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Introduction to DSM-5

by William W. Deardorff, Ph.D, ABPP.


4 Credit Hours - $79
Last revised: 05/02/2016

Course content © Copyright 2014 - 2017 by William W. Deardorff, Ph.D, ABPP. All rights reserved.



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Introduction

 

The DSM-5 has now been released and the flurry of comments and reactions has begun.  Mental health practitioners are rushing to understand and manage all the changes: learning about the new approach of the DSM-5, going over the new diagnostic sections, determining how to cope with the loss of the multiaxial system, wondering how this will change billing practices, editing pre-publication articles to include the DSM-5 nomenclature, and more. 

 

The DSM-5 is both the same and different than DSM-IV-TR.  DSM-5 is being released amidst other issues that were not present at the time of previous DSMs.  As will be discussed in detail in this course, these include at least the following: (1) The impact of the Health Insurance Portability and Accountability Act (HIPAA) that requires ICD diagnostic codes as of Oct 2014; (2) The powerful pressures toward the medicalization of mental health treatment focused on using psychotropic medications (obviously, the array of medication alternatives were not present at the time of previous DSMs); (3) The significant financial profit center that has become associated with the release of DSM-5 and associated materials; and, (4) The rejection of the DSM nosology by NIMH.  This course will present a brief history of the DSM and an overview of significant changes in the DSM-5 including removal of the multiaxial system and the changes in the diagnostic criteria for various conditions.  The course will then review some of the controversy surrounding the DSM-5 along with a discussion of the ICD.    

 

Course outline

 

Learning Objectives

History of DSM

Highlights of Organizational and Conceptual Changes

Overview of Specific Changes from DSM-IV-TR to DSM-5

Neurodevelopmental Disorders

Schizophrenia Spectrum and Other Psychotic Disorders

Bipolar and Related Disorders

Depressive Disorders

Anxiety Disorders

Obsessive-Compulsive and Related Disorders

Trauma- and Stressor-Related Disorders

Dissociative Disorders

Feeding and Eating Disorders

Somatic Symptom and Related Disorders

Sleep-Wake Disorders

Gender Dysphoria

Disruptive, Impulse-Control, and Conduct Disorders

Substance-Related and Addictive Disorders

Neurocognitive Disorders

Personality Disorders

Paraphilic Disorders

DSM, ICD and the Rest of the World

What is the International Classification of Diseases (ICD)?

Crosswalking Diagnostic Codes

A Brief Review of Controversial Issues Related to DSM-5

Critique of the Changes in the Diagnostic Categories

NIMH Rejects DSM-V

People Taking "Drugs They Don't Need"

Financial Conflict of the DSM-V Developers

The Cost of the DSM Manual (and future updates)

Summary and Conclusions

Resources

Reference

 

 

Learning Objectives

 

 

List 3 significant changes from DSM-IV-TR to DSM-5

Discuss two “new” diagnostic categories in DSM-5

Discuss the ICD

Explain 2 Criticisms of DSM-5

 

 

History of DSM

 

Initially, the need for a classification system in the United States was driven by the collection of statistical information in the census.  During the 1840 census, the frequency of “idiocy/insanity” was recorded.  By the 1880 census, seven categories of insanity had been established, including mania, melancholia, monomania, paresis, dementia, dipsomania, and epilepsy. In 1917, the American Psychiatric Association (APA) and National Commission on Mental Hygiene adopted a system similar to Kraepelin’s.  Kraepelin had developed a classification system for mental illness at that time.

Emil Kraepelin was a German psychiatrist who first ‘crystallized dementia praecox and manic–depressive illness from an amorphous mass of madness’ (1919).  He developed the Kraepelin dichotomy which was the assumption that schizophrenia and bipolar affective disorder (or the corresponding earlier terms, such as dementia praecox and manic–depressive illness) are distinct entities with separate underlying disease processes and treatments.

 

By the end of World War II, there were four competing classification systems: APA’s 1932 revision, US Army’s system, US Navy’s system, and the system of the Veterans Administration.  In addition, the first International Classification of Diseases (ICD) was released in 1900 to provide a standard format for morbidity and mortality statistics.  In 1948, the First World Health Assembly endorsed the report of the Sixth Revision Conference and the ICD-6 was adopted. ICD-6 was the first edition of that series to include mental disorders.  It offered 10 categories for psychoses, 9 for neuroses, and 7 for disorders of character, behavior, and intelligence.  However, ICD-6 lacked organization and was not widely accepted. At this time in the United States, there were 5 competing systems.  To lessen the confusion, APA’s Committee on Nomenclature and Statistics began work on the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).

 

The purpose of DSM-I was to create a common nomenclature based on a consensus of the contemporary knowledge about psychiatric disorders.  APA sent questionnaires to 10% of its members and asked for comments on the proposed categories.  The final version, which assigned categories based on lists of symptoms, was approved by a vote of the membership and published in 1952.  DSM-I included 3 categories of psychopathology: organic brain syndromes, functional disorders, and mental deficiency.  These categories contained 106 diagnoses.  Only one diagnosis, Adjustment Reaction of Childhood/Adolescence, could be applied to children.

 

DSM-II was published in 1968 to further facilitate communication among professionals.  It had 11 major diagnostic categories.  Increased attention was given to the problems of childhood and adolescence with the categorical addition of Behavior Disorders of Childhood-Adolescence.  This category included Hyperkinetic Reaction, Withdrawing Reaction, Overanxious Reaction, Runaway Reaction, Unsocialized Aggressive Reaction, and Group Delinquent Reaction.  There were 185 diagnoses in DSM-II.

 

DSM-I and DSM-II were widely criticized for a variety of reasons.  Most importantly, the reliability and validity of the first two editions were challenged.  The diagnostic descriptions were not detailed, leaving lots of room for error.  Additionally, the descriptions had been written by a small number of academics rather than being guided by empirical studies.  Many psychiatrists criticized the implicit medical model, stating that it was inappropriate because the cause of most disorders was unknown. The most outspoken critic was Thomas Szasz, who became the leader of the anti-psychiatrists.  His book The Myth of Mental Illness (1961) claimed that mental disorders are really “problems in living” and accused psychiatrists of being “moral policemen.”  Fear was developing surrounding stigmatization and self-fulfilling prophecies.  Subsequently, Rosenhan’s classic study (On Being Sane in Insane Places, 1973 – See Table 1) increased anxiety about the reliability and validity of the first two editions of DSM and about psychiatry/psychology as a profession.

 

Table 1. On being sane in insane places

The now famous Rosenhan experiment was done to determine the validity of psychiatric diagnosis. The study was conducted by a psychologist, David Rosenhan, and published by the journal Science in 1973 under the title "On being sane in insane places." The study is considered an important and influential related to its criticism of psychiatric diagnosis. Rosenhan's study was done in two parts. The first part involved the use of healthy associates or "pseudopatients" (three women and five men) who briefly simulated auditory hallucinations in an attempt to gain admission to 12 different psychiatric hospitals. The hospitals were in various locations around the the United States to ensure generalizability. All of the pseudopatients were admitted and diagnosed with psychiatric disorders. After admission, the pseudopatients acted normally and told staff that they felt fine and had not experienced any more hallucinations. All were forced to admit to having a mental illness and agree to take antipsychotic drugs as a condition of their release. The average time that the patients spent in the hospital was 19 days. All but one of the psuedopatients were diagnosed with schizophrenia "in remission" before their release.

 

The second part of the study involved a hospital who dismissed Rosenhan’s results and challenged him to send pseudopatients to its facility (to be identified). The hospital staff would then attempt to detect the psuedopatients.  Rosenhan agreed to the “test” of his results.  In the following weeks, out of 193 new patients admitted to this hospital, the staff identified 41 as potential pseudopatients.  Of these 41 possible psuedopatients, 19 received suspicion from at least 1 psychiatrist and 1 other staff member. In fact, Rosenhan had not sent any psuedopatients to the hospital.

