Podcast
Questions and Answers
When did the first edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders appear?
When did the first edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders appear?
Who was the individual that introduced important methodological innovations in DSM-III?
Who was the individual that introduced important methodological innovations in DSM-III?
Robert L. Spitzer
The development of DSM-III was not coordinated with the development of the International Classification of Diseases, specifically ICD-9.
The development of DSM-III was not coordinated with the development of the International Classification of Diseases, specifically ICD-9.
False
Who coordinated the evaluation of the strengths and weaknesses of DSM in 1999?
Who coordinated the evaluation of the strengths and weaknesses of DSM in 1999?
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What was the title of the 2002 monograph that documented the proceedings of the conferences in 1999?
What was the title of the 2002 monograph that documented the proceedings of the conferences in 1999?
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David J. Kupfer was named as the Vice-Chair of the DSM-5 Task Force in 2006.
David J. Kupfer was named as the Vice-Chair of the DSM-5 Task Force in 2006.
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The APA Board of Trustees initiated a vetting process to disclose sources of income and avoid conflicts of interest by task force and work group to develop ____.
The APA Board of Trustees initiated a vetting process to disclose sources of income and avoid conflicts of interest by task force and work group to develop ____.
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What is one measure taken in the past 3 years to enforce the disclosure of all income and research grants from commercial sources?
What is one measure taken in the past 3 years to enforce the disclosure of all income and research grants from commercial sources?
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How many advisors were involved in the process of classification of mental disorders and did not have voting authority?
How many advisors were involved in the process of classification of mental disorders and did not have voting authority?
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What was considered central to the task force and work groups' vision for the classification of mental disorders?
What was considered central to the task force and work groups' vision for the classification of mental disorders?
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Which activity was NOT part of the intensive 6-year process for revising DSM criteria?
Which activity was NOT part of the intensive 6-year process for revising DSM criteria?
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Which of the following participants were NOT involved in the revision process for DSM-5?
Which of the following participants were NOT involved in the revision process for DSM-5?
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What criteria were used by the work groups to develop proposals for DSM-IV revision?
What criteria were used by the work groups to develop proposals for DSM-IV revision?
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Approximately how many work group members were approved in 2007 and 2008?
Approximately how many work group members were approved in 2007 and 2008?
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What was one of the methods used to gather public feedback on the draft diagnostic criteria?
What was one of the methods used to gather public feedback on the draft diagnostic criteria?
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Which of the following principles guided the draft revisions for DSM-5?
Which of the following principles guided the draft revisions for DSM-5?
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What aspect related to the inclusion of a proposal for revision in Section II was considered?
What aspect related to the inclusion of a proposal for revision in Section II was considered?
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What was a requirement for new diagnoses, disorder subtypes, and specifiers in DSM-5?
What was a requirement for new diagnoses, disorder subtypes, and specifiers in DSM-5?
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What was the purpose of the DSM-5 field trials?
What was the purpose of the DSM-5 field trials?
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Which methodological concern did the work groups examine?
Which methodological concern did the work groups examine?
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What was NOT a stipulation for the inclusion of proposed conditions in “Conditions for Further Study” in Section III?
What was NOT a stipulation for the inclusion of proposed conditions in “Conditions for Further Study” in Section III?
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What was a notable improvement introduced in DSM-III?
What was a notable improvement introduced in DSM-III?
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Which principle indicates that DSM-5 is primarily intended to be used by clinicians?
Which principle indicates that DSM-5 is primarily intended to be used by clinicians?
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What statistical measure corrects for chance agreement due to prevalence rates?
What statistical measure corrects for chance agreement due to prevalence rates?
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Where did the field trials for DSM-5 take place?
Where did the field trials for DSM-5 take place?
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What was the purpose of screening full clinical patient populations arriving at each site?
What was the purpose of screening full clinical patient populations arriving at each site?
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What was the priority for selecting revisions to be included in the field trials?
What was the priority for selecting revisions to be included in the field trials?
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What tool was used by patients to assess cross-cutting symptoms?
What tool was used by patients to assess cross-cutting symptoms?
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What methodological design was used in large medical-academic settings for DSM field trials?
What methodological design was used in large medical-academic settings for DSM field trials?
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What initiative is exploring new areas for future clinical and basic research studies?
What initiative is exploring new areas for future clinical and basic research studies?
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During the field trials, how were the clinicians conducting the second interview blinded?
During the field trials, how were the clinicians conducting the second interview blinded?
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Which statistical measure was used to evaluate the agreement between two independent clinicians on a diagnosis?
Which statistical measure was used to evaluate the agreement between two independent clinicians on a diagnosis?
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What did the Routine Clinical Practice Field Trials measure?
What did the Routine Clinical Practice Field Trials measure?
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What kind of professionals were involved in the Routine Clinical Practice Field Trials?
What kind of professionals were involved in the Routine Clinical Practice Field Trials?
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What was the purpose of administering assessments to the same patient on two occasions up to 2 weeks apart?
What was the purpose of administering assessments to the same patient on two occasions up to 2 weeks apart?
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What does clinician-administered ratings assess?
What does clinician-administered ratings assess?
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What was the primary role of the APA website launched in 2010?
What was the primary role of the APA website launched in 2010?
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How many feedback submissions were reviewed after the first posting on the APA website?
How many feedback submissions were reviewed after the first posting on the APA website?
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What kind of feedback did work groups consider for DSM-5 Field Trials?
What kind of feedback did work groups consider for DSM-5 Field Trials?
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What role did the Scientific Review Committee (SRC) play in the DSM-5 revision process?
What role did the Scientific Review Committee (SRC) play in the DSM-5 revision process?
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Who was primarily responsible for the preparation of the diagnostic criteria and accompanying text?
Who was primarily responsible for the preparation of the diagnostic criteria and accompanying text?
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What was each proposal for diagnostic revision required to include?
What was each proposal for diagnostic revision required to include?
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Who coordinated the preparation of the text during the DSM-5 revision process?
Who coordinated the preparation of the text during the DSM-5 revision process?
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According to the passage, what types of validators were used to support the proposed diagnostic criteria?
According to the passage, what types of validators were used to support the proposed diagnostic criteria?
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Which aspect was generally seen as outside the purview of the SRC?
Which aspect was generally seen as outside the purview of the SRC?
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Who reviewed the proposals for diagnostic revisions for DSM-5 after the work groups?
Who reviewed the proposals for diagnostic revisions for DSM-5 after the work groups?
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What role did text coordinators from each work group have in the DSM-5 revision process?
What role did text coordinators from each work group have in the DSM-5 revision process?
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What aspects did the Clinical and Public Health Committee (CPHC) consider for DSM-IV disorders with known deficiencies?
What aspects did the Clinical and Public Health Committee (CPHC) consider for DSM-IV disorders with known deficiencies?
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How many external reviewers typically evaluated DSM-IV disorders with known deficiencies?
How many external reviewers typically evaluated DSM-IV disorders with known deficiencies?
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Who conducted forensic reviews of diagnostic criteria and text for disorders in forensic environments?
Who conducted forensic reviews of diagnostic criteria and text for disorders in forensic environments?
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What characterized the APA Assembly's Committee on DSM-5?
What characterized the APA Assembly's Committee on DSM-5?
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What role did the executive 'summit committee' play in the DSM-5 review process?
What role did the executive 'summit committee' play in the DSM-5 review process?
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What was included in the executive 'summit committee's' composition?
What was included in the executive 'summit committee's' composition?
