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DSM-5 Research Items in Section III

The DSM-5

Conditions Designated for Further Study in DSM-5 in Section III
Attenuated Psychosis Syndrome
Depressive Episodes with Short-Duration Hypomania
Persistent Complex Bereavement Disorder
Caffeine Use Disorder
Internet Gaming Disorder
Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure
Suicidal Behavior Disorder
Nonsuicidal Self-Injury
Dimensional Perspectives being Researched 

1. Specifiers to be used for each diagnostic category
Syntonic vs Dystonic
The first specifier to be used for each diagnostic category addresses the consideration of the “attitude of the client.” It will specify on the clients’ eagerness and motivation for counseling/therapy based upon their understanding and insight toward their own mental health disorder. This is designed to enhance the distinction made between Axis I and Axis II formats in the DSM III and DSM IV

These terms are borrowed from the terminology used in Motivational Interviewing.
Axis I disorder: is one for which the clients seek help because it causes them distress and this is referred to as DYSTONIC.

Axis II disorder: is one for which clients do not seek clinical help because they do not feel any concern about this disorder and this is referred to as SYNTONIC.

The rating for this Dimension will be as follows:

1. Good /Fair Insight = Dystonic

2. Poor Insight = Ambivalence

3. Absent Insight = Syntonic

Clearly the more Dystonic a client is about the disorder helps in case conceptualization and treatment planning and delineates where the therapist will begin therapy in the situation with the client.

Characteristic of Dystonic Conditions:

1. Client is experiencing significant distress, disability or impairment in functioning and such pain helps motivate the client to seek out help

2. Client has no capacity to cope with the condition at the current time

3. Client is motivated for therapy to help with the situation and condition

Characteristics of Syntonic Conditions:

1. Client is heavily defended

2. Client rationalizes the behaviors and is reluctant to change

3. Client is angry about being told what to do

4. Client is resigned to his or her fate

5. Client sees benefits to current behaviors

6. Client lacks insight into their condition – typical for children

7. Client is resistant to therapy and often has to be motivated to enter therapy

8. Client has no motivation to change

2. Correlated Disorders and Suicide Risk

Each diagnostic definition will comment on research based evidence of correlation among disorders (associated features).

There will be comments on each diagnosis as to vulnerability to suicide where appropriate

3. Respect for age, gender, and culture

Each diagnostic definition, where appropriate will incorporate:

1. Developmental symptom manifestation – regarding the age of the client

2. Gender specific disorders

3. Cultural sensitivity in regards to certain behaviors

4. Severity Index Across Time and Circumstances

Time and circumstances will be essential specifiers in all diagnostic categories

This will assure that individual does qualify for a mental disorder from definition and this it is a severe impairment.

This insures that the clinician will take time in diagnosing

This replaces the Axis V GAFscore


There is a need to avoid to rush to certainty given that: “Diagnostics is a process not an event”

Rating Scale of the Severity Index Across Time and Circumstances

0 = No impairment – Equivalent to GAF 71-100 (Normative Range)

1 = Mild impairment – Equivalent to GAF 61-70

2 = Moderate impairment – Equivalent to GAF 31-60

3 = Severe impairment – Equivalent to GAF 1-30

Specifier must indicate level 1 or 2 or 3 before a diagnosis is validated as a mental disorder.

5. Pathogenic care realms

There are five Pathogenic Care Realms in the Home, School and Community:

1. Settings in which there is persistent disregard for the child’s emotional needs

2. Settings in which there is persistent disregard for the child’s physical needs

3. Settings in which there are repeated changes in primary caregivers

4. Settings in which child is raised with limited opportunities for stable attachments

5. Setting in where there is persistent harsh punishment or types of grossly inept parenting (e.g.: Toxic Homes)

It requires one or more of these five essential specifiers for a diagnosis which depends on a pathogenic realm to be fully diagnosed

Diagnoses in the DSM-5 requiring the 5 Pathogenic Care Realms Specifiers are:

Reactive Attachment Disorder

Disinhibited Social Engagement Disorder

PTSD in Children

Disruptive Mood Dysregulation Disorder

Dissociative Disorders in Children

Oppositional Defiant Disorder

Conduct Disorder (Sociopathy Specifier)

6. Diagnosing a Personality Disorder

3 Measures to Assess Personality Pathology

1. Core Impairments in Personality Functioning

2. Pathological Personality Traits

3. Overall Measure of Severity

1. Core Impairments in Personality Functioning

1. Self-Functioning includes:

  • Identity: individual experiences oneself as unique, has boundaries, stable self-esteem, and can regulate emotions
  • Self-direction: individual has vocational, occupational, relational and social goals also has internal standards and displays a “moral compass”

2. Interpersonal Functioning includes:

  • Empathy: listens, appreciates others’ experiences and advice, tolerance and acceptance and understands how one’s behaviors affect others
  • Intimacy: positive connection to others, a desire and capacity for closeness and is emotionally responsive

2. Pathological Personality Traits

  1. Negative Affectivity: labile moods and emotional dysregulation
  2. Detachment: emotional constriction and intimacy avoidance
  3. Antagonism: manipulative
  4. Disinhibition or Compulsivity: perfectionism and controlling

3. Overall Measure of Severity

0 = very little

1 = Mild

2 = Moderate

3 = Extreme

The severity level is an assessment of how the behavior impacts on the therapy relationship.

Questions to be Asked in Deciding on Personality Disorder Diagnosis

1. Is there a significant impairment in self or interpersonal functioning?

2. What pathological personality traits are present?

3. Is the severity level so profound (2 or 3) that it may have an effect on treatment?

4. What would be the effect on treatment?