 

The study concluded "it is clear that we cannot distinguish the sane from the insane in psychiatric hospitals" and also illustrated the dangers of dehumanization and labeling in psychiatric institutions. It suggested that the use of community mental health facilities which concentrated on specific problems and behaviors rather than psychiatric labels might be a solution and recommended education to make psychiatric workers more aware of the social psychology of their facilities. The study has been critiqued but the conclusions were powerful enough to impact the course and method of psychiatric diagnosis. 

 

Rosenhan’s study caused Robert Spitzer and others to question the reliability of the DSM-II.  In 1974, Spitzer and Fleiss wrote “A Re-Analysis of the Reliability of Psychiatric Diagnosis.”  Spitzer and Fleiss used a statistic of inter-rater reliability (kappa) to re-compute the findings of 6 earlier studies.  For DSM-II, they found that no diagnostic category demonstrated uniformly high reliability.  Reliability appeared to be satisfactory for three categories: mental deficiency, organic brain syndrome (but not its subtypes), and alcoholism.  The level of reliability was no better than fair for psychosis and schizophrenia and was poor for the remaining categories.

 

To address this situation, Spitzer and others began work on the Research Diagnostic Criteria (RDC).  The RDC used research-based diagnostic criteria along with structured interviews to increase reliability.  Because of the impact of his work on the RDC, Spitzer was named the head of the DSM-III Task Force. In addition to the RDC, the other major work used in the creation of DSM-III was “Diagnostic Criteria for Use in Psychiatric Research” (Feighner et al., 1972).  Focusing on the problem of uniform definitions, Feighner et al. offered explicit criteria for 15 diagnostic categories.  The researchers also presented a considerable amount of evidence of validity for each category.  Because it appeared that Feighner et al. had found the solution to many of DSM-II’s problems, those criteria were accepted immediately.

 

DSM-III was revolutionary in many ways.  Although based on the medical model, it purported to be atheoretical.  It included a multiaxial system for assessment of the patient as an individual as well as a family and community member.  Its reliability was improved with the addition of explicit diagnostic criteria and structured interviews (much of it adopted from the RDC).  DSM-III stimulated additional research to ensure the adequacy of criteria.  Social and political debates over terminology and diagnoses, such as the use of the word “neurosis” and the removal of homosexuality as a diagnosis, were frequent.  DSM-III was so popular that its revenues lead to the formation of the American Psychiatric Press.

 

Even though it was innovative, DSM-III also presented challenges to professionals.  It contained 482 pages, a tremendous increase over DSM-II’s 92 pages.  DSM-III contained 265 diagnoses compared to DSM-II’s 185. As such, it was not particularly user-friendly in its bulk or number of categories.  In addition, a new problem of international communication was becoming apparent.  Although ICD and DSM were similar in terms of criteria, their codes were very different.  Also, many researchers were claiming that there were still significant issues of reliability in DSM-III.  For example, the reliability statistics used in the development of DSM-III were computed across broad classes of diagnoses rather than highly specific ones.  Therefore, if one clinician determined that a patient has a Histrionic Personality Disorder and another clinician determines that the same patient has Borderline Personality Disorder, they are in perfect agreement. This is due to the fact that they both diagnosed a personality disorder.  Due to new research, field trials, and the problem of coding, the American Psychiatric Association published DSM-III-R in 1987.

 

DSM-III-R was intended to be a short update to the 3rd edition manual; however, the differences between III and III-R were significant.  DSM-III-R had categories that were renamed, reorganized, and contained significant changes in criteria.  Six categories from DSM-III were deleted while others, such as Trichotillomania, were added.  Additional assurances of reliability were presented in the form of field trials and more diagnostic interviews.  Controversial diagnoses, such as Premenstrual Syndrome, Masochistic Personality Disorder, and Paraphilic Rapism were considered and discarded due to their social implications (Blashfield, 1998). Altogether, DSM-III-R contained 297 diagnoses. Although widely accepted, both DSM-III and DSM-III-R were widely criticized.  First, the scientific evidence was questioned. For instance, many of the field trials were conducted by experts in the field so true objectivism could not be assured.  Using this method, generalizability of the diagnostic reliability and validity to clinicians who were not “experts” in a particular diagnosis could not be assured.   

 

Although unique in its approach to capture more information about the patient, some argued that the multiaxial system prevented efficiency in diagnosis.  Also, DSM-III/III-R offered a different amount of support and direction for each axis.  Simply consider the following: There were  300 pages of description devoted to Axis I; 39 pages devoted to Axis II; while Axes IV and V were given only 2 pages each.  The rating scale format of IV and V was also foreign to many professionals.  The axes themselves were problematic for many practitioners because no one seemed to know how those particular areas were chosen.  In addition, there were many competing Axes that could have been adopted (e.g. Psychoanalysts began to argue for an axis on defense mechanisms, nurses wanted an axis for level of care, etc.). 

 

The Task Force for DSM-IV was chaired by Allen Frances, and it was published in 1994.  It was developed to reflect research conducted since 1987’s DSM-III-R.  The development of DSM-IV was a major undertaking that involved a steering committee of 27 people including 4 psychologists.  The steering committee created 13 work groups of 5-16 members, and each work group had approximately 20 advisors.  Individuals were chosen for their knowledge in the field as well as to maximize diversity.  The work groups conducted a 3-step process: (1) Each group conducted an extensive literature review of their diagnoses; (2) They requested for data from researchers, conducting analyses to determine which criteria required change; (3) They conducted multicenter field trials to be sure that clinical research was relevant to clinical practice.

 

The DSM-IV was a categorical classification system. The categories were prototypes, and a patient with a close approximation to the prototype was said to have that disorder. DSM-IV states, "there is no assumption each category of mental disorder is a completely discrete entity with absolute boundaries," but isolated, low-grade, and noncriterion (unlisted for a given disorder) symptoms are not given importance. Qualifiers were sometimes used, such as mild, moderate, or severe forms of a disorder. For nearly half the disorders, symptoms must be sufficient to cause "clinically significant distress or impairment in social, occupational, or other important areas of functioning." Each category of disorder in DSM-IV has a numeric code taken from the ICD coding system, used for health service (including insurance) administrative purposes. As most clinicians are quite familiar, the DSM-IV organizes each psychiatric diagnosis into five dimensions (axes) relating to different aspects of disorder or disability:

 

Axis I: All diagnostic categories except mental retardation and personality disorder

Axis II: Personality disorders and mental retardation

Axis III: General medical condition; acute medical conditions and physical disorders

Axis IV: Psychosocial and environmental factors contributing to the disorder

Axis V: Global Assessment of Functioning

 

DSM-IV saw the restructuring of several categories, but the multiaxial system was maintained.  DSM-IV offered detailed information about each disorder, including essential and associated features; presence, course, and familial pattern; differential diagnosis; and age, gender, and culture.  Source books, decision trees, glossaries, and alphabetical and numerical listings provided ways to increase the manual’s utility.  DSM-IV included 365 diagnoses.  At 886 pages, it was more than 7 times longer than DSM-II. Like its predecessors, DSM-IV was criticized.  The approach used in DSM-IV was criticized for leaning toward biological explanations of mental illness even though it purported to be atheoretical.  Comorbidity, symptom overlap, and heterogeneity of presentation were seen as threats to its reliability.  It did not solve the problem of PMS and the other controversial disorders; it simply listed them among disorders requiring further study.  Additionally, the axes problem remained unsolved with three alternative axes still being supported as substitutes (defense mechanisms, interpersonal functioning, and occupational functioning)

 

The DSM-IV-TR (2000) was released to correct any factual errors and make changes to reflect recent research. The diagnostic categories and the vast majority of the specific criteria for diagnosis were unchanged from the DSM-IV. The text sections giving extra information on each diagnosis were updated, as were some of the diagnostic codes to maintain consistency with the ICD. It did not attempt to address any of the major problems of DSM-IV, and the multiaxial system was maintained. The changes were limited to text, with particular emphasis placed on client-centered speech.  Phrases such as “a schizophrenic” were removed and replaced with “an individual with Schizophrenia” in an effort to classify disorders not people (DSM-IV-TR, 2000.)