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Which committee provided a final recommendation for the APA Assembly's Committee on DSM-5?
Which committee provided a final recommendation for the APA Assembly's Committee on DSM-5?
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What was the outcome of the preliminary review in November 2012?
What was the outcome of the preliminary review in November 2012?
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What is the primary function of the DSM Steering Committee appointed in Spring 2014?
What is the primary function of the DSM Steering Committee appointed in Spring 2014?
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Which of the following is NOT a type of validator used to support proposed diagnostic criteria in DSM-5?
Which of the following is NOT a type of validator used to support proposed diagnostic criteria in DSM-5?
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Submissions for changes to DSM-5 must include all of the following EXCEPT:
Submissions for changes to DSM-5 must include all of the following EXCEPT:
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What new model does the DSM-5 iterative revision process adopt?
What new model does the DSM-5 iterative revision process adopt?
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Which of the following is a component of the structured format required for proposals?
Which of the following is a component of the structured format required for proposals?
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Besides new disorders, what alterations can be proposed for DSM-5?
Besides new disorders, what alterations can be proposed for DSM-5?
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Who are the Vice Chairs of the DSM Steering Committee?
Who are the Vice Chairs of the DSM Steering Committee?
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Which type of validators may include genetic markers and family traits?
Which type of validators may include genetic markers and family traits?
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What is the role of the Review Committees in the DSM-5 text revision process?
What is the role of the Review Committees in the DSM-5 text revision process?
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Who are the final entities responsible for approving the revised DSM-5 text?
Who are the final entities responsible for approving the revised DSM-5 text?
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What step follows if the Steering Committee concurs that there is sufficient evidence for a proposed change?
What step follows if the Steering Committee concurs that there is sufficient evidence for a proposed change?
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What is the purpose of the initial review conducted by the Steering Committee?
What is the purpose of the initial review conducted by the Steering Committee?
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Who chaired the DSM-5-TR Revision Subcommittee?
Who chaired the DSM-5-TR Revision Subcommittee?
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What was the primary task of the experts involved in the DSM-5-TR development effort?
What was the primary task of the experts involved in the DSM-5-TR development effort?
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In what year did APA start the work on DSM-5-TR?
In what year did APA start the work on DSM-5-TR?
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What was a crucial step conducted to ensure objectivity in the DSM-5-TR revision process?
What was a crucial step conducted to ensure objectivity in the DSM-5-TR revision process?
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What is the primary purpose of the DSM classification of disorders?
What is the primary purpose of the DSM classification of disorders?
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Which of these indicators is NOT among the eleven recommended by the DSM-5 diagnostic spectra study group?
Which of these indicators is NOT among the eleven recommended by the DSM-5 diagnostic spectra study group?
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Who reviewed and approved changes in diagnostic criteria or specified definitions that resulted from the text revision process?
Who reviewed and approved changes in diagnostic criteria or specified definitions that resulted from the text revision process?
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What was NOT within the scope of the text revision process for DSM-5?
What was NOT within the scope of the text revision process for DSM-5?
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What was the role of the Ethno Racial Equity and Inclusion work group in the DSM-5 revision process?
What was the role of the Ethno Racial Equity and Inclusion work group in the DSM-5 revision process?
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What was the focus of the four cross-cutting review groups (Culture, Sex and Gender, Suicide, and Forensic)?
What was the focus of the four cross-cutting review groups (Culture, Sex and Gender, Suicide, and Forensic)?
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What is the primary purpose of the DSM according to the content?
What is the primary purpose of the DSM according to the content?
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Which of the following is NOT listed as an indicator for regrouping disorders in DSM-5?
Which of the following is NOT listed as an indicator for regrouping disorders in DSM-5?
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Which of the following groups reviewed chapters focusing on material involving specific expertise?
Which of the following groups reviewed chapters focusing on material involving specific expertise?
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Which group ensured the use of nonstigmatizing language in the revised DSM-5 text?
Which group ensured the use of nonstigmatizing language in the revised DSM-5 text?
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Which of these is a factor used to meaningfully separate psychiatric illness groups from one another in DSM-5?
Which of these is a factor used to meaningfully separate psychiatric illness groups from one another in DSM-5?
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Who were involved in approving changes to the diagnostic criteria and definitions within DSM-5?
Who were involved in approving changes to the diagnostic criteria and definitions within DSM-5?
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Which journals published papers documenting the usefulness of validators for suggesting large groupings of disorders?
Which journals published papers documenting the usefulness of validators for suggesting large groupings of disorders?
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What was the goal of the APA and WHO in their respective revisions of DSM and ICD?
What was the goal of the APA and WHO in their respective revisions of DSM and ICD?
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What was the nature of the diagnostic reform approach taken in the revisions of DSM and ICD?
What was the nature of the diagnostic reform approach taken in the revisions of DSM and ICD?
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Which factors did the revision process aim to encourage researchers to identify?
Which factors did the revision process aim to encourage researchers to identify?
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How did the shared organizational structure affect the harmonization of classifications?
How did the shared organizational structure affect the harmonization of classifications?
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Which type of literature showed particular strengths in the revision process?
Which type of literature showed particular strengths in the revision process?
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What was one of the empirical guidelines used to inform decision-making in the process of clustering disorders?
What was one of the empirical guidelines used to inform decision-making in the process of clustering disorders?
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What did the revised structure aim to stimulate in terms of clinical perspectives?
What did the revised structure aim to stimulate in terms of clinical perspectives?
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Which factor is considered important in the placement of ADHD in DSM-5?
Which factor is considered important in the placement of ADHD in DSM-5?
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Under which chapter is ADHD placed in DSM-5?
Under which chapter is ADHD placed in DSM-5?
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Which of the following is not categorized as an internalizing disorder in DSM-5?
Which of the following is not categorized as an internalizing disorder in DSM-5?
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What does DSM-5 aim to improve with its organization of disorders?
What does DSM-5 aim to improve with its organization of disorders?
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Which future approach is suggested to supplement or supersede categorical approaches in DSM-5?
Which future approach is suggested to supplement or supersede categorical approaches in DSM-5?
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What evidence supports the placement of ADHD within the 'Neurodevelopmental Disorders' chapter?
What evidence supports the placement of ADHD within the 'Neurodevelopmental Disorders' chapter?
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Which chapter includes disorders affecting cognitive functions like memory and attention in DSM-5?
Which chapter includes disorders affecting cognitive functions like memory and attention in DSM-5?
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What is one potential benefit of DSM-5's approach mentioned in the content?
What is one potential benefit of DSM-5's approach mentioned in the content?
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Which category of disorders is most likely to manifest early in life according to DSM-5?
Which category of disorders is most likely to manifest early in life according to DSM-5?
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What disorders are more commonly seen in adolescence and young adulthood as per DSM-5's framework?
What disorders are more commonly seen in adolescence and young adulthood as per DSM-5's framework?
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How does the DSM-5 structure assist in diagnostic decision-making?
How does the DSM-5 structure assist in diagnostic decision-making?
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Which disorder category is relevant to adulthood and later life according to DSM-5?
Which disorder category is relevant to adulthood and later life according to DSM-5?
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What was one goal shared by the groups tasked with revising DSM and ICD?
What was one goal shared by the groups tasked with revising DSM and ICD?
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What issue arises from having two major classifications of mental disorders?
What issue arises from having two major classifications of mental disorders?
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What was a significant challenge in fully harmonizing DSM-5 with ICD-11?
What was a significant challenge in fully harmonizing DSM-5 with ICD-11?
