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Culture is transmitted vised and recreated within the family and other social systems and institutions | [
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Diagnostic assessment must therefore consider whether an experiences symptoms and behaviors differ from sociocultural norms and lead to difficult ies in adaptation in the tures of origin and in specific social or familial contexts | [
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] | 501 |
Key aspects of culture relevant to agnostic classification and assessment have been considered in the development of In Section III the contains a detailed discussion of culture and diagnosis in including tools for th cultural assessment | [
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] | 502 |
In the Appendix the of Cultural Concepts of Distress provides a description of some common tural syndromes idioms of distress and causal explanations relevant to clinical practice The boundaries between normalit y and pathology vary across cultures for specific types of behaviors | [
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Thresholds of tolerance for spec ific symptoms or behaviors differ across tures social settings and fami lies | [
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] | 504 |
Hence the level at which an experience becomes lematic or pathological will differ | [
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] | 505 |
The judgment that a given behavior is abnormal and requires clinical attention depends on cultural norms that are internalized by the individual and applied by others around them including family members and clinicians | [
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Awareness of the significance of culture may correct mistaken interpretations of ps ychopathology but ture may also contribute to vulnerability and suffering g by amplif ying fears that tain panic disorder or health | [
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] | 507 |
Cultural meanings habits and traditions can also contribute to either stigma or support in the social and familial response to mental illness Culture may provide coping strategies that enhance resilience in response to illness or gest help seeking and options for accessing heal th care of various types including tive and complementary health systems | [
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Culture also affects the conduct of the cl inical as a result cultural differences between the clinician and the patient have implications fo r the accuracy and acceptance of diagnosis as well as for treatment decisions prognost ic considerations and clinical outcomes Historically the construct of the bound syndrome has been a key interest of cultural psychiatry | [
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] | 510 |
In this construct h as been replaced by three concepts that offer greater clinical 1 Cultural syndrome is a cluster or group of ing relatively invariant symptoms found in a specific cultural gr oup community or context g ataque de nervios | [
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The syndrome may or may not be recognized as an illness within the culture g it might be labeled in various but such cultural patterns of distress and features of illness may nevertheless be recognizab le by an outside observer 2 Cultural idiom of distress is a linguistic term phrase or way of talking about suffering among individuals of a cultural group g similar ethnicity and referring to shared concepts of pathology and ways of expressing communicating or naming sential features of distress g kufungisisa | [
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] | 512 |
An idiom of distress need not be associated with specific symptoms syndromes or perceived causes | [
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For example most cultures have common bodily idioms of dist ress used to express a wide range of fering and concerns 3 Cultura l explanation or perceived cause is a label attribution or feature of an explanatory model that provides a culturally conceived etiology or cause for symptoms illness or distress g maladi moun | [
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] | 515 |
Causal explanations may be salient features of folk fications of disease used by laypersons or healers | [
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] | 516 |
Introduction 15 These three concepts whic h discussion and examples are provided in Section III and the suggest cultural ways of understanding and describing illness ences that can be elicited in the clinical encounter | [
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] | 517 |
They influence symptomatology help seeking clinical presentations expectations of treatment illness adaptation and ment response | [
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] | 518 |
The same cultur al term often serves more than one of these functions Gender Differences Sex and gender differences as they relate to th e causes and expression of medical conditions are established for a number of diseases including selected mental disorders | [
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Revisions to included review of potential differenc es between men and women in the expression of mental illness | [
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In terms of nomenclature sex differences are variations attributable to an reproductive organs an d XX or XY chromosomal complement | [
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] | 522 |
The term gender differences is used in because more commonly the differences between men and women are a re sult of both biological sex and individual | [
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] | 523 |
However some of the di fferences are based on only biological sex Gender can influence illness in a variety of ways | [
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] | 524 |
First it may exclusively determine whether an individual is at risk for a disord er g as in premenstrual dysphoric | [
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] | 525 |
Second gender may moderate the overa ll risk for development of a disorder as shown by marked gender differences in the prevalence and incidence rates for selected mental disorders | [
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] | 527 |
ractivity disorder is an example of a disorder with differences in presentation that are most commonly rienced by boys or girls | [
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] | 528 |
Gender likely has other effects on the experience of a disorder that are indirectly relevant to psychiatric diagnosis | [
