as in
the case of Autism Spectrum Disorder (ASD), might miss out -
while there have been criticisms that developmentally appropri-
ate mood regulation difculties such as behavioural and
emotional outbursts and irritability in adolescents may be
labelled as Disruptive Mood Dysregulation Disorder, a new
diagnostic entity in DSM 5, and be subjected to unnecessary
treatment. The clinical implications of the changes in DSM 5 for
day to day practice will depend on a number of factors including
individual clinicians training and theoretical orientation, as well
as the nature of the specic disorder, the setting in which patients

http://dx.doi.org/10.1016/j.ajp.2014.04.008
1876-2018/ 2014 Elsevier B.V. All rights reserved.
 V. Eapen, R. Crncec / Asian Journal of Psychiatry 11 (2014) 114118
are seen, and the access to medical insurance or public resources
available to treat the disorder, both psychological and pharmaco-
logical. Further, in DSM 5, a clear direction towards a mixed
dimensional and categorical approach was expected. This has
been the case with only some disorders such as the removal of
Obsessive Compulsive Disorder (OCD) from the Anxiety Disorder
chapter and placement with other related disorders that share
similar neurobiology and treatment response. In this regard, the
addition of a new specier tic-related to OCD is worth noting as
those with OCD and tics often benet from augmentation with a
neuroleptic in conjunction with an SSRI. There is emerging
evidence that a similar differential treatment response exists
when tics are associated with ADHD, thus presenting the
argument for a dimensional approach to Tic Spectrum Disorder
(TSD) incorporating categories such as those with tics only, tics
with OCD, tics with ADHD, tics with ASD etc. to be given
consideration in the future.
The signicant changes in DSM 5 as these relate to several of
the child psychiatric disorders are reviewed by several authors in
this issue. In this paper we review some of the changes in the
conceptual organisation of DSM 5 and specically focus on
anxiety and related disorders. The most notable change in child
and adolescent psychiatry is that the chapter on Disorders Usually
First Diagnosed in infancy, Childhood or Adolescence has been
deleted. Instead, a new chapter in DSM 5 describes Neurodevelop-
mental Disorders which typically manifest early in development.
This change has been inspired by the general life-span approach
taken in DSM 5 with disorders starting in childhood and
adolescence found virtually throughout the manual. For example,
Separation Anxiety now sits within the Anxiety Disorders chapter
of DSM 5 and Pica within the Feeding and Eating Disorders chapter.
Another important change that clinicians in the eld of child
psychiatry will no doubt notice is the demise of the multiaxial
classication which in DSM IV allowed the integrated concep-
tualisation of the childs primary mental health disorder within
the context of their intellectual level, associated physical/
medical conditions, psychosocial situation and overall level of
functioning. Instead, DSM 5 has moved to a nonaxial documen-
tation of diagnosis with separate notations for important
psychosocial and contextual factors, as well as for the level of
functioning and disability. Clinicians should however continue to
assess how symptoms and behaviours might have arisen and
assess relevant contextual factors such as the childs relation-
ships, quality of care, any history of abuse, and so on. Further, it is
expected that the move to harmonise DSM 5 with the structure of
ICD 11 (scheduled for release in 2015) will make it easier for
clinicians in the future.
1. Introduction
At the time DSM 5 was released in 2013 (American Psychatric
Association, 2013) nearly two decades had elapsed since the last
major revision to the DSM series, DSM IV was published in 1994
(American Psychatric Association, 1994). The subsequent text
revision of DSM IV, DSM IV TR, published in 2000 contained
relatively minor changes that necessitated only modest adjust-
ments for clinicians. A preface to the DSM 5 highlights that
enhancements made include better representation both of
developmental issues related to diagnosis and of the research
literature. Thus, a relatively substantial overhaul to the main
nosological system underpinning ones practice happens several
times in ones career, with each of these new editions and revisions
necessitating the process of adapting and coming to understand
the nature of these changes within ones own unique setting,
which can be challenging. Given that the structure of the DSM 5 is
analogous to the upcoming ICD 11, however, clinicians working
115
within these major nosological frameworks may ultimately need
to acquaint themselves with the changes such as they are. This
special issue attempts to facilitate the process of clinicians
adaptation to DSM 5 by providing an overview of the main changes
as these relate to disorders with onset in infancy, childhood or
adolescence.