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According to the DSM-5, which category of diagnoses commonly manifests in young adulthood?
According to the DSM-5, which category of diagnoses commonly manifests in young adulthood?
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Which of the following chapters do not need to meet the definition of a mental disorder?
Which of the following chapters do not need to meet the definition of a mental disorder?
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What is a required element for all disorders identified in Section II of the manual?
What is a required element for all disorders identified in Section II of the manual?
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Which section in DSM-5 contains chapters that are exceptions to meeting the mental disorder definition?
Which section in DSM-5 contains chapters that are exceptions to meeting the mental disorder definition?
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What are the types of conditions listed under the chapters that do not need to meet the definition of a mental disorder in DSM-5?
What are the types of conditions listed under the chapters that do not need to meet the definition of a mental disorder in DSM-5?
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Which statement about the current understanding and classification of mental disorders in DSM-5 is true?
Which statement about the current understanding and classification of mental disorders in DSM-5 is true?
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Which of the following best describes a mental disorder?
Which of the following best describes a mental disorder?
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What is not considered a mental disorder according to the given criteria?
What is not considered a mental disorder according to the given criteria?
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Which of the following is true regarding the diagnosis of a mental disorder?
Which of the following is true regarding the diagnosis of a mental disorder?
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Which factor is not considered in the need for treatment of a mental disorder?
Which factor is not considered in the need for treatment of a mental disorder?
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Why might some individuals demonstrating clear need for treatment not meet the full criteria for a mental disorder?
Why might some individuals demonstrating clear need for treatment not meet the full criteria for a mental disorder?
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What additional purposes, beyond clinical use, is the definition of mental disorder meant to serve?
What additional purposes, beyond clinical use, is the definition of mental disorder meant to serve?
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What factor is considered when determining the need for treatment of a mental disorder?
What factor is considered when determining the need for treatment of a mental disorder?
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What is the primary focus when a diagnosis of a mental disorder is not considered equivalent to a need for treatment?
What is the primary focus when a diagnosis of a mental disorder is not considered equivalent to a need for treatment?
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What evidence has suggested structural problems in the categorical design of the DSM?
What evidence has suggested structural problems in the categorical design of the DSM?
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Why have twin designs, familial transmission studies, and molecular analyses raised questions about the DSM's categorical approach?
Why have twin designs, familial transmission studies, and molecular analyses raised questions about the DSM's categorical approach?
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What do numerous studies of comorbidity and disease transmission suggest about the boundaries between disorder categories?
What do numerous studies of comorbidity and disease transmission suggest about the boundaries between disorder categories?
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What is an advantage of a dimensional approach to diagnosis?
What is an advantage of a dimensional approach to diagnosis?
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Despite its advantages, why has the dimensional approach been less useful in clinical practice compared to the categorical system?
Despite its advantages, why has the dimensional approach been less useful in clinical practice compared to the categorical system?
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How does symptom heterogeneity within disorders challenge the DSM's categorical approach?
How does symptom heterogeneity within disorders challenge the DSM's categorical approach?
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What do astute clinicians observe regarding disorder categories over the life course?
What do astute clinicians observe regarding disorder categories over the life course?
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Which statement best describes how dimensional systems compare to categorical systems in terms of reliability and clinical communication?
Which statement best describes how dimensional systems compare to categorical systems in terms of reliability and clinical communication?
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Why is DSM-5 described as primarily categorical with dimensional elements?
Why is DSM-5 described as primarily categorical with dimensional elements?
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What necessity does DSM-5 emphasize for clinicians regarding diagnosis?
What necessity does DSM-5 emphasize for clinicians regarding diagnosis?
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What is a characteristic of the DSM-5 Level 1 Cross-Cutting Symptom Measure?
What is a characteristic of the DSM-5 Level 1 Cross-Cutting Symptom Measure?
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Why is there no assumption in DSM-5 that each category of mental disorder is a completely discrete entity?
Why is there no assumption in DSM-5 that each category of mental disorder is a completely discrete entity?
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What does the existence of boundary cases in DSM-5 imply?
What does the existence of boundary cases in DSM-5 imply?
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What does the integration of dimensional elements in DSM-5 aim to promote?
What does the integration of dimensional elements in DSM-5 aim to promote?
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Which of the following is a goal of the DSM-5 Level 1 Cross-Cutting Symptom Measure?
Which of the following is a goal of the DSM-5 Level 1 Cross-Cutting Symptom Measure?
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What does the familiarity with dimensional systems in clinical practice likely lead to?
What does the familiarity with dimensional systems in clinical practice likely lead to?
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What is the primary purpose of the DSM-5 Level 1 Cross-Cutting Symptom Measure?
What is the primary purpose of the DSM-5 Level 1 Cross-Cutting Symptom Measure?
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Which statement is true regarding the DSM-5 documentation of diagnosis?
Which statement is true regarding the DSM-5 documentation of diagnosis?
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What has replaced the DSM-IV Global Assessment of Functioning (GAF) scale in DSM-5?
What has replaced the DSM-IV Global Assessment of Functioning (GAF) scale in DSM-5?
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Where can versions of the DSM-5 Level 1 Cross-Cutting Symptom Measure be found?
Where can versions of the DSM-5 Level 1 Cross-Cutting Symptom Measure be found?
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Which types of disorders and conditions are listed together in DSM-5 without formal differentiation?
Which types of disorders and conditions are listed together in DSM-5 without formal differentiation?
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Which chapter of DSM-5 includes psychosocial and contextual factors?
Which chapter of DSM-5 includes psychosocial and contextual factors?
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How are symptoms and conditions listed in DSM-5?
How are symptoms and conditions listed in DSM-5?
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What role does the DSM-5 Level 1 Cross-Cutting Symptom Measure serve in psychiatric evaluations?
What role does the DSM-5 Level 1 Cross-Cutting Symptom Measure serve in psychiatric evaluations?
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What factors shape the experience and expression of mental disorder symptoms, signs, and behaviors?
What factors shape the experience and expression of mental disorder symptoms, signs, and behaviors?
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Which aspect is NOT explicitly mentioned as being influenced by sociocultural contexts in the diagnosis of mental disorders?
Which aspect is NOT explicitly mentioned as being influenced by sociocultural contexts in the diagnosis of mental disorders?
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What should be included in diagnostic assessment to understand an individual's difficulties in adaptation?
What should be included in diagnostic assessment to understand an individual's difficulties in adaptation?
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Which of the following is a key element affecting the clinical presentation of individuals?
Which of the following is a key element affecting the clinical presentation of individuals?
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What must clinicians consider about the sociocultural context when evaluating patients?
What must clinicians consider about the sociocultural context when evaluating patients?
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How are cultural elements transmitted, revised, and recreated?
How are cultural elements transmitted, revised, and recreated?
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What is considered crucial for diagnostic assessment as per the DSM-5-TR?
What is considered crucial for diagnostic assessment as per the DSM-5-TR?
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In what way do cultural norms impact clinical judgment of behaviors or concerns?
In what way do cultural norms impact clinical judgment of behaviors or concerns?
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What does a cultural idiom of distress primarily refer to?
What does a cultural idiom of distress primarily refer to?
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Which of the following statements is true regarding cultural idioms of distress?
Which of the following statements is true regarding cultural idioms of distress?
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Which of the following is an example of a cultural idiom of distress?
Which of the following is an example of a cultural idiom of distress?
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How has the concept of culture-bound syndrome been addressed in DSM-5?
