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Table Of Contents-Part 2
4. Highlights of Changes from DSM-IV-TR to DSM-5
The creators of the DSM-5 see the following improvements in the new manual:
There are “few notable differences from the DSM-IV. One distinction is DSM-5’s emphasis on numerous issues important to diagnosis and clinical care, including the influence of development, gender, and culture on the presentation of disorders. This is present in select diagnostic criteria, in text, or in both, which include variations of symptom presentations, risk factors, course, comorbidities, or other clinically useful information that might vary depending on a patient’s gender, age, or cultural background.” (Kupfer et al., 2013)
In the earlier versions of DSM, disorders were described and arranged by category, with a specific list of symptoms for each mental illness. In this categorical system, a person either had a symptom or they didn’t, and having a certain number of symptoms was required to receive a diagnosis. If this number was not met, the disorder could not be diagnosed.
There has not been much evidence that disorders are categorical, both in terms of being categorically distinct from each other and from normal behavior. The categorical syndromes did not always fit the range of symptoms that individuals experience. (Apple, 2013) The reason so many people have more than one psychiatric disorder is because many disorders reflect problems in the same dimension or system. This new approach means thinking about what disorders have in common instead of what makes them different. (Hopewood et al., 2011)
When the DSM-5 planning began in 1999 there was much written and speculated about the magnitude of the changes through use of words like “revolutionary change” to help the clinician capture the symptoms and severity of mental illnesses, by using dimensional assessments. These would allow clinicians to systematically evaluate patients on the full range of symptoms they may be experiencing and rate both the presence and the severity of symptoms, such as “very severe,” “severe,” “moderate” or “mild.” (Apple, 2013)
Therefore a sweeping change based on using a manual-wide dimensional model of diagnosis versus the historic traditional categorical model was frequently discussed. (Beach et al., 2006 and Regier et al., 2011) “The question of whether mental disorders are discrete clinical conditions or arbitrary distinctions along dimensions of functioning is a long-standing issue, but its importance is escalating with the growing recognition of the frustrations and limitations engendered by the categorical model.” (Widiger & Samuel, 2005)
Although the revised manual represents the first substantial revision to its clinical practice guidelines in more than 30 years, the categorical model has primarily survived. While the DSM-5 still lists separate disorders, it also incorporates dimensional measures of severity for many disorders. That shift is based on the realization that the lines between many disorder categories blur over the life span and that symptoms attributed to a single disorder may also appear in other disorders, just with different levels of severity.
Across diagnostic groups, the use of functional impairment as a criterion for diagnosis has been reduced, but not eliminated. For example, autism and other disorders involving neuropsychiatric deficits retain functional diagnostic criteria, because functional impairment is considered a cornerstone of these disorders. (Gever, 2012) For other conditions, functionality has been removed from diagnostic criteria and included in the dimensional assessments.
In previous editions of the DSM, the not otherwise specified (NOS) diagnoses tended to be catchall categories. For example, more than half of all eating disorders were listed in the Eating Disorder NOS diagnostic classification. (Gever, 2012)
In the new manual, NOS have been replaced with not elsewhere classified (NEC). “Although this sounds similar to the previous system, the inclusion of a requisite list of specifiers, each with a specific diagnostic code, refines and streamlines the process and conveys important, distinct clinical information. For example, depressive disorder NEC may involve any one or any combination of five specifiers, such as ‘short duration,’ that indicate the patient’s clinical condition and provide rationale as to why the presenting condition does not meet criteria for one of the main depressive syndromes.” (Halter et al., 2013)
The DSM-5 lists approximately the same number of disorders as the DSM-IV-TR, roughly 300 across 20 diagnostic categories. Some diagnoses were eliminated, others were regrouped.
