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a Mental Disorder V62 89 Borderline Intellectual Functioning The American Psychiatric Diagnostic and Statistical Manual of Mental Disorders is a classification of mental di sorders with associ ated criteria signed to facilitate more reliable diagnoses of these disorders | [
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] | 300 |
With successive editions over the past 60 years it has become a standard reference for clinical practice in the mental health field | [
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] | 301 |
Since a complete description of the underlying pathological processes is not possible for most mental diso rders it is important to emph asize that the current tic criteria are the best available descriptio n of how mental disord ers are expressed and can be recognized by trained clinicians | [
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] | 302 |
DSM is intended to serve as a practical functional and flexible guide for organizing information that can aid in the accurate diagnosis and treatment of mental disorders | [
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It is a tool for clinicians an essential educational resource for students and practitioners and a reference for researchers in the field Although this edition of DSM was designed fi rst and foremost to be a useful guide to clinical practice as an official nomenclature it must be applicable in a wide diversity of contexts | [
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DSM has been used by clinicians and researchers from diff erent orientations ological psychodynamic cognitive behavior al interpersonal all of whom strive for a common language to commu nicate the essential ch aracteristics of tal disorders presented by their patients | [
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] | 305 |
The information is of value to all professionals associated with various aspects of mental health care including psychiatrists other physicians psychologists social workers nu rses counselors forensic and legal ists occupational and rehabilitation therapists and other health professionals | [
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The criteria are concise and explicit and intended to fac ilitate an objective asse ssment of symptom sentations in a variety of clinical outpatient partial hospital clinical private practice an d primary well in general community epidemiological studies of mental disorders | [
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is also a tool for collecting and municating accurate public health statistics on mental disorder morbidity and mortality rates | [
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] | 308 |
Finally the criteria and corresponding text serve as a textbook for students early in their profession who need a structured way to understand and diagnose mental disorders as well as for seasoned professionals encounteri ng rare disorders for the first time | [
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] | 309 |
nately all of these uses are mutually compatible These diverse needs and interests were take n into consideration in planning The classification of disorders is harmoniz ed with the World Health national Classification of Diseases the official coding system used in the United States so that the DSM criteria define disorders identified by ICD diagnostic names and code numbers | [
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] | 310 |
In both and codes latter scheduled for tion in October are attached to the relevant disorders in the classification Although remains a catego rical classification of sepa rate disorders we nize that mental disorders do not always fit completely within the boundaries of a single disorder | [
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] | 311 |
Some symptom domains such as de pression and anxiety involve multiple agnostic categories and may reflect common underlying vulnerabilities for a larger group of disorders | [
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] | 312 |
In recognition of this reality the disorders in cluded in were reordered into a revised organizational structure meant to stimulate new clinical perspectives | [
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Other enhancements have been introduced to mote ease of use across all Preface of developmental issues related to diagnosis | [
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] | 315 |
The change in chapter organization better reflects a lifespan approach with disorders more frequently nosed in childhood g neurodevelopmental at the beginning of the ual and disorders more applicable to olde r adulthood g neurocognitive at the end of the manual | [
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] | 316 |
Also within the text subheadings on development and course provide descriptions of how disorder pr esentations may change across the lifespan factors specific to diagnosis g symptom presentation and prevalence differences in certain age are also included in the text | [
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For added emphasis these factors have been added to the criteria themselves where applicable g in the criteria sets for insomnia di sorder and posttraumati c stress disorder cific criteria describe how symptoms might be expressed in | [
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] | 318 |
Likewise gender and cultural issues have been integrat ed into the disorders where applicable of scientific findings from th e latest research in genetics and ing | [
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] | 319 |
The revised chapter structure was informed by recent research in neuroscience and by emerging genetic linkages between diag nostic groups | [
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] | 320 |
Genetic and physiological risk factors prognostic indicators and so me putative diagnostic markers are lighted in the text | [
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This new structure shoul d improve ability to identify agnoses in a disorder spectrum based on common neurocircuitry genetic vulnerability and environmental exposures of autistic disorder Asperg disorder and pervasive tal disorder into autism spectrum disorder | [
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Symptoms of these disorders represent a single continuum of mild to severe impair ments in the two domains of social nication and restrictive repetitive interests rather than being distinct ders | [
