Category Archives: DSM-5

Key Changes to the DSM-5 for the Product Liability, Personal Injury, and Aviation Defense Lawyer

DSM-5 book

The creation of the fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was a massive undertaking that involved hundreds of psychiatrists, psychologists, physicians, and other medical professionals working together over a 12-year period.  The DSM-5, which replaced the 2000 DSM-IV (TR), is the foundation for reliable diagnosis and treatment of psychological and mental disorders.  As with prior DSM publications, which now date back decades, it is not intended to be a substitute for sound, objective clinical judgment, training, and skill.

Reflecting and prompted by the many new longitudinal studies, research papers, and experimental treatment modalities that have appeared since 2000, this new DSM edition contains significant changes in the classification of some disorders, and the removal or addition of other disorders.  This discussion will provide a brief overview of some of the key changes to the DSM-V and will touch on issues of interest to legal professionals working in the areas of product liability, personal injury, and aviation defense.

In a trial setting, familiarity with the DSM-5 and the underlying literature will be critical to an effective cross-examination of plaintiff’s expert.  Often, with forensic psychologists, the defense can make significant inroads on the basis that plaintiff’s expert is not sufficiently familiar with the DSM or associated literature.  For example, a significant new body of literature related to “resiliency and benefit realization” after a traumatic experience is largely unknown to most plaintiffs’ forensic psychologists.

A substantial percentage of high exposure cases in those categories involve a diagnosis of PTSD by plaintiff’s expert and a Global Assessment of Functioning (GAF) score based on the five-level multiaxial system, with Axis 5 providing the GAF score.  This brief post will focus on the changes to ­– or more accurately, the elimination of – the multiaxial system, as well as the changes to the criteria, symptoms, and diagnosis of PTSD.

A subsequent post will deal specifically with the criteria for PTSD and will include suggestions for cross-examination of plaintiff’s diagnosing mental health professional.

Changes to the Multiaxial System in DSM-5

Despite its widespread use, particularly among some insurance agencies and the government, the multiaxial system in DSM-IV was not required to make a mental disorder diagnosis.  DSM-5 has moved to a nonaxial diagnostic model (formerly AXES I, II, and III), with separate notations for important psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V).  The approach of distinguishing diagnosis from psychosocial and contextual factors is also consistent with established WHO and ICD guidelines, which consider the individual’s functional status separately from his or her diagnosis or symptom status.

DSM-IV Axis V consisted of the Global Assessment of Functioning (GAF) scale, representing the clinician’s judgment of the individual’s overall level of “functioning on a hypothetical continuum of mental health-illness.”  It was recommended that the GAF be dropped from DSM-5 for a number of reasons, including its conceptual lack of clarity (e.g., including symptoms, suicide risk, and disabilities in the descriptors) and questionable psychometrics in routine practice.  In order to provide a global measure of disability, the WHO Disability Assessment Schedule (WHODAS) is included in DSM-5 for further study.

Changes to PTSD in DSM-5

Post-Traumatic Stress Disorder (“PTSD”) is a Trauma- and Stressor-Related Disorder.  DSM-5 criteria for PTSD differ significantly from the DSM-IV.  The stressor criterion (Criterion A) is more explicit with regard to events that qualify as “traumatic” experiences.  Also, DSM-IV Criterion A2 (subjective reaction) has been eliminated.

Whereas there were three major symptom clusters in DSM-IV – re-experiencing, avoidance/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.  The latter category, which retains most of the DSM-IV numbing symptoms, also includes new or re-conceptualized 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 angry outbursts and reckless or self-destructive behavior.

PTSD 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.

The DSM-IV childhood diagnosis of reactive attachment disorder had two subtypes: emotionally withdrawn/inhibited and indiscriminately social/disinhibited.  In DSM-5, these subtypes are defined as distinct disorders: “reactive attachment disorder” and “disinhibited social engagement disorder.”

Olson Brooksby is a product liability, personal injury, and aviation defense firm.

Hoarding and its relation to fire, product liability, and personal injury cases

Tech room

Olson Brooksby regularly handles the defense in product liability and high-exposure negligence cases.  The purpose of this article is to make other defense firms aware of the new stand-alone designation for Hoarding presented in the latest (Fifth) version of the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-V).