 

DSM-5 is the fifth edition of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders. In the United States the DSM continues to serve as a universal authority for the diagnosis of psychiatric disorders (versus the ICD used by the rest of the world).  The DSM-5 was published on May 18, 2013, superseding the DSM-IV-TR, which was published in 2000. The development of the new edition began with a conference in 1999.  This was followed by the formation of a Task Force in 2007, which developed and field-tested a variety of new classifications. In many areas, the DSM-5 is not significantly changed from the DSM-IV-TR, but it is markedly different in others. Notable innovations will be discussed subsequently, but one clear difference is that the multiaxial system is gone. Another obvious difference is the name of text: DSM-5 (versus DSM-V).  This was evidently done to more easily allow for updates as new research becomes available (e.g. DSM-5.1; 5.2, 5.3, etc.).  Of course, one immediate criticism of this approach is the cost to the practitioners and institutions that use this publication and all of its updates. As will be discussed, the ICD Diagnostic Manual (used by the rest of the world and to which DSM-5 is purported to be consistent) is always provided free of charge.  Each “new” revision of the DSM can come with significant purchase cost.

 

As with other editions of the DSM, the fifth edition has been criticized by a number of authorities even before it was formally published. The main thrust of criticism has been that changes in the DSM have not kept pace with advances in scientific understanding of psychiatric dysfunction. Another criticism is that the development of DSM-5 was unduly influenced by input from the psychiatric drug industry (more details to follow). A number of scientists have objected that the DSM forces clinicians to make distinctions that are not supported by solid evidence. These distinctions may have major treatment implications, including drug prescriptions and the availability of health insurance coverage.        

 

Highlights of changes

 

DSM-5 Task Force Chair, David Kupfer, has outlined some of the overarching conceptual ideas that have informed the development of diagnostic criteria and the organization of the text. These include incorporation of a developmental approach to psychiatric disorders, recognition of the influence of culture and gender on how psychiatric illness presents in individual patients, a move toward the use of dimensional measures to rate severity and disaggregate symptoms that tend to occur across multiple disorders, harmonization of the text with ICD, and integration of genetic and neurobiological findings by grouping clusters of disorders that share genetic or neurobiological substrates. DSM-5 consists of three sections: Section 1 gives an introduction to DSM-5 with instructions on how to use the updated manual; Section 2 outlines the categorical diagnoses according to a revised chapter organization that eliminates the multiaxial system; and Section 3 includes conditions that require further research before their consideration as formal diagnoses, as well as cultural formulations and other information. The Table of Contents of the DSM-5 can be found here.

 

One significant change is that DSM-5 combines the first three DSM-IV-TR axes into one list that contains all mental disorders, includ­ing personality disorders and intellectual disability, as well as other medical diagnoses. Contributing psychosocial and environmental factors or other reasons for visits are now represented through an expanded selected set of ICD-9-CM V-codes and, from the forthcoming ICD-10-CM, Z-codes. These codes provide ways for clinicians to indicate other conditions or problems that may be a focus of clinical attention or otherwise affect the diagnosis, course, prognosis, or treatment of a mental disorder (such as relationship problems between patients and their intimate partners). These conditions may be coded along with the patient’s mental and other medical disorders if they are a focus of the current visit or help to explain the need for a treatment or test. Alternatively, they may be entered into the patient’s clinical record as useful information on circumstances that may affect the patient’s care.

 

As is well-known to clinicians, the Global Assessment of Functioning (GAF) scale (Axis V in the DSM-IV) of the multiaxial assessment, combined assessment of symptom severity, dangerousness to self or others, and decre­ments in self-care and social functioning, into a single global assessment. The GAF was used for deter­minations of medical necessity for treatment by many payers and eligibility for short- and long-term disability compensation. The DSM-5 conceptualizes need for treatment as based on assessments of diagnosis, severity of symptoms and diagnosis, dangerousness to self or others, and disability in social and self-care spheres. It was determined that a single score from a global assessment, such as the GAF, did not convey enough information to adequately assess each of these components, which are likely to vary indepen­dently over time (this has been one of the primary criticisms of the GAF and Axis V). There was concern about evidence that the GAF requires specific training for proper use, and that good reliability and prediction of outcomes in routine clinical practice may depend on such training (it was found that without specific training in the use of GAF, reliability is poor). Therefore, DSM-5 recommends that clinicians continue to assess the risk of suicidal and homicidal behavior and use avail­able standardized assessments for symptom severity, diagnostic severity, and disability such as the measures in Section III (examples can be found here or at www.dsm5.org).

 

For those who relied on the use of a GAF number, there will clearly be a transitional period from the GAF to the use of separate assessments of severity and disability. The World Health Organization Disability Assessment Schedule (WHODAS 2.0) was judged by the DSM-5 Disability Study Group to be the best current measure of disability for routine clinical use (for a copy of the 36-item version click here). The WHODAS 2.0 is based on the International Classification of Functioning, Disability, and Health (ICF) and is applicable to patients with any health condition, thereby bringing DSM-5 into greater alignment with other medical disciplines. It was tested in the DSM-5 field trials and found to be feasible and reliable in routine clinical evaluations. This change in the recommended assessment is consistent with WHO rec­ommendations to move toward a clear conceptual distinction between the disorders contained in the ICD and the disabilities resulting from disorders, which are described in the ICF.

 

Although the new manual retains a categorical listing of separate disorders, an important change to DSM-5 is the incorporation of dimensional measures of severity for a number of disorders. This reflects what a considerable body of research—as well as clinical observation—has revealed: that the boundaries between many disorder “categories” are more fluid over the life course than was previously understood, and many symptoms assigned to a single disorder may occur, at varying levels of severity, in many other disorders. So, for instance, the criteria for autism spectrum disorder include three levels of severity for the two principal symptoms—“deficits in social communication and social interaction” and “restrictive and repetitive behavior patterns”—to indicate the level of supportive services required by an individual patient.

 

Overview of Specific Changes from DSM-IV-TR to DSM-5

 

The following is a summary of the APA publication, Highlights of Changes from DSM-IV-TR to DSM-5 (APA, 2013; or click here if there are problems with the link). As part of the course, please review the detailed document which is summarized subsequently.  Changes made to the DSM-5 diagnostic criteria and texts are outlined in the following (and the APA publication above) 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 con­tains 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.

 

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 phono­logical 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.

 

Autism Spectrum Disorder (ASD).  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 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 symp­tom 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 related to examples of criterion items, addition of the cross-situational requirement, the onset criterion, subtypes have been replaced with presentation specifiers, a comorbid diagnosis with autism spectrum disorder is now allowed; and a symptom threshold change has been made for adults. Also, 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.

 

Motor Disorders.  The following motor disorders are included in the DSM-5 neurodevelopmental disorders chapter: devel­opmental coordination disorder, stereotypic movement disorder, Tourette’s disorder, persistent (chron­ic) motor or vocal tic disorder, provisional tic disorder, other specified tic disorder, and unspecified tic disorder. Stereotypic movement disorder has been more clearly differentiated from body-focused repetitive behavior disor­ders 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. 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, or disorganized speech.

 

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; instead, a dimensional approach to rating severity for the core symptoms of schizo­phrenia 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 pres­ent for a majority of the disorder’s total duration after Criterion A has been met. It makes schizoaffective disorder a longitudinal instead of a cross-sectional diagnosis.

 

Delusional Disorder.  Criterion A for delusional disorder no longer has the requirement that the delusions must be non­bizarre. A specifier for bizarre type delusions provides continuity with DSM-IV. DSM-5 no longer separates delusional disorder from shared delusional dis­order.