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] | 323 |
This change is designed to improve the se nsitivity and specificity of the criteria for the diagnosis of autism spectrum disorder and to identify more focused treatment gets for the specific impairments identified classification of bi polar and depressive disorders | [
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Bipolar and sive disorders are the most co mmonly diagnosed conditions in psychiatry | [
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] | 325 |
It was fore important to streamline th e presentation of these disorders to enhance both clinical and educational use | [
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] | 326 |
Rather than separating the definition of ma nic hypomanic and major depressive episodes from the definition of bipolar I disorder bipolar II disorder and major depressive disorder as in the prev ious edition we included all of the ponent criteria within the respective criteria for each disorder | [
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] | 327 |
This approach will itate bedside diagnosis and treatment of these important disorders | [
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] | 328 |
Likewise the explanatory notes for differentiating bereav ement and major depres sive disorders will provide far greater clinical guidance than was previously provided in the simple reavement exclusion criterion | [
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] | 329 |
The new specifiers of anxious distress and mixed tures are now fully described in the narrativ e on specifier variations that accompanies the criteria for these disorders of substance use diso rders for consistency and clarity | [
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] | 330 |
The categories of substance abuse and substance dependence have been eliminated and replaced with an overarching new category of substance use the specific substance used defining the specific disorders has been easily confused with the term when in fa ct the tolerance and withdrawal that previously defined dependence are actually very normal responses to prescr ibed medications that affect the central nervous system and do not necessar ily indicate the presence of an addiction By revising and clarifying these criteria in we hope to alleviate some of the widespread misunderstanding about these issues specificity for major and mild neurocognitive disorders | [
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] | 331 |
Given the sion in neuroscience neuropsychology and br ain imaging over the pa st 20 years it was critical to convey the current in the diagnosis of specific types of ders that were previously referred to as the or organic brain diseases | [
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] | 332 |
ological markers identified by imaging for vascular and traumatic brain disorders andPreface xliii specific molecular genetic fi ndings for rare variants of disease and disease have greatly advanced cl inical diagnoses and these disorders and others have now been separated into specific subtypes in conceptualizing personality disorders | [
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] | 333 |
Although the benefits of a more dimensional approach to personality disorder s have been identified in previous tions the transition from a ca tegorical diagnostic system of individual disorders to one based on the relative distribution of personality traits ha s not been widely accepted | [
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] | 335 |
However an alternative model has been proposed in Section III to guide future research that separates interp ersonal functioning assessments and the pression of pathological personality traits for six specific disorders | [
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] | 336 |
A more dimensional profile of personality trait expression is also proposed for a approach new disorders and features | [
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] | 337 |
A new section has been added to highlight disorders that requir e further study but are not sufficiently well established to be a part of the official classification of me ntal disorders for routine clinical use | [
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] | 338 |
sional measures of symptom severity in 13 symptom domains have also been rated to allow for the measurement of symp tom levels of varying severity across all diagnostic groups | [
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Likewise the WHO Di sability Assessment Schedule a standard method for assessing global disabilit y levels for mental disorders that is based on the International Classification of Functi oning Disability and Health and is plicable in all of medicine has been provid ed to replace the more limited Global sessment of Functioning scale | [
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] | 340 |
It is our hope that as these measures are implemented over time they will provide greater accuracy and flexibility in the clinical description of individual symptomatic presen tations and associated disability during diagnostic sessments enhancements | [
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] | 341 |
features online supplemental information Additional and diagnostic severity measures are available online psychiatry linked to the re levant disorders | [
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] | 342 |
In addition the tural Formulation Interview Cultural Formulation Version and supplementary modules to the core Cultural Formulation Interview are also included online at www psychiatry These innovations were designed by the leadin g authorities on mental disorders in the world and were implemented on the basis of their expert review public commentary and independent peer review | [
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] | 343 |
The 13 work group s under the direction of the Task Force in conjunction with other review bodi es and eventually the APA Board of ees collectively represent the gl obal expertise of the specialty | [
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] | 344 |
This effort was supported by an extensive base of advisors and by the professional staff of the APA Division of the names of everyone involved are to o numerous to mention here but are listed in the Appendix | [
