Synthesizing and Evaluating Concepts

  • Part 4—Synthesizing and Evaluating Concepts :

    Using your knowledge from the textbook and/or lecture notes, answer each question by typing your response in the space provided below. For each question, your answer should be one or more healthy paragraphs (Your total answer should be at least 100 words or more).

    1. You decide to go to work for a presidential candidate in the next election. You

    think that the way for you to get folks to vote for your candidate is to use some psychology. So, you make a deal with a soft-drink company to insert a picture of your candidate into its commercials for only a brief instant. It will be so quick that no one will notice the picture. That way, the candidate’s image will enter viewers’ subconscious minds and make them vote for your candidate. What psychological processes are you trying to use and will they be likely to work?

    2. Describe how sound waves become nerve impulses as they enter the ear. How are the important characteristics of sound coded?

    3. List and explain two binocular cues for depth perception and two monocular cues. Why do we have two different types of cues for depth?

    4. Why do perceptual illusions occur? Give an example of a perceptual illusion and explain it according to your answer to the first part of this question.

    5. Compare and contrast the trichromatic and opponent-process theories of color vision. How has this debate been resolved?


    Part 4—Synthesizing and Evaluating Concepts :

    Using your knowledge from the textbook and/or lecture notes, answer each question by typing your response in the space provided below. For each question, your answer should be one or more healthy paragraphs (Your total answer should be at least 100 words or more).

    1. If you were a behaviorist, would you agree with the idea that consciousness is an area of serious psychological research? Please explain why you agree or disagree.

    2. List and describe the different stages of sleep. What position do you hold regarding the purpose of sleep and its stages?

    3. List and describe three different sleep disorders. Note the symptoms associated with each, and identify who is most likely to develop each condition.

    4. Compare and contrast two theories of dreams. Which one do you believe makes more sense and why? What is your theory of dreams?

    5. What are the main differences between physical dependence and psychological dependence? Give examples of both types of dependence.


    Part 5—Synthesizing and Evaluating Concepts :

    Using your knowledge from the textbook and/or lecture notes, answer each question by typing your response in the space provided below. For each question, your answer should be one or more healthy paragraphs (Your total answer should be at least 100 words or more).

    1. Compare and contrast classical and operant conditioning. How are they similar? How are they different? Make sure to describe relevant terms from each type of learning.

    2. Define learning. Given this definition, what types of behaviors would not be considered learning? How does the concept of instinctive drift relate to these examples? What types of behaviors would be included?

    3. Explain what learned helplessness is and describe how it develops. Also discuss the effects it has on people and animals once it is established.

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Importance of Diagnosis

Diagnosis in the Assessment Process

It was 1975, and part of my job as an outpatient therapist at a mental health center entailed answering the crisis counseling phones every ninth night. I would sleep at the center and answer a very loud phone that would ring periodically throughout the night, usually with a person in crisis on the other end. Every once in a while, a former client of the center would call in and start to read aloud from his case notes, which he had stolen from the center. Parts of these notes were a description of his diagnosis from what was then the second edition of the Diagnostic and Statistical Manual (DSM-II). In a sometimes angry, sometimes funny tone, he would read these clinical terms that were supposed to be describing him. I could understand his frustration when reading these notes over the phone, as in some ways, the diagnosis seemed removed from the person—a label. “Was this really describing the person, and how was it helpful to him?” I would often wonder.

—Ed Neukrug

An important aspect of the clinical assessment and appraisal process is skillful diagnosis. Today, the use of diagnosis permeates the mental health professions, and although there continues to be some question as to its helpfulness, it is clear that making diagnoses and using them in treatment planning has become an integral part of what all mental health professionals do. Thus, in this chapter we examine the use of diagnosis.

We begin this chapter by discussing the importance of diagnosis in the assessment process and then provide a brief overview of the history of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and its evolution over the past several decades. We then introduce the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and note some of the differences from previous versions, such as the use of a single axis and factors that now come into play when making and reporting diagnosis. Next, we highlight the DSM-5 diagnostic categories and follow up with other important considerations when making a diagnosis, such as medical concerns, psychosocial and environmental concerns, and cross-cultural issues. There are several case studies and exercises that will help to hone some of your diagnostic skills. At the end of the chapter, we relate the importance of formulating a diagnosis within the overall assessment process.

The Importance of Diagnosis

· John is in fifth grade and has been assessed as having a conduct disorder and attention-deficit/hyperactivity disorder (ADHD). John’s mother has panic disorder and is taking antianxiety medication. His father has bipolar and is taking lithium. Jill is John’s school counselor. John’s individualized education plan (IEP) states that he will work with Jill individually and in small groups to address behavior, attention, and social skills deficits. Jill must also periodically consult with John’s mother, father, and teachers.

· Tamara has just started college. After breaking up with her boyfriend, she became severely depressed and unable to concentrate on her schoolwork; her grades have dropped from As to Cs. She comes to the college counseling center and sobs during most of her first session with her counselor. She admits having always struggled with depression but states that “This is worse than ever; I need to get better if I am going to stay in school. Can you give me any medication to help me so I won’t have to drop out?”

· Benjamin goes daily to the day treatment center at the local mental health center. He seems fairly coherent and generally in good spirits. He has been hospitalized for schizophrenia on numerous occasions and now takes risperdone to relieve his symptoms. He admits to Jordana, one of his counselors, that when he doesn’t take his medication because he believes that computers have consciousness and are conspiring through the World Wide Web to take over the world. His insurance company pays for his treatment. He will not receive treatment unless Jordana specifies a diagnosis on the insurance form.

As you can see from these examples, diagnosis is an essential tool for professionals in a wide range of settings. In fact, current research suggest that up to 20 percent of all children and adults struggle with a diagnosable mental disorders each year (<BIB>Centers for Disease Control and Prevention [CDC], 2013</BIB>; <BIB>Substance Abuse and Mental Health Services Administration, 2012</BIB>), and approximately 50 percent of adults in the United States will experience mental illness in their lifetime (<BIB>CDC, 2011</BIB>). Therefore, all persons serving in helping roles will encounter persons dealing with a mental disorder and will need to be familiar with a common diagnostic language to best serve these individual and to effectively communicate with other professionals. The importance of an accurate diagnosis is relatively new and is the result of a number of changes that have occurred over the past years. Some of these include the following:

1. Interventions and accommodations for children with emotional, behavioral, and learning disorders are now required by federal and state laws (e.g., PL94-142, Individuals with Disabilities Education Act [IDEA]) and a diagnosis is generally necessary if professionals are to identify students with such disorders. Today, teachers, school counselors, school psychologists, child study team members, and other school professionals are often the first to recognize and diagnose young people with these disorders.

2. Today, a diagnosis is viewed as one aspect of holistically understanding the client. Along with testing, interviews, and other measures, it can be used to help conceptualize client problems and assist in the accurate development of treatment plans.

3. Due to laws like the Americans with Disabilities Act (e.g., <BIB>United States Department of Justice, n.d.</BIB>), employers are now required to make reasonable accommodations for individuals with disabilities, including those with mental disorders. Mental health professionals must know about diagnosis if they are to help individuals maintain themselves at work and assist employers in understanding the conditions of individuals with mental disorders.

4. In the past 50 years, a mental disorder diagnosis has generally become mandatory if medical insurance is to reimburse for treatment. Accurate diagnosing is important because the insurance carrier often allows only a certain number of treatments per a particular diagnosis.

5. The diagnostic nomenclature of the DSM has increasingly become an essential and effective way of communicating with community partners who may be part of the client’s same treatment team (e.g., other mental health professionals, doctors, representatives of the legal system).

6. It has become increasingly evident that accurately and appropriately communicating a mental health diagnosis to a client can help the individual understand his or her prognosis and aid in forming reasonable expectations for treatment.

These items show why it is important for a wide range of professionals to understand diagnosis. Although the DSM-IV-TR (4th ed. with text revisions; <BIB>American Psychiatric Association [APA], 2000</BIB>) had been the most well-known diagnostic classification system, with the recent release of DSM-5 (<BIB>APA, 2013</BIB>), a revised nomenclature was developed. But what is the DSM and how does it work?

The Diagnostic and Statistical Manual (DSM): A Brief History

Derived from the Greek words dia (apart) and gnosis (to perceive or to know), the term diagnosis refers to making an assessment of an individual from an outside, or objective, viewpoint (<BIB>Segal & Coolidge, 2001</BIB>). One of the first attempts to classify mental illness occurred during the mid-1800s when the United States Census Bureau started counting the incidence of “idiocy” and “insanity” (<BIB>Smith, 2012</BIB>). However, it was not until 1943 that a formal classification system called the Medical 203 was developed by the U.S. War Department (<BIB>Houts, 2000</BIB>). Revised over the next few years, in 1952 this publication became the basis for APA’s first DSM (DSM-I), which included 106 diagnoses in 3 broad categories (<BIB>APA, 1952</BIB>; <BIB>Houts, 2000</BIB>). In 1968 DSM-II was released (<BIB>APA, 1968</BIB>), which created 11 diagnostic categories with 185 discrete diagnoses and included a large increase in childhood diagnoses. In an effort to improve the science behind diagnosis as well as increase the compatibility with the American Medical Association’s International Classification of Disease (ICD) manual, the third edition of the DSM was released in 1980 (<BIB>APA, 1980</BIB>), which included 265 diagnoses and a multiaxial approach to diagnosis. In 1994 DSM-IV was released, and in 2000 an additional text revision of DSM-IV became available (DSM-IV-TR) and contained 365 diagnoses (<BIB>APA, 1994, 2000</BIB>). Although there were many critics of the DSM-IV-TR (<BIB>Beutler & Malik, 2002</BIB>; <BIB>Thyer, 2006</BIB>; <BIB>Zalaquett, Fuerth, Stein, Ivey, & Ivey, 2008</BIB>), it became the most widely utilized diagnostic classification system for mental health disorders (<BIB>Seligman, 1999, 2004</BIB>). A DSM-IV diagnosis consisted of five axes that included clinical disorders, personality disorders and mental retardation, medical conditions, psychosocial and environmental factors, and a global assessment of functioning (GAF) scale (see <LINK>Table 3.1</LINK>).

Table 3.1 Former Five Axis Diagnostic System

Axis Category Examples
Axis I Clinical disorders Depression, anxiety, bipolar, schizophrenia, etc.
Axis II Personality disorders and mental retardation Borderline personality disorder, antisocial personality disorder, etc.
Axis III General medical conditions High blood pressure, diabetes, sprained ankle, etc.
Axis IV Psychosocial and environmental factors Recent loss of job, recent divorce, homelessness, etc.
Axis V Global assessment of functioning A single score from 1 to 100 summarizing one’s functioning and symptoms

The practice of utilizing the multiaxial diagnostic system allowed mental health professionals to present a thorough description of clients and communicate their concerns and symptoms to other professionals (<BIB>Neukrug & Schwitzer, 2006</BIB>). However, there were drawbacks to a multiaxial approach and the DSM-5 moved toward a one-axis approach.

The DSM-5

The newest diagnostic manual, DSM5 (<BIB>APA, 2013</BIB>), was under development from 1999 to 2013 (<BIB>Smith, 2012</BIB>) and was first published in May of 2013. The DSM-5 includes a sleeker, more computer-friendly name, which replaces the Roman numeral tradition of the DSM. Subsequent editions, like computer software, will follow with editions 5.1, 5.2, 5.3, and so on. In addition to the print version of DSM-5, an online component ( is now available for supplemental materials such as assessment measures, but it also includes related news articles, fact sheets, and audiovisual materials. Another important change that has been made to the DSM-5 is an effort to align it with the ICD-9, and later, the ICD-10 (release date: October 1, 2014). This serves to unify the diagnostic and billing process between psychological and medical professions. Thus the DSM-5 gives both the ICD-9 and ICD-10 codes, and when making a diagnosis, one may want to list the ICD-9 code first and place the ICD-10 code in parenthesis. Clearly, it is important to know which version of the ICD is being used when making your diagnosis.

Single-Axis vs. Multiaxial Diagnosis

Perhaps the most significant change in the DSM-5 was the return to a single-axis diagnosis (<BIB>APA, 2013</BIB>; <BIB>Wakefield, 2013</BIB>). This was done for a number of reasons. First, the separation of personality disorders to Axis II under DSM-IV gave these disorders undeserved status and the misguided belief that they were largely untreatable (<BIB>Good, 2012</BIB>; <BIB>Krueger & Eaton, 2010</BIB>). Clients who met the criteria for an Axis II diagnosis may now find it easier to navigate mental health treatment as they will no longer be seen as having a diagnosis that is more difficult to treat than a host of other disorders. In DSM-5, medical conditions are no longer listed on a separate axis (Axis III in DSM-IV). Thus, they will likely take a more significant role in mental health diagnosis as they can be listed side-by-side with the mental disorder (<BIB>Wakefield, 2013</BIB>). Also, psychosocial and environmental stressors, previously listed on Axis IV of DSM-IV, will be listed alongside mental disorders and physical health issues. In fact, DSM-5 has increased the number of “V codes” (Z codes in ICD-10), which are considered nondisordered conditions that sometimes are the focus of treatment and often are reflective of a host of psychosocial and environmental issues (e.g., homelessness, divorce, etc.). As for the GAF score, previously on Axis V of DSM-IV, the APA intended to replace this historically unreliable tool with a different scaling assessment altogether. One assessment instrument, now being researched, is the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). This 36-item, self-administered questionnaire assesses a client’s functioning in six domains: understanding and communicating, getting around, self-care, getting along with people, life activities, and participation in society (<BIB>APA, 2013</BIB>). Disorders and other assessments that are under review for further research can be found in Section III of the DSM-5.

Making and Reporting Diagnosis

In the next section of the chapter, we discuss specific diagnostic categories, but first let’s look at other factors involved in making and reporting diagnoses, including how to order the diagnoses; the use of subtypes, specifiers, and severity; making a provisional diagnosis; and use of “other specified” or “unspecified” disorders.

Ordering diagnoses. Individuals will often have more than one diagnosis, so it is important to consider their ordering. The first diagnosis is called the principal diagnosis. In an inpatient setting, this would be the most salient factor that resulted in the admission (<BIB>APA, 2013</BIB>). In an outpatient environment, this would be the reason for the visit or the main focus of treatment. The secondary and tertiary diagnosis should be listed in order of need for clinical attention. If a mental health diagnosis is due to a general medical condition, the ICD coding rules require listing the medical condition first, followed by the psychiatric diagnosis, due to the general medical condition.