 

Catatonia.  The same criteria are used to diagnose catatonia whether the context is a psychotic, bipolar, depres­sive, or other medical disorder, or an unidentified medical condition. 

 

Bipolar and Related Disorders

 

Bipolar Disorders.  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 simulta­neously 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 hy­pomania 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.

 

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 overtreat­ment of bipolar disorder in children, a new diagnosis, disruptive mood dysregulation disorder, is includ­ed for children up to age 18 years who exhibit persistent irritability and frequent episodes of extreme behavioral dyscontrol. Premenstrual dysphoric disorder is now in DSM-5. Dysthymia in DSM-IV now falls under the category of persistent depressive dis­order (chronic major depressive disorder and the previous dysthymic disorder).

 

Major Depressive Disorder.  The core criterion symptoms and duration for major depressive episode are unchanged.

 

Bereavement Exclusion.  In DSM-IV, there was an exclusion criterion for a major depressive episode that was applied to depres­sive symptoms lasting less than 2 months following the death of a loved one. This exclusion is omitted in DSM-5 for several reasons discussed in the Manual. In summary, al­though 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.

 

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). 

 

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. Instead, the anxiety must be out of proportion to the actual danger or threat in the situation, af­ter taking cultural contextual factors into account. In addition, the 6-month duration is now extended to all ages.

 

Panic Attack.  The essential features of panic attacks remain unchanged, although the complicated DSM-IV terminology for describing different types of panic attacks (i.e., situationally bound/cued, situationally predis­posed, and unexpected/uncued) is replaced with the terms unexpected and expected panic attacks.

 

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.

 

Specific Phobia.  The core features of specific phobia remain the same, but there is no longer a requirement that indi­viduals over age 18 years must recognize that their fear and anxiety are excessive or unreasonable. The duration requirement (“typically lasting for 6 months or more”) now applies to all ages.

 

Social Anxiety Disorder (Social Phobia).  The essential features of social anxiety disorder (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 sig­nificant change is that the “generalized” specifier has been deleted and replaced with a “performance only” specifier.

 

Separation Anxiety Disorder.  Separation anxiety disorder is now classified as an anxiety disorder, but the core features remain mostly unchanged  Also, the diagnostic criteria no longer specify that age at onset must be before 18 years, and a duration criterion—“typically lasting for 6 months or more”—has been added for adults to minimize overdiagnosis of transient fears.

 

Selective Mutism.  Selective mutism 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 in­creasing 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 obses­sive-compulsive and related disorder, and obsessive-compulsive and related disorder due to another medical condition.

 

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 be­liefs, including absent insight/delusional symptoms.

 

Body Dysmorphic Disorder.  For DSM-5 body dysmorphic disorder, a diagnostic criterion describing repetitive behaviors or mental acts in response to preoccupations with perceived defects or flaws in physical appearance has been added.

 

Hoarding Disorder.  Hoarding disorder is a new diagnosis in DSM-5. There is evidence for the diagnostic validity and clinical utility of a separate diagnosis of hoarding disorder, which reflects persistent difficulty dis­carding 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.

 

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-Compul­sive and Related Disorder Due to Another Medical Condition.  Given that obses­sive-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-compul­sive 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 pres­ent with symptoms similar to primary obsessive-compulsive and related disorders.

 

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.

 

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 symp­toms, 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: (1) The stressor criterion (Criterion A) is more explicit with regard to how an individual experienced “traumatic” events, (2) Criterion A2 (subjective reaction) has been eliminated, (3) 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 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. 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 with­drawn/inhibited and indiscriminately social/disinhibited. In DSM-5, these subtypes are defined as distinct disorders: reactive attachment disorder and disinhibited social engagement disorder.

 

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. 

 

Dissociative Identity Disorder.  Several changes to the criteria for dissociative identity disorder have been made in DSM-5: (1) Criterion A has been expanded to include certain possession-form phenomena and functional neurological symp­toms (2) Criterion A now specifically states that transitions in identity may be observable by others or self-reported (3) according to Criterion B, in­dividuals with dissociative identity disorder may have recurrent gaps in recall for everyday events not just for traumatic experiences.

 

Somatic Symptom and Related Disorders

 

In DSM-5, somatoform disorders are now referred to as somatic symptom and related disorders. The 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. Individuals previously diag­nosed 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. Because the distinction between somatization disor­der 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.  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 fea­ture in conversion disorder and pseudocyesis because it is possible to demonstrate 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 pejora­tive and not conducive to an effective therapeutic relationship. Most of those individuals will receive a diagnosis of somatic symptom disorder. In DSM-5, indi­viduals with high health anxiety without somatic symptoms would receive a diagnosis of illness anxiety disorder.

 

Pain Disorder.  DSM-5 takes a different approach to the important clinical realm of individuals with pain. 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 ad­justment 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. This disorder and factitious disorder are placed among the somatic symptom and related disor­ders because somatic symptoms are predominant in both disorders. 

 

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 psychologi­cal 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 In­fancy, Childhood, or Adolescence.” In addition, brief descriptions and preliminary diagnostic criteria are provided for several conditions under other specified feeding and eating disorders; insufficient information 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.

 

Anorexia Nervosa. The core diagnostic criteria for anorexia nervosa are conceptually unchanged from DSM-IV with one ex­ception: the requirement for amenorrhea has been eliminated.

 

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.

 

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 buli­mia 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.

 

Sleep-Wake Disorders

 

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. 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 hypersomno­lence. These changes are warranted by neurobiological and genetic evidence validating this reorganiza­tion. 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: obstruc­tive sleep apnea hypopnea, central sleep apnea, and sleep-related hypoventilation. 

 

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 disor­ders have been combined into one disorder: female sexual interest/arousal disorder. 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.

 

Genito-Pelvic Pain/Penetration Disorder. Genito-pelvic pain/penetration disorder is new in DSM-5 and represents a merging of the DSM-IV cat­egories of vaginismus and dyspareunia, which were highly comorbid and difficult to distinguish. The di­agnosis 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 di­agnosis made by mental health care providers, although a large proportion of the treatment is endocri­nological 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.

 

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 chapters “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence” and  “Impulse-Control Disorders Not Otherwise Specified”. 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. (1) Symptoms are now grouped into three types: angry/irritable mood, argumentative/defiant behavior, and vindictive­ness. (2) The exclusion criterion for conduct disorder has been removed. (3) Given that many behav­iors 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. (4) A severity rating has been added to the criteria to reflect research showing that the degree of pervasiveness of symp­toms across settings is an important indicator of severity.

 

Conduct Disorder.  The criteria for conduct disorder are largely unchanged from DSM-IV.

 

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 non­destructive/noninjurious physical aggression also meet criteria in DSM-5. DSM-5 also provides more specific criteria defining frequency and impairment. Also, a minimum age of 6 years (or equivalent developmental level) is now required.

 

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. The DSM-5 substance use disorder criteria are nearly identical to the DSM-IV substance abuse and de­pendence criteria combined into a single list, with two exceptions (1) 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. (2) the threshold for substance use disorder diagnosis in DSM-5 is set at two or more criteria which differs from DSM-IV. Canna­bis and caffeine withdrawal are new for DSM-5, and tobacco use disorder is now the same as those for other substance use disorders. 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  specifier for a physiological subtype has been eliminated in DSM-5, as has the 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 re­mission is defined as at least 12 months without criteria (except craving). Additional new DSM-5 speci­fiers 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 major neurocognitive disorder (NCD). DSM-5 now recognizes a less severe level of cogni­tive impairment, mild NCD, which is a new disorder that permits the diagnosis of less disabling syn­dromes 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.