How has the concept of culture-bound syndrome been addressed in DSM-5?
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Which domain of distress is not necessarily required for an idiom of distress to be applicable?
Which domain of distress is not necessarily required for an idiom of distress to be applicable?
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What common feature exists across most cultural groups with respect to distress?
What common feature exists across most cultural groups with respect to distress?
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What is a cultural explanation in the context of cultural psychiatry?
What is a cultural explanation in the context of cultural psychiatry?
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Which of the following describes a cultural syndrome?
Which of the following describes a cultural syndrome?
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What is an example of a cultural syndrome?
What is an example of a cultural syndrome?
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True or False: Race has a strong biological basis according to the provided content.
True or False: Race has a strong biological basis according to the provided content.
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What term is used to describe the social process by which categories of identity are constructed based on racial ideologies?
What term is used to describe the social process by which categories of identity are constructed based on racial ideologies?
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Which of the following is affected by racialized identities according to the content?
Which of the following is affected by racialized identities according to the content?
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What influence do cultural syndromes have on clinical practice?
What influence do cultural syndromes have on clinical practice?
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What is an example of a cultural explanation?
What is an example of a cultural explanation?
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What is a major consequence of social structural racism?
What is a major consequence of social structural racism?
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Which of the following best describes systemic/institutional racism?
Which of the following best describes systemic/institutional racism?
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How can individuals unknowingly contribute to systemic racism?
How can individuals unknowingly contribute to systemic racism?
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Which type of racism involves explicit behaviors and microaggressions?
Which type of racism involves explicit behaviors and microaggressions?
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Which mental health disorder is mentioned as being more frequently misdiagnosed among African Americans due to clinician bias?
Which mental health disorder is mentioned as being more frequently misdiagnosed among African Americans due to clinician bias?
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What negative health outcomes are associated with racism?
What negative health outcomes are associated with racism?
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What is the purpose of the Cross-Cutting Review Committee on Cultural Issues during the DSM-5-TR review process?
What is the purpose of the Cross-Cutting Review Committee on Cultural Issues during the DSM-5-TR review process?
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What terminology does DSM-5-TR use to highlight the socially constructed nature of race?
What terminology does DSM-5-TR use to highlight the socially constructed nature of race?
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How are the U.S. Census categories such as Hispanic, White, or African American referred to in DSM-5-TR?
How are the U.S. Census categories such as Hispanic, White, or African American referred to in DSM-5-TR?
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How does DSM-5-TR address the term 'Latino/a' to promote gender-inclusivity?
How does DSM-5-TR address the term 'Latino/a' to promote gender-inclusivity?
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Which term is avoided in DSM-5-TR because it is based on obsolete views about the geographic origin of a prototypical ethnicity?
Which term is avoided in DSM-5-TR because it is based on obsolete views about the geographic origin of a prototypical ethnicity?
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What does DSM-5-TR avoid using the terms 'minority' and 'non-White'?
What does DSM-5-TR avoid using the terms 'minority' and 'non-White'?
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What is one function of the Ethnoracial Equity and Inclusion Work Group in the DSM-5-TR review process?
What is one function of the Ethnoracial Equity and Inclusion Work Group in the DSM-5-TR review process?
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When is the practice of using specific group labels from studies permitted in DSM-5-TR?
When is the practice of using specific group labels from studies permitted in DSM-5-TR?
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How is sex determined?
How is sex determined?
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What does gender include in addition to reproductive organs?
What does gender include in addition to reproductive organs?
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Which type of information about psychiatric illnesses is commonly based on?
Which type of information about psychiatric illnesses is commonly based on?
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How are sex differences relevant in medical conditions?
How are sex differences relevant in medical conditions?
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Which terminology does DSM-5-TR commonly use?
Which terminology does DSM-5-TR commonly use?
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Which specific disorder is mentioned as being exclusively determined by sex?
Which specific disorder is mentioned as being exclusively determined by sex?
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How do sex and gender influence the likelihood of experiencing specific symptoms of a disorder?
How do sex and gender influence the likelihood of experiencing specific symptoms of a disorder?
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What can reproductive life cycle events like pregnancy and menopause contribute to?
What can reproductive life cycle events like pregnancy and menopause contribute to?
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In addition to symptom endorsement, what other aspect can gender-based differences affect?
In addition to symptom endorsement, what other aspect can gender-based differences affect?
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The specifier 'with peripartum onset' is relevant to which of these conditions?
The specifier 'with peripartum onset' is relevant to which of these conditions?
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Why might postpartum alterations in sleep and energy affect diagnosis reliability?
Why might postpartum alterations in sleep and energy affect diagnosis reliability?
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What kind of information does the diagnostic manual include related to sex and gender?
What kind of information does the diagnostic manual include related to sex and gender?
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Why are prevalence estimates for mental disorders provided based on sex and gender?
Why are prevalence estimates for mental disorders provided based on sex and gender?
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What is the purpose of including the section 'Association With Suicidal Thoughts or Behavior' in DSM-5-TR?
What is the purpose of including the section 'Association With Suicidal Thoughts or Behavior' in DSM-5-TR?
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What should clinicians rely on when assessing an individual's suicide risk according to DSM-5-TR?
What should clinicians rely on when assessing an individual's suicide risk according to DSM-5-TR?
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What factor makes the 'Association With Suicidal Thoughts or Behavior' section variable within groups of individuals with the same diagnosis?
What factor makes the 'Association With Suicidal Thoughts or Behavior' section variable within groups of individuals with the same diagnosis?
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Why is an individualized assessment crucial in suicide risk evaluation?
Why is an individualized assessment crucial in suicide risk evaluation?
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Which aspect is beyond the scope of the DSM-5-TR manual when it comes to clinical risk assessment?
Which aspect is beyond the scope of the DSM-5-TR manual when it comes to clinical risk assessment?
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What should be used to inform clinical judgment in the assessment of suicide risk?
What should be used to inform clinical judgment in the assessment of suicide risk?
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Study Notes
Brief History of Prior DSM Editions
- The first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) was published in 1952 by the American Psychiatric Association.
- The first edition introduced a glossary of descriptions of diagnostic categories and reflected Adolf Meyer's psychobiological view that mental disorders were reactions of the personality to psychological, social, and biological factors.
- The second edition (DSM-II) was developed in 1968, based on the mental disorders section of the eighth revision of the International Classification of Diseases (ICD-8).
- DSM-III was published in 1980, with development beginning in 1974, and was coordinated with the development of ICD-9.
- DSM-III introduced methodological innovations, including explicit diagnostic criteria and a descriptive approach neutral to theories of etiology of mental disorders.
- Robert L. Spitzer, M.D. directed the development of DSM-III.
- Inconsistencies in DSM-III led to the appointment of a Workgroup to Revise DSM-III.
Key Milestones
- 1952: Publication of DSM-I
- 1968: Implementation of DSM-II and ICD-8
- 1974: Development of DSM-III begun
- 1975: Publication of ICD-9
- 1978: Implementation of ICD-9
- 1980: Publication of DSM-III
DSM-5 Revision Process
- In 1999, the APA launched an evaluation of the strengths and weaknesses of DSM, coordinated with the WHO's Division of Mental Health, the World Psychiatric Association, and the NIMH.
- The evaluation effort was conducted through conferences, resulting in the 2002 monograph "A Research Agenda for DSM-V".
- Between 2003 and 2008, the APA and WHO convened 13 international DSM-5 research planning conferences, involving 400 participants from 39 countries.