Subtypes, Specifiers, and Severity. Subtypes for a diagnosis can be used to help communicate greater clarity. They can be identified in the DSM-5 by the instruction “Specify whether” and represent mutually exclusive groupings of symptoms (i.e., the clinician can only pick one). For example, the ADHD has three different subtypes to choose from: predominantly inattentive, predominantly hyperactive/impulsive, or a combined presentation. Specifiers, on the other hand, are not mutually exclusive, so more than one can be used. The clinician chooses which specifiers apply, if any, and they are listed in the manual as “Specify if.” The ADHD diagnosis offers only one specifier that is “in partial remission” (<BIB>APA, 2013, p. 60</BIB>). Some diagnoses will offer an opportunity to rate the severity of the symptoms. These are identified in the DSM as “Specify current severity.” Referencing the ADHD diagnosis, there are three options of severity: mild, moderate, or severe. The DSM-5 authors have attempted to offer greater flexibility in rating severity through dimensional diagnosis. For example, some diagnoses offer greater options when rating severity. The Autism Spectrum Disorder has “Table 2 Severity levels of autism spectrum disorder” (<BIB>APA, 2013, p. 52</BIB>), which classifies autism on three levels of severity “requiring support,” “requiring substantial support,” and “requiring very substantial support.” Similarly, schizophrenia has the user go to a “Clinician-Rated Dimensions of Psychosis Symptom Severity” chart (<BIB>pp. 743–744</BIB>) to rate symptoms on a five-point Likert scale. It is easy to see how insurance companies might use severity classification as one method of determining which clients they will fund for treatment. In summary, the three types of specifiers are identified by:

· Subtype: “Specify whether”—only choose one,

· Specifier: “Specify if”—pick as many as apply, and

· Severity: “Specify current severity”—choose the most accurate level of symptomology.

Provisional Diagnosis. Sometimes, the clinician has a strong inclination that a client will meet the criteria for a diagnosis, but does not yet have enough information to make the diagnosis. This is when the clinician can make a provisional diagnosis. Once the criteria are later confirmed, the provisional label can be removed. These situations often occur when a client is not able to give an adequate history or further collateral information is required. In addition, there are informal diagnostic labels not listed in the DSM-5 that are helpful in communicating additional information. They are generally found in a diagnostic summary or when communicating informally with other clinicians. They include the following:

· Rule-out—the client meets many of the symptoms but not enough to make a diagnosis at this time; it should be considered further (e.g., rule-out major depressive disorder).

· Traits—this person does not meet criteria, however, he or she presents with many of the features of the diagnosis (e.g., borderline traits or cluster B traits).

· By history—previous records (another provider or hospital) indicate this diagnosis; records can be inaccurate or outdated (e.g., alcohol dependence by history).

· By self-report—the client claims this as a diagnosis; it is currently unsubstantiated; these can be inaccurate (e.g., bipolar by self-report).

For example, you may receive a fax from a hospital or other provider that might say, “Provisional Borderline Personality Disorder. Bipolar Diagnosis by self-report—no manic symptoms identified.”

Other Specified Disorders and Unspecified Disorders. The DSM-IV had a diagnosis of not otherwise specified (NOS) to capture symptomology that did not fit well into a structured category. In lieu of the NOS diagnosis, the DSM-5 offers two options when these situations arise. The other specified and unspecified disorders should be used when a provider believes an individual’s impairment to functioning or distress is clinically significant, however, it does not meet the specific diagnostic criteria in that category. The “other specified” should be used when the clinician wants to communicate specifically why the criteria do not fit. The “unspecified disorder” should be used when he or she does not wish, or is unable to, communicate specifics. For example, if someone appeared to have significant panic attacks but only had three of the four required criteria, the diagnosis could be “Other Specified Panic Disorder—due to insufficient symptoms.” Otherwise, the clinician would report “Unspecified Panic Disorder.”

Specific Diagnostic Categories

Section II of DSM-5 offers an in-depth discussion of 22 broad diagnostic categories and their subtypes as well as descriptions of medication-induced disorders and what is called “other conditions that may be a focus of clinical attention.” The following offers a brief description of these disorders and is summarized from DSM-5 (<BIB>APA, 2013</BIB>). Please refer to the DSM-5 for an in-depth review of each disorder. When you finish reviewing these diagnoses, the class may want to do Exercise 3.1.

· Neurodevelopmental Disorders. This group of disorders typically refers to those that manifest during early development, although diagnoses are sometimes not assigned until adulthood. Examples of neurodevelopmental disorders include intellectual disabilities, communication disorders, autism spectrum disorders (incorporating the former categories of autistic disorder, Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder), ADHD, specific learning disorders, motor disorders, and other neurodevelopmental disorders.

· Schizophrenia Spectrum and Other Psychotic Disorders. The disorders that belong to this section all have one feature in common: psychotic symptoms, that is, delusions, hallucinations, grossly disorganized or abnormal motor behavior, and/or negative symptoms. The disorders include schizotypal personality disorder (which is listed again, and explained more comprehensively, in the category of Personality Disorders in the DSM-5), delusional disorder, brief psychotic disorder, schizophreniform disorder, schizophrenia, schizoaffective disorder, substance/medication-induced psychotic disorders, psychotic disorders due to another medical condition, and catatonic disorders.

· Bipolar and Related Disorders. The disorders in this category refer to disturbances in mood in which the client cycles through stages of mania or mania and depression. Both children and adults can be diagnosed with bipolar disorder, and the clinician can work to identify the pattern of mood presentation, such as rapid-cycling, which is more often observed in children. These disorders include bipolar I, bipolar II, cyclothymic disorder, substance/medication-induced, bipolar and related disorder due to another medical condition, and other specified or unspecified bipolar and related disorders.

· Depressive Disorders. Previously grouped into the broader category of “mood disorders” in the DSM-IV-TR, these disorders describe conditions where depressed mood is the overarching concern. They include disruptive mood dysregulation disorder, major depressive disorder, persistent depressive disorder (also known as dysthymia), and premenstrual dysphoric disorder.

· Anxiety Disorders. There are a wide range of anxiety disorders, which can be diagnosed by identifying a general or specific cause of unease or fear. This anxiety or fear is considered clinically significant when it is excessive and persistent over time. Examples of anxiety disorders that typically manifest earlier in development include separation anxiety and selective mutism. Other examples of anxiety disorders are specific phobia, social anxiety disorder (also known as social phobia), panic disorder, and generalized anxiety disorder.

· Obsessive-Compulsive and Related Disorders. Disorders in this category all involve obsessive thoughts and compulsive behaviors that are uncontrollable and the client feels compelled to perform them. Diagnoses in this category include obsessive-compulsive disorder, body dysmorphic disorder, hoarding disorder, trichotillomania (or hair-pulling disorder), and excoriation (or skin-picking) disorder.

· Trauma- and Stressor-Related Disorders. A new category for DSM-5, trauma and stress disorders emphasize the pervasive impact that life events can have on an individual’s emotional and physical well-being. Diagnoses include reactive attachment disorder, disinhibited social engagement disorder, posttraumatic stress disorder, acute stress disorder, and adjustment disorders.

· Dissociative Disorders. These disorders indicate a temporary or prolonged disruption to consciousness that can cause an individual to misinterpret identity, surroundings, and memories. Diagnoses include dissociative identity disorder (formerly known as multiple personality disorder), dissociative amnesia, depersonalization/derealization disorder, and other specified and unspecified dissociative disorders.

· Somatic Symptom and Related Disorders. Somatic symptom disorders were previously referred to as “somatoform disorders” and are characterized by the experiencing of a physical symptom without evidence of a physical cause, thus suggesting a psychological cause. Somatic symptom disorders include somatic symptom disorder, illness anxiety disorder (formerly hypochondriasis), conversion (or functional neurological symptom) disorder, psychological factors affecting other medical conditions, and factitious disorder.

· Feeding and Eating Disorders . This group of disorders describes clients who have severe concerns about the amount or type of food they eat to the point that serious health problems, or even death, can result from their eating behaviors. Examples include avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, binge eating disorder, pica, and rumination disorder.

· Elimination Disorders. These disorders can manifest at any point in a person’s life, although they are typically diagnosed in early childhood or adolescence. They include enuresis, which is the inappropriate elimination of urine, and encopresis, which is the inappropriate elimination of feces. These behaviors may or may not be intentional.

· Sleep-Wake Disorders. This category refers to disorders where one’s sleep patterns are severely impacted, and they often co-occur with other disorders (e.g., depression or anxiety). Some examples include insomnia disorder, hypersomnolence disorder, restless legs syndrome, narcolepsy, and nightmare Disorder. A number of sleep-wake disorders involve variations in breathing, such as sleep-related hypoventilation, obstructive sleep apnea hypopnea, or central sleep apnea. See the DSM-5 for the full listing and descriptions of these disorders.

· Sexual Dysfunctions. These disorders are related to problems that disrupt sexual functioning or one’s ability to experience sexual pleasure. They occur across sexes and include delayed ejaculation, erectile disorder, female orgasmic disorder, and premature (or early) ejaculation disorder, among others.

· Gender Dysphoria. Formerly termed, “gender identity disorder,” this category includes those individuals who experience significant distress with the sex they were born and with associated gender roles. This diagnosis has been separated from the category of sexual disorders, as it is now accepted that gender dysphoria does not relate to a person’s sexual attractions.

· Disruptive, Impulse Control, and Conduct Disorders. These disorders are characterized by socially unacceptable or otherwise disruptive and harmful behaviors that are outside of the individual’s control. Generally, more common in males than in females, and often first seen in childhood, they include oppositional defiant disorder, conduct disorder, intermittent explosive disorder, antisocial personality disorder (which is also coded in the category of personality disorders), kleptomania, and pyromania.

· Substance-Related and Addictive Disorders. Substance use disorders include disruptions in functioning as the result of a craving or strong urge. Often caused by prescribed and illicit drugs or the exposure to toxins, with these disorders the brain’s reward system pathways are activated when the substance is taken (or in the case of gambling disorder, when the behavior is being performed). Some common substances include alcohol, caffeine, nicotine, cannabis, opioids, inhalants, amphetamine, phencyclidine (PCP), sedatives, hypnotics or anxiolytics. Substance use disorders are further designated with the following terms: intoxication, withdrawal, induced, or unspecified.

· Neurocognitive Disorders. These disorders are diagnosed when one’s decline in cognitive functioning is significantly different from the past and is usually the result of a medical condition (e.g., Parkinson’s or Alzheimer’s disease), the use of a substance/medication, or traumatic brain injury, among other phenomena. Examples of neurocognitive disorders (NCD) include delirium, and several types of major and mild NCDs such as frontotemporal NCD, NCD due to Parkinson’s disease, NCD due to HIV infection, NCD due to Alzheimer’s disease, substance- or medication-induced NCD, and vascular NCD, among others.

· Personality Disorders. The 10 personality disorders in DSM-5 all involve a pattern of experiences and behaviors that are persistent, inflexible, and deviate from one’s cultural expectations. Usually, this pattern emerges in adolescence or early adulthood and causes severe distress in one’s interpersonal relationships. The personality disorders are grouped into three following clusters based on similar behaviors:

· Cluster A: Paranoid, schizoid, and schizotypal. These individuals seem bizarre or unusual in their behaviors and interpersonal relations.

· Cluster B: Antisocial, borderline, histrionic, and narcissistic. These individuals seem overly emotional, are melodramatic, or unpredictable in their behaviors and interpersonal relations.

· Cluster C: Avoidant, dependent, and obsessive-compulsive (not to be confused with obsessive-compulsive disorder). These individuals tend to appear anxious, worried, or fretful in their behaviors.

In addition to these clusters, one can be diagnosed with other specified or unspecified personality disorder, as well as a personality change due to another medical condition, such as a head injury.

· Paraphilic Disorders. These disorders are diagnosed when the client is sexual aroused to circumstances that deviate from traditional sexual stimuli and when such behaviors result in harm or significant emotional distress. The disorders include exhibitionistic disorder, voyeuristic disorder, frotteurisitc disorder, sexual sadism and sexual masochism disorders, fetishistic disorder, transvestic disorder, pedophilic disorder, and other specified and unspecified paraphilic disorders.

· Other Mental Disorders. This diagnostic category includes mental disorders that did not fall within one of the previously mentioned groups and do not have unifying characteristics. Examples include other specified mental disorder due to another medical condition, unspecified mental disorders due to another medical condition, other specified mental disorder, and unspecified mental disorder.

· Medication-Induced Movement Disorders and Other Adverse Effects of Medications. These disorders are the result of adverse and severe side effects to medications, although a causal link cannot always be shown. Some of these disorders include neuroleptic-induced parkinsonism, neuroleptic malignant syndrome, medication-induced dystonia, medication-induced acute akathisia, tardive dyskinesia, tardive akathisia, medication-induced postural tremor, other medication-induced movement disorder, antidepressant discontiunation syndrome, and other adverse effect of medication.

· Other Conditions That May Be a Focus of Clinical Assessment. Reminiscent of Axis IV of the previous edition of the DSM, this last part of Section II ends with a description of concerns that could be clinically significant, such as abuse/neglect, relational problems, psychosocial, personal, and environmental concerns, educational/occupational problems, housing and economic problems, and problems related to the legal system. These conditions, which are not consider mental disorders, are generally lised as V codes, which correspond to ICD-9, or Z codes, which correspond to ICD-10.

Sometimes, mental health conditions can co-occur or be “comorbid.” For example, suppose a client presents with an anxiety disorder but also abuses alcohol. In this situation, it would be appropriate to denote both disorders when making a diagnosis (e.g., generalized anxiety disorder and alcohol abuse). Sometimes disorders can even exacerbate each other. An example of this could be someone who meets the criteria for depression, but his or her symptoms only present while withdrawing from cocaine use. Rather than diagnosing this as a major depressive episode, it is more appropriate that he or she be diagnosed with a substance-induced mood disorder (see <LINK>Exercise 3.1</LINK>).

Other Medical Considerations

Sometimes, physical symptoms caused by a medical condition may look a lot like one or more of the mental disorders. For example, some of the symptoms for depression include appetite disturbance (increase or decrease), irritability or restlessness, hyper or insomnia (i.e., sleeping too much or too little), difficulty concentrating, and fatigue or decreased energy. Interestingly, all of these symptoms can also be attributed to hypothyroidism or underactive thyroid. Thus, in addition to clients being assessed for mental health problems, it is also important for them to be assessed for potential medical problems. One way to address this is to obtain specific details about when the client began experiencing his or her symptoms. Such information will help determine whether symptoms began while a medical condition was present and whether it is likely that the medical condition was the cause of the mental disorder. For instance, suppose you have a client who is presenting with all of the criteria for an anxiety disorder (such as restlessness, irritability, and insomnia), but you know that these symptoms began when the client’s thyroid began declining and he or she found out it was underactive. If the client’s anxiety disorder only came about because of the hypothyroidism, then it would be appropriate to designate it as such, that is, anxiety disorder due to a general medical condition, hypothyroidism. Of course, it is always prudent to refer a client to his or her primary care physician if there is any suspicion that a medical problem may be the source of a psychological issue (see <LINK>Exercise 3.2</LINK>). If reporting a medical problem, the ICD code for the particular problem can be used along with the DSM-5 mental health disorder diagnosis.