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It may be that certain symptoms are more readily endorsed by men or women and that this contributes to differences in service vision g women may be more likely to recognize a depr essive bipolar or anxiety order and endorse a more comprehen sive list of symptoms than Reproductive life cycle events including estr ogen variations also contribute to gender differences in risk and expression of illness | [
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] | 530 |
Thus a specifier for postpartum onset of mania or major depressive episode denotes a time frame wherein women may be at increased risk for the onset of an illness episode | [
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In the case of sleep and energy alterations are often mative postpartum and thus may have lower diagnostic reliability in postpartum women The manual is configured to include information on gender at multiple levels | [
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] | 532 |
If there are symptoms th ey have been added to the di agnostic criteria | [
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] | 533 |
A related specifier such as perinatal onset of a mood episode provides additional tion on gender and diagnosis | [
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] | 534 |
Finally other issues that are pertinent to diagnosis and der considerations can be found in the se ction Diagnostic Issues Use of Other Specified and Unspecified Disorders To enhance diagnostic specificity repl aces the previous NOS designation with two options for clinical other specified disorder and unspecified disorder | [
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] | 535 |
The other specified disorder category is provided to allow the clinician to communicate the specific reason that the presentation does not meet the criteria for any specific category within a tic class | [
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] | 537 |
For example for an in dividual with clin ically significant depressive symptoms lasting 4 weeks but whose symptomatology falls short of the diagnostic threshold for a major depressive episode the clinician would re cord specified depressive disorder depressive episode with insufficient symptoms If the clinician chooses not to specify the16 Introduction reason that the criteria are not met for a sp ecific disorder then depressive would be diagnosed | [
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] | 538 |
Note that th e differentiation between other specified and unspecified disorders is based on the clinic decision providing maximum flexibility for diagnosis | [
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] | 539 |
Clinicians do not have to diff erentiate between other specified and ified disorders based on some feature of the presentation itself | [
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] | 540 |
When the clinician mines that there is evidence to specify the na ture of the clinical presentation the other specified diagnosis can be given | [
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] | 541 |
When the clinician is not able to further specify and scribe the clinical presentation the unspecifie d diagnosis can be given | [
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] | 542 |
This is left entirely up to clinical judgment For a more detailed discussion of how to us e other specified and unspecified tions see of the in Section I The Multiaxial System Despite widespread use and its adoption by certain insurance and governmental agencies the multiaxial system in was not requ ired to make a mental disorder diagnosis | [
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] | 543 |
A nonaxial assessment system was also included that simply listed the appropriate Axis I II and III disorders and conditio ns without axial designations | [
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has moved to a ial documentation of diagnosis Axes I II and with separate notations for important psychosocial and contextual factors Ax is and disability Axis | [
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This revision is consistent with the text that states multiaxial tinction among Axis I Axis II and Axis III disorders does not imply that there are mental differences in their conceptualizatio n that mental disorders are unrelated to physical or biological factors or processes or that general medical conditions are unrelated to behavioral or psychosocial factors or processes The approa ch of separately noting agnosis from psychosocial and contextual fact ors is also consistent with established WHO and ICD guidance to consider the functional status separately from his or her diagnoses or symptom status | [
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] | 546 |
In Axis III has been combined with Axes I and II Clinicians should continue to list medical cond itions that are import ant to the ing or management of an mental Axis IV covered psychosocial and en vironmental problems that may affect the diagnosis treatment and prognosis of ment al disorders | [
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] | 547 |
Although this axis provided helpful information even if it was not us ed as frequently as intended the Task Force recommended that should not deve lop its own classification of psychosocial and environmental problems bu t rather use a selected set of the V codes and the new Z codes contained in | [
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] | 548 |
Th e Z codes were examined to mine which are most relevant to mental disorders and also to identify gaps Axis V consisted of the Global Assessment of Functionin g scale senting the judgment of the individu overall level of on a pothetical continuum of ment al It was recommended that the GAF be dropped from for several reasons including its conceptual lack of clarity e cluding symptoms suicide risk and disabilities in its and questionable chometrics in routine practice | [
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] | 549 |
In order to provide a global measur e of disability the WHO Disability Assessment Schedule is included for further stud y in Section III of the chapter Measure | [
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The WHODAS is based on the tional Classification of Functioning Disability and Health for use across all of medicine and health care | [
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The WHODAS 2 and a modification developed for adolescents and their parents by the Impairment and Disability Study Group were cluded in the field trial Introduction 17 Online Enhancements It was challenging to determine what to incl ude in the print version of to be most clinically relevant and useful and at the same time maintain a manageable size | [
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] | 552 |
For this reason the inclusion of clinical rating scales and measures in the pr int edition is limited to those considered most relevant | [
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] | 553 |
Additional as sessment measures used in the field trials are available online psychiatry linked to the relevant disorders | [