- The conferences reviewed world literature in specific diagnostic areas and aimed to prepare for revisions in developing both DSM-5 and ICD-11.
- Reports from these conferences formed the basis for future DSM-5 Task Force reviews and set the stage for the new edition of DSM.
DSM-5 Task Force
- In 2006, the APA named David J. Kupfer, M.D., as Chair and Darrel A. Regier, M.D., M.P.H., as Vice-Chair of the DSM-5 Task Force.
- The task force was responsible for overseeing the development of DSM-5 and recommending chairs for the 13 diagnostic work groups with a multidisciplinary range of expertise.
- An additional vetting process was initiated by the APA Board of Trustees to disclose sources of income and avoid conflicts of interest by task force and work group members.
Disclosure of Income and Research Grants
- Members are required to disclose all income and research grants from commercial sources, including the pharmaceutical industry.
- An income cap from commercial sources and publication of disclosures on a website were imposed to enforce this requirement in the past 3 years.
Task Force and Work Groups
- The task force consisted of 28 members.
- Over 130 work group members were approved in 2007 and 2008.
- The task force involved over 400 advisors with no voting authority.
- These advisors participated in the classification of mental disorders.
Centralized Vision for Classification
- The classification of mental disorders was considered the next evolutionary stage.
- A clear concept of the classification emerged from the efforts of the task force and work groups.
- The vision for this classification was based on the history of DSM-IV, its strengths and limitations, and strategic directions for its revision.
6-Year Process for Revising Criteria
- The process for revising the criteria took 6 years to complete.
- It involved conducting literature reviews and secondary analyses, publishing research reports, developing draft diagnostic criteria, and posting preliminary drafts for public comment.
- Preliminary findings were presented at professional meetings, and field trials were performed to revise the criteria and text.
Participants Involved
- The 6-year process involved a wide range of participants, including health professionals, educational groups, physicians, psychologists, social workers, nurses, counselors, epidemiologists, statisticians, neuroscientists, neuropsychologists, individuals with mental disorders, families, lawyers, consumer organizations, and advocacy groups.
Proposed Revisions for DSM-IV Criteria
- Proposals for revising DSM-IV diagnostic criteria were developed by work group members.
- These proposals were based on rationale, scope of change, expected impact, strength of supporting research evidence, overall clarity, and clinical utility.
DSM-5 Field Trials
- Changes to diagnostic criteria in DSM-5 included adding new disorders, subtypes, and specifiers, and deleting existing disorders.
- Strengths and weaknesses in current criteria and nosology were identified, and novel scientific findings from the past two decades were considered.
- Four principles guided draft revisions:
- DSM-5 is primarily for clinicians, and revisions must be feasible for routine clinical practice.
- Recommendations for revisions should be guided by research evidence.
- Continuity should be maintained with previous editions of DSM where possible.
- No a priori constraints should be placed on the degree of change between DSM-IV and DSM-5.
Revision Process
- Work groups identified key issues within their diagnostic areas and examined broader methodological concerns.
- Concerns included contradictory findings, developing a refined definition of mental disorder, and considering cross-cutting issues relevant to all disorders.
Inclusion and Exclusion Criteria
- Proposals for revision were informed by consideration of advantages and disadvantages for public health and clinical utility, strength of evidence, and magnitude of change.
- New diagnoses and disorder subtypes and specifiers required demonstration of reliability (the degree to which two clinicians could independently arrive at the same diagnosis).
- Disorders with low clinical utility and weak validity were considered for deletion.
Conditions for Further Study
- Placement of proposed conditions in Section III was contingent on the amount of empirical evidence generated, diagnostic reliability or validity, presence of clear clinical need, and potential benefit in advancing research.
Field Trials
- The use of field trials to demonstrate reliability was a noteworthy improvement introduced in DSM-III.
- The DSM-5 Field Trials design and implementation strategy represented several improvements.
Changes from DSM-III and DSM-IV
- DSM-III and DSM-IV kappa reliability estimates were obtained in real-world clinical settings to assess precision.
- Two study designs were used: one in large, diverse medical-academic settings and another in routine clinical practices.
- The former design focused on large sample sizes to test hypotheses on reliability and clinical utility of diagnoses.
- The latter design contributed valuable information about revisions in everyday clinical settings among a diverse sample of DSM users.
Need for Future Research
- Future studies will focus on the validity of revised categorical diagnostic criteria and underlying dimensional features of disorders.
- The NIMH Research Domain Criteria initiative is exploring new areas.
Field Trials for DSM-5
- Field trials took place at 11 North American medical-academic sites from December 2010 to October 2011.
- The trials assessed the reliability, feasibility, and clinical utility of select revisions.
- Priority was given to revisions representing significant changes from DSM-IV or those with potential public health impact.
- Full clinical patient populations were screened for DSM-IV diagnoses or qualifying symptoms.
- Stratified samples of four to seven specific disorders were identified for each site.
Patient Consent and Interview Procedures
- Patients consented to the study and were randomly assigned for a clinical interview by a clinician blind to the clinical diagnosis.
- A second interview, occurring within two weeks, was conducted by a clinician unfamiliar with the first interviewer's diagnoses.
- Patients completed a computer-assisted inventory of cross-cutting symptoms in over a dozen psychological domains.
- A computer scored the inventory, and the results were provided to clinicians before they conducted a typical clinical interview without a structured protocol.
DSM-5 Diagnostic Criteria
- Clinicians used a computer-assisted DSM-5 diagnostic checklist to score the presence of qualifying criteria
- The checklist allowed clinicians to:
- Determine diagnoses
- Score the severity of the diagnosis
- Upload data to a central repository
Inter-Rater Reliability
- The study design enabled calculation of inter-rater reliability using the Intraclass Kappa statistic
- Clinician-administered ratings were used to assess agreement on:
- Cross-cutting and diagnosis-specific symptom severity (using intraclass correlation coefficients)
- Self-reported cross-cutting symptoms
- Personality traits
- Disability
- Diagnostic severity
Routine Clinical Practice Field Trials
- The trials recruited individual psychiatrists and other mental health clinicians from October 2011 to March 2012
- The volunteer sample consisted of:
- Generalist and specialty psychiatrists
- Psychologists
- Licensed clinical social workers
- Counselors
- Marriage and family therapists
- Advanced practice psychiatric mental health nurses
- The trials assessed the feasibility and clinical utility of proposed DSM-5 diagnoses and dimensional measures
Public and Professional Review
- The APA launched a website in 2010 to facilitate public and professional input into DSM-5
- The website posted draft diagnostic criteria and proposed changes for a 2-month comment period, receiving over 8,000 submissions
- The feedback was systematically reviewed by each of the 13 work groups, and revisions were made based on the feedback and field trial results
- A second posting occurred in 2011, and work groups considered feedback from both web postings and the results of the DSM-5 Field Trials
Expert Review and Final Approval of DSM-5
- 13 work groups, representing expertise in their respective areas, collaborated with advisors and reviewers to draft diagnostic criteria and accompanying text.
- The DSM-5 Task Force provided overall direction, supported by APA Division of Research staff and a network of text coordinators from each work group.
- The text editor coordinated the preparation of the text, working closely with the work groups and under the direction of the task force chairs.
Scientific Review Committee (SRC)
- The SRC was established to provide a scientific peer review process external to the work groups.
- The SRC consisted of a chair, vice-chair, and six committee members, reviewing the degree to which proposed changes from DSM-IV could be supported with scientific evidence.