Psychosocial and Environmental Considerations

As a part of a complete diagnosis, it is imperative for the clinician to assess the client’s psychosocial and environmental stressors. Such a focus promotes a holistic view of the client, provides important diagnostic clues, and can help to identify important issues in treatment planning. Not considered mental disorders, some of the many psychosocial and environmental concerns may include problems with the client’s primary support group, social environment, education, occupation, housing, economic situation, access to health care, crime or the legal system, or other significant psychosocial and environmental considerations (<BIB>APA, 2013</BIB>). Whereas these concerns were previously listed on Axis IV of DSM-IV, they are now denoted in the single-axis system, are mostly listed under “Other conditions that may be a focus of clinical attention” discussed earlier, and are correlated to V codes in DSM-5 (which matches ICD-9) or Z codes (which matches ICD-10 ) (e.g., Z59.0 Homelessness; Z65.1 Imprisonment; Z55.3 Underachievement in school).

To illustrate the importance of psychosocial and environmental considerations, consider a 48-year-old male experiencing severe anxiety and depression. He explains that his symptoms started immediately after a tornado caused severe damage to his home and neighboring farm (natural disaster). The man and his family have been staying with relatives about 70 miles away from home (homelessness), and have had no source of income for the past three months (economic issues) since their crop of soy was also destroyed in the tornado (occupational problem). By understanding the client’s psychosocial and environmental considerations, his anxiety and depression can be viewed in the context of his life circumstances.

Cultural Considerations

Because people from diverse cultures may express themselves in different ways, symptomatology may vary as a function of culture (<BIB>Mezzich & Caracci, 2008</BIB>). Thus, some have argued that although diagnosis can be helpful in treatment planning, it can lead to the misdiagnosis of culturally oppressed groups when clinicians do not fully take into account cultural, gender, and ethnic differences (<BIB>Rose & Cheung, 2012</BIB>; <BIB>Eriksen & Kress, 2005, 2006, 2008</BIB>; <BIB>Kress, Eriksen, Rayle, & Ford, 2005</BIB>; <BIB>Madesen & Leech, 2007</BIB>).

The <BIB>APA (2013)</BIB> has attempted to combat some of these problems by asking clinicians to understand and acknowledge “culturally patterned differences in symptoms” (<BIB>p. 758</BIB>). For example, Latin American culture acknowledges that ataque de nervios (“attack of nerves”) is a common disorder related to difficult and burdensome life experiences and may exhibit itself through “headaches and ‘brain aches’ (occipital neck tension), irritability, stomach disturbances, sleep difficulties, nervousness, easy tearfulness, inability to concentrate, trembling, tingling sensations, and mareos (dizziness with occasional vertigo-like exacerbations)” (<BIB>p. 835</BIB>). A clinician who ignores the client’s culture could easily misdiagnose a client who presents with symptoms like this and begin to treat the client with inappropriate strategies. Best practice for multicultural counseling suggests that the clinician have some understanding of differences in cross-cultural expression of symptoms and that the clinician explore the client’s culture with him or her when deciding on appropriate treatment strategies.

Finally, DSM-5 offers a section entitled Cultural Formulation Interview (CFI) that helps clinicians understand the kinds of values, experiences, and influences that have come to shape the client’s worldview and provides an outline for how to appropriately interview clients from diverse backgrounds. In addition, DSM-5 offers definitions of some cross-cultural symptoms and identifies how cross-cultural issues impact a wide-range of diagnoses.

Final Thoughts on DSM-5 in the Assessment Process

DSM-5 is one additional piece of the total assessment process. Along with the clinical interview, the use of tests, and informal assessment procedures, it can provide a broad understanding of the client and can be a critical piece in the treatment planning process. Consider what it might be like to establish a treatment plan if only one test were used. Then, consider what it would be like if two tests were used, then two tests and an informal assessment procedure; then two tests, an informal assessment procedure, and a clinical interview; and finally, two tests, an informal assessment procedure, a clinical interview, and a diagnosis. Clearly, the more “pieces of evidence” we can gather, the clearer our snapshot of our client becomes and this, in turn, yields better treatment planning (se

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Highlights of Changes from DSM-IV-TR to DSM-5

Highlights of Changes from DSM-IV-TR to DSM-5

Changes made to the DSM-5 diagnostic criteria and texts are outlined in this chapter in the same order in which they appear in the DSM-5 classification. This is not an exhaustive guide; minor changes in text or wording made for clarity are not described here. It should also be noted that Section I of DSM-5 con- tains a description of changes pertaining to the chapter organization in DSM-5, the multiaxial system, and the introduction of dimensional assessments (in Section III).

Terminology The phrase “general medical condition” is replaced in DSM-5 with “another medical condition” where relevant across all disorders.

Neurodevelopmental Disorders Intellectual Disability (Intellectual Developmental Disorder) Diagnostic criteria for intellectual disability (intellectual developmental disorder) emphasize the need for an assessment of both cognitive capacity (IQ) and adaptive functioning. Severity is determined by adaptive functioning rather than IQ score. The term mental retardation was used in DSM-IV. However, intellectual disability is the term that has come into common use over the past two decades among medical, educational, and other professionals, and by the lay public and advocacy groups. Moreover, a federal statue in the United States (Public Law 111-256, Rosa’s Law) replaces the term “mental retarda- tion with intellectual disability. Despite the name change, the deficits in cognitive capacity beginning in the developmental period, with the accompanying diagnostic criteria, are considered to constitute a mental disorder. The term intellectual developmental disorder was placed in parentheses to reflect the World Health Organization’s classification system, which lists “disorders” in the International Classifica- tion of Diseases (ICD; ICD-11 to be released in 2015) and bases all “disabilities” on the International Classification of Functioning, Disability, and Health (ICF). Because the ICD-11 will not be adopted for several years, intellectual disability was chosen as the current preferred term with the bridge term for the future in parentheses. Communication Disorders The DSM-5 communication disorders include language disorder (which combines DSM-IV expressive and mixed receptive-expressive language disorders), speech sound disorder (a new name for phono- logical disorder), and childhood-onset fluency disorder (a new name for stuttering). Also included is social (pragmatic) communication disorder, a new condition for persistent difficulties in the social uses of verbal and nonverbal communication. Because social communication deficits are one component of autism spectrum disorder (ASD), it is important to note that social (pragmatic) communication disorder cannot be diagnosed in the presence of restricted repetitive behaviors, interests, and activities (the oth- er component of ASD). The symptoms of some patients diagnosed with DSM-IV pervasive developmen- tal disorder not otherwise specified may meet the DSM-5 criteria for social communication disorder.

Autism Spectrum Disorder Autism spectrum disorder is a new DSM-5 name that reflects a scientific consensus that four previously separate disorders are actually a single condition with different levels of symptom severity in two core

2 • Highlights of Changes from DSM-IV-TR to DSM-5

domains. ASD now encompasses the previous DSM-IV autistic disorder (autism), Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified. ASD is characterized by 1) deficits in social communication and social interaction and 2) restricted repetitive behaviors, interests, and activities (RRBs). Because both components are required for diagnosis of ASD, social communication disorder is diagnosed if no RRBs are present.

Attention-Deficit/Hyperactivity Disorder The diagnostic criteria for attention-deficit/hyperactivity disorder (ADHD) in DSM-5 are similar to those in DSM-IV. The same 18 symptoms are used as in DSM-IV, and continue to be divided into two symp- tom domains (inattention and hyperactivity/impulsivity), of which at least six symptoms in one domain are required for diagnosis. However, several changes have been made in DSM-5: 1) examples have been added to the criterion items to facilitate application across the life span; 2) the cross-situational requirement has been strengthened to “several” symptoms in each setting; 3) the onset criterion has been changed from “symptoms that caused impairment were present before age 7 years” to “several inattentive or hyperactive-impulsive symptoms were present prior to age 12”; 4) subtypes have been replaced with presentation specifiers that map directly to the prior subtypes; 5) a comorbid diagnosis with autism spectrum disorder is now allowed; and 6) a symptom threshold change has been made for adults, to reflect their substantial evidence of clinically significant ADHD impairment, with the cutoff for ADHD of five symptoms, instead of six required for younger persons, both for inattention and for hyperactivity and impulsivity. Finally, ADHD was placed in the neurodevelopmental disorders chapter to reflect brain developmental correlates with ADHD and the DSM-5 decision to eliminate the DSM-IV chapter that includes all diagnoses usually first made in infancy, childhood, or adolescence.

Specific Learning Disorder Specific learning disorder combines the DSM-IV diagnoses of reading disorder, mathematics disorder, disorder of written expression, and learning disorder not otherwise specified. Because learning deficits in the areas of reading, written expression, and mathematics commonly occur together, coded speci- fiers for the deficit types in each area are included. The text acknowledges that specific types of read- ing deficits are described internationally in various ways as dyslexia and specific types of mathematics deficits as dyscalculia.

Motor Disorders The following motor disorders are included in the DSM-5 neurodevelopmental disorders chapter: devel- opmental coordination disorder, stereotypic movement disorder, Tourette’s disorder, persistent (chron- ic) motor or vocal tic disorder, provisional tic disorder, other specified tic disorder, and unspecified tic disorder. The tic criteria have been standardized across all of these disorders in this chapter. Stereotypic movement disorder has been more clearly differentiated from body-focused repetitive behavior disor- ders that are in the DSM-5 obsessive-compulsive disorder chapter.

Schizophrenia Spectrum and Other Psychotic Disorders Schizophrenia Two changes were made to DSM-IV Criterion A for schizophrenia. The first change is the elimination of the special attribution of bizarre delusions and Schneiderian first-rank auditory hallucinations (e.g., two or more voices conversing). In DSM-IV, only one such symptom was needed to meet the diagnostic requirement for Criterion A, instead of two of the other listed symptoms. This special attribution was

Highlights of Changes from DSM-IV-TR to DSM-5 • 3

removed due to the nonspecificity of Schneiderian symptoms and the poor reliability in distinguishing bizarre from nonbizarre delusions. Therefore, in DSM-5, two Criterion A symptoms are required for any diagnosis of schizophrenia. The second change is the addition of a requirement in Criterion A that the individual must have at least one of these three symptoms: delusions, hallucinations, and disorganized speech. At least one of these core “positive symptoms” is necessary for a reliable diagnosis of schizo- phrenia.

Schizophrenia subtypes The DSM-IV subtypes of schizophrenia (i.e., paranoid, disorganized, catatonic, undifferentiated, and residual types) are eliminated due to their limited diagnostic stability, low reliability, and poor validity. These subtypes also have not been shown to exhibit distinctive patterns of treatment response or lon- gitudinal course. Instead, a dimensional approach to rating severity for the core symptoms of schizo- phrenia is included in Section III to capture the important heterogeneity in symptom type and severity expressed across individuals with psychotic disorders.

Schizoaffective Disorder The primary change to schizoaffective disorder is the requirement that a major mood episode be pres- ent for a majority of the disorder’s total duration after Criterion A has been met. This change was made on both conceptual and psychometric grounds. It makes schizoaffective disorder a longitudinal instead of a cross-sectional diagnosis—more comparable to schizophrenia, bipolar disorder, and major depres- sive disorder, which are bridged by this condition. The change was also made to improve the reliability, diagnostic stability, and validity of this disorder, while recognizing that the characterization of patients with both psychotic and mood symptoms, either concurrently or at different points in their illness, has been a clinical challenge.

Delusional Disorder Criterion A for delusional disorder no longer has the requirement that the delusions must be non- bizarre. A specifier for bizarre type delusions provides continuity with DSM-IV. The demarcation of delusional disorder from psychotic variants of obsessive-compulsive disorder and body dysmorphic disorder is explicitly noted with a new exclusion criterion, which states that the symptoms must not be better explained by conditions such as obsessive-compulsive or body dysmorphic disorder with absent insight/delusional beliefs. DSM-5 no longer separates delusional disorder from shared delusional dis- order. If criteria are met for delusional disorder then that diagnosis is made. If the diagnosis cannot be made but shared beliefs are present, then the diagnosis “other specified schizophrenia spectrum and other psychotic disorder” is used.

Catatonia The same criteria are used to diagnose catatonia whether the context is a psychotic, bipolar, depres- sive, or other medical disorder, or an unidentified medical condition. In DSM-IV, two out of five symp- tom clusters were required if the context was a psychotic or mood disorder, whereas only one symp- tom cluster was needed if the context was a general medical condition. In DSM-5, all contexts require three catatonic symptoms (from a total of 12 characteristic symptoms). In DSM-5, catatonia may be diagnosed as a specifier for depressive, bipolar, and psychotic disorders; as a separate diagnosis in the context of another medical condition; or as an other specified diagnosis.

4 • Highlights of Changes from DSM-IV-TR to DSM-5

Bipolar and Related Disorders Bipolar Disorders To enhance the accuracy of diagnosis and facilitate earlier detection in clinical settings, Criterion A for manic and hypomanic episodes now includes an emphasis on changes in activity and energy as well as mood. The DSM-IV diagnosis of bipolar I disorder, mixed episode, requiring that the individual simulta- neously meet full criteria for both mania and major depressive episode, has been removed. Instead, a new specifier, “with mixed features,” has been added that can be applied to episodes of mania or hy- pomania when depressive features are present, and to episodes of depression in the context of major depressive disorder or bipolar disorder when features of mania/hypomania are present.

Other Specified Bipolar and Related Disorder DSM-5 allows the specification of particular conditions for other specified bipolar and related disorder, including categorization for individuals with a past history of a major depressive disorder who meet all criteria for hypomania except the duration criterion (i.e., at least 4 consecutive days). A second condi- tion constituting an other specified bipolar and related disorder is that too few symptoms of hypoma- nia are present to meet criteria for the full bipolar II syndrome, although the duration is sufficient at 4 or more days.

Anxious Distress Specifier In the chapter on bipolar and related disorders and the chapter on depressive disorders, a specifier for anxious distress is delineated. This specifier is intended to identify patients with anxiety symptoms that are not part of the bipolar diagnostic criteria.

Depressive Disorders DSM-5 contains several new depressive disorders, including disruptive mood dysregulation disorder and premenstrual dysphoric disorder. To address concerns about potential overdiagnosis and overtreat- ment of bipolar disorder in children, a new diagnosis, disruptive mood dysregulation disorder, is includ- ed for children up to age 18 years who exhibit persistent irritability and frequent episodes of extreme behavioral dyscontrol. Based on strong scientific evidence, premenstrual dysphoric disorder has been moved from DSM-IV Appendix B, “Criteria Sets and Axes Provided for Further Study,” to the main body of DSM-5. Finally, DSM-5 conceptualizes chronic forms of depression in a somewhat modified way. What was referred to as dysthymia in DSM-IV now falls under the category of persistent depressive dis- order, which includes both chronic major depressive disorder and the previous dysthymic disorder. An inability to find scientifically meaningful differences between these two conditions led to their combi- nation with specifiers included to identify different pathways to the diagnosis and to provide continuity with DSM-IV.