It may be important to observe at the outset that the DSM 5, or
any other nosological system, should not dictate our practice.
Clinicians must continue to assess individual patients including in
their relational context, dene their symptoms, make an accurate
and comprehensive formulation of why they are presenting with
these symptoms at this time, and then offer targeted psychological
and pharmacological therapies. Notwithstanding the concerted
and unprecedented efforts to link the DSM 5 to the scientic
literature, perhaps we ought to consider all nosological systems,
especially at this time of change, with a grain of proverbial
historical salt. Related to this, a particular difculty for child and
adolescent clinicians is that the DSM 5 would appear in general
terms to have been attributed in the community with a level of
certainty and comprehensiveness that it was never meant to-and
cannot-have.
Within this special issue the reader will nd a range of
manuscripts discussing changes within the DSM 5 with respect to
specic disorders, including ASD, disruptive behavioural dis-
orders a new diagnostic category of Disruptive Mood Dysregula-
tion Disorder, Separation Anxiety Disorder and Tourettes
Disorder. In this paper we endeavour to introduce the reader to
some of the conceptual and overarching changes within the DSM 5
that are of relevance to the child and adolescent clinician, and also
to focus some attention upon changes with the anxiety disorders
and OCD.
2. Major conceptual and criterion changes in DSM 5
The reader may already be aware of changes to the meta-
structure of the DSM 5 specically of the ordering and content of
chapters dealing with mental disorders. With the removal of the
DSM IV Disorders Usually First Diagnosed in Infancy, Childhood or
Adolescence chapter, disorders of childhood and adolescence may
now be found virtually throughout the manual. Age-related
aspects of disorders are identied by arranging each diagnostic
chapter in a chronological fashion, with diagnoses most applicable
to infancy and childhood listed rst, followed by diagnoses more
common to adolescence and early adulthood.
A useful example relates to anxiety disorders where the Anxiety
Disorders chapter in DSM IV has been replaced with three adjacent
chapters in DSM 5: Anxiety Disorders, Obsessive-Compulsive and
Related Disorders, and Trauma- and Stressor-Related Disorders, the
latter two of which are new to the DSM. In general terms the
chapters in DSM 5 are designed to cluster together around current
understanding of antecedent, concurrent and predictive validators.
For example, the separation of Obsessive-Compulsive and Related
Disorders from the Anxiety Disorders has occurred in response to the
accumulating evidence over the past several decades with regard
to the distinct neurocircuitry and treatment response of obsessive
compulsive disorders (Phillips et al., 2010a). This arrangement of
chapters holds the potential to aide in clinical decision making, as
related disorders are more likely to be found within the same or
adjacent chapters. A further chapter change to highlight to child
and adolescent clinicians is the new chapter on Disruptive, Impulse-
control and Conduct Disorders which addresses disorders char-
acterised by problems in emotional and behavioural self-control,
and that are frequently comorbid with ADHD. The articles in this
special issue by Florence levy and David Hawes relating to
disruptive behavioural disorders covers many of the changes in
this area. One notable change in the case of Conduct Disorder is the
116 V. Eapen, R. Crncec / Asian Journal of Psychiatry 11 (2014) 114118
inclusion of a specier for those young people with limited
prosocial emotions.
Other relevant changes include the introduction of several new
diagnoses relevant to child and adolescent clinicians. Of the 13 new
diagnoses in the manual, several are worth highlighting including
Social (Pragmatic) Communication Disorder, Disruptive Mood
Dysregulation Disorder, Excoriation (Skin Picking) Disorder,
Disinhibited Social Engagement Disorder, and Binge Eating
Disorder. Changes to ASD and the new category of Social
(Pragmatic) Communication Disorder are covered in the contribu-
tion by Antonio Hardan, while the new diagnostic category of
Disruptive Mood Dysregulation Disorder forms the focus of the
manuscript by Uma Rao. We deal with Excoriation (Skin Picking)
Disorder below: This disorder has been added to Obsessive
compulsive and Related Disorders chapter in DSM 5 due to the
compulsive/habitual nature of the condition. Disinhibited Social
Engagement Disorder is within the Trauma- and Stressor-Related
Disorders chapter and describes a pattern in children of disin-
hibited interactions with unfamiliar adults related to extremes of
insufcient care (e.g., neglect; repeated changes of primary
caregivers). This diagnosis was split from Reactive Attachment
Disorder in DSM IV. Yet another addition in DSM 5 is the
introduction of Gender Dysphoria as a new diagnostic class.