 

Etiological Subtypes.  In DSM-IV, individual criteria sets were designated for dementia of the Alzheimer’s type, vascular dementia, and substance-induced dementia.  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 re­tained, 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 Sec­tion III, a revised personality functioning criterion (Criterion A) has been developed. Further­more, 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 per­sonality 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 consis­tently 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 em­pirically 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 pathologi­cal personality traits, replaces personality disorder not otherwise specified and provides a much more informative diagnosis for patients who are not optimally described as having a specific personality dis­order. 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 ap­proach provides a clear conceptual basis for all personality disorder pathology and an efficient assess­ment approach with considerable clinical utility.

 

Paraphilic Disorders

 

Specifiers.  An overarching change from DSM-IV is the addition of the course specifiers “in a controlled environ­ment” 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.

 

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 impair­ment 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. 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.

 

DSM, ICD and the Rest of the World

 

What is the International Classification of Diseases (ICD)?

 

The International Classification of Diseases (ICD) is a publication of the World Health Organization (WHO) of which the United States is a Member State. The ICD was first published in the early 1900’s and is now in its 10th version.  The ICD is the world’s standard tool to capture mortality and morbidity data. It organizes and codes health information that is used for statistics and epidemiology, health care management, allocation of resources, monitoring and evaluation, research, primary care, prevention and treatment. It helps to provide a picture of the general health situation of countries and populations. The purpose is to provide a standardized system of reporting data which supports WHO in the collection and analysis of health related data including morbidity and mortality.

 

While the United States currently uses ICD-9, the transition to using the ICD-10-CM is set for Oct. 1, 2014. This is due to the fact that the Health Insurance Portability and Accountability Act (HIPAA) requires that ICD diagnostic codes (ICD-10-CM), not DSM, must be used for billing.  As a note, every country is allowed to modify the ICD to suit its own particular circumstances. The Centers for Disease Control has that responsibility for the U.S., and the modification that is produced is tagged with "CM" — meaning clinical modification. The number ICD-10-CM indicates which version of the ICD-10 the U.S. is using.

 

The current ICD in use in this country (ICD-9) is actually consistent with DSM-IV-TR - the codes are essentially the same.  The DSM-IV-TR is aligned to the ICD-9 and the U.S. adaptation, the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM). Probably unknown to the vast majority of mental health practitioners is that most insurance carriers and other payor systems use the ICD to perform actual data tracking, review, and payment processing.  When mental health practitioners submit billing using the DSM-IV-TR codes, they are “crosswalked” (converted to the corresponding ICD code) for billing and other purposes. All of this occurs behind the scenes. Since the DSM-IV-TR and ICD codes are essentially the same, the process has been seamless. Even though the ICD codes are used for claims processing (including all medical, behavioral health and substance use claims), the DSM, used in the United States, has greater clinical and research application with its inclusion of diagnostic criteria (which is much more detailed than the ICD Manual). 

 

The mental health profession is the only healthcare group in the U.S. that uses a unique diagnostic system (DSM) that is different from the rest of the world.  Other groups (Medicine) use ICD as does the rest of the world. The American Psychiatric Association publishes a diagnostic manual on mental disorders (DSM) that has been widely used for training and diagnostic purposes across mental health professions. However, the rest of the health care industry has used the ICD for diagnostic codes. The U.S., as a member of the World Health Assembly, is expected to report morbidity and mortality data using the World Health Organization's international standard, the ICD. To the extent that DSM and ICD have been harmonized, that has not been a problem in years past. To the extent that these systems diverge in the future, health statistics such as morbidity and mortality data will be required to be reported to WHO via ICD.

 

It is important to note that the WHO published ICD-10 in 1992; and most countries in the world have converted to ICD-10 since that time, but the U.S. has not (we still use ICD-9-CM). The U.S. is not scheduled to convert to ICD-10-CM until Oct. 1, 2014; however, the WHO anticipates publishing ICD-11 in 2015. The CDC (United States) hopes to use an annual updating process to bring ICD-10-CM closer in alignment to ICD-11 so that the conversion from version 10 to 11 will not take as long nor be as abrupt with the next transition process. However, for now, mental health practitioners should focus solely on the transition to the ICD-10-CM as it impacts the use of DSM-5.

 

So, what does all of this mean related to the DSM-5? In summary, up until DSM-5, the correlation with ICD has been so consistent, there have been no problems.  The APA DSM-5 Task Force was certainly aware of these issues. In fact, the DSM-5 classification of disorders is largely harmonized with the WHO’s International Classification of Diseases (ICD) so that the DSM criteria sets are more parallel with the proposed ICD-11. In DSM-5 both the current ICD-9-CM and the future standard ICD-10-CM codes (scheduled for use in the U.S. in October of 2014) are attached to the relevant disorders in the classification.  The following are some examples (See Table 2).  This suggests that practitioners should not have a problem using the DSM-5 Codes even after the full adoption of ICD-10-CM in October 2014 (since they are already “crosswalked” in the manual).  Of course, the real issue comes in the future, specifically related to the annual update of ICD-10-CM to align with ICD-11 and beyond (one of the mission statements related to the U.S. aligning itself with ICD).  One can imagine annual or bi-annual update of DSM-5 (e.g. 5.1, 5.2, 5.3) in the future (with whatever associated costs).  The ICD Manual is always available for free. For strictly billing purposes, once the U.S. fully adopts the ICD system (after October 2014), there is no reason that a clinician cannot simply use the ICD.  Of course, one of the strengths of the DSM over the ICD is that it is much more detailed relative to diagnostic descriptors. 

 

In summary, the introductory material to the DSM-IV and DSM-5 code set indicates that the DSM-IV and DSM-5 are “compatible” with the ICD-9-CM diagnosis codes. The updated DSM-5 codes are crosswalked to both ICD-9-CM and ICD-10-CM. As of October 1, 2014, the ICD-10-CM code set is the HIPAA adopted standard and required for reporting diagnosis for dates of service on and after October 1, 2014. Neither the DSM-IV nor DSM-5 is a HIPAA adopted code set and may not be used in HIPAA standard transactions. It is expected that clinicians may continue to base their diagnostic decisions on the DSM-IV/DSM-5 criteria, and, if so, to crosswalk those decisions to the appropriate ICD-9-CM and, as of October 1, 2014, ICD-10 CM codes. In addition, it is still perfectly permissible for providers and others to use the DSM-IV and DSM-5 codes, descriptors and diagnostic criteria for other purposes such as medical records, quality assessment, medical review, consultation and patient communications. As can be seen in Table 2, this can result in situations in which the DSM-5 disorder description yields the same code as another disorder due to the ICD crosswalking (As an example, see Hoarding Disorder and Other specified obsessive compulsive and related disorders in the Table).

 

Table 2. Examples of DSM Disorders/ICD Titles and Codes

DSM-5 Disorder

DSM-5/

ICD-9-CM

(Use until 09-30-2014)

CD-9-CM Title

DSM-5/ICD-10-CM

(Use after 10-01-2014)

ICD-10-CM Title

Social (pragmatic) communication disorder

315.39

Other Developmental speech or language disorder

F80.89

Other developmental disorders of speech and language  

Disruptive mood dysregulation disorder

296.99

Other specified episodic mood disorder

F34.8

Other persistent mood [affective] disorders

Premenstrual dysphoric disorder

625.3

Premenstrual tension syndromes

N94.3

Premenstrual tension syndromes

Hoarding Disorder

300.3

Obsessive-compulsive disorder

F42

Obsessive-compulsive disorder

Other specified obsessive compulsive and related disorder

300.3

Obsessive-compulsive disorder

F42

Obsessive-compulsive disorder

Binge eating disorder

307.51

Bulimia nervosa

F50.8

Other eating disorders

Adapted from Insurance Implications of DSM-5 (APA, 2013). Please see complete article here.