Major Depressive Disorder Neither the core criterion symptoms applied to the diagnosis of major depressive episode nor the req- uisite duration of at least 2 weeks has changed from DSM-IV. Criterion A for a major depressive episode in DSM-5 is identical to that of DSM-IV, as is the requirement for clinically significant distress or impair- ment in social, occupational, or other important areas of life, although this is now listed as Criterion B rather than Criterion C. The coexistence within a major depressive episode of at least three manic symptoms (insufficient to satisfy criteria for a manic episode) is now acknowledged by the specifier “with mixed features.” The presence of mixed features in an episode of major depressive disorder in-

Highlights of Changes from DSM-IV-TR to DSM-5 • 5

creases the likelihood that the illness exists in a bipolar spectrum; however, if the individual concerned has never met criteria for a manic or hypomanic episode, the diagnosis of major depressive disorder is retained.

Bereavement Exclusion In DSM-IV, there was an exclusion criterion for a major depressive episode that was applied to depres- sive symptoms lasting less than 2 months following the death of a loved one (i.e., the bereavement exclusion). This exclusion is omitted in DSM-5 for several reasons. The first is to remove the implication that bereavement typically lasts only 2 months when both physicians and grief counselors recognize that the duration is more commonly 1–2 years. Second, bereavement is recognized as a severe psy- chosocial stressor that can precipitate a major depressive episode in a vulnerable individual, generally beginning soon after the loss. When major depressive disorder occurs in the context of bereavement, it adds an additional risk for suffering, feelings of worthlessness, suicidal ideation, poorer somatic health, worse interpersonal and work functioning, and an increased risk for persistent complex bereavement disorder, which is now described with explicit criteria in Conditions for Further Study in DSM-5 Section III. Third, bereavement-related major depression is most likely to occur in individuals with past personal and family histories of major depressive episodes. It is genetically influenced and is associated with similar personality characteristics, patterns of comorbidity, and risks of chronicity and/or recurrence as non–bereavement-related major depressive episodes. Finally, the depressive symptoms associated with bereavement-related depression respond to the same psychosocial and medication treatments as non–bereavement-related depression. In the criteria for major depressive disorder, a detailed footnote has replaced the more simplistic DSM-IV exclusion to aid clinicians in making the critical distinction be- tween the symptoms characteristic of bereavement and those of a major depressive episode. Thus, al- though most people experiencing the loss of a loved one experience bereavement without developing a major depressive episode, evidence does not support the separation of loss of a loved one from other stressors in terms of its likelihood of precipitating a major depressive episode or the relative likelihood that the symptoms will remit spontaneously.

Specifiers for Depressive Disorders Suicidality represents a critical concern in psychiatry. Thus, the clinician is given guidance on assess- ment of suicidal thinking, plans, and the presence of other risk factors in order to make a determination of the prominence of suicide prevention in treatment planning for a given individual. A new specifier to indicate the presence of mixed symptoms has been added across both the bipolar and the depressive disorders, allowing for the possibility of manic features in individuals with a diagnosis of unipolar de- pression. A substantial body of research conducted over the last two decades points to the importance of anxiety as relevant to prognosis and treatment decision making. The “with anxious distress” specifier gives the clinician an opportunity to rate the severity of anxious distress in all individuals with bipolar or depressive disorders.

Anxiety Disorders The DSM-5 chapter on anxiety disorder no longer includes obsessive-compulsive disorder (which is included with the obsessive-compulsive and related disorders) or posttraumatic stress disorder and acute stress disorder (which is included with the trauma- and stressor-related disorders). However, the sequential order of these chapters in DSM-5 reflects the close relationships among them.

6 • Highlights of Changes from DSM-IV-TR to DSM-5

Agoraphobia, Specific Phobia, and Social Anxiety Disorder (Social Phobia) Changes in criteria for agoraphobia, specific phobia, and social anxiety disorder (social phobia) include deletion of the requirement that individuals over age 18 years recognize that their anxiety is excessive or unreasonable. This change is based on evidence that individuals with such disorders often overesti- mate the danger in “phobic” situations and that older individuals often misattribute “phobic” fears to aging. Instead, the anxiety must be out of proportion to the actual danger or threat in the situation, af- ter taking cultural contextual factors into account. In addition, the 6-month duration, which was limited to individuals under age 18 in DSM-IV, is now extended to all ages. This change is intended to minimize overdiagnosis of transient fears.

Panic Attack The essential features of panic attacks remain unchanged, although the complicated DSM-IV terminol- ogy for describing different types of panic attacks (i.e., situationally bound/cued, situationally predis- posed, and unexpected/uncued) is replaced with the terms unexpected and expected panic attacks. Panic attacks function as a marker and prognostic factor for severity of diagnosis, course, and comor- bidity across an array of disorders, including but not limited to anxiety disorders. Hence, panic attack can be listed as a specifier that is applicable to all DSM-5 disorders.

Panic Disorder and Agoraphobia Panic disorder and agoraphobia are unlinked in DSM-5. Thus, the former DSM-IV diagnoses of panic disorder with agoraphobia, panic disorder without agoraphobia, and agoraphobia without history of panic disorder are now replaced by two diagnoses, panic disorder and agoraphobia, each with separate criteria. The co-occurrence of panic disorder and agoraphobia is now coded with two diagnoses. This change recognizes that a substantial number of individuals with agoraphobia do not experience panic symptoms. The diagnostic criteria for agoraphobia are derived from the DSM-IV descriptors for agora- phobia, although endorsement of fears from two or more agoraphobia situations is now required, be- cause this is a robust means for distinguishing agoraphobia from specific phobias. Also, the criteria for agoraphobia are extended to be consistent with criteria sets for other anxiety disorders (e.g., clinician judgment of the fears as being out of proportion to the actual danger in the situation, with a typical duration of 6 months or more).

Specific Phobia The core features of specific phobia remain the same, but there is no longer a requirement that indi- viduals over age 18 years must recognize that their fear and anxiety are excessive or unreasonable, and the duration requirement (“typically lasting for 6 months or more”) now applies to all ages. Although they are now referred to as specifiers, the different types of specific phobia have essentially remained unchanged.

Social Anxiety Disorder (Social Phobia) The essential features of social anxiety disorder (social phobia) (formerly called social phobia) remain the same. However, a number of changes have been made, including deletion of the requirement that individuals over age 18 years must recognize that their fear or anxiety is excessive or unreasonable, and duration criterion of “typically lasting for 6 months or more” is now required for all ages. A more sig- nificant change is that the “generalized” specifier has been deleted and replaced with a “performance only” specifier. The DSM-IV generalized specifier was problematic in that “fears include most social situ- ations” was difficult to operationalize. Individuals who fear only performance situations (i.e., speaking

Highlights of Changes from DSM-IV-TR to DSM-5 • 7

or performing in front of an audience) appear to represent a distinct subset of social anxiety disorder in terms of etiology, age at onset, physiological response, and treatment response.

Separation Anxiety Disorder Although in DSM-IV, separation anxiety disorder was classified in the section “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence,” it is now classified as an anxiety disorder. The core features remain mostly unchanged, although the wording of the criteria has been modified to more adequately represent the expression of separation anxiety symptoms in adulthood. For example, at- tachment figures may include the children of adults with separation anxiety disorder, and avoidance behaviors may occur in the workplace as well as at school. Also, in contrast to DSM-IV, the diagnostic criteria no longer specify that age at onset must be before 18 years, because a substantial number of adults report onset of separation anxiety after age 18. Also, a duration criterion—“typically lasting for 6 months or more”—has been added for adults to minimize overdiagnosis of transient fears.

Selective Mutism In DSM-IV, selective mutism was classified in the section “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence.” It is now classified as an anxiety disorder, given that a large majority of children with selective mutism are anxious. The diagnostic criteria are largely unchanged from DSM-IV.

Obsessive-Compulsive and Related Disorders The chapter on obsessive-compulsive and related disorders, which is new in DSM-5, reflects the in- creasing evidence that these disorders are related to one another in terms of a range of diagnostic validators, as well as the clinical utility of grouping these disorders in the same chapter. New disorders include hoarding disorder, excoriation (skin-picking) disorder, substance-/medication-induced obses- sive-compulsive and related disorder, and obsessive-compulsive and related disorder due to another medical condition. The DSM-IV diagnosis of trichotillomania is now termed trichotillomania (hair-pull- ing disorder) and has been moved from a DSM-IV classification of impulse-control disorders not else- where classified to obsessive-compulsive and related disorders in DSM-5.

Specifiers for Obsessive-Compulsive and Related Disorders The “with poor insight” specifier for obsessive-compulsive disorder has been refined in DSM-5 to allow a distinction between individuals with good or fair insight, poor insight, and “absent insight/delusional” obsessive-compulsive disorder beliefs (i.e., complete conviction that obsessive-compulsive disorder beliefs are true). Analogous “insight” specifiers have been included for body dysmorphic disorder and hoarding disorder. These specifiers are intended to improve differential diagnosis by emphasizing that individuals with these two disorders may present with a range of insight into their disorder-related be- liefs, including absent insight/delusional symptoms. This change also emphasizes that the presence of absent insight/delusional beliefs warrants a diagnosis of the relevant obsessive-compulsive or related disorder, rather than a schizophrenia spectrum and other psychotic disorder. The “tic-related” specifier for obsessive-compulsive disorder reflects a growing literature on the diagnostic validity and clinical utility of identifying individuals with a current or past comorbid tic disorder, because this comorbidity may have important clinical implications.

Body Dysmorphic Disorder For DSM-5 body dysmorphic disorder, a diagnostic criterion describing repetitive behaviors or mental

8 • Highlights of Changes from DSM-IV-TR to DSM-5

acts in response to preoccupations with perceived defects or flaws in physical appearance has been added, consistent with data indicating the prevalence and importance of this symptom. A “with muscle dysmorphia” specifier has been added to reflect a growing literature on the diagnostic validity and clini- cal utility of making this distinction in individuals with body dysmorphic disorder. The delusional vari- ant of body dysmorphic disorder (which identifies individuals who are completely convinced that their perceived defects or flaws are truly abnormal appearing) is no longer coded as both delusional disor- der, somatic type, and body dysmorphic disorder; in DSM-5 this presentation is designated only as body dysmorphic disorder with the absent insight/delusional beliefs specifier.

Hoarding Disorder Hoarding disorder is a new diagnosis in DSM-5. DSM-IV lists hoarding as one of the possible symptoms of obsessive-compulsive personality disorder and notes that extreme hoarding may occur in obsessive- compulsive disorder. However, available data do not indicate that hoarding is a variant of obsessive- compulsive disorder or another mental disorder. Instead, there is evidence for the diagnostic validity and clinical utility of a separate diagnosis of hoarding disorder, which reflects persistent difficulty dis- carding or parting with possessions due to a perceived need to save the items and distress associated with discarding them. Hoarding disorder may have unique neurobiological correlates, is associated with significant impairment, and may respond to clinical intervention.

Trichotillomania (Hair-Pulling Disorder) Trichotillomania was included in DSM-IV, although “hair-pulling disorder” has been added parentheti- cally to the disorder’s name in DSM-5.

Excoriation (Skin-Picking) Disorder Excoriation (skin-picking) disorder is newly added to DSM-5, with strong evidence for its diagnostic validity and clinical utility.

Substance/Medication-Induced Obsessive-Compulsive and Related Disorder and Obsessive-Compul- sive and Related Disorder Due to Another Medical Condition DSM-IV included a specifier “with obsessive-compulsive symptoms” in the diagnoses of anxiety disor- ders due to a general medical condition and substance-induced anxiety disorders. Given that obses- sive-compulsive and related disorders are now a distinct category, DSM-5 includes new categories for substance-/medication-induced obsessive-compulsive and related disorder and for obsessive-compul- sive and related disorder due to another medical condition. This change is consistent with the intent of DSM-IV, and it reflects the recognition that substances, medications, and medical conditions can pres- ent with symptoms similar to primary obsessive-compulsive and related disorders.

Other Specified and Unspecified Obsessive-Compulsive and Related Disorders DSM-5 includes the diagnoses other specified obsessive-compulsive and related disorder, which can include conditions such as body-focused repetitive behavior disorder and obsessional jealousy, or unspecified obsessive-compulsive and related disorder. Body-focused repetitive behavior disorder is characterized by recurrent behaviors other than hair pulling and skin picking (e.g., nail biting, lip biting, cheek chewing) and repeated attempts to decrease or stop the behaviors. Obsessional jealousy is char- acterized by nondelusional preoccupation with a partner’s perceived infidelity.

Highlights of Changes from DSM-IV-TR to DSM-5 • 9

Trauma- and Stressor-Related Disorders Acute Stress Disorder In DSM-5, the stressor criterion (Criterion A) for acute stress disorder is changed from DSM-IV. The criterion requires being explicit as to whether qualifying traumatic events were experienced directly, witnessed, or experienced indirectly. Also, the DSM-IV Criterion A2 regarding the subjective reaction to the traumatic event (e.g., “the person’s response involved intense fear, helplessness, or horror”) has been eliminated. Based on evidence that acute posttraumatic reactions are very heterogeneous and that DSM-IV’s emphasis on dissociative symptoms is overly restrictive, individuals may meet diagnostic criteria in DSM-5 for acute stress disorder if they exhibit any 9 of 14 listed symptoms in these catego- ries: intrusion, negative mood, dissociation, avoidance, and arousal.

Adjustment Disorders In DSM-5, adjustment disorders are reconceptualized as a heterogeneous array of stress-response syndromes that occur after exposure to a distressing (traumatic or nontraumatic) event, rather than as a residual category for individuals who exhibit clinically significant distress without meeting criteria for a more discrete disorder (as in DSM-IV ). DSM-IV subtypes marked by depressed mood, anxious symp- toms, or disturbances in conduct have been retained, unchanged.

Posttraumatic Stress Disorder DSM-5 criteria for posttraumatic stress disorder differ significantly from those in DSM-IV. As described previously for acute stress disorder, the stressor criterion (Criterion A) is more explicit with regard to how an individual experienced “traumatic” events. Also, Criterion A2 (subjective reaction) has been eliminated. Whereas there were three major symptom clusters in DSM-IV—reexperiencing, avoid- ance/numbing, and arousal—there are now four symptom clusters in DSM-5, because the avoidance/ numbing cluster is divided into two distinct clusters: avoidance and persistent negative alterations in cognitions and mood. This latter category, which retains most of the DSM-IV numbing symptoms, also includes new or reconceptualized symptoms, such as persistent negative emotional states. The final cluster—alterations in arousal and reactivity—retains most of the DSM-IV arousal symptoms. It also includes irritable or aggressive behavior and reckless or self-destructive behavior. Posttraumatic stress disorder is now developmentally sensitive in that diagnostic thresholds have been lowered for children and adolescents. Furthermore, separate criteria have been added for children age 6 years or younger with this disorder.