A substantial number of DSM IV disorders have also been
merged together to replace some of their constituent diagnoses,
including Autism Spectrum Disorder (replacing Autistic Disorder;
Aspergers Disorder; Childhood Disintegrative Disorder; Retts
Disorder; and Pervasive Developmental Disorder NOS), Language
Disorder, Specic Learning Disorder, Panic Disorder, and Somatic
Symptom Disorder. Other disorders have been renamed, for
example, Avoidant/Restrictive Food Intake Disorder expands upon
and replaces the DSM IV Feeding Disorder of Infancy or Early
Childhood diagnosis, and Mental Retardation is now Intellectual
Disability (Intellectual Developmental Disorder). DSM IV not
otherwise specied (NOS) diagnoses have been replaced with
other specied and unspecied diagnoses and we would urge
readers to acquaint themselves with this change. Particularly as
other specied diagnoses have the potential to hold some use for
treatment planning and for the accurate description and commu-
nication of the difculties faced by a young person whereas NOS
diagnoses, the most commonly given diagnostic category in DSM
IV, typically did not.
For some of the disorders, the criteria have changed in ways
that are substantial. We certainly cannot claim to be comprehen-
sive in describing these here, but do offer some key examples. In
the case of Schizophrenia, the removal of subtypes and the
reduction of emphasis upon Schneiderian rst-rank symptoms
are notable changes. There has also been a shift from a cross-
sectional to a longitudinal approach in the diagnosis of
Schizoaffective Disorder, with a requirement that a major mood
episode be present for a majority of the disorders total duration,
after criterion A for Schizophrenia has been met. Another
diagnosis that may be of relevance in adolescence is the inclusion
of Attenuated Psychosis Syndrome in Section 3 of DSM 5 as a
condition for further study and possible inclusion in the main
body of subsequent versions of DSM. The syndrome requires the
presence of delusions, hallucinations or disorganised speech in an
attenuated form with relatively intact reality testing, but of
sufcient severity or frequency to warrant clinical attention.
Symptoms must be present at least once per week in the past
month, and must have begun or worsened during the past year.
People with the syndrome often also experience anxiety and/or
depression.
Changes in relation to disorders involving mood include the
addition of a with mixed features specier to the depressive and
bipolar disorders; the removal of the bereavement exclusion from
the Major Depressive Episode criteria, and altering of the previous
post-partum specier to a peri-partum specier in recognition
that depression is common during pregnancy. Another change
includes moving Prementrual Dysphoric Disorder from DSM IV
Appendix B (a disorder requiring further study) to the main body of
DSM 5, while Nonsuicidal Self-Injury (NSSI) is included as a
condition for further study in DSM 5.
There are some subtle but important changes to the ADHD
criteria such that (1) symptoms can be present prior to age 12 years
as opposed to 7 years in the DSM IV, (2) in recognition of the
lifespan nature and adult form of the disorder, for young people
aged 17 and older, only 5/9 symptoms of inattention and
hyperactivity/impulsivity are required for diagnosis, and (3) the
terminology of ADHD subtypes has been altered to current
presentation speciers in recognition of these tending to be
unstable over time.