- Each proposal for diagnostic revisions required a memorandum of evidence for change, accompanied by a summary of supportive data organized around validators.
- Validators included:
- Antecedent validators (e.g., familial aggregation)
- Concurrent validators (e.g., biological markers)
- Prospective validators (e.g., response to treatment or course of illness)
- The SRC reviewed submissions and scored them according to the strength of the supportive scientific data.
- Justifications for change from clinical experience, need, or conceptual reframing of diagnostic categories were generally seen as outside the purview of the SRC.
Scores, Commentary, and Consideration
- Scores from different proposals were sent to the APA Board of Trustees and work groups for consideration and response.
Clinical and Public Health Committee (CPHC)
- The CPHC reviewed additional information for criteria, including clinical utility, public health, and logical clarification.
- These aspects were only considered if enough evidence was deemed sufficient to make changes.
DSM-IV Deficiency Review
- The review process was particularly important for DSM-IV disorders with known deficiencies.
- Proposed remedies for these disorders had neither been considered in the DSM revision process nor been subjected to replicated research studies.
- The disorders were evaluated by 4-5 external reviewers.
- The blinded results were reviewed by CPHC members who made recommendations to the APA Board of Trustees and work groups.
Forensic Review
- The APA Council on Psychiatry and Law conducted forensic reviews of diagnostic criteria and text for disorders appearing in forensic environments and ones with high potential for influencing civil and criminal judgments.
- Work groups also added forensic experts to complement expertise provided by the Council on Psychiatry and Law.
APA Assembly's Committee on DSM-5
- A final recommendation from the task force was provided to the APA Assembly's Committee on DSM-5 to consider some of the clinical utility and feasibility features of the proposed revisions.
- The Assembly represents the district branches and wider membership, composed of psychiatrists from throughout the United States, providing geographic, practice size, and interest-based diversity.
- The Committee on DSM-5 was composed of a diverse group of Assembly leaders.
Executive "Summit Committee"
- The executive "summit committee" convened to consolidate input from review.
- The committee included: Assembly committee chairs, task force chairs, a forensic advisor, and a statistical advisor.
- The committee conducted a preliminary review of each disorder for both the Assembly and the APA Board of Trustees executive committees.
- There was also a preliminary review by the full APA Board of Trustees.
- In November 2012, a vote took place to recommend that the Board approve the publication of DSM-5.
DSM-5 Revision Process
- The American Psychiatric Association has adopted an iterative improvement model for DSM revisions, enabled by advances in digital publishing.
- Revisions are based on specific scientific advances.
DSM Steering Committee
- The committee was established in Spring 2014, chaired by Paul S. Appelbaum, M.D.
- Ellen Leibenluft, M.D. and Kenneth Kendler, M.D. serve as Vice Chairs.
- The committee oversees the iterative revision process and manages a web portal (www.dsm5.org) for submitting proposals.
Submitting Proposals
- Proposed changes can include adding new disorders, modifying diagnostic criteria, or changing text.
- Submissions must include:
- Reasons for the change
- Magnitude of change
- Data documenting improvements in validity across multiple validators
- Evidence of reliability and clinical utility
- Consideration of potential deleterious consequences
Validating Diagnostic Criteria
- Approaches to validation include:
- Antecedent validators: Genetic markers, family traits, temperament, and environmental exposure
- Concurrent validators: Neural substrates, biomarkers, emotional and cognitive processing, and symptom similarity
- Predictive validators: Clinical course and treatment response
- New criteria for current disorders are adopted if they improve validity in some of these classes.
- New disorders are added to DSM if they demonstrate validity by a substantial subset of these validators.
DSM-5 Text Revision Process
- Validators must meet the criteria for a mental disorder and demonstrate clinical utility.
- Proposals are submitted to the DSM web portal and undergo an initial review by the Steering Committee.
- The Steering Committee determines whether the proposal appears likely to meet the criteria for approval based on the evidence provided.
Review Committee Process
- Approved proposals are referred to one of the five standing Review Committees, which cover broad domains of psychiatric diagnosis.
- The Review Committee considers the evidence in support of the proposed change and requests additional information if necessary.
- The Review Committee returns the proposal to the Steering Committee with recommendations for disposition and suggested modifications.
Public Comment and Approval
- The proposed revision is posted on the DSM-5 website for public comment if the Steering Committee concurs that sufficient evidence exists.
- The final stage involves making necessary adjustments based on the comments and forwarding the final version to the APA Assembly and Board of Trustees for approval.
- Once approved, the online version of the manual is updated to reflect the changes.
DSM-5-TR Development
- The DSM-5-TR development effort was started in Spring 2019 with Michael B. First, M.D., and Philip Wang, M.D., Dr.P.H., as Revision Subcommittee Co-Chairs, and Wilson M. Compton, M.D., and Daniel S. Pine, M.D., as Revision Subcommittee Vice Chairs.
- The development effort involved over 200 experts, who conducted literature reviews covering the past 10 years and reviewed the text to identify out-of-date material.
- A review of conflicts of interest for all proposed changes to the text was conducted to eliminate any possible compromise of the objectivity of the content.
DSM-5 Organizational Structure
- DSM is a medical classification of disorders, serving as a cognitive schema to organize clinical and scientific information for better comprehension and utility.
Regrouping of Disorders in DSM-5
- The DSM-5 diagnostic spectra study group examined the use of scientific validators to regroup related disorders within the existing categorical framework.
- The study group recommended 11 indicators to separate groups of psychiatric illness:
- Neural substrates
- Family traits
- Genetic risk factors
- Specific environmental risk factors
- Biomarkers
- Temperamental antecedents
- Abnormalities of emotional or cognitive processing
- Symptom similarity
- Course of illness
DSM-5 Organizational Structure
- DSM is a medical classification of disorders, serving as a cognitive schema to organize clinical and scientific information for better comprehension and utility.
Regrouping of Disorders in DSM-5
- The DSM-5 diagnostic spectra study group examined the use of scientific validators to regroup related disorders within the existing categorical framework.
- The study group recommended 11 indicators to separate groups of psychiatric illness:
- Neural substrates
- Family traits
- Genetic risk factors
- Specific environmental risk factors
- Biomarkers
- Temperamental antecedents
- Abnormalities of emotional or cognitive processing
- Symptom similarity
- Course of illness
Revising Diagnostic Manuals
- The Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD) are being revised.
- The revision process aims to use shared treatment responses and comorbidity as empirical guidelines to inform decision-making in clustering disorders.
Criteria and Validations
- Validators were found to be useful in suggesting large groupings of disorders and validating proposed changes to diagnostic criteria through a series of papers in Psychological Medicine.
- The American Psychological Association (APA) and World Health Organization (WHO) considered improving clinical utility by rethinking the organizational structures of DSM and ICD.
- This was done to facilitate scientific investigation and explain apparent comorbidity.
Revision Approach
- The revision process was guided by emerging scientific evidence on relationships between disorder groups, taking a conservative, evolutionary approach to diagnostic reform.
- The goal was to stimulate new clinical perspectives and encourage researchers to identify cross-cutting factors that are not bound by strict categorical designations.
Harmonizing Classifications
- A shared organizational structure helped harmonize the classifications, with large sections of content falling into place easily.
- This reflects strengths in areas such as epidemiology, analyses of scientific information, and relationships between disorders.
Placement of ADHD in DSM-5
- ADHD's placement in DSM-5 has been debated due to its co-occurrence with other disorders.