Reactive Attachment Disorder The DSM-IV childhood diagnosis reactive attachment disorder had two subtypes: emotionally with- drawn/inhibited and indiscriminately social/disinhibited. In DSM-5, these subtypes are defined as distinct disorders: reactive attachment disorder and disinhibited social engagement disorder. Both of these disorders are the result of social neglect or other situations that limit a young child’s opportunity to form selective attachments. Although sharing this etiological pathway, the two disorders differ in important ways. Because of dampened positive affect, reactive attachment disorder more closely re- sembles internalizing disorders; it is essentially equivalent to a lack of or incompletely formed preferred attachments to caregiving adults. In contrast, disinhibited social engagement disorder more closely resembles ADHD; it may occur in children who do not necessarily lack attachments and may have es- tablished or even secure attachments. The two disorders differ in other important ways, including cor- relates, course, and response to intervention, and for these reasons are considered separate disorders.

10 • Highlights of Changes from DSM-IV-TR to DSM-5

Dissociative Disorders Major changes in dissociative disorders in DSM-5 include the following: 1) derealization is included in the name and symptom structure of what previously was called depersonalization disorder and is now called depersonalization/derealization disorder, 2) dissociative fugue is now a specifier of dissociative amnesia rather than a separate diagnosis, and 3) the criteria for dissociative identity disorder have been changed to indicate that symptoms of disruption of identity may be reported as well as observed, and that gaps in the recall of events may occur for everyday and not just traumatic events. Also, experi- ences of pathological possession in some cultures are included in the description of identity disruption.

Dissociative Identity Disorder Several changes to the criteria for dissociative identity disorder have been made in DSM-5. First, Criterion A has been expanded to include certain possession-form phenomena and functional neurological symp- toms to account for more diverse presentations of the disorder. Second, Criterion A now specifically states that transitions in identity may be observable by others or self-reported. Third, according to Criterion B, in- dividuals with dissociative identity disorder may have recurrent gaps in recall for everyday events, not just for traumatic experiences. Other text modifications clarify the nature and course of identity disruptions.

Somatic Symptom and Related Disorders In DSM-5, somatoform disorders are now referred to as somatic symptom and related disorders. In DSM-IV, there was significant overlap across the somatoform disorders and a lack of clarity about their boundaries. These disorders are primarily seen in medical settings, and nonpsychiatric physicians found the DSM-IV somatoform diagnoses problematic to use. The DSM-5 classification reduces the number of these disorders and subcategories to avoid problematic overlap. Diagnoses of somatization disorder, hypochondriasis, pain disorder, and undifferentiated somatoform disorder have been removed.

Somatic Symptom Disorder DSM-5 better recognizes the complexity of the interface between psychiatry and medicine. Individu- als with somatic symptoms plus abnormal thoughts, feelings, and behaviors may or may not have a diagnosed medical condition. The relationship between somatic symptoms and psychopathology exists along a spectrum, and the arbitrarily high symptom count required for DSM-IV somatization disorder did not accommodate this spectrum. The diagnosis of somatization disorder was essentially based on a long and complex symptom count of medically unexplained symptoms. Individuals previously diag- nosed with somatization disorder will usually meet DSM-5 criteria for somatic symptom disorder, but only if they have the maladaptive thoughts, feelings, and behaviors that define the disorder, in addition to their somatic symptoms.

In DSM-IV, the diagnosis undifferentiated somatoform disorder had been created in recognition that somatization disorder would only describe a small minority of “somatizing” individuals, but this disor- der did not prove to be a useful clinical diagnosis. Because the distinction between somatization disor- der and undifferentiated somatoform disorder was arbitrary, they are merged in DSM-5 under somatic symptom disorder, and no specific number of somatic symptoms is required.

Medically Unexplained Symptoms DSM-IV criteria overemphasized the importance of an absence of a medical explanation for the somatic symptoms. Unexplained symptoms are present to various degrees, particularly in conversion disorder,

Highlights of Changes from DSM-IV-TR to DSM-5 • 11

but somatic symptom disorders can also accompany diagnosed medical disorders. The reliability of medically unexplained symptoms is limited, and grounding a diagnosis on the absence of an explana- tion is problematic and reinforces mind -body dualism. The DSM-5 classification defines disorders on the basis of positive symptoms (i.e., distressing somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to these symptoms). Medically unexplained symptoms do remain a key fea- ture in conversion disorder and pseudocyesis because it is possible to demonstrate definitively in such disorders that the symptoms are not consistent with medical pathophysiology.

Hypochondriasis and Illness Anxiety Disorder Hypochondriasis has been eliminated as a disorder, in part because the name was perceived as pejora- tive and not conducive to an effective therapeutic relationship. Most individuals who would previously have been diagnosed with hypochondriasis have significant somatic symptoms in addition to their high health anxiety, and would now receive a DSM-5 diagnosis of somatic symptom disorder. In DSM-5, indi- viduals with high health anxiety without somatic symptoms would receive a diagnosis of illness anxiety disorder (unless their health anxiety was better explained by a primary anxiety disorder, such as gener- alized anxiety disorder).

Pain Disorder DSM-5 takes a different approach to the important clinical realm of individuals with pain. In DSM-IV, the pain disorder diagnoses assume that some pains are associated solely with psychological factors, some with medical diseases or injuries, and some with both. There is a lack of evidence that such distinctions can be made with reliability and validity, and a large body of research has demonstrated that psycho- logical factors influence all forms of pain. Most individuals with chronic pain attribute their pain to a combination of factors, including somatic, psychological, and environmental influences. In DSM-5, some individuals with chronic pain would be appropriately diagnosed as having somatic symptom disorder, with predominant pain. For others, psychological factors affecting other medical conditions or an ad- justment disorder would be more appropriate.

Psychological Factors Affecting Other Medical Conditions and Factitious Disorder Psychological factors affecting other medical conditions is a new mental disorder in DSM-5, having formerly been included in the DSM-IV chapter “Other Conditions That May Be a Focus of Clinical Atten- tion.” This disorder and factitious disorder are placed among the somatic symptom and related disor- ders because somatic symptoms are predominant in both disorders, and both are most often encoun- tered in medical settings. The variants of psychological factors affecting other medical conditions are removed in favor of the stem diagnosis.

Conversion Disorder (Functional Neurological Symptom Disorder) Criteria for conversion disorder (functional neurological symptom disorder) are modified to emphasize the essential importance of the neurological examination, and in recognition that relevant psychologi- cal factors may not be demonstrable at the time of diagnosis.

Feeding and Eating Disorders In DSM-5, the feeding and eating disorders include several disorders included in DSM-IV as feeding and eating disorders of infancy or early childhood in the chapter “Disorders Usually First Diagnosed in In- fancy, Childhood, or Adolescence.” In addition, brief descriptions and preliminary diagnostic criteria are provided for several conditions under other specified feeding and eating disorder; insufficient informa-

12 • Highlights of Changes from DSM-IV-TR to DSM-5

tion about these conditions is currently available to document their clinical characteristics and validity or to provide definitive diagnostic criteria.

Pica and Rumination Disorder The DSM-IV criteria for pica and for rumination disorder have been revised for clarity and to indicate that the diagnoses can be made for individuals of any age.

Avoidant/Restrictive Food Intake Disorder DSM-IV feeding disorder of infancy or early childhood has been renamed avoidant/restrictive food intake disorder, and the criteria have been significantly expanded. The DSM-IV disorder was rarely used, and limited information is available on the characteristics, course, and outcome of children with this disorder. Additionally, a large number of individuals, primarily but not exclusively children and adoles- cents, substantially restrict their food intake and experience significant associated physiological or psy- chosocial problems but do not meet criteria for any DSM-IV eating disorder. Avoidant/restrictive food intake disorder is a broad category intended to capture this range of presentations.

Anorexia Nervosa The core diagnostic criteria for anorexia nervosa are conceptually unchanged from DSM-IV with one ex- ception: the requirement for amenorrhea has been eliminated. In DSM-IV, this requirement was waived in a number of situations (e.g., for males, for females taking contraceptives). In addition, the clinical characteristics and course of females meeting all DSM-IV criteria for anorexia nervosa except amenor- rhea closely resemble those of females meeting all DSM-IV criteria. As in DSM-IV, individuals with this disorder are required by Criterion A to be at a significantly low body weight for their developmental stage. The wording of the criterion has been changed for clarity, and guidance regarding how to judge whether an individual is at or below a significantly low weight is now provided in the text. In DSM-5, Criterion B is expanded to include not only overtly expressed fear of weight gain but also persistent behavior that interferes with weight gain.

Bulimia Nervosa The only change to the DSM-IV criteria for bulimia nervosa is a reduction in the required minimum average frequency of binge eating and inappropriate compensatory behavior frequency from twice to once weekly. The clinical characteristics and outcome of individuals meeting this slightly lower thresh- old are similar to those meeting the DSM-IV criterion.

Binge-Eating Disorder Extensive research followed the promulgation of preliminary criteria for binge eating disorder in Ap- pendix B of DSM-IV, and findings supported the clinical utility and validity of binge-eating disorder. The only significant difference from the preliminary DSM-IV criteria is that the minimum average frequency of binge eating required for diagnosis has been changed from at least twice weekly for 6 months to at least once weekly over the last 3 months, which is identical to the DSM-5 frequency criterion for buli- mia nervosa.

Elimination Disorders No significant changes have been made to the elimination disorders diagnostic class from DSM-IV to DSM-5. The disorders in this chapter were previously classified under disorders usually first diagnosed in infancy, childhood, or adolescence in DSM-IV and exist now as an independent classification in DSM-5.

Highlights of Changes from DSM-IV-TR to DSM-5 • 13

Sleep-Wake Disorders Because of the DSM-5 mandate for concurrent specification of coexisting conditions (medical and mental), sleep disorders related to another mental disorder and sleep disorder related to a general medical condition have been removed from DSM-5, and greater specification of coexisting conditions is provided for each sleep-wake disorder. This change underscores that the individual has a sleep disorder warranting independent clinical attention, in addition to any medical and mental disorders that are also present, and acknowledges the bidirectional and interactive effects between sleep disorders and coex- isting medical and mental disorders. This reconceptualization reflects a paradigm shift that is widely ac- cepted in the field of sleep disorders medicine. It moves away from making causal attributions between coexisting disorders. Any additional relevant information from the prior diagnostic categories of sleep disorder related to another mental disorder and sleep disorder related to another medical condition has been integrated into the other sleep-wake disorders where appropriate. Consequently, in DSM-5, the diagnosis of primary insomnia has been renamed insomnia disorder to avoid the differentiation of primary and secondary insomnia. DSM-5 also distinguishes narcolepsy, which is now known to be associated with hypocretin deficiency, from other forms of hypersomno- lence. These changes are warranted by neurobiological and genetic evidence validating this reorganiza- tion. Finally, throughout the DSM-5 classification of sleep-wake disorders, pediatric and developmental criteria and text are integrated where existing science and considerations of clinical utility support such integration. This developmental perspective encompasses age-dependent variations in clinical presentation.

Breathing-Related Sleep Disorders In DSM-5, breathing-related sleep disorders are divided into three relatively distinct disorders: obstruc- tive sleep apnea hypopnea, central sleep apnea, and sleep-related hypoventilation. This change reflects the growing understanding of pathophysiology in the genesis of these disorders and, furthermore, has relevance to treatment planning.

Circadian Rhythm Sleep-Wake Disorders The subtypes of circadian rhythm sleep-wake disorders have been expanded to include advanced sleep phase syndrome, irregular sleep-wake type, and non-24-hour sleep-wake type, whereas the jet lag type has been removed.

Rapid Eye Movement Sleep Behavior Disorder and Restless Legs Syndrome The use of DSM-IV “not otherwise specified” diagnoses has been reduced by designating rapid eye movement sleep behavior disorder and restless legs syndrome as independent disorders. In DSM-IV, both were included under dyssomnia not otherwise specified. Their full diagnostic status is supported by research evidence.

Sexual Dysfunctions In DSM-IV, sexual dysfunctions referred to sexual pain or to a disturbance in one or more phases of the sexual response cycle. Research suggests that sexual response is not always a linear, uniform process and that the distinction between certain phases (e.g., desire and arousal) may be artificial. In DSM-5, gender-specific sexual dysfunctions have been added, and, for females, sexual desire and arousal disor- ders have been combined into one disorder: female sexual interest/arousal disorder.

To improve precision regarding duration and severity criteria and to reduce the likelihood of overdiag-

14 • Highlights of Changes from DSM-IV-TR to DSM-5

nosis, all of the DSM-5 sexual dysfunctions (except substance-/medication-induced sexual dysfunction) now require a minimum duration of approximately 6 months and more precise severity criteria. These changes provide useful thresholds for making a diagnosis and distinguish transient sexual difficulties from more persistent sexual dysfunction.

Genito-Pelvic Pain/Penetration Disorder Genito-pelvic pain/penetration disorder is new in DSM-5 and represents a merging of the DSM-IV cat- egories of vaginismus and dyspareunia, which were highly comorbid and difficult to distinguish. The di- agnosis of sexual aversion disorder has been removed due to rare use and lack of supporting research.

Subtypes DSM-IV included the following subtypes for all sexual disorders: lifelong versus acquired, generalized versus situational, and due to psychological factors versus due to combined factors. DSM-5 includes only lifelong versus acquired and generalized versus situational subtypes. Sexual dysfunction due to a general medical condition and the subtype due to psychological versus combined factors have been deleted due to findings that the most frequent clinical presentation is one in which both psychological and biological factors contribute. To indicate the presence and degree of medical and other nonmedical correlates, the following associated features are described in the accompanying text: partner factors, relationship factors, individual vulnerability factors, cultural or religious factors, and medical factors.

Gender Dysphoria Gender dysphoria is a new diagnostic class in DSM-5 and reflects a change in conceptualization of the disorder’s defining features by emphasizing the phenomenon of “gender incongruence” rather than cross-gender identification per se, as was the case in DSM-IV gender identity disorder. In DSM-IV, the chapter “Sexual and Gender Identity Disorders” included three relatively disparate diagnostic classes: gender identity disorders, sexual dysfunctions, and paraphilias. Gender identity disorder, however, is neither a sexual dysfunction nor a paraphilia. Gender dysphoria is a unique condition in that it is a di- agnosis made by mental health care providers, although a large proportion of the treatment is endocri- nological and surgical (at least for some adolescents and most adults). In contrast to the dichotomized DSM-IV gender identity disorder diagnosis, the type and severity of gender dysphoria can be inferred from the number and type of indicators and from the severity measures.