One of the signicant alterations in DSM 5 is that it has moved
back to a nonaxial documentation of diagnosis (i.e. collapsing of
Axes I, II and III in DSM IV) with separate notations for important
psychosocial and contextual factors (Axis IV in DSM IV) and
disability (Axis V in DSM IV). A great deal of child and adolescent
work is of course couched within the context of family and
relationship difculties as well as other psychosocial factors. These
relational aspects have historically been difcult to encapsulate
within a framework focused upon mental disorders experienced by
an individual. We note that the former Axis IV in DSM IV of
Psychosocial and Environmental Problems is essentially retained
and expanded upon within DSM 5, but now under the chapter
Other Conditions that May Be a Focus of Clinical Attention. There is
also no longer a specic requirement for clinicians to complete a
disability rating, that is, an assessment of overall functioning as
had been suggested in Axis V of DSM IV with the Global
Assessment of Functioning. However, DSM 5 does include,
amongst a range of other useful tools, a measure in Section 3 of
the manual that is suggested for this purpose. An alternative model
for personality disorders is also presented in Section 3 of the
manual along with a range of other conditions for further study,
although the actual personality disorders criteria have remained
unchanged. There have been concerns that placing the personality
disorders on the same axis as other mental disorders may lead to
over diagnosis in this area.
A further conceptual shift within the DSM 5 has been towards
an increasingly dimensional approach to diagnosis. That is, in
addition to making a categorical diagnosis, including subtypes and/
or speciers, clinicians are also now asked to rate a number of
disorders along a continuum of severity. There is also a
requirement for a number of disorders to provide descriptive
features such as those related to insight, and information about
course such as remission status when making a diagnosis.
3. Anxiety disorders
We will focus our attention at this point upon some of the
specic changes within the Anxiety Disorders in DSM 5.Unfortu-
nately space constraints do not afford the possibility of contrasting
the DSM 5 nosology with alterative systems for encapsulating
anxiety disorders for example, that related to fear and
distress disorders (cf. Clark & Watson, 2006). We may do well
in the rst instance to remind ourselves of the landscape with
respect to anxiety within the paediatric context. Specically, that
anxiety disorders are impairing and common (Creswell et al.,
2014), occurring with a lifetime prevalence of 1520% of children
and adolescents; and that a majority of young people that have
developed an anxiety disorder will be affected by the same
condition or other psychiatric disorders (including other anxiety
 V. Eapen, R. Crncec / Asian Journal of Psychiatry 11 (2014) 114118
disorders, depressive disorders, or substance use disorders) over
the further course of life (Beesdo et al., 2009).
Given the removal of the Disorders Usually First Diagnosed in
Infancy chapter, Separation Anxiety Disorder and Selective Mutism
have now found a home amongst the anxiety disorders. The
wording of the criteria for Separation Anxiety Disorder have been
modied to better recognise that symptoms can also be expressed
in adulthood and the article by Derrick Silove in this special issue
addresses this fully.
The reader will also notice that PTSD and Acute Stress Disorder
have been removed from the Anxiety Disorders section. This leaves
the following diagnoses within this chapter: Separation Anxiety
Disorder; Selective Mutism; Specic Phobia; Social Anxiety
Disorder (Social Phobia); Panic Disorder; panic attack specier;
Agoraphobia; Generalised Anxiety Disorder; and then the sub-
stance/medication-Induced, due to another medical condition,
other specied and unspecied variants.
Of the specic changes to criteria within the Anxiety Disorders
chapter it is fair to observe that these are not particularly
substantial. Indeed for Generalised Anxiety Disorder and Selective
Mutism there were no changes. We highlight the more signicant
of the revisions here.
For Panic Disorder, the criteria now clarify that panic attacks
can arise from a calm or an anxious state. This was done partly to
improve the cultural sensitivity of Panic Disorder, as was the
addition of some culturally specic symptoms of panic such as
tinnitus and headache (Lewis-Fernandez et al., 2010). Further, the
previous terminology for describing different types of panic
attacks (i.e., situationally bound/cued, situationally predisposed,
and unexpected/uncued) was replaced with the terms unexpected
and expected panic attacks. The diagnoses of Panic Disorder and
Agoraphobia were unlinked which helps to simplify this section.
Importantly, panic attack has now been included as a specier
that is applicable to all DSM 5 disorders in recognition of the
important role of panic attacks across a range of disorders.
Phobias are described more consistently than was the case in
DSM IV and all emphasise fear, anxiety and avoidance. DSM IV
Social Phobia is now called Social Anxiety Disorder (Social Phobia)
and the generalised specier has been deleted and replaced with
a performance only specier in recognition of the distinct
aetiology and treatment response of this group (Bogels et al., 2010).