 

In some “systems”, the use of DSM-IV (or TR) may or may not be required even after the full adoption of ICD and/or DSM-5.  For instance, federal education laws, such as No Child Left Behind, have requirements for Individualized Education Programs (IEPs) and special education, but the text of those bills does not mandate DSM, or any other diagnostic manual. The laws leave it to the states to define the criteria for admission. While many states do not specify criteria and indicate “professional expertise” as the determinant, some state laws and regulations do specify DSM. This is also true with state laws addressing other issues (e.g. a workers’ compensation system that uses the DSM-IV five axis system; a state law that require use of Axis V or the GAF for determination of disability, a state law which uses DSM diagnostic categories to determine eligibility for special education programs, etc.).

 

The 11th version of the ICD is now being developed through an innovative, collaborative process. For the first time WHO is calling on experts and users to participate in the revision process through a web-based platform (some of you may have been asked to participate). The outcome will be a classification that is based on user input and needs. The ICD is being revised to better reflect progress in health sciences and medical practice. In line with advances in information technology, ICD-11 will be used with electronic health applications and information systems. The ICD-11 revision process allows for collaborative web-based editing that is open to all interested parties. To assure quality, it will be peer reviewed for accuracy and relevance. As with the other ICDs, ICD-11 will be free to download online for personal use (and in print form for a fee).  As with other ICDs, it will be available in multiple languages. Definitions, signs and symptoms, and other content related to diseases will be defined in a structured way so it can be recorded more accurately. The ICDs are compatible with electronic health applications and information systems. The ICD-11 is scheduled for release in 2015 and the precise timeline can be found here. As mandated by HIPAA, the U.S. will continue to use the ICD system, including updates and new versions.

 

Most mental health practitioners have been trained using the DSM and upon the publication of new editions, have simply bought the most recent edition in order to be certain they are using the current criteria for diagnosis. Even though DSM-5 has crosswalked ICD codes in the manual (at least for ICD-9 and ICD-10), practitioners may want to start to familiarize themselves with the ICD (used by the rest of the world) in order to identify the appropriate codes and be paid for their services (if necessary in the future). The World Health Organization, publishers of the ICD, have created the "blue book" — the ICD-10 Classification of Mental and Behavioural Disorders Clinical Descriptions and Diagnostic Guidelines (PDF, 1.3MB) — which mental health practitioners can use to determine diagnoses. However, as will be seen, this document does not have the same level of detail that the DSM contains. The ICD is the code set used for classification and billing purposes, but the ICD itself does not contain extensive criteria for the purposes of diagnosis. It is presumed that the health care professional has that knowledge, or access to that knowledge, and the expertise to use that knowledge appropriately.

 

A Brief Review of Controversial Issues Related to DSM-5

 

Similar to the release of previous DSMs, there has been considerable critique of DSM-5 both before and since its recent release.  The following is not meant to take a position but, rather, to allow the reader to be exposed to the most controversial issues. As time goes on, there is no doubt that all of these will be addressed in more detail by researchers, the public, advocacy groups, professional groups, payors, etc.   

 

Critique of the Changes in the Diagnostic Categories

 

Allen Frances, M.D. has been one of the major critics of the DSM-5.  Although many may criticize the publication, his views are particularly poignant since he was the Chair of the DSM-IV Task Force. He feels that the DSM-5 will result in diagnostic inflation causing overdiagnosis and overtreatment of patients who are essentially well. He feels that the process by which DSM committee members arrived at their expanded diagnoses was flawed.  As he states, the DSM-5 did not address professional and public concerns.  He feels that its changes lack sufficient scientific support and defy clinical common sense. He reports that field trials produced reliability results that did not meet historical standards, and deadlines were consistently missed. He states that the American Psychiatric Association refused a petition for an independent scientific review of the DSM-5 that was endorsed by more than 50 mental health associations. In addition he comments, "I believe that the American Psychiatric Association (APA)'s financial conflict of interest, generated by DSM publishing profits needed to fill its budget deficit, led to premature publication of an incompletely tested and poorly edited product."  He concludes that, "The problems associated with the DSM-5 prove that the APA should no longer hold a monopoly on psychiatric diagnosis.... The codes needed for reimbursement are available for free on the Internet."  (please see www.dxrevisionwatch.com for more detail related to all of these issues).

 

In contrast, the APA has also weighed in on this issue.  According to the American Psychiatric Association, the DSM-5 was compiled from a comprehensive review of scientific advances. The DSM-5 Task Force also posted frequent reports about the proposed changes on its website. Starting in 2010, representatives for the DSM made hundreds of presentations at leading medical conferences around the world. In a Forbes interview, Dr. James H. Scully, the medical director and CEO of the American Psychiatric Association, stated, “At every step of development, we have worked to make the process as open and inclusive as possible.” The Task Force has received some 13,000 comments from clinicians, researchers, and patients since 2010. However, dozens of medical and patient advocacy groups have mounted attacks on the new guide. In contrast, the National Institute of Mental Health (NIMH) weighed in with a statement from its director, Dr. Thomas Insel, saying, “The weakness [in the DSM-5] is its lack of validity." The NIMH says it will no longer be funding research projects based on DSM diagnoses and is working on developing its own diagnostic system (to be discussed subsequently).

 

One of the primary criticisms related to DSM-5 is that it will stigmatize normal behavior.  On the one hand, the DSM-5 Task Force reports that it conducted “field trials” to evaluate the impact of certain diagnoses. They estimate that, in general, the rates of these disorders using DSM-5 criteria “are slightly lower than DSM-IV prevalence.” However, a coalition of 32 organizations (www.dsm5-reform.com) including divisions of the American Psychological Association, argue that the DSM-5 lowers the threshold for a diagnosis of mental illness and contributes to “excessive medicalization,” “stigmatization,” and “pathologization” of normal human responses and behavior. Dr. Allen Frances fears that there will be a backlash against the DSM-5 and its propensity to stigmatize normal behavior and over-diagnose (in his opinion).  He feels it will cause the public and legislators to question the value of psychiatry (and mental health treatment). As he states, “Funding for mental healthcare has already been cut in many states, and many people who are mentally ill or even suicidal aren’t getting the help they desperately need.” Professionals with similar views also wonder how long before payors will be begin to revolt against reimbursing for treatment of the “questionable” diagnoses in DSM-5.

 

The following has been mostly excerpted from an article by Dr. Frances in which he discusses his concerns.  The following also has been expanded with commentary from others related to each of these issues.  Dr. Frances reviews the ten “most potentially harmful changes” (in his opinion) that emerged in DSM-5 and suggests that they be “ignored” or used “with extreme caution” since to him they “make no sense.” "Drug companies take marketing advantage of the loose DSM definitions by promoting the misleading idea that everyday life problems are actually undiagnosed psychiatric illness caused by a chemical imbalance and requiring a solution in pill form," Dr. Frances writes.

 

1) Disruptive Mood Dysregulation Disorder. One of the most controversial new childhood disorders is called disruptive mood dysregulation disorder (DMDD), which requires kids to have at least three tantrums a week and frequent irritability for a year to be diagnosed. The Task Force came up with this diagnosis in a bid to address concerns about the overdiagnosis of childhood bipolar disorder—a once rare condition that has skyrocketed by 40-fold during the past 15 years. However, as stated by child psychologist Tom Frazier, Ph.D., who heads the Cleveland Clinic Children’s Center for Autism, “The major problem with DMDD is that there is very little scientific data to support this diagnosis” and “The only data I’ve seen suggests that it will have a high overlap with existing conditions like ADHD and oppositional defiant disorder, so I honestly don’t know why it was included, except that a few people with influence pushed for it.”  Dr. Frances has another name for the temper-tantrum disorder: “These kids have a disease called childhood,” he says, admitting that the DSM-IV Task Force he headed in the 1990s inadvertently created an “epidemic of overdiagnosis” by adding two then-new mental disorders to the manual, autism and bipolar disorder II (an adult disorder sometimes applied to children).