The experienced gender incongruence and resulting gender dysphoria may take many forms. Gender dysphoria thus is considered to be a multicategory concept rather than a dichotomy, and DSM-5 ac- knowledges the wide variation of gender -incongruent conditions. Separate criteria sets are provided for gender dysphoria in children and in adolescents and adults. The adolescent and adult criteria include a more detailed and specific set of polythetic symptoms. The previous Criterion A (cross-gender identification) and Criterion B (aversion toward one’s gender) have been merged, because no support- ing evidence from factor analytic studies supported keeping the two separate. In the wording of the criteria, “the other sex” is replaced by “some alternative gender.” Gender instead of sex is used system- atically because the concept “sex” is inadequate when referring to individuals with a disorder of sex development.

In the child criteria, “strong desire to be of the other gender” replaces the previous “repeatedly stated desire” to capture the situation of some children who, in a coercive environment, may not verbalize the desire to be of another gender. For children, Criterion A1 (“a strong desire to be of the other gender or

Highlights of Changes from DSM-IV-TR to DSM-5 • 15

an insistence that he or she is the other gender . . .)” is now necessary (but not sufficient), which makes the diagnosis more restrictive and conservative.

Subtypes and Specifiers The subtyping on the basis of sexual orientation has been removed because the distinction is not considered clinically useful. A posttransition specifier has been added because many individuals, after transition, no longer meet criteria for gender dysphoria; however, they continue to undergo various treatments to facilitate life in the desired gender. Although the concept of posttransition is modeled on the concept of full or partial remission, the term remission has implications in terms of symptom reduc- tion that do not apply directly to gender dysphoria.

Disruptive, Impulse-Control, and Conduct Disorders The chapter on disruptive, impulse-control, and conduct disorders is new to DSM-5. It brings together disorders that were previously included in the chapter “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence” (i.e., oppositional defiant disorder; conduct disorder; and disruptive be- havior disorder not otherwise specified, now categorized as other specified and unspecified disruptive, impulse-control, and conduct disorders) and the chapter “Impulse-Control Disorders Not Otherwise Specified” (i.e., intermittent explosive disorder, pyromania, and kleptomania). These disorders are all characterized by problems in emotional and behavioral self-control. Because of its close association with conduct disorder, antisocial personality disorder has dual listing in this chapter and in the chapter on personality disorders. Of note, ADHD is frequently comorbid with the disorders in this chapter but is listed with the neurodevelopmental disorders.

Oppositional Defiant Disorder Four refinements have been made to the criteria for oppositional defiant disorder. First, symptoms are now grouped into three types: angry/irritable mood, argumentative/defiant behavior, and vindictive- ness. This change highlights that the disorder reflects both emotional and behavioral symptomatology. Second, the exclusion criterion for conduct disorder has been removed. Third, given that many behav- iors associated with symptoms of oppositional defiant disorder occur commonly in normally developing children and adolescents, a note has been added to the criteria to provide guidance on the frequency typically needed for a behavior to be considered symptomatic of the disorder. Fourth, a severity rating has been added to the criteria to reflect research showing that the degree of pervasiveness of symp- toms across settings is an important indicator of severity.

Conduct Disorder The criteria for conduct disorder are largely unchanged from DSM-IV. A descriptive features specifier has been added for individuals who meet full criteria for the disorder but also present with limited pro- social emotions. This specifier applies to those with conduct disorder who show a callous and unemo- tional interpersonal style across multiple settings and relationships. The specifier is based on research showing that individuals with conduct disorder who meet criteria for the specifier tend to have a rela- tively more severe form of the disorder and a different treatment response.

Intermittent Explosive Disorder The primary change in DSM-5 intermittent explosive disorder is the type of aggressive outbursts that should be considered: physical aggression was required in DSM-IV, whereas verbal aggression and non- destructive/noninjurious physical aggression also meet criteria in DSM-5. DSM-5 also provides more

16 • Highlights of Changes from DSM-IV-TR to DSM-5

specific criteria defining frequency needed to meet criteria and specifies that the aggressive outbursts are impulsive and/or anger based in nature, and must cause marked distress, cause impairment in oc- cupational or interpersonal functioning, or be associated with negative financial or legal consequences. Furthermore, because of the paucity of research on this disorder in young children and the potential difficulty of distinguishing these outbursts from normal temper tantrums in young children, a minimum age of 6 years (or equivalent developmental level) is now required. Finally, especially for youth, the relationship of this disorder to other disorders (e.g., ADHD, disruptive mood dysregulation disorder) has been further clarified.

Substance-Related and Addictive Disorders Gambling Disorder An important departure from past diagnostic manuals is that the substance-related disorders chapter has been expanded to include gambling disorder. This change reflects the increasing and consistent evidence that some behaviors, such as gambling, activate the brain reward system with effects similar to those of drugs of abuse and that gambling disorder symptoms resemble substance use disorders to a certain extent.

Criteria and Terminology DSM-5 does not separate the diagnoses of substance abuse and dependence as in DSM-IV. Rather, cri- teria are provided for substance use disorder, accompanied by criteria for intoxication, withdrawal, sub- stance/medication-induced disorders, and unspecified substance-induced disorders, where relevant. The DSM-5 substance use disorder criteria are nearly identical to the DSM-IV substance abuse and de- pendence criteria combined into a single list, with two exceptions. The DSM-IV recurrent legal problems criterion for substance abuse has been deleted from DSM-5, and a new criterion, craving or a strong desire or urge to use a substance, has been added. In addition, the threshold for substance use disorder diagnosis in DSM-5 is set at two or more criteria, in contrast to a threshold of one or more criteria for a diagnosis of DSM-IV substance abuse and three or more for DSM-IV substance dependence. Canna- bis withdrawal is new for DSM-5, as is caffeine withdrawal (which was in DSM-IV Appendix B, “Criteria Sets and Axes Provided for Further Study”). Of note, the criteria for DSM-5 tobacco use disorder are the same as those for other substance use disorders. By contrast, DSM-IV did not have a category for tobacco abuse, so the criteria in DSM-5 that are from DSM-IV abuse are new for tobacco in DSM-5. Severity of the DSM-5 substance use disorders is based on the number of criteria endorsed: 2–3 criteria indicate a mild disorder; 4–5 criteria, a moderate disorder; and 6 or more, a severe disorder. The DSM- IV specifier for a physiological subtype has been eliminated in DSM-5, as has the DSM-IV diagnosis of polysubstance dependence. Early remission from a DSM-5 substance use disorder is defined as at least 3 but less than 12 months without substance use disorder criteria (except craving), and sustained re- mission is defined as at least 12 months without criteria (except craving). Additional new DSM-5 speci- fiers include “in a controlled environment” and “on maintenance therapy” as the situation warrants.

Neurocognitive Disorders Delirium The criteria for delirium have been updated and clarified on the basis of currently available evidence.

Major and Mild Neurocognitive Disorder The DSM-IV diagnoses of dementia and amnestic disorder are subsumed under the newly named entity

Highlights of Changes from DSM-IV-TR to DSM-5 • 17

major neurocognitive disorder (NCD). The term dementia is not precluded from use in the etiological subtypes where that term is standard. Furthermore, DSM-5 now recognizes a less severe level of cogni- tive impairment, mild NCD, which is a new disorder that permits the diagnosis of less disabling syn- dromes that may nonetheless be the focus of concern and treatment. Diagnostic criteria are provided for both major NCD and mild NCD, followed by diagnostic criteria for the different etiological subtypes. An updated listing of neurocognitive domains is also provided in DSM-5, as these are necessary for establishing the presence of NCD, distinguishing between the major and mild levels of impairment, and differentiating among etiological subtypes.

Although the threshold between mild NCD and major NCD is inherently arbitrary, there are important reasons to consider these two levels of impairment separately. The major NCD syndrome provides consistency with the rest of medicine and with prior DSM editions and necessarily remains distinct to capture the care needs for this group. Although the mild NCD syndrome is new to DSM-5, its presence is consistent with its use in other fields of medicine, where it is a significant focus of care and research, notably in individuals with Alzheimer’s disease, cerebrovascular disorders, HIV, and traumatic brain injury.

Etiological Subtypes In DSM-IV, individual criteria sets were designated for dementia of the Alzheimer’s type, vascular dementia, and substance-induced dementia, whereas the other neurodegenerative disorders were classified as dementia due to another medical condition, with HIV, head trauma, Parkinson’s disease, Huntington’s disease, Pick’s disease, Creutzfeldt-Jakob disease, and other medical conditions specified. In DSM-5, major or mild vascular NCD and major or mild NCD due to Alzheimer’s disease have been re- tained, whereas new separate criteria are now presented for major or mild NCD due to frontotemporal NCD, Lewy bodies, traumatic brain injury, Parkinson’s disease, HIV infection, Huntington’s disease, prion disease, another medical condition, and multiple etiologies. Substance/medication-induced NCD and unspecified NCD are also included as diagnoses.

Personality Disorders The criteria for personality disorders in Section II of DSM-5 have not changed from those in DSM-IV. An alternative approach to the diagnosis of personality disorders was developed for DSM-5 for further study and can be found in Section III. For the general criteria for personality disorder presented in Sec- tion III, a revised personality functioning criterion (Criterion A) has been developed based on a litera- ture review of reliable clinical measures of core impairments central to personality pathology. Further- more, the moderate level of impairment in personality functioning required for a personality disorder diagnosis in DSM-5 Section III was set empirically to maximize the ability of clinicians to identify per- sonality disorder pathology accurately and efficiently. With a single assessment of level of personality functioning, a clinician can determine whether a full assessment for personality disorder is necessary. The diagnostic criteria for specific DSM-5 personality disorders in the alternative model are consis- tently defined across disorders by typical impairments in personality functioning and by characteristic pathological personality traits that have been empirically determined to be related to the personality disorders they represent. Diagnostic thresholds for both Criterion A and Criterion B have been set em- pirically to minimize change in disorder prevalence and overlap with other personality disorders and to maximize relations with psychosocial impairment. A diagnosis of personality disorder—trait specified, based on moderate or greater impairment in personality functioning and the presence of pathologi- cal personality traits, replaces personality disorder not otherwise specified and provides a much more

18 • Highlights of Changes from DSM-IV-TR to DSM-5

informative diagnosis for patients who are not optimally described as having a specific personality dis- order. A greater emphasis on personality functioning and trait-based criteria increases the stability and empirical bases of the disorders.

Personality functioning and personality traits also can be assessed whether or not an individual has a personality disorder, providing clinically useful information about all patients. The DSM-5 Section III ap- proach provides a clear conceptual basis for all personality disorder pathology and an efficient assess- ment approach with considerable clinical utility.

Paraphilic Disorders Specifiers An overarching change from DSM-IV is the addition of the course specifiers “in a controlled environ- ment” and “in remission” to the diagnostic criteria sets for all the paraphilic disorders. These specifiers are added to indicate important changes in an individual’s status. There is no expert consensus about whether a long-standing paraphilia can entirely remit, but there is less argument that consequent psy- chological distress, psychosocial impairment, or the propensity to do harm to others can be reduced to acceptable levels. Therefore, the “in remission” specifier has been added to indicate remission from a paraphilic disorder. The specifier is silent with regard to changes in the presence of the paraphilic inter- est per se. The other course specifier, “in a controlled environment,” is included because the propensity of an individual to act on paraphilic urges may be more difficult to assess objectively when the individu- al has no opportunity to act on such urges.

Change to Diagnostic Names In DSM-5, paraphilias are not ipso facto mental disorders. There is a distinction between paraphilias and paraphilic disorders. A paraphilic disorder is a paraphilia that is currently causing distress or impair- ment to the individual or a paraphilia whose satisfaction has entailed personal harm, or risk of harm, to others. A paraphilia is a necessary but not a sufficient condition for having a paraphilic disorder, and a paraphilia by itself does not automatically justify or require clinical intervention.

The distinction between paraphilias and paraphilic disorders was implemented without making any changes to the basic structure of the diagnostic criteria as they had existed since DSM-III-R. In the diag- nostic criteria set for each of the listed paraphilic disorders, Criterion A specifies the qualitative nature of the paraphilia (e.g., an erotic focus on children or on exposing the genitals to strangers), and Crite- rion B specifies the negative consequences of the paraphilia (distress, impairment, or harm—or risk of harm—to others).

The change for DSM-5 is that individuals who meet both Criterion A and Criterion B would now be diagnosed as having a paraphilic disorder. A diagnosis would not be given to individuals whose symp- toms meet Criterion A but not Criterion B—that is, to those individuals who have a paraphilia but not a paraphilic disorder.

The distinction between paraphilias and paraphilic disorders is one of the changes from DSM-IV that applies to all atypical erotic interests. This approach leaves intact the distinction between normative and nonnormative sexual behavior, which could be important to researchers or to persons who have nonnormative sexual preferences, but without automatically labeling nonnormative sexual behavior as

Highlights of Changes from DSM-IV-TR to DSM-5 • 19

psychopathological. This change in viewpoint is reflected in the diagnostic criteria sets by the addition of the word disorder to all the paraphilias. Thus, for example, DSM-IV pedophilia has become DSM-5 pedophilic disorder.

DSM is the manual used by clinicians and researchers to diagnose and classify mental disorders. The American Psychiatric Association (APA) will publish DSM-5 in 2013, culminating a 14-year revision process. For more information, go to www.

APA is a national medical specialty society whose more than 36,000 physician members specialize in the diagnosis, treat- ment, prevention and research of mental illnesses, including substance use disorders. Visit the APA at For more information, please contact Eve Herold at 703-907-8640 or

© 2013 American Psychiatric Association

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fields of psychology

Week 4 Presentation:

Please use resources from Weeks 1 – 3 for this assignment. From the list below, answer the following questions in your PowerPoint presentation. This presentation should be no less than twelve slides, not including title and Reference slide. Your presentation should include graphics, as well as utilizing the Note portion of the PowerPoint template. There are several YouTube tutorials available to help guide you through this presentation, e.g.


Your presentation should include the following subsets of psychology:  Developmental, Personality, Learning/Memory and Psychopathology, BioPsychology and Perception Psychology.

The following questions should be substantively addressed and answered.

· What is your current interest in each of the above subfields of psychology covered thus far?

· How can one utilize a degree in each of these fields of psychology?

· What should your undergraduate degree plan be for the field that interests you the most?

· Will you need to go to Graduate School to pursue these careers?

· What surprised you the most about each of these fields?

· Thinking about the career field that interests you the most, what do you believe you will have to improve upon to meet or exceed expectations?

· The last two – four slides of your presentation should substantively summarize what you found most interesting while completing this assignment and at least one element you learned during this assignment of which you can benefit in knowing more.

Your presentation should include:

1. Title Slide

2. Body of slides, with Note portions (8-10 slides)

3. Conclusion/Summary (2-4 slides)

4. Reference Slide (at least three academic references)

IMPORTANT:  You  MUST  utilize the Note portion of the PowerPoint. Each slide should have at least one substantive paragraph, e.g. five- seven sentences regarding what you have highlighted on the slides. The Note portion is worth a significant amount of points for this assignment. 