Beginning in 1980, the DSM-III (American Psychiatric Association, 1980) created a multiaxial system to organize diagnostic conceptualization. DSM-5 authors concluded that there was no scientific basis for these categories. Therefore, the new edition of the DSM retired the five axes and replaced them by a non-axial documentation of diagnosis. “The categories in the DSM-5 are at once simpler and more complex.” (Halter et al., 2013 a)
The former Axes I, II, and III are collapsed into a single axis. “This is largely due to its incompatibility with diagnostic systems in the rest of medicine, as well as the result of a decision to place personality disorders and intellectual disability at the same level as other mental disorders.” (Kupfer et al., 2013)
There are separate notations for psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V). The DSM-5 incorporates a 15-page ICD checklist (World Health Organization, 2010 b) for assessment of psychosocial and contextual factors previously assessed on Axis IV. They are represented through an expanded selected set of ICD-9-CM V-codes and the forthcoming ICD-10-CM Z-codes. (American Psychiatric Association, n. d. b)
The traditional Axis V Global Assessment of Functioning (GAF) score, that combined assessment of symptom severity, suicide risk, and social functioning into a single global assessment, has been criticized for mixing symptom severity with functional severity. Therefore it was replaced by the WHO Disability Assessment Schedule (WHODAS) (World Health Organization, 2010 a) “WHODAS is a 36-item measure that addresses six domains – cognition, mobility, self-care, getting along with others, life activities, and participation. Self-administration takes 5 to 10 minutes, and clinician administration takes 20 minutes.” (Halter et al., 2013)
The chapter structure of the DSM-5 generally follows a neurodevelopmental life span approach, as do the disorders identified within category listings. In other words, categories generally follow a sequence from problems that typically are diagnosed in childhood through those typical of adolescents, adults, and finally, older adults. Because this approach is congruent with the system used by the ICD (World Health Organization, 2010 b), this restructuring brings greater alignment of DSM-5 to the structuring of disorders in the future ICD-11. (Kupfer et al., 2013)
“The DSM-5 authors also sought to arrange disorders by relatedness, taking into account similar vulnerabilities and characteristic symptoms for disorders listed within individual categories. For example, schizophrenia and bipolar disorder are listed in succession, as individuals affected by one of these two disorders may share common genetic variations and overlapping manifestations (Craddock, O’Donovan, & Owen, 2005). Likewise, depression is listed immediately before anxiety, reflecting the long-recognized interrelationship of these two disorders.” (Halter et al., 2013)
The manual is composed of three sections:
(American Psychiatric Association, 2013 and Peele, R., 2013)
Diagnoses that were not changed in the revision process have the same codes as in the DSM-IV-TR. The DSM-5 contains both ICD-9-CM codes for immediate use and ICD-10-CM codes in parentheses. The inclusion of ICD-10-CM codes facilitates a cross-walk to the new coding system that is to be implement¬ed on October 1, 2014. This change will result in the use of a seven-digit code that replaces the current five-digit coding system. “This feature will eliminate the need for separate training on ICD-10-CM codes for mental disorders that is now being offered for all other diseases/disorders by other medical societies and vendors to prepare for the 2014 implementation. …
DSM-5 and the ICD should be thought of as companion publications. DSM-5 contains the most up-to-date criteria for diagnosing mental disorders, along with extensive descriptive text, providing a common language for clinicians to communicate about their patients. The ICD contains the code numbers used in DSM-5 and all of medicine, needed for insurance reimbursement and for monitoring of morbidity and mortality statistics by national and international health agencies. …
Because the DSM-5 diagnostic codes are limited to those contained in the ICD, some disorders must share codes for record¬ing and billing purposes. For a few new disorders, such as Disruptive Mood Dysregulation Disorder (DMDD), the only ICD-9-CM code available for DSM-5 was a ‘Not Otherwise Specified’ (NOS) code from DSM-IV (Mood Disorder NOS 296.99). For ICD-10-CM the code will be F34.8, which is now Mood Disor¬der, Other Specified.” (American Psychiatric Association, n. d. b)
The ICD-10-CM will become the official health classification of the U.S. government and for all electronic health care transactions, such as billing and reimbursement on October 1, 2014. Information about the ICD-10-CM is available at the National Center for Health Statistics website (https://www.cdc.gov/nchs/icd/icd10cm.htm#10update).
There may be another alteration of the codes again when the ICD-11 is released. In an e-version of the DSM-5, the manual can be updated. An open revision process might present new opportunities and challenges for users of the DSM at that time. (Munson, 2013)
The DSM-IV-TR had the first official recognition of the role of culture in diagnosing mental illness in its Appendix I, which contained an abbreviated list of “Culture-Bound Syndromes” and an “Outline of Cultural Formulation”. This provided a method of categorizing and normatively defining culturally bound disorders that parallel, but did not precisely fit, defined disorders.
Building on evidence, the DSM-5 aimed for increased cross-cultural application. (Halter et al., 2013) Therefore the previous cultural formulation was replaced with the Cultural Formulation Interview (CFI) (Bäärnhielm & Scarpinati-Rosso, 2009), a standard method for simple and efficient cultural assessment, into criteria for diagnosis. The structured clinical interview with 14 questions is to be administered during a patient’s initial assessment. The CFI is designed to make cultural formulation quicker and easier and “improve patient-centered care while reducing racial and ethnic disparities in treatment. Furthermore, it may help providers screen and identify individuals who would benefit from the presence of language translators.” (Halter et al., 2013)
The changes made to the DSM-5 diagnostic criteria of specific disorders that are most relevant for mental health practitioners are outlined in this section. They are listed in the same order in which they appear in the DSM-5 classification.