 

Dr. Frances states the following: 

 

DSM 5 will turn temper tantrums into a mental disorder - a puzzling decision based on the work of only one research group. We have no idea whatever how this untested new diagnosis will play out in real life practice settings, but my fear is that it will exacerbate, not relieve, the already excessive and inappropriate use of medication in young children. During the past two decades, child psychiatry has already provoked three fads- a tripling of Attention Deficit Disorder, a more than twenty-fold increase in Autistic Disorder, and a forty-fold increase in childhood Bipolar Disorder. The field should have felt chastened by this sorry track record and should engage itself now in the crucial task of educating practitioners and the public about the difficulty of accurately diagnosing children and the risks of over- medicating them. DSM 5 should not be adding a new disorder likely to result in a new fad and even more inappropriate medication use in vulnerable children.

 

2) Major Depressive Disorder (related to bereavement).  Dr. Frances and others are concerned that this can make grief a psychiatric condition. In DSM-5, grief over the death of a loved one could qualify as major depressive disorder if it lasts more than two weeks and the bereaved person experiences such symptoms as loss of appetite and interest in daily activities, trouble sleeping and focusing, and feelings of worthlessness or despair. This change is one of the most controversial in the DSM-5, but some experts believe it will have a positive impact on patients. “While everyone experiences grief, for some people, a major loss can be a trigger for depression,” notes Dr. Daniel Amen, MD, a board-certified child and general psychiatrist with clinics in several cities. “Making the criteria more expansive could help those people be identified and treated sooner, thus reducing their suffering."  However, others comment that, normal grief will become a major depressive disorder, thus medicalizing and trivializing our expectable and necessary emotional reactions to the loss of a loved one and substituting pills and superficial medical rituals for the deep consolations of family, friends, religion, and the resiliency that comes with time and the acceptance of the limitations of life. 

 

3) Minor Neurocognitive Disorder. Another concern is that the everyday forgetting characteristic of old age will now be misdiagnosed as Minor Neurocognitive Disorder, creating a huge false positive population of people who are not at special risk for dementia. Since there is no effective treatment for this 'condition' (or for dementia), the label provides absolutely no benefit (while creating great anxiety) even for those at true risk for later developing dementia. It is a dead loss for the many who will be mislabeled.

 

4) Adult Attention Deficit Disorder. The DSM-5 reduces the number of symptoms adults need to qualify for this already common label from six to five and raises the age limit by which symptoms must start. The DSM-IV required that "symptoms that caused impairment were present before age 7 years," while the DSM-5 expands the definition to "several inattentive or hyperactive-impulsive symptoms were present prior to age 12."  Dr. Frances predicts that DSM 5 will likely trigger a fad of Adult Attention Deficit Disorder leading to widespread misuse of stimulant drugs for performance enhancement and recreation and contributing to the already large illegal secondary market in diverted prescription drugs. 

 

5) Binge Eating Disorder. As Dr. Frances critiques it, “Excessive eating 12 times in 3 months is no longer just a manifestation of gluttony and the easy availability of really great tasting food. DSM 5 has instead turned it into a psychiatric illness called Binge Eating Disorder.”

 

6) Autism Spectrum Disorder. The DSM-5 will now fold Asperger’s disorder, autism disorder, childhood disintegrative disorder, and pervasive developmental disorder into a single condition called autism spectrum disorder, which the American Psychiatric Association believes will lead to more accurate diagnosis. The changes in the DSM 5 definition of Autism will result in lowered rates- 10% according to estimates by the DSM 5 work group, perhaps 50% according to outside research groups. However other experts, including Dr. Frazier of the Cleveland Clinic, feel that, “The impact on children with autism will probably be very small, with about 2 percent, mainly high-functioning kids, being affected by the changed criteria.” This reduction can be seen as beneficial in the sense that the diagnosis of Autism will be more accurate and specific- but advocates understandably fear a disruption in needed school services. However, some experts believe that children who don’t meet the DSM-5 criteria for autism might also fall within the definition of the new social communication disorder (SCD), in which patients have communication impairments similar to autism but do not exhibit repetitive movements.  Because it is a diagnosable psychiatric disorder, children with SCD would likely qualify for healthcare services and therapies through their insurance provider.

 

7) Substance Abuse. First time substance abusers will be lumped definitionally in with hard core addicts despite their very different treatment needs, prognosis, and well as the  and the stigma this will cause.

 

8) Behavioral Addictions. According to Dr. Frances, DSM 5 has created a slippery slope by introducing the concept of Behavioral Addictions that eventually can spread to make a mental disorder of everything we like to do a lot. He cautions, “Watch out for careless over-diagnosis of internet and sex addiction and the development of lucrative treatment programs to exploit these new markets.”

 

9) Generalized Anxiety Disorder versus normal worry.  DSM 5 obscures the already fuzzy boundary been Generalized Anxiety Disorder and the worries of everyday life. Small changes in definition can create millions of anxious new 'patients' and expand the already widespread practice of inappropriately prescribing addicting anti-anxiety medications. 

 

10) Post Traumatic Stress Disorder. DSM 5 has opened the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings. 

 

NIMH Rejects DSM-V

 

One the most headline-grabbing issues that occurred after the release of DSM-5 was the decision by the National Institute of Mental Health (NIMH) that it would be “re-orienting its research away from DSM categories”.  The following is an excerpt from the text of a blog statement from the NIMH Director, Tom Insel, M.D. (posted April 29, 2013; See Table 3)).

 

 

Table 3. The Director of NIMH on DSM-5

 

 

The goal of this new manual, as with all previous editions, is to provide a common language for describing psychopathology. While DSM has been described as a “Bible” for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.

 

Patients with mental disorders deserve better. NIMH has launched the Research Domain Criteria (RDoC) project to transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system. Through a series of workshops over the past 18 months, we have tried to define several major categories for a new nosology (see below). This approach began with several assumptions:

 

A diagnostic approach based on the biology as well as the symptoms must not be constrained by the current DSM categories,

 

Mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior,

 

Each level of analysis needs to be understood across a dimension of function,

 

Mapping the cognitive, circuit, and genetic aspects of mental disorders will yield new and better targets for treatment.

 

It became immediately clear that we cannot design a system based on biomarkers or cognitive performance because we lack the data. In this sense, RDoC is a framework for collecting the data needed for a new nosology. But it is critical to realize that we cannot succeed if we use DSM categories as the “gold standard.” The diagnostic system has to be based on the emerging research data, not on the current symptom-based categories. Imagine deciding that EKGs were not useful because many patients with chest pain did not have EKG changes. That is what we have been doing for decades when we reject a biomarker because it does not detect a DSM category. We need to begin collecting the genetic, imaging, physiologic, and cognitive data to see how all the data – not just the symptoms – cluster and how these clusters relate to treatment response.

 

That is why NIMH will be re-orienting its research away from DSM categories. Going forward, we will be supporting research projects that look across current categories – or sub-divide current categories – to begin to develop a better system. What does this mean for applicants? Clinical trials might study all patients in a mood clinic rather than those meeting strict major depressive disorder criteria. Studies of biomarkers for “depression” might begin by looking across many disorders with anhedonia or emotional appraisal bias or psychomotor retardation to understand the circuitry underlying these symptoms. What does this mean for patients? We are committed to new and better treatments, but we feel this will only happen by developing a more precise diagnostic system. The best reason to develop RDoC is to seek better outcomes.