As we mentioned in a previous blog post, the new DSM-V, which was published in May, 2013, includes “Hoarding Disorder” (often abbreviated “HD” in the literature) as a stand-alone mental disorder for the first time in the history of the APA’s DSM publication.  Although HD had been discussed in earlier versions of the DSM as an aspect of Obsessive Compulsive Disorder (OCD), it did not provide anywhere near the detail of diagnostic criteria that the DSM-V provides.  Moreover, recent studies show that hoarding and OCD are not as similar as previously thought.

The new hoarding diagnosis could have important implications in the product liability defense context.  Some studies suggest that as many as six percent of all house fires are the direct result of hoarding.  With any product producing a heat source sufficient to cause a fire if used improperly, placing combustible materials in sufficient quantity, or sufficient proximity, to the ignition source has the potential to cause a fire.  This is often the scenario with fires involving hoarding behavior.

Will a hoarding diagnosis provide the product manufacturer a defense, based on misuse of the product, and thereby dispose a jury to allocate a significant percentage of comparative fault to a diagnosed hoarder?  Or will jurors be more inclined to sympathize with, or overlook, the hoarding behavior and be lenient in the assignment of comparative fault to the hoarder?  Since the hoarding diagnosis is new, this remains to be seen.

The Basic DSM-V Diagnostic Criteria

The basic criteria for a diagnosis of hoarding include:

  1.  Persistent difficulty discarding or parting with possessions, regardless of their actual value.
  2. This difficulty is due to a perceived need to save the items and to the distress associated with discarding them.
  3. The difficulty discarding possessions results in the accumulation of possessions that congest and clutter active living areas and substantially compromise their intended use.  If living areas are uncluttered, it is only because of the interventions of third parties (e.g., family members, cleaners, authorities).
  4. The hoarding causes clinically significant distress or impairment in social, occupational, or other important areas of functioning (including maintaining a safe environment for self and others).
  5. The hoarding is not better explained by the symptoms of another mental disorder (e.g., obsessions in obsessive-compulsive disorder, decreased energy in major depressive disorder, delusions in schizophrenia or another psychotic disorder, cognitive deficits in major neurocognitive disorder, or restricted interests in autism spectrum disorder).

The Essential Diagnostic Features

A complete treatment of the diagnostic features of this newly categorized stand-alone mental disorder is beyond the scope of this article.  The essential feature of hoarding disorder is “persistent difficulties discarding or parting with possessions, regardless of their actual value.  (Criterion A).  The word persistent indicates a long-standing difficulty rather than more transient life circumstances that may lead to excessive clutter, such as inheriting property.  The difficulty in discarding possessions noted in Criterion A refers to any form of discarding, including throwing away, selling, giving away, or recycling.  The main reasons given for these difficulties are the perceived utility or aesthetic value of the items or strong sentimental attachment to the possessions.  Some individuals feel responsible for the fate of their possessions and often go to great lengths to avoid being wasteful.


Approximately 80%-90% of individuals with hoarding disorder display excessive acquisition features.  The most frequent form of acquisition is excessive buying, followed by acquisition of free items (e.g., leaflets, items discarded by others).  Stealing is not common.  Some individuals may deny excessive acquisition when first assessed, but this symptomology may appear later during the course of treatment.  Individuals with hoarding disorder typically experience distress if they are unable to, or are prevented from, acquiring items.

Prevalence, Development and Course

Nationally representative prevalence studies of hoarding disorder are not available.  Community surveys estimate the point prevalence of clinically significant hoarding in the United States and Europe to be approximately 2% – 6%, or roughly between 6 and 15 million Americans.  Hoarding symptoms may first emerge between the ages of 11 and 15, start interfering with the individual’s function by the mid-20s, and cause clinically significant impairment by the mid-30s.  Most participants in clinical studies are in their 50s, with the severity increasing with each decade of life.  Hoarding symptoms appear to be almost three times more prevalent in older adults (ages 55 – 94 years) compared with younger adults (ages 34 – 44 years).  Most study participants report the disorder symptoms a nearly constant presence, and not episodic.