- The classification of ADHD requires consideration of various factors, including symptoms, comorbidity, shared risk factors, and evidence.
Organisation of Disorders in DSM-5
- DSM-5 organizes disorders using a categorization framework that separates internalizing and externalizing disorders.
- Internalizing disorders are characterized by feelings of anxiety, depression, and somatic symptoms.
- Externalizing disorders are associated with impulsive, disruptive conduct, and substance use.
- Neurocognitive disorders affect cognitive functions like memory or attention.
Future Directions
- Research is needed to understand the underlying pathophysiological mechanisms contributing to comorbidity and symptom heterogeneity.
- DSM-5 aims to improve diagnosis by primary care physicians by organizing disorders based on clinical reality.
- Dimensional approaches to diagnosis may supplement or supersede categorical approaches in the future.
- These approaches will serve as a bridge for new diagnoses without disrupting existing practices.
Combining Developmental and Life Span Considerations
- DSM-5 is organized along developmental and life span trajectories.
- The manual begins with diagnoses that reflect early life developmental processes (e.g., neurodevelopmental disorders, schizophrenia spectrum and other psychotic disorders).
- Diagnoses that commonly manifest in adolescence and young adulthood (e.g., bipolar and related disorders, depressive disorders, anxiety disorders) follow.
- The manual concludes with diagnoses relevant to adulthood and later life (e.g., neurocognitive disorders).
- A similar approach has been taken within each chapter to facilitate the use of life span information in diagnostic decision-making.
Harmonization With ICD-11
- The goal of harmonizing DSM and ICD systems was to facilitate:
- Collection and use of national health statistics
- Design of clinical trials for new treatments
- Global applicability of results by international regulatory agencies
- Two major classifications of mental disorders (DSM and ICD) hinder:
- Replication of scientific results across national boundaries
- Identification of identical patient populations
- DSM-IV and ICD-10 diagnoses did not always agree, even when intended to identify the same patient populations.
- Harmonization efforts were confined to the organizational structure, with no complete harmonization of diagnostic criteria due to differences in timing.
Definition of a Mental Disorder
- Each identified disorder in Section II of the manual, excluding Medication-Induced Movement Disorders and Other Adverse Effects of Medication, and Other Conditions That May Be a Focus of Clinical Attention, must meet the definition of a mental disorder.
- The definition of a mental disorder is not exhaustive, but it includes certain required elements.
- The DSM-5 definition of a mental disorder is applicable to all disorders in Section II, with a few exceptions.
Mental Disorder Definition
- A mental disorder is a syndrome characterized by a clinically significant disturbance in an individual's cognition, emotion regulation, or behavior.
- This disturbance reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.
Characteristics of Mental Disorders
- Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities.
- An expectable or culturally approved response to a common stressor or loss is not considered a mental disorder.
- Socially deviant behavior or conflicts between the individual and society are not mental disorders unless they result from a dysfunction in the individual.
Diagnosis of Mental Disorders
- A diagnosis of a mental disorder should have clinical utility, helping clinicians determine prognosis, treatment plans, and potential treatment outcomes.
- The diagnosis of a mental disorder does not necessarily mean a need for treatment.
- Factors considered in determining the need for treatment include symptom severity, symptom salience, individual distress, disability related to symptoms, risks and benefits of available treatments, and other factors.
Access to Care
- Clinicians may encounter individuals who do not meet full criteria for a mental disorder but still demonstrate a clear need for treatment or care.
- The fact that some individuals do not show all symptoms indicative of a diagnosis should not limit their access to appropriate care.
Purpose of the Definition
- The definition of mental disorder was developed for clinical, public health, and research purposes.
- Additional information is usually required beyond that contained in the DSM-5 diagnostic criteria to make legal judgments on issues such as criminal responsibility.
Categorical Approach to Diagnosis
- High rates of comorbidity among disorders, symptom heterogeneity within disorders, and the need for other specified and unspecified diagnoses are structural problems with the categorical design of DSM.
- The categorical approach does not capture clinical experience or important scientific observations.
- The boundaries between many disorder "categories" are more fluid over the life course than has been recognized.
- Many symptoms that make up the essential features of a particular disorder may occur, at varying levels of severity, in many other disorders.
Dimensional Approach to Diagnosis
- A dimensional approach classifies clinical presentations on the basis of quantification of attributes rather than the assignment to categories.
- Dimensional systems work best in describing phenomena that are distributed continuously and do not have clear boundaries.
- Dimensional systems increase reliability and communicate more clinical information.
- Dimensional systems report clinical attributes that might be subthreshold in a categorical system.
- Despite advantages, dimensional systems have serious limitations and have been less useful than categorical systems in clinical practice.
Numerical Dimensional Descriptions
- Numerical dimensional descriptions are less familiar and vivid than category names of mental disorders
- There is no agreement on the optimal dimensions to be used for classification purposes
- Dimensional approaches are likely to gain greater acceptance as a method of conveying clinical information and as a research tool
- DSM-5 combines categorical and dimensional elements to classify mental disorders into types based on criteria sets with defining features
- The categorical framework does not assume that each mental disorder is a completely discrete entity with absolute boundaries
- Individuals with the same mental disorder are likely to be heterogeneous in regard to the defining features of the diagnosis
- Boundary cases are difficult to diagnose in a non-probabilistic fashion
Cross-Cutting Symptom Measures
- Psychiatric pathologies are not reliably discrete with sharp boundaries from one another
- The DSM-5 Level 1 Cross-Cutting Symptom Measure was developed to help clinicians assess all major areas of psychiatric functioning
- The measure aims to uncover possible disorders, atypical presentations, subsyndromal conditions, and coexistent pathologies
- The measure assesses areas such as mood, psychosis, cognition, personality, and sleep
DSM-5 Level 1 Cross-Cutting Symptom Measure
- A tool used to identify latent disorders and symptoms in need of assessment or treatment
- Acts as an inventory of mental systems to help clinicians better understand their patients' issues
- Recommended as an important component of the psychiatric evaluation of individuals presenting for psychiatric care
- Endorsed by the American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults as a first step in identifying and addressing symptoms across diagnostic categories
- Available online for clinical use at www.psychiatry.org/dsm5
Removal of the DSM-IV Multiaxial System
- DSM-IV offered a multiaxial system of recording diagnoses with assessments on several axes
- DSM-5 has moved to a nonaxial documentation of diagnosis
- Disorders and conditions formerly listed on Axis I, Axis II, and Axis III are now listed together without formal differentiation, typically in order of clinical importance
- Psychosocial and contextual factors are listed along with the diagnoses and conditions using Z codes in the chapter “Other Conditions That May Be a Focus of Clinical Attention”
- DSM-IV Axis V consisted of the Global Assessment of Functioning (GAF) scale, which has been replaced by the WHO Disability Assessment Schedule (WHODAS)
Cultural and Social Structural Issues
- Mental disorders are defined and recognized within the context of local sociocultural and community norms and values.
- Cultural contexts influence the experience and expression of symptoms, signs, behaviors, and thresholds of severity for diagnosis.
- Sociocultural contexts shape aspects of identity (e.g. ethnicity or race) that affect social positions and exposure to social determinants of health, including mental health.
- Cultural elements are transmitted, revised, and recreated within families, communities, and social systems and institutions, and change over time.
Impact of Cultural Norms and Practices
- The boundaries between normality and pathology vary across cultural contexts for specific behaviors.
- Thresholds of tolerance for symptoms or behaviors differ across cultural contexts, social settings, and families.