With respect to Social Anxiety disorder (Social Phobia), Specic
Phobia, and Agoraphobia, the criteria no longer requires a patient
aged over 18 years to recognise that their fear is excessive or
unreasonable. This is replaced with phrasing that makes the
clinicians judgement. Note that there was reportedly insufcient
research to include a specic insight specier, as is now the case
with respect to OCD and Body Dysmorphic Disorder (LeBeau et al.,
2010). In addition, the 6-month duration, which was limited to
individuals under age 18 in DSM IV, is now extended to all ages.
Another important change in the DSM 5 has been the inclusion
of a with anxious distress specier for the Depressive and Bipolar
and Related Disorders. This was done in recognition of the frequent
occurrence of anxiety symptoms in the context of depression and
bipolar disorder, and the often different course and treatment
response for patients who were anxious/agitated as part of their
presentation(Coryell et al., 1992; Goldberg & Fawcett, 2012)
4. Obsessive compulsive disorder
There are more notable changes within the Obsessive-Compul-
sive and Related Disorders chapter, including the addition of two of
the new disorders to DSM, Hoarding Disorder and Excoriation (Skin
Picking) Disorder. In addition, Body Dysmorphic Disorder has been
moved to this section from the DSM IV Somatoform Disorders
chapter and Trichotillomania (Hair-Pulling Disorder) from the
117
DSM IV Impulse-Control Disorders Not Elsewhere Classied chapter.
This gives the following grouping of disorders; Obsessive-
Compulsive Disorder, Body Dysmorphic Disorder, Hoarding
Disorder, Trichotillomania (Hair-Pulling Disorder), Excoriation
(Skin-Picking) Disorder, and then substance/medication-induced,
due to another medical condition, other specied and unspecied
obsessive-compulsive and related disorder variants.
Hoarding Disorder was added in light of the substantial
scientic literature supporting this as a separate disorder that
can be severe and prevalent, occurring in 26% of the population
(Mataix-Cols et al., 2010). Moreover, most hoarders (up to 80%) do
not meet criteria for OCD, which had been the typical diagnosis
given in DSM IV. Amongst a range of differentiating features from
OCD include a more chronic course, as well as poorer response to
SSRI medication and exposure/response prevention techniques -
which form the mainstay of treatment for OCD. The core feature of
Hoarding Disorder is difculty discarding or parting with
possessions regardless of actual value. A specier was also added
with respect to excessive acquisition of items. While many
children have collections, pathological hoarding in children seems
to be easily distinguished from normal saving behaviour (Plimpton
et al., 2009), and thus, it is clear that Hoarding Disorder does not
simply reect a culturally sanctioned activity (Frost et al., 2012;
Mataix-Cols et al., 2010).
Excoriation (Skin Picking) Disorder was also added in recogni-
tion of the substantial underpinning scientic literature, the often
severe nature of the condition and the prevalence of 12% in the
community - but the absence of an existing diagnosis within DSM
to adequately cover these patients (Stein et al., 2010). The core
feature is recurrent skin picking resulting in lesions, however these
can be concealed. The face, arms and hands are most commonly
picked but any part of the body may be affected. The skin picking is
not thought to be done due to any particular cognition, for example
to improve the appearance of the skin, but is more akin to a habit or
compulsion with no intent to self-harm. In this regard, habit reversal
training can be an effective intervention. Given skin picking can
occur in the context of a number of other medical and mental
disorders, these need to be carefully excluded including
Stereotypic Movement Disorder, Body Dysmorphic Disorder and
Psychosis.
The changes to OCD criteria themselves are relatively minor. In
the denition of obsession urge replaces impulse, and
unwanted replaces inappropriate to improve cultural inter-
pretations. Perhaps the main change relates to the addition of a
new specier tic-related. It would appear highly useful and
important to ask patients with a diagnosis of OCD whether they
have a current or past history of a tic disorder. The literature also
suggests that this form of OCD is highly heritable, with an early
age of onset. Furthermore, a gender dependent difference in the
expression of the putative Tourette gene(s) has been suggested
with male members of the family having tics and female members
having obsessive compulsive behaviours (Eapen et al., 1993). We
would refer the reader to the paper by Mary Robertson and
Valsamma Eapen in this special issue where tic disorders are
explored comprehensively. From a treatment perspective,
patients with a history of tic disorder tend to show better
response to neuroleptic augmentation of an SSRI than patients
with OCD without a history of tic disorder (Leckman et al., 2010).