Once you have completed the above assignment, please save as a .pptx file and upload to the assignment link for Week 4.

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Beauty is in the eye of the beer holder

‘Beauty is in the eye of the beer holder’: People who think they are drunk also think they are attractive

Laurent Bègue1∗, Brad J. Bushman2,3, Oulmann Zerhouni1, Baptiste Subra4 and Medhi Ourabah5 1University of Grenoble 2, France 2The Ohio State University, Columbus, Ohio, USA 3VU University, Amsterdam, The Netherlands 4University of Paris Descartes, France 5University of Paris 8, Saint-Denis, France

This research examines the role of alcohol consumption on self-perceived attractiveness. Study 1, carried out in a barroom (N = 19), showed that the more alcoholic drinks customers consumed, the more attractive they thought they were. In Study 2, 94 non- student participants in a bogus taste-test study were given either an alcoholic beverage (target BAL [blood alcohol level] = 0.10 g/100 ml) or a non-alcoholic beverage, with half of each group believing they had consumed alcohol and half believing they had not (balanced placebo design). After consuming beverages, they delivered a speech and rated how attractive, bright, original, and funny they thought they were. The speeches were videotaped and rated by 22 independent judges. Results showed that participants who thought they had consumed alcohol gave themselves more positive self-evaluations. However, ratings from independent judges showed that this boost in self-evaluation was unrelated to actual performance.

‘Beauty is in the eye of the beer holder’ —Kinky Friedman

Alcohol has many consequences on social perception and relationships. After a drink, intoxicated people see members of the opposite sex through ‘beer goggles’, which makes them look especially attractive (Jones, Jones, Thomas, & Piper, 2003; Lyvers, Cholakians, Puorro, & Sundram, 2011; Neave, Tsang, & Heather, 2008). But alcohol can also influence self-perceptions. Previous research on alcohol and self-awareness has found that alcohol reduces self-awareness by inhibiting self-relevant encoding processes (Hull, Levenson, Young, & Sher, 1983). The purpose of the present research is to test the hypothesis

∗Correspondence should be addressed to Laurent Bègue, University of Grenoble 2, LIP, 1251, Av. Centrale, BP47, 38040 Grenoble, France (e-mail:


British Journal of Psychology (2013), 104, 225–234

© 201 The British Psychological Society



that alcohol consumption increases self-perceived attractiveness. Whereas meta-analytic reviews indicate that alcohol consumption enhances mood and sexual arousal (Hull & Bond, 1986), the link between alcohol consumption and self-perceived attractiveness remains to be clarified and theoretically developed.

In order to understand the link between alcohol and self-processes, we relied on the dual-process model of alcohol-related behaviour (Moss & Albery, 2009; see also Moss & Albery, 2010; Wiers & Stacy, 2010). This model suggests that although alcohol consumption disrupts cognitive controlled processes, the mind may still become ‘intoxicated’ even in the absence of alcohol consumption (Moss & Albery, 2009). For example, when people believe that they are intoxicated, they behave more aggressively (Bègue et al., 2009), and show more sexually disinhibited behaviours (Crowe & Georges, 1989). Various studies indicate that the effects of alcohol on human cognition and behaviour should distinguish pharmacological and social psychological consequences of alcohol consumption. In the field of sexual arousal, for example, a meta-analytic review indicated that alcohol consumption had a non-significant effect on sexual arousal, whereas the mere expectation of drinking alcohol significantly increased sexual arousal (Hull & Bond, 1986). From this perspective, behaviours that are disinhibited after drinking a placebo can be understood as a consequence of the activation of alcohol- related concepts in memory. In one study, the mere subliminal activation of alcohol- related concepts caused men to rate the faces of women as more sexually attractive (Friedman, McCarty, Forster, & Denzler, 2005).

Drunkenness is thus not merely a physiological consequence of alcohol, but involves complex interactions of both limited processing capacities (myopia theory, see below) and chronically and temporarily activated mental representations that make certain patterns of responding more accessible (expectancy theory, see below). According to the dual-process model of the alcohol behaviour (Moss & Albery, 2009), a full understanding of alcohol effects has to integrate both pharmacological and extra-pharmacological consequences of alcohol on human cognition and behaviour. Expectancies are the first component of the model. They are considered as the result of learned associations between alcohol-related representations in memory. The sources of this associative process could be referred to as conditioning (Hull & Bond, 1986) or vicarious learning (Bandura, 1965). For example, content analyses show that media characters who drink alcohol are generally depicted as more attractive than those who do not drink alcohol (McIntosh, 1999). Hence, to the extent that people strongly endorse alcohol- self-enhancement expectancies, concepts of ‘alcohol’ and ‘attractiveness’ would be linked together in memory. According to alcohol expectancy theory, alcohol-related cues could implicitly activate alcohol-related expectancies, which could, in turn, affect social judgements and behaviours that are in line with these alcohol-related expectancies. The concept of alcohol expectancy is based on a semantic network model of memory (Collins & Quillian, 1969), which posits that concepts that frequently co-occur, or share a similar meaning, are stored close together in memory. When one concept is activated, other related concepts also become more accessible through a spreading activation process (Collins & Loftus, 1975). For instance, social knowledge regarding alcohol effects is automatically activated in memory during the natural course of perception, without awareness or intention. Knowledge activation, in turn, shapes and guides people’s impressions, judgements, feelings, and intentions without awareness that such influence is occurring (see Bargh & Erin, 2006; Bargh & Ferguson, 2000; Ferguson & Bargh, 2004).

Another aspect of the dual-process model is related to the physiological consequences of alcohol consumption. According to the attention allocation model, alcohol has a

226 Laurent B�egue et al.

‘myopic’ or narrowing effect on attention (Giancola & Corman, 2007; Steele & Josephs, 1990), which causes people to focus attention on the most salient cues and to not pay attention to more subtle or distal cues. Alcohol myopia is therefore defined as a state of short-sightedness in which superficially understood, immediate aspects of experience have a disproportionate influence on behaviours and emotions (Steele & Josephs, 1990). Although a sober individual can consider a range of information more or less salient before responding to a social situation, an intoxicated individual will be less concerned with consideration distal in time and place because he will be captive of an impoverished version of reality in which the breadth, depth, and timeline of his understanding will be affected. Various studies show that intoxicated people no longer have the prerequisite processing skills to attend to all of the multiple cues involved in social behaviour (Streufert, Pogash, & Gingrich, 1993) and seek cognitive closure (Lange, 2002).

In our study on perceived attractiveness, two hypotheses were possible. First, alcohol could lead to a general increase of perceived attractiveness, because being attractive is a salient feature of the self. Second, alcohol could produce more polarized responses such that attractive people would judge themselves even more attractive, whereas unattractive people would judge themselves as even less attractive.

Overview of present research The present research investigates the effects of alcohol consumption on self-perceived attractiveness. In Study 1, carried out in a barroom, we analyse the relationship between an objective measure of intoxication (i.e., breathalyser reading) and self-perceived attractiveness. Study 2, an experimental study, clarifies the causal link between alcohol consumption and self-perceived attractiveness using a balanced placebo design (Marlatt & Rohsenow, 1980), which allows one to separate the pharmacological effects of alcohol from the psychological effects of alcohol. In Study 2, objective measure of attractiveness were also obtained by independent raters to determine whether the effects of alcohol consumption on self-perceived attractiveness are grounded in reality, or whether they are simply an illusion of the drinker.

STUDY 1 Study 1 provided an initial test of the hypothesis that intoxicated people think they are more attractive than sober people do. One major strength of Study 1 is that it was conducted in a naturalistic setting – a barroom.

Method Participants Participants were 19 customers (63% males; Mage = 22.5, SD = 5.0, range = 19–40) in a barroom in Grenoble, France. They received a lottery ticket in exchange for their voluntary participation.

Procedure Participants rated how attractive, bright, original, and funny they felt at the moment (1 = not at all to 7 = extremely; Cronbach’s � = .71; M = 4.27, SD = 1.11). Next, we

Alcohol and perceived attractiveness 227

estimated blood alcohol level (BAL) using a breathalyser (Draeger 5100S; M = 0.34%, SD = 0.38). A debriefing followed.

Results and Discussion Because they were not normally distributed, BAL values were transformed using a natural log function. As expected, the higher the BAL, the more attractive participants thought they were, r = .56, p = .012.

These results are consistent with the hypothesis that intoxicated people think they are more attractive than sober people do. Because of the correlational nature of Study 1, however, we cannot rule out the possibility that individuals who think they are attractive tend to drink more in barrooms, or that some third factor is related to perceived attractiveness and alcohol consumption.

Study 1 also does not allow one to determine whether it is the actual consumption of alcohol or the mere belief that one has consumed alcohol that relates to perceived attractiveness. In the real world it is impossible to separate the pharmacological and expectancy effects of alcohol, but in the laboratory it is possible to separate them using a balanced placebo design (Marlatt & Rohsenow, 1980). Study 2 was therefore carried out to disentangle both possible origins of the alcohol-self-perceived attractiveness relationship.

Study 1 also did not allow us to test whether intoxicated participants were, in fact, more attractive. We wanted to conduct videotaped interviews with barroom patrons, and then show these interviews to independent judges, but this was not possible. Study 2 also overcomes this weakness of Study 1.

STUDY 2 In Study 2, we experimentally tested the expectancy and pharmacological effects of alcohol consumption on self-evaluated attractiveness. Participants drank a beverage that contained or did not contain alcohol. Within each group, half were told the beverage contained alcohol and half were told it contained no alcohol. Next, participants delivered a message that was filmed, supposedly to be used in future advertisements for the beverage. After watching the filmed message, participants rated how attractive, bright, original, and funny they thought they were. We predicted that alcohol consumption would increase self-perceived attractiveness, as in Study 1. However, we were unsure whether this effect would be due to the pharmacological effects of alcohol, the expectancy effects of alcohol, or both.

As an objective measure of how attractive participants were, independent judges, blind to beverage conditions, also rated participants on the same dimensions. Because the judges were sober, we predicted that alcohol consumption would be unrelated to this objective measure of attractiveness.

Method Participants Participants were 94 French men. Three did not follow instructions, and two in placebo condition and three participants in anti-placebo condition suspected a discrepancy between what they were told concerning their beverage and what they were actually

228 Laurent B�egue et al.

given. We therefore excluded them from the sample. Thus, the final sample included 86 men (Mage = 27, SD = 7). Participants were recruited via newspaper advertisements for a taste-test study and were paid 14€ ($21) per hour. Men who responded to the ads were interviewed over the phone, ostensibly to determine if they were allergic to any foods, including alcohol. Potential at-risk drinkers were identified by the CAGE screening test for alcohol dependence (Beresford, Blow, Hill, Singer, & Lucey, 1990), and were excluded from the study.

Procedure Participants were told the private research firm Stat-Food (actually a bogus company) was conducting a taste-test study at a community health centre. Participants fasted from food and drink (except water) for 3 hr prior to their scheduled appointment (Millar, Hammersley, & Finnigan, 1992). A physician verified that each participant was healthy.

After informed consent was obtained, participants were randomly assigned to beverage conditions in a balanced placebo design. The balanced placebo design is a 2 × 2 factorial design that crosses alcohol content (participants drink a beverage that contains either alcohol or no alcohol) with alcohol-related expectancies (participants are told that their beverage either contains or does not contain alcohol). The major strength of the balanced placebo design is that it allows researchers to untangle the pharmacological effects of alcohol from the expectancy effects of alcohol.

Unfortunately, suspicion is often very high in the balanced placebo design, as high as 90% in some studies (Martin & Sayette, 1993). Three different types of cues can make participants suspicious: (1) internal cues (i.e., participants in the placebo condition do not feel intoxicated even though they are told their beverage contains alcohol; participants in the anti-placebo condition feel intoxicated even though they are told their beverage contains no alcohol); (2) gustative cues (i.e., participants in the placebo condition expect to taste alcohol, but do not taste it; participants in the anti-placebo condition do not expect to taste alcohol, but they taste it), and (3) instructional cues (e.g., manipulation checks make participants question the actual content of the beverage, cover stories are not believable). In Study 2, as in our previous research (e.g., Bègue et al., 2009), we attempt to reduce suspicion by focusing on all three cues. We handled the issue of internal cues indirectly by using several distracting tasks to divert participants’ attention away from their bodily sensations. Previous alcohol research has shown that distraction decreases the salience of interoceptive cues (Rohsenow & Marlatt, 1981). The issue of gustative cues was handled by a major change in typical procedures used in alcohol-related research. In the anti-placebo condition, participants were told that we were testing a new non-alcoholic beverage that tasted like alcohol, for people who appreciated the taste of alcohol but wished to avoid drinking alcohol. In the placebo group, we mixed a small quantity of alcohol in the beverage, placed alcohol on the surface of the beverage, and sprayed alcohol on the rim of the glass. We handled the issue of instructional cues by disguising the study as a taste-test study. In addition to handling these three cues, we also used people from the general population as participants, because they are far less suspicious about psychological studies than college students are.

Each participant was given three cold isovolemic glasses that contained a cocktail of grapefruit and grenadine cordial, mint, and lemon concentrate. For half the participants, the beverage contained 2.01 oz of pure alcohol to target a peak BAL of 0.10 g/100 ml. The dose was not adjusted, except when the participant’s weight was more than 20 kg

Alcohol and perceived attractiveness 229

under or over the median weight (75 kg). Within each group, half the participants were told that the beverage contained alcohol (the equivalent of five to six shots of vodka), whereas the remaining participants were told that the beverage contained no alcohol. In the expected alcohol conditions, the rims of the glasses were sprayed with alcohol immediately prior to serving. The drinks were mixed by a research assistant, allowing the experimenter to be blind to beverage condition.

Participants were given 10 min to consume their beverage. Next, they were given 5 min to write an advertising message that would allegedly be used by the (bogus) company Stat-Food to promote their products. Participants then evaluated their drinks, which took 15 additional minutes (giving time for alcohol absorption for participants who consumed an alcoholic beverage and distracting participants who consumed a placebo beverage from focusing on internal cues). Next, participants delivered their advertising message on a stage while a female experimenter filmed them. After the recording, participants viewed their advertising message and, as in Study 1, rated how attractive, bright, original, and funny they thought they were (1 = not at all to 7 = extremely; Cronbach’s � = .70).

Participants then left the main room, were offered some food and drink, and were kept busy with various tasks. When their BAL was theoretically near to 0, an experimenter posing as the person in charge of the food evaluation agency took them to another room and asked various questions about the agency’s hostess and the tasting experience. By that pre-debriefing procedure, we expected to hinder the participants’ propensity to answer consistently with what another experimenter had previously told them (see Knight, Barbaree, & Boland, 1986 for a description of this debriefing procedure). The experimenter doing the debriefing pretended not to be informed of what they had drunk and the participants had simply to inform him at the beginning of the interview (see Knight et al., 1986). If there was a discrepancy between the quantity of alcohol said to be in the drink and what the participant reported in the debriefing, or if the participant expressed doubts about the content of the drink, he was considered suspicious and was discarded from the sample. Five participants were discarded, two in the placebo condition and three in anti-placebo condition.