Pathological hoarding in children is easily distinguishable from developmentally saving and collecting behaviors.  Hoarding behavior is familial, with about 50% of individuals who hoard reporting having a relative who also hoards.  Twin studies indicate that approximately 50% of the variability in hoarding behavior is attributable to additive genetic factors.  Approximately 75 metropolitan communities in the United States have task forces to address this disorder.

Hoarding Disorder AS Distinct From Obsessive Compulsive Disorder

When defending a product liability case that resulted in a fire, it will be important to understand the new research distinguishing hoarding from OCD.  A new study, authored by Dr. David Tolin in the Journal of the American Medical Association, shows that patients with hoarding disorder exhibit different brain activity during decision making than patients with OCD, pointing to a biological distinction.  Dr. Jeff Szymanski of the International OCD foundation reported that after the study, they concluded that a hoarder is not a pack rat, a slob, or lazy.  “A part of their brain doesn’t work the way your brain works.”

Dr. Tolin used brain imaging (fMRI) to test how 107 people reacted when asked whether they wanted to keep a piece of junk mail or discard it.  Sometimes it was junk mail that belonged to the patient, and sometimes it belonged to someone else.  Forty-three participants had hoarding disorder and another 31 had OCD, or obsessive compulsive disorder, according to the study.

When the junk mail had a hoarding patient’s name on it, certain parts of that patient’s brain lit up, showing “abnormal activity” in the decision-making regions (the anterior cingulated cortex and the insula), according to the study.  When the mail listed someone else’s name, the same parts of the hoarder’s brain were abnormally quiet.  According to Tolin, “only hoarding patients showed this kind of activity, and OCD patients did not.


Now that Hoarding Disorder (HD) is a distinct, APA sanctioned, mental disorder, it will likely have ramifications in product liability cases for both plaintiffs and defendants.  Given the relatively high number of fires, usually implicating a product, defense attorneys involved in product liability litigation will need to understand the disorder in those cases where HD is suspected.  Because jurors may tend to sympathize with hoarders, who are often characterized by their counsel as suffering from something akin to a mental handicap (thereby – erroneously – relieving them of any fault), the impact of HD may be greater on product liability defense counsel than on plaintiffs’ counsel.

Strategies for companies defending against claims for PTSD

Most plaintiff and defense attorneys would likely admit that treatment of forensic psychological experts and posttraumatic stress disorder (PTSD) claims on behalf of their respective clients is difficult.  For the defense of a personal injury claim involving PTSD, it is essential that defense counsel have a thorough understanding of the interaction between the DSM-5, standardized testing, how the testing was scored, whether the tests administered had validity scales, and what other personal historical factors and information the plaintiff’s examining physician had available to him or her.  It is also important to determine whether the plaintiff’s expert considered other mental diseases or defects besides PTSD.  All of this is necessary for thorough cross-examination of a plaintiff’s expert and attacking misdiagnosed claims of PTSD.

There is no single test that will clinically establish the presence of PTSD.  Typically a number of tests such as the MMPI, the TSI or other standardized tests are administered.  Defense counsel should understand whether there are validity scales and what they show and be prepared to cross-examine the plaintiff’s expert in that regard.

Defense counsel should also cross-examine the plaintiff’s expert on his or her awareness of recent longitudinal studies done on PTSD  Defense counsel must determine whether the plaintiff’s expert is an experienced clinician.  What clinical judgment did the plaintiff’s expert apply to reach his or her diagnosis?  Did the plaintiff’s expert account for malingering?  If so, how?

Defense counsel should also cross-examine the plaintiff’s expert extensively on key diagnostic criteria such as “life-threatening” and “persistence”.

Posttraumatic Stress Disorder (“PTSD”) (DSM-IV-TR Code 309.81) is categorized by the DSM-IV(TR) as an Anxiety Disorder.

Posttraumatic Stress Disorder (PTSD) will be included in a new chapter in DSM-5 on Trauma- and Stressor-Related Disorders. This move from DSM-IV, which addressed PTSD as an anxiety disorder, is among several changes approved for this condition that is increasingly at the center of public as well as professional discussion.