Similarly, it has been noted that children with ADHD and tics
would benet more from clonidine than those with ADHD without
tics, suggesting overlapping and yet distinct neurchemical and
neuronal circuitry involvement (Robertson and Eapen, 2013).
With the wide range of comorbidities occurring within the
context of tics, and similar patterns of differential treatment
response when tics are also present, due consideration should be
given to a nosological entity of Tic Spectrum Disorder (TSD)
118 V. Eapen, R. Crncec / Asian Journal of Psychiatry 11 (2014) 114118
covering those with pure tics only and those with tics and OCD,
tics and ADHD, tics and ASD etc.
A further substantial change to the OCD criteria relates to the
addition of a new insight specier. We note that this specier also
applies to Hoarding Disorder and Body Dysmorphic Disorder. The
insight specier has been expanded to include absent insight or
delusional beliefs, and the specier thus describes good or fair
insight; poor insight; and absent insight/delusional beliefs. This is
an important development for a variety of reasons. One is that
patients no longer need to recognise, as was the case in DSM IV,
that their OCD obsessions or compulsions are excessive or
unreasonable. A second is to highlight the reality that many
patients with poor insight may require motivational interviewing
before commencing treatment. Perhaps most importantly, how-
ever, is that OCD and Body Dysmorphic Disorder no longer have
delusional variants in other sections of the DSM. This had
previously led to the situation where patients with, say, absent
insight into their OCD symptoms, may be diagnosed in DSM IV as
having OCD, or delusional disorder or even psychotic disorder NOS.
Many were misdiagnosed with Schizophrenia and treated inap-
propriately with antipsychotic monotherapy as opposed to with an
SSRI (Leckman et al., 2010; Phillips et al., 2010b).
For Body Dysmorphic Disorder (BDD) we note the addition of a
new criterion B which requires the presence of repetitive BDD
behaviours. These are compulsive behaviours, similar to OCD
compulsions, that are performed in response to a preoccupation
with respect to the perceived body defect(s) and may include
compulsive mirror checking; grooming; skin picking (to make the
skin look better); and comparing with other people. This aspect is a
prominent part of the clinical picture and helps to differentiate
BDD from Social Phobia and depression with which it is often
confused. We would also draw attention to the with muscle
dysmorphia specier, which has been included due to the
signicantly poorer clinical course of these patients, and increased
likelihood of anabolic steroid abuse and suicide attempts (Phillips
et al., 2010b).
Some minor changes to the Trichotillomania (Hair Pulling
Disorder) criteria include that hair loss does not need to be
noticeable and also that the previous criterion related to tension/
gratication has been removed. The latter was replaced with a
criterion pertaining to repeated attempts to decrease or stop hair
pulling (Stein et al., 2010).
5. Conclusions
It must be observed that child and adolescent psychiatry did not
have a particularly prominent place in DSM IV, and this position
has improved little in DSM 5, notwithstanding the worthwhile
attempts that have been made to include a developmental focus
throughout the new manual. For example, DSM 5 does not include
the full range and nuances of early disorders recognised by child
and adolescent psychiatrists, and practitioners are likely to
continue using other classications for attachment disorders, such
as the DC: 0-3 system (Zero to Three, 2005) and the criteria
proposed by Zeanah and colleagues (OConnor & Zeanah, 2003).
What we have at this early post-DSM 5 release stage is arguably the
beginning of a next phase in child and adolescent mental health
practice and research; and regardless of ones individual assess-
ment of the DSM 5, we would commend clinicians and researchers
to engage in the process of understanding the changes so as to
energise the profession and set the stage for clinically informed
debate about assisting our patients through the development of
subsequent iterations of the DSM.
Funding
No Funding.
Conict of interest statement
Both authors report no conict of interest.
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