When the manipulation verification phase was complete, each participant received a thorough debriefing. All participants agreed that the collected data could be used for research purposes. We then estimated BAL with a breath alcohol testing device (Draeger 5100S). Once BAL was equal to 0.00, participants were thanked, paid, and released from the lab.

Validation of self-evaluations of attractiveness by independent judges To obtain an objective measure of how attractive speakers were, an independent group also evaluated the filmed messages. Judges were 22 university students (36% males; Mage = 20, SD = 3). Each judge evaluated the filmed messages from all 86 participants. The judges were blind to any information about the alcohol consumption/expectancy status of the participant. They used the same rating dimensions and rating scales as participants did. Judges rated whether the person in the filmed performance was attractive, bright, original, and funny (1 = not at all to 7 = extremely; Cronbach’s � = .95).

230 Laurent B�egue et al.

Results and Discussion Self-evaluations Data were analysed using a 2 (given alcohol vs. given no alcohol) × 2 (expected alcohol vs. expected no alcohol) ANOVA. Results showed that participants who thought they had consumed alcohol expressed more positive self-evaluations than did those who thought they had not consumed alcohol, Ms = 3.91 and 3.42, respectively, F(1,85) = 4.03, p = .04, d = 0.44. The main effect of alcohol content was non-significant, and the interaction between alcohol content and alcohol expectancy, were both non-significant, F(1,82) = 2.46, p = .12, and F(1,82) = 1.38, p = .24, respectively. A Levene’s test showed that alcohol and non-alcohol group variances did not differ (p = .55), which suggested that no polarization effect of alcohol of self-perceived attractiveness was observed. Descriptive statistics are in Table 1. These results suggest that alcohol related expectancies, but not actual alcohol content, influenced self-evaluations of attractiveness.

Validation of self-evaluations by independent judges Judges’ ratings of speeches were analysed using a 2 (given alcohol vs. given no alcohol) × 2 (expected alcohol vs. expected no alcohol) ANOVA. No significant effects were found. These findings indicate that the boost in self-perceived attractiveness experienced by people who thought they were drunk was unrelated to the way they were perceived by independent raters. Judges blind to beverage condition gave similar attractiveness ratings to people who thought they were drunk and to people who thought they were sober, Ms = 3.51 and 3.45, respectively, F(1,85) = 0.09, p > .80, d = 0.065. Descriptive statistics are in Table 2.

Table 1. Self-perceived attractiveness as a function of alcohol consumption and alcohol expectancy


Alcohol No alcohol


Alcohol 3.96 1.33 3.42 1.12 No alcohol 3.86 1.00 3.09 1.11

Table 2. Judges evaluations of attractiveness as a function of target’s alcohol consumption and alcohol expected


Alcohol No alcohol


Alcohol 3.61 1.13 3.55 0.87 No alcohol 3.40 0.78 3.35 0.73

Alcohol and perceived attractiveness 231

GENERAL DISCUSSION Our results showed that when people drink alcohol, they evaluate themselves as more attractive (or at least, less unattractive), but this self-perception appears to be an illusion. When independent judges evaluate attractiveness, the ratings are not influenced by expected or actual alcohol consumption. Our use of the balanced placebo design in Study 2 showed that the boost in self-perceived attractiveness can be interpreted as a consequence of the activation of mental representations implicitly related to alcohol in long-term memory. These findings are consistent with dual-process alcohol models that propose that the mind may still become ‘intoxi- cated’ if people expect to consume alcohol, even if they do not consume a single drop (Moss & Albery, 2009). These results are consistent with the hypothesis that alcohol stimuli operate on implicit expectancies, which, in turn, influence explicit self-perception.

Our findings also indicate that alcohol-related expectancies lead to a general increase of perceived attractiveness. There was no evidence that alcohol-related expectancies decreased perceived attractiveness in unattractive individuals. Indeed, almost everyone thinks they are more attractive after they think they have con- sumed alcohol. Moreover, our analysis showed that alcohol and non-alcohol group variances did not differ, which suggested that no polarization effect of alcohol of self-perceived attractiveness was observed. In order to find such a polarization, we maybe should have introduced salient cues referring to body self-esteem. According to the alcohol myopia theory (Steele & Josephs, 1990), in such a case, attractive people could have perceived themselves as even more attractive, whereas the re- verse may have occurred with less attractive people. Future research is needed to clarify the interesting issue of polarization under the physiological influence of alcohol.

Our study has also indicated that the quantity of alcohol ingested was not related to self-perceived attractiveness. We may hypothesize that pre-experimental individuals’ alcohol use and chronic self-representations should be further investigated to understand such a result. A within-subjects experiment could provide useful information regarding this issue.

Previous studies have shown that alcohol consumption increases the attractiveness of members of the opposite sex (Jones, Jones, Thomas, & Piper, 2003). Our studies provide complementary results showing that the mere belief that one has consumed alcohol increases self-perceived attractiveness. This is an important topic to deal with because self-perceived attractiveness has been shown to significantly influence intimate interactions. For example, in one diary study it was observed that people who thought they were attractive had more intimate interactions of all types than did those who thought they were less attractive (Nezlek, 1999).

In summary, the present research shows that alcohol-related expectancies can significantly boost self-perceived attractiveness. However, the perceived attractiveness lies in the eyes of the ‘beer holder’ and is not shared by anyone else.

Acknowledgement We would like to thank the editor and three anonymous reviewers for their insightful comments and their very useful suggestions.

232 Laurent B�egue et al.

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grant proposal

For this assignment, you will select a topic for your grant proposal (i.e., Final Project due in Week Six). Then you will write the Specific Aims section and create a preliminary bibliography. You will conduct a search in the Ashford University Library and/or on PubMedCentral  to locate at least 10 scholarly peer-reviewed articles that are relevant and that support your funding request.  Create your preliminary annotated bibliography and ensure that your resources are relevant and supportive of the Specific Aims as well as the Background and Significance sections of your grant proposal (the Background and Significance sections will be written in Week Three).

Specific Aims:

Specific Aims: (1 page) Clearly and concisely state the goals of your grant proposal. Summarize the expected outcome(s), including the impact that the results of the proposed research will exert on the research field(s) involved. List the specific objectives of your grant proposal (e.g., to test a stated hypothesis, create a novel design, solve a specific problem, challenge an existing paradigm or clinical practice, address a critical barrier to progress in the field, or develop new technology).

Week Six Guidelines (this is not part of this assignment, just a look ahead for what is expected)

For your final project, you will finalize your grant proposal to secure funding for a neuroscience investigation. This assignment will involve integrating information covered in previous weeks about brain networks and disorders that occur as the result of dysfunction in these networks. The grant proposal will require you to identify a research question based on a thorough review of the literature related to a particular disorder/syndrome and design a scientifically sound grant proposal using current methods of neuroscience investigation.

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The primary goal of the Learning and Cognition Handbook is to integrate concepts from the discipline of learning and cognitive psychology into a usable and professional guide that is designed for a specified audience which will be designated based on students’ current or future career goals. Students will choose one of five assigned constructs and focus their handbook on this specific area of learning and cognition. Skills and information learned throughout the course will be applied in the design and creation of this handbook. Findings from required sources, including those from the text and individual peer-reviewed articles, will be incorporated into the handbook; however, these findings will not constitute the total information for each of the sub-constructs addressed within the project. Students should include the relevant sources they researched in the Week Two Discipline-Based Literature Review as well as those from the Week Three Assignment. The purpose of the handbook is to share helpful strategies, apply the chosen construct to seven sub-constructs in the field, and present a holistic guide for others that can be used in the discipline.

To complete this assignment, students may utilize the Learning and Cognition Handbook template (Links to an external site.)Links to an external site. or create their own using the template as a guide. Each section of the handbook should be written in the student’s own words with use of limited paraphrased material cited according to APA standards. Each section of the handbook should include a minimum of one visual (e.g., table, figure, or image) with a maximum of five visuals per section. Each image must be retrieved and cited based on current copyright laws. Students may wish to use the. for assistance with accessing freely available public domain and/or Creative Commons licensed images.

The sections listed below must be used within the paper to delineate the sections of content.

Table of Contents
In this section, students will list all sections and subsections included in the handbook with the applicable page numbers.

In this section, students will provide an overview of the handbook and its potential use by the chosen audience.

Introduction to Chosen Construct: The Neurosciences:  A Look at Our Brains
In this section, students will provide an introductory summary of the chosen construct and discuss any careers in psychology specifically related to this construct. Beginning with the work completed in Week One, students will include the language from their personal epistemology (revised based on instructor feedback and the further development of their ideas and beliefs throughout the course and the program thus far).

Chosen Construct The Neurosciences:  A Look at Our Brains
In this section, students will provide information that communicates how and why the chosen construct of learning and cognition affects the following sub-constructs through synthesizing the learning principles and/or theories. For each of the sub-constructs, students will apply basic research methods and skeptical inquiry to explain the theoretical perspectives and empirical findings that substantiate the relationship between the construct and the sub-constructs. Although creative liberties are encouraged, all information incorporated should be supported and professionally presented through the consistent application of ethical principles and adherence to professional standards of learning and cognition psychology as applied to the chosen audience.

Information for each sub-construct will be presented

  • Comprehension
  • Problem Solving
  • Memory Development/Retention
  • Lifelong Learning
  • Domains and Domain Learning
  • Affective Outcomes of Emotion
  • Effects of Demographic Differences (e.g., gender, socioeconomics, religious affiliation, race)

In this section, students will provide a summarization of the handbook in which they describe the importance of the chosen construct and assigned sub-constructs within the learning and cognition domain and their applicability within the psychology profession for the chosen audience

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impact of the divorce on children

You are a professional counselor specializing in the treatment of children.  You have decided to implement an 8-week parenting program for divorcees.  How would you teach parenting skills from the perspective of either (choose) Erikson’s theory or Piaget’s theory with the participants regarding each age level of needs: preschool, school-age, and adolescent. Some of the participants hope to begin family sessions with you once the program has ended. How will you evaluate the impact of the divorce on children in each age level: preschool, school-age, and adolescent?

(This will need a reference)

Single-parent households and an increase in women in the workforce have both contributed to a significant increase in alternative care giving situations like day care or nursery school. Based on your understanding of attachment theory, how does this affect children?  Now, discuss ethical and cultural strategies for promoting resilience, development, and wellness in early childhood.

(This will need a reference) 

Here is our text for class, you can use it as well as something else.

Kail, R.V, & Cavanaugh, J.C (2014).  Human development; A life-span view . [Cengage Learning. Boston, MA.]

These are only worth 5 points each. please only write a short paragraph for each. These do not need to be done in apa paper format. Just a simple answer paragraph of about 230 words or so for each question.

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Personality Test

This exercise is designed to provide the student with basic knowledge about their personality type.

Below are links to free personality inventories.


Review the following 2  videos on Personality Inventories as an additional resource.  One is an actual inventory.

watch VideoPersonality Test: What Do You See?Duration: (6:38)
User: n/a –    Added: 10/16/14YouTube URL: VideoThe Coolest Personality Inventory Ever — The Essential EnneagramDuration: (2:44)
User: n/a –    Added: 11/1/13YouTube URL:

Follow the instructions indicated below for completing the assignment:

  • Choose and complete ONLY one Personality Inventory on yourself;
  • Write a complete summary of your findings based on the categories indicated in the inventory and ATTACH it to this Assignment box.
  • Indicate whether you agreed or disagreed with the findings and state why.
  • State if any of the personality traits discussed in the article correspond to your inventory analysis.
  • Post your summary on the graded Discussion Board to share your findings and respond to at least 3 other virtual classmates.
  • The Discussion Board has a different closing date. This means that students are to post their personality inventory following their submission to this assignment box.

Please remember to cite your sources.

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Identifying Relevant Theories and Models

Identifying Relevant Theories and Models

To complete this assignment, use the required APA “Identifying Relevant Theories and Models Template,” linked in the Resources. Address the following sections:

  • Theory Identification:
    • Review three theories that you feel might be appropriate for addressing the client’s sexual problem. Include a section on how neuroscience has facilitated our understanding of the client’s problem.
    • Pick the theory you believe best represents the client’s situation, and provide a rationale for your selection.
    • In addition, describe a systems perspective that provides an understanding of family and other systems theories and major models of family and related interventions as it pertains to human sexuality.
  • Reference:
    • Continue to build the Reference section by adding the references you utilized to complete this section of your treatment plan.



Client is a 22 year old female. She states she has come to counseling because she wants to do a better job knowing herself and be brave enough to let others know her too. Client reports that she came out as bisexual several months ago and has had mixed reactions to this announcement. She states that she has told a few friends and some of them have disowned her. She also states that she has not told her parents or her best friend because she is worried that the same thing might happen (being disowned). She reports being conflicted about her sexuality for the past 4 or 5 years and states that she has known that she was different for a long time. She reports that she did not do anything about this in high school and ignored how she felt because she was worried about what others would say. She states now that she is in college and on her own that she feels it is safer to be able to explore her sexuality. She reports three relationships with men and two relationships with women but the relationships with women were a secret. She states that the last woman broke up with her because the client insisted on secrecy.

Client reports a stable family environment growing up in a two-parent home. She reports that her mother was very controlling and tried to make her do ‘all sorts of things’ while she was growing up. She states she mostly complied because she did not want to get into trouble. She reports that her dad was somewhat dismissive and allowed her mom to ‘control the house’. She states that she received good grades throughout high school and was basically ‘a stellar child’. She reports that she played basketball and tennis and was interested in sports her junior and senior year. She reports one older brother and one younger sister and strong relationships with both siblings. She reports that she has lived away from home for the past three years with the first year on campus and the last two years living in a house with friends. She has been part of a sorority since her freshman year and feels very connected to the women who also are part of the sorority. She is worried that if they find out about her secret, they might kick her out of the sorority. Client states that she is studying environmental sciences and is happy with this choice.

Client reports little income and is primarily supported by her parents. She states she works part-time on campus in the dean’s office and she likes this job, but she knows she needs to find something different that is more in her field of study. She reports no drug use, but she does reports some alcohol use. She states she primarily drinks when she is at parties with her sorority sisters. She reports no past or current legal problems. She reports no medical problems. She states that she has grown up Catholic, but she is currently not practicing. She states that she believes there is a God but she does not know how to reconcile this belief with her thoughts and feelings about herself. She states that her faith only makes her feel guilt. She states that she is worried that she is bisexual and that she is never going to ‘pick a side’. Her gay and lesbian friends are always joking around with her because she just ‘falls in the middle’. She reports this is her only real problem of concern. Her grades are As and Bs and she is on track to graduate in the fall.

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