“The essential feature of PTSD is the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one’s physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person, or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate.”  DSM-IV-TR at p. 463.

The response to the event must involve intense fear, helplessness, or horror.  In children, the response must involve disorganized or agitated behavior.  Characteristic symptoms include persistent re-experiencing of the traumatic event, persistence of stimuli associated with the trauma and numbing of general responsiveness and persistent symptoms of increased arousal.  DSM-IV-TR also states that the full symptom picture must be present for more than one month and the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

A nonexclusive list of traumatic events that are experienced directly include military combat, violent personal assault (sexual assault, physical attack, robbery, mugging), being kidnapped, begin taken hostage, terrorist attack, torture, incarceration as a prisoner of war or in a concentration camp, natural or manmade disasters, severe automobile accidents, or being diagnosed with a life-threatening illness.  For children, sexually traumatic events may include developmentally inappropriate sexual experiences without threatened or actual violence  or injury.

An individual will have persistent symptoms of anxiety or increased arousal that were not present before the trauma.  These symptoms may include difficulty falling or staying asleep that may be due to recurrent nightmares during which the traumatic event is relived, hyper-vigilance, and exaggerated startle response.  Some individuals report irritability or outbursts of anger or difficulty concentrating or completing tasks.

Associated Descriptive Features and Mental Disorders 

Part of the difficulty in an accurate diagnosis of PTSD, is that it is associated with many other anxiety and other mental disorders.  PTSD is also associated with increased rates of Major Depressive Disorder, Substance-Related Disorders, Panic disorder, Agoraphobia, Obsessive-Compulsive Disorder, Generalized Anxiety Disorder, Social Phobia, Specific Phobia, and Bipolar Disorder.  These disorders can either precede, follow, or emerge concurrently with the onset of PTSD.

PTSD Prevalence Rates

The DSM-IV-TR discusses community-based studies which reveal a lifetime prevalence for PTSD of approximately 8% of the adult population in the United States.  Information about general prevalence rates in other countries is not available.   Studies of at-risk individuals yield variable findings, with the highest rates (ranging between one third and more than half of those exposed) found among survivors of rape, military combat and captivity, and ethnically or politically motivated internment and genocide.

Differential Diagnosis

The DSM-IV-TR emphasizes that with PTSD, the stressor must be of an extreme, (i.e., “life-threatening) nature. DSM-IV-TR at p. 467.  In contrast, other mental disorders often mistakenly diagnosed as PTSD include Adjustment Disorder, where the stressor can be of any severity.  The test also points out that not all psychopathology that occurs in individuals exposed to an extreme stressor should necessarily be attributed to PTSD and may be the result of many other mental disorders.  Mentioned are Acute Stress Disorder, Obsessive Compulsive Disorder Schizophrenia  and other Psychotic Disorders or Mood Disorders with Psychotic Features.  Significantly, the test emphasizes that “[m]alingering should be ruled out in those situations in which financial remuneration, benefit eligibility, and forensic determinations play a role.”  DSM-IV-TR at p. 467.  Although a discussion of all diagnostic criteria is beyond the scope of this article, virtually each of the diagnostic criteria for PTSD emphasize that persistence of the symptoms, the re-experiencing of the event, and the avoidance of associated stimuli is essential.


Even a complete summary of the criteria and methodology for most effectively questioning or attacking a plaintiff’s claim of PTSD is far beyond the scope of this blog post.  Defense counsel must undertake a thorough investigation and consultation with a qualified expert, preferably one who also maintains a clinical practice.  When defense counsel is cross-examining plaintiff’s expert witness regarding a PTSD diagnosis, there is absolutely no substitute for thorough preparation and understanding of the DSM-IV criteria, clinical judgment, test results, current longitudinal or other studies and an awareness of all factors taken into account by plaintiff’s expert as the plain text of the DSM-IV-TR, and examples of the trauma and criteria typically associated with PTSD can often be easily contrasted with the data to disprove or minimize the emotional distress damages.  Olson Brooksby often defends high-exposure personal injury or product liability cases where plaintiffs seek damages for emotional distress and claim PTSD.  For more information, contact our office.