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The Cultural Formulation Interview Cultural Fo rmulation Version and supplementary modules to the core Cultural Formulation Interview are also available line at www psychiatry is available as an online subscription at PsychiatryOnline org as well as an book | [
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will be alyzed over time to continually assess its validity and enhance its value to clinicians This page intentionally left blank 19Use of the Manual The introduction contains much of the history and developmental process of the revision | [
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] | 559 |
This section is designed to prov ide a practical guide to using ticularly in clinical practice | [
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The primary purp ose of is to assist trained clinicians in the diagnosis of their mental diso rders as part of a case formulation ment that leads to a fully informed treatmen t plan for each individual | [
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] | 561 |
The symptoms tained in the respective diagnostic criter ia sets do not constitute comprehensive definitions of underlying disorders which encompass cognitive emotional behavioral and physiological processes that are far more co mplex than can be described in these brief summaries | [
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Rather they are intended to summa rize characteristic syndromes of signs and symptoms that point to an underlying disord er with a characteristic developmental tory biological and environmental risk factors neuropsychological and physiological relates and typical clinical course Approach to Clinical Case Formulation The case formulation for any given patient must involve a careful clinical history and cise summary of the social psychological and biological factors that may have uted to developing a given mental disorder | [
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] | 563 |
Hence it is not sufficient to simply check off the symptoms in the diag nostic criteria to make a mental disorder diagnosis | [
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] | 564 |
Although a systematic check for the presence of these crit eria as they apply to each patient will assure a more reliable assessment the relative severity and valence of in dividual criteria and their contribution to a diagnosis require clin ical judgment | [
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] | 565 |
The symptoms in our tic criteria are part of the relatively limited repertoire of human emotional responses to ternal and external stresses that are genera lly maintained in a homeostatic balance without a disruption in normal functioning | [
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] | 566 |
It requires clinical training to recognize when the bination of predisposing precipitating perpetuating and protective factors has resulted in a psychopathological condition in which physical signs and symptoms exceed normal ranges | [
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The ultimate goal of a clinical case formulation is to use the available contextual and diagnostic information in developing a comprehensive treatment plan that is formed by the cultural and social context | [
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] | 568 |
However recommendations for the selection and use of the most appropriate ev treatment options for each order are beyond the scope of this manual Although decades of scientific effort have go ne into developing the diagnostic criteria sets for the disorders included in Section II it is well recognized that this set of categorical diagnoses does not fully describe the full rang e of mental disorders that individuals perience and present to clinicians on a daily basis throughout the world | [
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] | 569 |
As noted ously in the introduction the range of interactions over the course of human development affecting cognitive em otional and behavioral function is virtually limitless | [
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] | 570 |
As a result it is impossible to capt ure the full range of psychopathology in the categorical diagnostic categories that we are now using | [
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] | 571 |
Hence it is also necessary to clude disorder options for presentations that do not fit exactly into the diagnostic boundaries of disorders in each chapter | [
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] | 572 |
In an emergency partment setting it may be possible to id entify only the most prominent symptom pressions associated with a particular chap example delusions hallucinations 20 Use of the Manual mania depression anxiety substance intoxi cation or neurocognitive that an disorder in that category is identified until a fuller differential diagnosis is possible Definition of a Mental Disorder Each disorder identified in Section II of the manual those in the chapters tled Movement Disord ers and Other Adverse Effects of and Conditions That May Be a Fo cus of Clinical must meet the definition of a mental disorder | [
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Although no definition can capture all aspects of all orders in the range contained in the following elements are A mental disorder is a syndrome characte rized by clinically significant bance in an cognition emotion regulation or behavior that reflects a dysfunction in the psychological biological or developmental processes derlying mental functioning | [
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] | 574 |
Mental disorders are usually associated with icant distress or disability in social occupational or other important activities An expectable or culturally approved response to a common stressor or loss such as the death of a loved one is not a mental disorder | [
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Socially deviant havior g political religious or sex and conflicts that are primarily tween the individual and society are not mental disorders unless the deviance or conflict results from a dysfuncti on in the individual as described above The diagnosis of a mental disorder should have clinical it should help clinicians to determine prognosis treatment plans and potential treatment outcomes for their tients | [
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However the diagnosis of a mental disorder is not equivalent to a need for ment | [
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] | 577 |
Need for treatment is a complex clinic al decision that takes into consideration symptom severity symptom salience g the pr esence of suicidal the distress associated with the sy disability related to the symptoms risks and benefits of available trea tments and other factors g psychiatric symptoms complicating other | [