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] | 345 |
We owe tremendous thanks to those who devoted countless hours and valuable expertise to this effort to improve the diagno sis of mental disorders We would especially like to acknowledge th e chairs text coordinators and members of the 13 work groups listed in the front of th e manual who spent many hours in this unteer effort to improve the scientific basis of clinical practice over a sustained riod | [
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Susan K | [
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Schultz M D who served as text editor worked tirelessly with Emily A Kuhl Ph D senior science writer and st aff text editor to coordinate the efforts of the work groups into a cohesive whole | [
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] | 350 |
P H led the research group that developed the overall research stra tegy for including the field trials that greatly enhanced the eviden ce base for this revision | [
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] | 351 |
In addition we are grateful to those who contributed so much time to the in dependent review of the revision proposals including Kenneth S | [
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] | 352 |
Ke ndler M D and Robert Freedman M D of the tific Review John S | [
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] | 353 |
McIntyre M D and Joel Ya ger M D of the Clinical and Public Health and Glenn Martin M D chair of the APA Preface bly review process | [
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] | 354 |
Special thanks go to Helena C | [
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] | 356 |
First M D for his valuable input on the coding and review of and Paul S | [
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] | 359 |
Ward M Ed RHIT also helped in verifying all ICD coding | [
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The Summit Group which included these consultants the chairs of all review groups the task force chairs and the APA executive officers chaired by Dilip V | [
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] | 361 |
Jeste M D provided le adership and vision in helping to achieve compromise and consensus | [
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] | 362 |
This level of commitment has contributed to the balance and objectivity that we feel are hallmarks of We especially wish to recognize the outst anding APA Division of Research identified in the Task Force and Work Grou p listing at the front of this worked tirelessly to interact with the task force work groups advisors and reviewers to resolve issues serve as liaison s between the groups direct and manage the academic and routine clinical practice field trials and record decisions in this important process | [
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In ticular we appreciate the support and guidan ce provided by James H | [
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] | 364 |
Scully Jr M D Medical Director and CEO of the APA throug h the years and travails of the development process | [
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] | 365 |
Finally we thank the editorial and pr oduction staff of American Psychiatric Rebecca Rinehart Publish John McDuffie Edit orial Ann Eng Senior Greg Kuny Managing and Tammy Cordova Graphics Design their guidance in bringing this all together and creating the final product | [
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] | 366 |
It is the culmination of efforts of many talented individuals who dedicated their time tise and passion that made possible David J | [
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] | 370 |
Task Force December 19 2012SECTION I Basics Introduction 5 Use of the Manual 19 Cautionary Statement for Forensic Use of 25 This page intentionally left blank This section is a basic orientation to the purpose structure content and use of | [
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It is not intended to provide an exhaustive account of the lution of but rather to give readers a succinct overview of its key ments | [
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] | 372 |
The introductory section descr ibes the public professional and expert review process that was used to extensively evaluate the diagnostic criteria presented in Section II | [
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A summary of t he structure harmonization with and the transition to a system with a new approach to sessing disability is also presented of the includes of a Mental Disorder forensic considerations and a brief overview of the nostic process and use of coding and recording procedures This page intentionally left blank 5Introduction The creation of the fifth edition of Diagnostic and Statistical Manual of Mental Disorders was a massive undertaking that involv ed hundreds of peop le working toward a common goal over a process | [
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] | 374 |
Much thought and deliberation were involved in evaluating the diagnostic criter ia considering the organization of every aspect of the ual and creating new features believed to be mo st useful to clinicians | [
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] | 375 |
All of these efforts were directed toward the goal of enhancing th e clinical usefulness of as a guide in the diagnosis of mental disorders Reliable diagnoses are essential for guidin g treatment recommendations identifying prevalence rates for mental health service pl anning identifying patient groups for clinical and basic research and documenting importan t public health information such as bidity and mortality rates | [
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As the understand ing of mental disorders and their treatments has evolved medical scientific and clinical professionals have focused on the istics of specific disorders and their im plications for treatment and research While DSM has been the cornerstone of substant ial progress in reliability it has been well recognized by both the American Psychiatric Association and the broad scientific munity working on mental diso rders that past science was no t mature enough to yield fully validated is to provide consistent strong and objective scientific validators of individual DSM disorders | [
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] | 377 |
The science of mental disorders continues to evolve | [