- The level at which an experience becomes problematic or is perceived as pathological differs depending on cultural norms.
- Cultural norms internalized by the individual and applied by others (including family members and clinicians) influence the judgment of whether a behavior requires clinical attention.
Cultural Concepts of Distress
- Historically, cultural psychiatry and psychology focused on the construct of culture-bound syndrome, but it has been replaced by three concepts that offer greater clinical utility since DSM-5.
Cultural Idiom of Distress
- Refers to a behavior, linguistic term, phrase, or way of talking about symptoms, problems, or suffering among individuals with similar cultural backgrounds.
- Used to express or communicate essential features of distress, e.g., stating "I feel so depressed" to express low mood or discouragement that does not meet the threshold for major depressive disorder.
- Does not necessarily imply specific symptoms, syndromes, or perceived causes.
- May be used to convey a wide range of discomfort, including everyday concerns, subclinical conditions, or suffering due to social circumstances rather than mental disorders.
- Most cultural groups have common bodily idioms of distress used to express a wide range of suffering and concerns.
Cultural Explanations
- A cultural explanation is a label or attribution that provides a culturally coherent concept of etiology or cause for symptoms, illness, or distress.
- Examples of cultural explanations include attributing psychopathology to "stress", spirits, or failure to follow culturally prescribed practices.
Cultural Syndromes
- A cultural syndrome is a cluster or group of co-occurring, distinctive symptoms found in specific cultural groups, communities, or contexts.
- An example of a cultural syndrome is ataque de nervios (attack of nerves).
- Cultural syndromes may or may not be recognized as an illness in the local cultural context.
Impact of Racism and Discrimination on Psychiatric Diagnosis
- Race is a social, not a biological construct, used to divide people into groups based on superficial physical traits such as skin color.
- There is no biological basis for the construct of race.
- Discriminatory practices based on race have profound effects on physical and mental health.
- Racialization is the social process by which specific categories of identity are constructed on the basis of racial ideologies and practices.
- Racialized identities are strongly associated with systems of discrimination, marginalization, and social exclusion.
Racism and its Effects
- Racism affects individuals and society as a whole.
Forms of Racism
- Personal Racism: internalized stereotypes and experiences of threat, devaluation, neglect, and injustice.
- Interpersonal Racism: explicit behaviors and microaggressions.
- Systemic/Institutional Racism: embedded in everyday practices of institutions and organizations.
Implicit Bias in Systemic Racism
- Systemic racism is maintained by implicit biases, habits, routines, and practices that result in misrecognition and inequity.
- Individuals can unknowingly contribute to systemic racism.
Social Structural Racism
- Manifested in the organization and norms of society and public policy.
- Perpetuates pervasive inequities in economic resources, power, and privilege.
- Impacts exposure to health risks and access to healthcare.
Consequences of Racism
- Negative effects on mental health, including hypertension, suicidal behavior, posttraumatic stress disorder, and psychosis.
- Racial stereotypes and attitudes affect the psychological development and well-being of racialized groups.
- Unequal access to care and clinician bias in diagnosis and treatment lead to misdiagnosis, e.g., schizophrenia among African Americans.
Addressing Cultural and Racial Biases in DSM-5-TR
- A Cross-Cutting Review Committee on Cultural Issues reviewed the DSM-5-TR texts to address cultural influences on disorder characteristics.
- The committee consisted of 19 experts in cultural psychiatry, psychology, and anthropology from the US and internationally.
Ethnoracial Equity and Inclusion Work Group
- A separate work group reviewed the texts to avoid perpetuating stereotypes and discriminatory clinical information.
- The work group consisted of 10 mental health practitioners from diverse ethnic and racialized backgrounds with expertise in disparity-reduction practices.
Language and Terminology
- DSM-5-TR avoids language that implies races are discrete and natural entities.
- The term "racialized" is used instead of "racial" to highlight the socially constructed nature of race.
- "Ethnoracial" combines ethnic and racialized identifiers, such as Hispanic, White, or African American, based on US Census categories.
- The term "Latinx" is used to promote gender-inclusive terminology, replacing "Latino/a".
- The term "Caucasian" is not used due to its outdated and erroneous views on European ethnicity.
- Terms like "minority" and "non-White" are avoided as they perpetuate social hierarchies.
- Study-specific labels are used for clarity in reporting epidemiological or other information.
Sex and Gender Differences
- Sex is determined by an individual's reproductive organs and chromosomes, which can be either XX or XY.
- Gender encompasses not only reproductive organs but also an individual's self-representation, including social, behavioral, and psychological consequences of their perceived gender.
- Research on psychiatric illnesses often relies on self-identified gender, particularly in the DSM-5-TR.
- The terms "women and men" or "boys and girls" are commonly used in the DSM-5-TR to refer to gender.
Importance of Sex Differences
- Sex differences are crucial in understanding topics like the metabolism of substances.
- These differences are also significant in instances where only one sex is affected, such as during specific life stages.
Sex and Gender Influence on Illness
- Sex determines risk for certain disorders, such as premenstrual dysphoric disorder, which is exclusively determined by sex.
- Sex and gender affect the overall risk for developing a disorder, resulting in differences in prevalence and incidence rates of mental disorders between men and women.
- Sex and gender influence the likelihood of experiencing specific symptoms of a disorder, for example, ADHD may manifest differently in boys and girls.
Sex and Gender Effects on Diagnosis
- Certain symptoms may be more readily endorsed by men or women, influencing how healthcare providers recognize and diagnose mental illnesses.
- Women are more likely to be diagnosed with depression, bipolar disorder, or anxiety disorder and may present a broader range of symptoms.
- Gender-based differences in symptom endorsement lead to variations in service provision.
Reproductive Life Cycle Events
- Changes in ovarian hormones during menstruation, pregnancy, and menopause contribute to sex-related differences in mental illness.
- The specifier "with peripartum onset" of an illness, such as brief psychotic disorder, indicates a time period where women are more susceptible to developing these mental illnesses.
Diagnostic Considerations
- Postpartum alterations in sleep and energy are common and may affect diagnosis reliability.
- The diagnostic manual contains information on sex and gender at multiple levels, including gender-specific symptoms.
- Specifiers, such as "with peripartum onset" of a mood episode, provide information on the relationship between sex and diagnosis.
- Prevalence estimates for each mental disorder are provided based on sex and gender.
- Further issues related to sex and gender are discussed in the "Sex and Gender-Related Diagnostic Issues" section of the manual.
Association With Suicidal Thoughts or Behavior
- No specific information provided, but it is related to the topic of sex and gender differences in mental illness.
DSM-5-TR Features
- The DSM-5-TR includes a new section called "Association With Suicidal Thoughts or Behavior" for each diagnosis, where relevant literature is available.
- This section provides information on the associations between suicidal thoughts or behavior and a particular diagnosis, based on studies that have demonstrated such links.
Suicide Risk Assessment
- Within a group of individuals with the same diagnosis, there can be a wide range in suicide risk, from none to severe, depending on individual psychopathology.
- Clinicians should use their clinical judgment, informed by known risk factors, to assess an individual's suicide risk, rather than relying solely on the presence of a diagnosis associated with suicidal thoughts or behavior.
Clinical Implications
- The "Association With Suicidal Thoughts or Behavior" section serves as an alert to clinicians to conduct further inquiry for an individual with a particular diagnosis.
- Clinical risk assessment requires an individualized assessment that goes beyond the formulation of a DSM-5 diagnosis and the scope of the manual, encompassing many factors.
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