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] | 578 |
Clinicians may thus encounter individuals whose symptoms do not meet full crit eria for a mental disorder bu t who demonstrate a clear need for treatment or care | [
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] | 579 |
The fact that some in dividuals do not show all symptoms indicative of a diagnosis should not be used to justify limiting their access to appropriate care Approaches to validating diagnostic criteria for discrete categorical mental disorders have included the following types of antecedent validators genetic ers family traits temperament and environmen tal concurrent validators lar neural substrates biomarkers emotional and cognitive processing and symptom and predictive validators r clinical course and treatment | [
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In we recognize that the current diagnostic criteria for any single disorder will not essarily identify a homogeneous group of patients who can be characterized reliably with all of these validators | [
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] | 581 |
Available evidence shows that these va lidators cross existing diagnostic boundaries but tend to congregate more frequently within and across adjacent ter groups | [
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] | 582 |
Until incontrovertible etiological or pathophysiological mechanisms are fied to fully validate specific disorders or disorder spectra the most important standard for the disorder criteria will be their clin ical utility for the assessment of clinical course and treatment response of individuals groupe d by a given set of diagnostic criteria This definition of mental disorder was developed for clinical public health and search purposes | [
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] | 583 |
Additional information is usua lly required beyond that contained in the diagnostic criteria in or der to make legal judgments on such issues as criminal sponsibility eligibility for disability compen sation and competency Statement for Forensic Use of elsewhere in this Use of the Manual 21 Criterion for Clinical Significance There have been substantial e fforts by the Task Force and the World Health nization to separate the concepts of mental disorder and disability in social occupational or other important areas of | [
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] | 584 |
In the WHO system the ternational Classification of Diseases c overs all diseases and disorders while the ternational Classification of Functioning Disability and Health provides a separate classification of global disability | [
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However in the absence of clea r biological markers or clinically useful surements of severity for many mental disord ers it has not been possible to completely separate normal and pathological symptom expressions contained in diagnostic criteria This gap in information is particularly problematic in clinical situations in which the symptom presentation by itself larly in mild is not inherently ological and may be encountered in individuals for whom a diagnosis of would be inappropriat e | [
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] | 587 |
Therefore a generic diagno stic criterion requiring tress or disability has been used to establish disorder thresholds usually worded turbance causes clinically significant distre ss or impairment in social occupational or other important areas of functioning The text following the revised definition of a mental disorder acknowledges that this criterion may be especially helpful in determining a need for treatment | [
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] | 588 |
Use of informatio n from family members and other third parties addition to the regarding the perf ormance is recommended when necessary Elements of a Diagnosis Diagnostic Criteria and Descriptors Diagnostic criteria are offered as guidelines for making diagnoses and their use should be informed by clinical judgment | [
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Text descript ions including introductory sections of each diagnostic chapter can help support diagnosis g providing differential scribing the criteria more fully under Following the assessment of diagnostic criter ia clinicians should consider the tion of disorder subtypes or specifiers as appropriate | [
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Severity and course specifiers should be applied to denote the current presentation but only when the full criteria are met | [
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] | 591 |
When full criteria are no t met clinicians should consider whether the symptom presentation meets crit eria for an or tion | [
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] | 592 |
Where applicable specific criteria for defining disorder severity g mild ate severe descriptive features g with good to fair in a controlled and course g in partial remi ssion in full remission are vided with each diagnosis | [
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] | 593 |
On the basis of the clinical interview text descriptions criteria and clinician judgment a final diagnosis is made The general convention in is to allo w multiple diagnoses to be assigned for those presentations that meet criteria for more than one disorder Subtypes and Specifiers Subtypes and specifiers of which are code d in the fourth fifth or sixth are provided for increased specificity | [
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] | 594 |
Subtypes define mutually exclusive and jointly tive phenomenological subgroupings within a diagnosis and are indicated by the tion Specify in the criteria set | [
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] | 595 |
In contrast specifiers are not intended to be mutually exclusive or jointly exhaustive and as a consequence more than one specifier may be given | [
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] | 597 |
Specifiers provide an opportunity to define a more homogeneous subgrouping of22 Use of the Manual individuals with the disorder who share certai n features g major depressive disorder with mixed and to conv ey information that is relevant to the management of the disorder such as the other medical specifier in wake disorders | [
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Although a fifth digit is sometimes assigned to code a subtype or specifier g 294 11 major neurocognitive disorder due to disease with havioral or severity 21 major depressive disorder single episode the majority of subtypes and specifie rs included in cannot be coded within the and systems and are indicated only by including the subtype or specifier after the name of the disorder g social anxiety disorder formance | [
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Subsets and Splits