 

 

People Taking "Drugs They Don't Need"

 

This criticism has also been expressed by Dr. Frances and others.  Dr. Frances predicts a false spike in mental disorders due to the DSM-5 and the further “medicalization” of behavioral conditions.  He feels that, “There will be massive diagnostic inflation that could lead to tens of millions of people receiving psychiatric drugs they don’t need.”  Incorrectly prescribed psychiatric medication can have dangerous side effects—and may be especially dangerous for kids. For example, the FDA has mandated a “black box label warning” that certain antidepressants called SSRIs (selective serotonin reuptake inhibitors)—such as Prozac, Zoloft and Paxil, among others—may increase risk for suicidal behavior or thinking in teens and children. Antipsychotic drugs, currently prescribed to more than 3 million Americans for such mental illnesses as bipolar disorder, severe depression, and schizophrenia, often cause weight gain, boosting risk for diabetes, high cholesterol, and heart disease. Other adverse effects can include dizziness, blurred vision, rapid heartbeat, tremors, and persistent muscles spasms. The NIMH also reports that every year, about 5 percent of people taking typical antipsychotic drugs develop a disorder called tardive dyskinesia, which is an often chronic condition characterized by uncontrollable muscle movements, such as facial grimaces, repetitive chewing, tongue thrusting, or finger movements, that can range from mild to severe. The potential expansion of those being diagnosed with some type of depressive or anxiety disorder could lead to greater prescribing of anti-depressants and anxiolytic medications (the vast majority of which are now prescribed by non-psychiatrists).

 

Financial Conflict of the DSM-V Developers

 

Adding to the discussion is the research demonstrating the still persistent financial conflict of interest associated with the "political/scientific" decisions related to DSM-5.  This is outlined in an essay entitled, “A comparison of DSM-IV and DSM-5 Panel Members Financial Associations with Industry: A Pernicious Problem Persists (Cosgrove and Krimsky, PLOS Medicine, 2013, accessed 7-09-2-13). In the article, the summary points are as follows:

 

  • The American Psychiatric Association (APA) instituted a financial conflict of interest disclosure policy for the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).
  • The new disclosure policy has not been accompanied by a reduction in the financial conflicts of interest of DSM panel members.
  • Transparency alone cannot mitigate the potential for bias and is an insufficient solution for protecting the integrity of the revision process.
  • Gaps in APA's disclosure policy are identified and recommendations for more stringent safeguards are offered.

 

Excerpts from the article provide a nice summary of their findings.  In 2006 the authors analyzed all DSM-IV panel members' financial associations with industry. They have undertaken a similar analysis for DSM-5 panels, which allowed them to compare the proportions of DSM-IV and -5 panel members who have industry ties. There are 141 panel members on the 13 DSM-5 panels and 29 task force members. The members of these 13 panels are responsible for revisions to diagnostic categories and for inclusion of new disorders within a diagnostic category.

 

It was found that three-fourths of the work groups continue to have a majority of their members with financial ties to the pharmaceutical industry. It is also noteworthy that, as with the DSM-IV, the most conflicted panels are those for which pharmacological treatment is the first-line intervention. For example, 67% (N = 12) of the panel for Mood Disorders, 83% (N = 12) of the panel for Psychotic Disorders, and 100% (N = 7) of the Sleep/Wake Disorders (which now includes “Restless Leg Syndrome”) have ties to the pharmaceutical companies that manufacture the medications used to treat these disorders or to companies that service the pharmaceutical industry.

 

Although the results are suggestive of bias towards pharmaceutical interventions, Dr. Frances does not believe the panel members were acting nefariously.  As he states:

 

The motives of the people working on DSM 5 have often been questioned. They have been accused of having a financial conflict of interest because some have (minimal) drug company ties and also because so many of the DSM 5 changes will enhance pharmaceutical profits by adding to our already existing societal overdose of carelessly prescribed psychiatric medicine. But I know the people working on DSM 5 and know this charge to be both unfair and untrue. Indeed, they have made some very bad decisions, but they did so with pure hearts and not because they wanted to help the drug companies. Their's is an intellectual, not financial, conflict of interest that results from the natural tendency of highly specialized experts to over value their pet ideas, to want to expand their own areas of research interest, and to be oblivious to the distortions that occur in translating DSM 5 to real life clinical practice (particularly in primary care where 80% of psychiatric drugs are prescribed).

 

The Cost of the DSM Manual

 

Another criticism of the DSM (DSM-5 and those prior), is the cost to the practitioner for the manual and accompanying materials (including training, etc.).  As discussed above, the DSM-III was so popular and successful that its revenues led to the formation of the American Psychiatric Press.  The publication of the DSMs and associated materials produces very significant revenue.  As discussed by Dr. Frances just before the release of DSM-5 (and echoed by others):

 

The APA's deep dependence on the publishing profits generated by the DSM 5 business enterprise creates a far less pure motivation. There is an inherent and influential conflict of interest between the DSM 5 public trust and DSM 5 as a best seller. When its deadlines were consistently missed due to poor planning and disorganized implementation, APA chose quietly to cancel the DSM 5 field testing step that was meant to provide it with a badly needed opportunity for quality control. The current draft has been approved and is now being rushed prematurely to press with incomplete field testing for one reason only- so that DSM 5 publishing profits can fill the big hole in APA's projected budget and return dividends on the exorbitant cost of 25 million dollars that has been charged to DSM 5 preparation. 

 

Many have also expressed concerns that DSM-5 has now gone to a system that allows for more frequent updates (e.g. DSM-5.1, 5.2, 5.3, etc.). Certainly this is a great idea in terms of making the DSM (or any nosologic system) consistent with the most current research. This is common practice in the computer software development in which updates and “patches” are frequently released (e.g. version 1.0, 1.1., 1.2, etc.).  However, the obvious concern is cost. Common sense questions include: Will each update (e.g. version 5.1) come with an additional cost?; How often will these updates be released?; How will they be distributed?; In what form will they be released?; etc.  One can imagine a system whereby the mental health practitioner subscribes to a DSM update service (annual fee maybe?) and updates, etc., are delivered periodically.  As discussed by Dr. Frances, how does an organization separate the obvious conflict of interest (huge and recurring profits versus the actual need for each update)?  

 

As pointed out by many, the ICD is produced by WHO and is used by the rest of the world for diagnostic classification (and by Medicine in the United States).  It is available on-line for free (http://www.who.int/classifications/icd/en/) as is the mental health section titled, The ICD-10 Classification of Mental and Behavioural Disorders: Clinical descriptions and diagnostic guidelines.

 

Summary and Conclusions

 

As with all previous DSM releases, the DSM-5 has been met with both acceptance and controversy. However, this time things may be different in terms of the long term and universal acceptance of the Manual.  As discussed, the world is now a different place relative to the time of previous releases.  The United States is moving toward integrating into health systems the nomenclature that has already been adopted by the rest of the world (ICD). The United States is the only country that uses the DSM and, even though its codes can be “crosswalked” to the ICD system, one can only wonder why not simply adopt an ICD orientation. Granted, the DSM provides much more detail in diagnostic descriptions (versus ICD) but other nosologic systems are available and are constantly being developed. Other unique issues for DSM-5 include the cost, the cost of associated materials, the potential cost of updates, the charge that it is overly biased toward enhancing pharmaceutical treatments, etc.  Only time will tell how extensive DSM-5 will be accepted and utilized.  As with anything, the professional consumer needs to be up to date about all the issues (as this course attempted to present) and then make informed decisions about DSM-5

 

 

Resources

 

The DSM Information Site from the American Psychiatric Association

 

The World Health Organization including information on ICD

 

Dx Revision Watch: Monitoring the development of DSM-5, ICD-11, ICD-10-CM

 

ReferenceS

 

Blashfield, R. K. (1998). Diagnostic models and systems. In a. S. Bellack & M. Hersen (Eds.), Comprehensive clinical psychology (pp. 57-80).

 

Feighner et al. (1972). Diagnostic Criteria for Use in Psychiatric Research. Archives of General Psychiatry, 26(1), 57-63.

 

Rosenhan, D. (1973). On being sane in insane places.

 

Spitzer, R.L. & Fleiss, J.L. (1974). A re-analysis of the reliability of psychiatric diagnosis. The British Journal of Psychiatry.

 

Szasz, T.S. (1960). The myth of mental illness." American Psychologist 15, 113.

 

Szasz, T.S. (2011).  The myth of mental illness: Foundations of a theory of personal conduct. HarperCollins

 

 

 

 

 



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