Neurodevelopmental disorders were formerly identified as “disorders usually first evident in infancy, childhood, and adolescence”. The DSM-5 adds a specifier for all neurodevelopmental disorders associated with known medical or genetic conditions, or environmental factors. Specifiers are also included for specific learning disorders in reading, writing, and mathematics. (Brunk, 2013)
Intellectual Disability (Intellectual Developmental Disorder)
In the DSM-IV-TR, intellectual developmental disorder was called mental retardation. The revised name aligns the DSM-5 with federal legislative language (Moran, 2013b). Impairment in adaptive functioning was coupled with intelligence quotient to serve as the dual bases for diagnosis (Sederer, 2011). Severity measures for mild, moderate, severe, and profound intellectual disability are now included. (Halter et al., 2013)
“Despite the name change, the deficits in cognitive capacity beginning in the developmental period, with the accompanying diagnostic criteria, are considered to constitute a mental disorder. The term intellectual developmental disorder was placed in parentheses to reflect the World Health Organization’s classification system, which lists “disorders” in the International Classifica¬tion of Diseases (ICD) and bases all “disabilities” on the International Classification of Functioning, Disability, and Health (ICF).” (American Psychiatric Association, 2013 b)
Communication Disorders
The DSM-5 communication disorders include
“Because social communication deficits are one component of autism spectrum disorder (ASD), it is important to note that social (pragmatic) communication disorder cannot be diagnosed in the presence of restricted repetitive behaviors, interests, and activities (the oth¬er component of ASD). The symptoms of some patients diagnosed with DSM-IV pervasive developmen¬tal disorder not otherwise specified may meet the DSM-5 criteria for social communication disorder.” (American Psychiatric Association, 2013 b)
Autism Spectrum Disorder
Autism spectrum disorder (ASD) is a new DSM-5 name that reflects a scientific consensus – based on evidence from clinical field trials – that four previously separate disorders are actually a single condition with different levels of symptom severity in two core domains. These conditions fall on a continuum of mild to severe.
The new autism criteria combine Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder (not otherwise specified) into the one diagnosis. (American Psychiatric Association, 2012) Therefore these previous diagnoses relinquish their separate identity.
This change grew out of the concern within the clinical and research field that it was not possible to consistently break out autism, Asperger’s disorder, and pervasive developmental disorder not otherwise specified (Scrowley, 2013). The Neurodevelopmental Disorders Work Group concluded that distinctions between the disorders tend to be in terms of overall severity rather than in terms of symptoms. (Moran, 2013b) For the clinician, it should be easier to diagnose ASD than trying to distinguish between high-functioning autism and Asperger’s disorder. (Lohr & Tanguay, 2013)
The new criteria are intended to lead to more accurate diagnoses and, as a result, more focused treatment. (American Psychiatric Association, 2012 f)The hope is that mental health professionals can better address the needs of people with autism spectrum disorders of all developmental levels and ages – including girls, who were not represented as well as they should be in DSM-IV-TR. (Scrowley, 2013)
The DSM-IV-TR criteria included three separate behavioral dimensions – social impairment, deficits in communication, and restricted, repetitive behaviors and interests. An individual qualified for a diagnosis by exhibiting six of the 12 identified deficits in these three domains, including two deficits in socialization and one deficit in each of the other two domains.
The DSM-5 recognizes autism spectrum disorder on the basis of only two domains: one is impaired social communication, and the other is restrictive or repetitive behaviors that may be current or historical. To qualify for a diagnosis, an individual must exhibit three social communication deficits and at least two deficits in the category of restricted interests/repetitive behaviors.
This builds on the DSM-IV by adding information about sensory interests and aversions. (Scrowley, 2013) Further, the symptoms must affect the child’s functioning in daily life/activities, and the diagnostic criteria more clearly reflect those impacts on function.
The DSM-5 workgroup considered ranking people on the basis of their impairment in those two domains to be much more informative for guiding treatment and educational programs. (Brunk, 2013) Scientific American found that the DSM-IV offered 2,027 different ways to be diagnosed with autism; the DSM-5 provides just 11. (Jabr, 2012) “The APA argued that past criteria were too loose: some people who received a diagnosis probably did not have autism, and this misdiagnosis has surely contributed to skyrocketing rates of autism diagnoses worldwide since the 1980s.” (Jabr, 2013)
Another change is removing the requirement of symptom onset before age 3. The DSM-IV required that a child exhibit symptoms before the age of 3. The DSM-5 criteria indicate that symptoms must present in “early childhood,” and go on to add that these symptoms may not fully manifest until the child is in a situation where demands exceed his or her capabilities. Therefore, older children may receive a diagnosis, and patient history may play a bigger role. (American Psychiatric Association, 2012 f)
Rett’s Disorder continues to be a separate disorder, and no longer considered part of the autism spectrum (which makes sense due to its unique symptoms, including deceleration of head growth between 5-48 months of age, and loss of purposeful hand movements, replaced by repetitive, “stereotyped” hand movement [hand washing or wringing motions]).” (Hill, 2013)
If a child exhibits symptoms in the domain of social communication impairments, but not in the domain of restricted interests/repetitive behaviors, he or she may qualify for a diagnosis of Social Communication Disorder. (“Autism Speaks”, n. d.)