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However the last two decades since was released have seen real and durable progress in such areas as cognitive neuroscience brain imaging epidemiology and genetics | [
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] | 379 |
The Task Force overseeing the new edition recognized that research advances will require careful ative changes if DSM is to maintain its place as the touchstone classifi cation of mental ders | [
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] | 381 |
Speculative results do not belong in an official nosology but at the same time DSM must evolve in the context of other clinical research tiatives in the field | [
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] | 382 |
One important aspect of this transition derives from the broad recognition that a categorical system does not capt ure clinical experience or important scientific observations | [
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The results of nu merous studies of comorbidity and disease transmission in ilies including twin studies and molecular genetic studies make strong arguments for what many astute clinicians have long the boundaries between many disorder are more fluid over the li fe course than recognized and many symptoms signed to a single disorder may occur at vary ing levels of severity in many other disorders These findings mean that DSM like other medi cal disease classifications should date ways to introduce dimens ional approaches to mental di sorders including dimensions that cut across current categories | [
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] | 384 |
Such an appr oach should permit a more accurate description of patient presentations and increase the validity of a diagnosis e the degree to which nostic criteria reflect the comprehensive mani festation of an underlying psychopathological | [
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is designed to better fill the need of clinicians patients families and searchers for a clear and concise description of ea ch mental disorder organized by explicit agnostic criteria supplemented when approp riate by dimensional measures that cross diagnostic boundaries and a brie f digest of information about th e diagnosis risk factors sociated features research advances and various expressions of the disorder Clinical training and experience are needed to use DSM for determining a diagnosis | [
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The diagnostic criteria identify symptoms behavior s cognitive functions personality traits ical signs syndrome combinations and durations that require clinical expertise to ate from normal life variation and transient responses to stress | [
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To facilitate a thorough6 Introduction examination of the range of symptoms present DSM can serve clinicians as a guide to identify the most prominent symptoms that should be assessed when diagnosing a disorder | [
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] | 388 |
Although some mental disorders may have boundaries around symptom clusters tific evidence now places many if not most disorders on a spectrum with closely related orders that have shared symptoms shared genetic and environmental risk factors and possibly shared neural substrates most strongly established for a subset of anxiety disorders by neuroimaging and animal | [
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] | 389 |
In short we have come to recognize that the boundaries between disorders are more porous than originally perceived Many health profession and educational groups have been involved in the development and testing of including physicians psychologists social workers nurses counselors epidemiologists statisticians neuroscientists and neuropsychologists | [
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] | 390 |
Finally patients ilies lawyers consumer organizations and advoca cy groups have all participated in revising by providing feedback on the mental di sorders described in this volume | [
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Their toring of the descriptions and explanatory text is essential to improve understanding reduce stigma and advance the treatment and eventual cures for these conditions A Brief History The APA first published a predecessor of DSM in 1844 as a statistical classification of stitutionalized mental patients | [
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It was designed to improve co mmunication about the types of patients cared for in these hospitals | [
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] | 394 |
After World War II DSM evolved through four major editions into a diagnostic classification system for psychiatrists other physicians and other mental health professionals that descri bed the essential features of the full range of mental disorders | [
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] | 395 |
The current ed ition builds on the go al of its predecessors recently or Text Revision published in of providing guidelines for agnoses that can inform treatment and management decisions Revision Process In 1999 the APA launched an evaluation of the strengths and weaknesses of DSM based on emerging research that did not support the bo undaries established for some mental ders | [
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This effort was coordinated with the World Health Organization Division of Mental Health the World Psychiatric Associat ion and the National Institute of Mental Health in the form of several conferen ces the proceedings of which were published in 2002 in a monograph entitled A Research Agenda for | [
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] | 397 |
Thereafter from 2003 to 2008 a cooperative agreement with the APA and th e WHO was supported by the NIMH the tional Institute on Drug Abuse and the National Institute on Alcoholism and hol Abuse to convene 13 internatio nal research planning conferences involving 400 participants from 39 countries to review the world litera ture in specific nostic areas to prepare for revision s in developing both and the International fication of Diseases 11th Revision | [
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] | 398 |
Reports from these conferences formed the basis for future Task Force reviews and set the stage for the new edition of DSM In 2006 the APA named David J | [
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Subsets and Splits