American Psychiatric Association approves DSM-5

A December 1 vote by the American Psychiatric Association’s (APA) Board of Trustees approved the final diagnostic criteria for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), closing nearly 14 years of extensive and sometimes controversial debate and clearing the way for the first publication of the new DSM-5 in spring 2013. The DSM is the guidebook used by clinicians and researchers to diagnose and classify a wide range of mental health, addiction, and psychiatric disorders.

“We have sought to be very conservative in our approach to revising DSM-5. Our work has been aimed at more accurately defining mental disorders that have a real impact on people’s lives, not expanding the scope of psychiatry,” said David J. Kupfer, MD, chair of the DSM-5 Task Force, the group that managed the huge revision effort.  According to the APA, the DSM-5 will include approximately the same number of disorders as were included in DSM-IV.

Behavioral Healthcare reviewed the DSM-5 revisions with John Grohol, PsyD, a Massachusetts-based psychologist and editor-in-chief of PsychCentral.com, an online mental health guide for consumers. Overall, he echoed the view that the DSM-5 revision may be considered conservative, explaining that technology, notably the internet, played an important role in the often noisy DSM-5 development process.

“The controversy was related largely to perceptions about the ‘transparency’ of the review process,” said Grohol, noting that previous editions of the DSM (DSM-IV was completed in 1994) were developed in a very different way. “For previous editions, there was generally not a public process—it was pretty ‘closed door’,” he remarked. Because the internet wasn’t there, he said that people didn’t have a way to learn about, rally around, and complain about issues of concern to them.

The latest DSM is the product of a very different, very public process that, according to the APA, drew more than 13,000 comments regarding proposed DSM-5 changes. “At every step of development, we have worked to make the process as open and independent as possible. The level of transparency we have strived for is not seen in any other area of medicine,” said James H. Scully, MD, medical director and chief executive officer of APA.

Overall Changes to DSM-5

Organization.  The new DSM-5 will be comprised of three sections:

·         Section one will contain an introduction to DSM-5 with information on how to use the updated manual;

·         Section 2 will contain an outline of the guide’s categorical diagnoses according to a revised chapter organization; and,

·         Section 3 will contain a listing of conditions that conditions that require further research before their consideration as formal disorders, as well as cultural formulations, glossary, the names of individuals involved in DSM-5’s development and other information.

Chapters: DSM-5’s 20 chapters will be restructured based on disorders’ apparent relatedness to one another, as reflected by similarities in disorders’ underlying vulnerabilities and symptom characteristics, said the APA. These changes will, it said, align DSM-5 with the World Health Organization’s (WHO) International Classification of Diseases, eleventh edition (ICD-11), support easier communications, and foster the common use of diagnoses across disorders.  

No more “multi-axis” diagnoses: DSM-5 will move to a non-axial documentation of diagnosis, combining the former Axes I, II, and III, with separate notations for psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V).  Grohol suggested that this change may have occurred because “People weren’t using it” and the distinctions that it generated “weren’t seen as being clinically meaningful.”  However, he pointed out that despite the demise of the axes, all 10 of the personality disorders recognized under DSM-4’s Axis 2 are maintained in DSM-5 (see item 7 below). 

Changes to DSM-5 disorders (Section 2)

1. A reorganized section discussing autism spectrum disorders will consolidate Asperger’s disorder with a range of related DSM-IV diagnoses—autistic disorder, childhood disintegrative disorder, and pervasive developmental disorder (not otherwise specified). “Asperger’s is seen as a mild form of autism, rather than a separate diagnosis,” said Grohol.  

2.  Binge eating disorder, which was noted in DSM-IV’s Appendix B: Criteria Sets and Axes Provided for Further Study will now be categorized as a disorder in DSM-5 Section 2.

3.  Disruptive mood dysregulation disorder will be included in DSM-5 to diagnose children who exhibit persistent irritability and frequent episodes of behavior outbursts three or more times a week for more than a year. The diagnosis is intended to address concerns about potential over-diagnosis and overtreatment of bipolar disorder in children.

4.  Excoriation (skin-picking) disorder is new to DSM-5 and will be included in the Obsessive-Compulsive and Related Disorders chapter.

5.  Hoarding disorder has been added to DSM-5, based on extensive scientific research. This disorder will help characterize people with persistent difficulty discarding or parting with possessions, regardless of their actual value.

6.  The disorder called pedophilia will be renamed to pedophilic disorder, but its criteria remain unchanged from DSM-IV.

7.  Although DSM-5 will no longer use the five axes for documenting a diagnosis, DSM-5 will maintain the categorical model and criteria for the 10 personality disorders included in DSM-IV.  It will also include its new trait-specific methodology in a separate area of Section 3 (items for further research) to encourage further study as to how the methodology could be used to diagnose personality disorders in clinical practice. 

8.  Posttraumatic stress disorder (PTSD) will be included in a new chapter in DSM-5 on Trauma- and Stressor-Related Disorders. DSM-5 pays more attention to the behavioral symptoms that accompany PTSD and proposes four distinct diagnostic clusters instead of three. PTSD will also be more developmentally sensitive for children and adolescents.

9.  Bereavement exclusion for major depression removed: The exclusion criterion in DSM-IV applied to people experiencing depressive symptoms lasting less than two months following the death of a loved one has been removed and replaced by several notes within the text delineating the differences between grief and depression. This reflects the recognition that bereavement is a severe psychosocial stressor that can precipitate a major depressive episode beginning soon after the loss of a loved one.

10.  Specific learning disorder broadens the DSM-IV criteria to represent distinct disorders which interfere with the acquisition and use of one or more of the following academic skills: oral language, reading, written language, or mathematics.

11.  Substance use disorder will combine the DSM-IV categories of substance abuse and substance dependence. In this one overarching disorder, the criteria have not only been combined, but strengthened. Previous substance abuse criteria required only one symptom while the DSM-5’s mild substance use disorder requires two to three symptoms.

Changes to Section 3 (Disorders requiring further research)

Four disorders are added here:

·         Attenuated psychosis syndrome

·         Internet use gaming disorder

·         Non-suicidal self-injury

·         Suicidal behavioral disorder

Excluded conditions

Four conditions were considered, but ultimately not included in any section of DSM-5:

·         Anxious depression

·         Hypersexual disorder

·         Parental alienation syndrome

·         Sensory processing disorder