Attention-Deficit/Hyperactivity Disorder (ADHD)
The DSM-5 eliminated the DSM-IV chapter that included all diagnoses usually first made in infancy, childhood, or adolescence. Therefore, ADHD was placed in the neurodevelopmental disorders chapter to reflect brain developmental correlates with ADHD.
The diagnostic criteria for attention-deficit/hyperactivity disorder (ADHD) in DSM-5 are similar to those in DSM-IV. The same primary 18 symptoms are used as in DSM-IV, and continue to be divided into two symp¬tom domains (inattention and hyperactivity/impulsivity), of which at least six symptoms in one domain are required for diagnosis. The following changes have been made:
(American Psychiatric Association, 2013 b)
The DSM-5 extended diagnostic inclusion criteria to age 12 because many reports have shown symptom onset among children older than 7 (American Psychiatric Association, 2010).
Specific learning disorder
This 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. (American Psychiatric Association, 2013 b) “Because learning deficits in the areas of reading, written expression, and mathematics commonly occur together, coded speci¬fiers for the deficit types in each area are included. The text acknowledges that specific types of read¬ing deficits are described internationally in various ways as dyslexia and specific types of mathematics deficits as dyscalculia.” (American Psychiatric Association, 2013 b)
Motor Disorders
“The following motor disorders are included in the DSM-5: devel¬opmental coordination disorder, stereotypic movement disorder, Tourette’s disorder, persistent (chron¬ic) motor or vocal tic disorder, provisional tic disorder, other specified tic disorder, and unspecified tic disorder.
“The tic criteria have been standardized across all of these disorders in this chapter. Stereotypic movement disorder has been more clearly differentiated from body-focused repetitive behavior disor¬ders that are in the DSM-5 obsessive-compulsive disorder chapter.” (American Psychiatric Association, 2013 b)
Schizophrenia Spectrum and Other Psychotic Disorders
Schizophrenia
“Previously listed under the category of schizophrenia, disorders sharing schizophrenia-like symptoms and underlying causes are now listed in the schizophrenia spectrum disorders, roughly arranged from least to most severe. This change is one of the least controversial in the new manual.” (Halter, et al., 2013 a)
Two changes were made to the primary symptom criteria for schizophrenia:
The APA believes this helps increase the reliability of a schizophrenia diagnosis.
Catatonic, disorganized, paranoid, residual, and undifferentiated have been removed as subtypes of schizophrenia. These schizophrenia subtypes have been eliminated in the DSM-5 because of their limited diagnostic stability, low reliability, poor validity, and because they didn’t appear to help with providing kbetter targeted treatment, or predicting treatment response. The APA proposes that clinicians instead use a “dimensional approach to rating severity for the core symptoms of schizophrenia”. (American Psychiatric Association, 2013 b)
However, catatonia is retained as a specifier for depressive, bipolar, and psychotic disorders or as a separate diagnosis in the context of another medical condition.
Schizoaffective Disorder
The primary and biggest change to schizoaffective disorder is the requirement that a major mood episode be pres¬ent for a majority of the disorder’s total duration after Criterion A has been met. “This change was made on both conceptual and psychometric grounds. It makes schizoaffective disorder a longitudinal instead of a cross-sectional diagnosis – more comparable to schizophrenia, bipolar disorder, and major depres¬sive disorder, which are bridged by this condition. The change was also made to improve the reliability, diagnostic stability, and validity of this disorder, while recognizing that the characterization of patients with both psychotic and mood symptoms, either concurrently or at different points in their illness, has been a clinical challenge.” (American Psychiatric Association, 2013 b)
Delusional Disorder
Mirroring the change in the schizophrenia diagnostic criteria, delusions in delusion disorder are no longer required to be of the non-bizarre type. A person can now be diagnosed with delusional disorder with bizarre delusions, via a new specifier in the DSM-5.
The differential diagnosis of delusional disorder from psychotic variants of obsessive-compulsive disorder and body dysmorphic disorder is explicitly noted with a new exclusion criterion. This criterion states that the symptoms must not be “better explained by conditions such as obsessive-compulsive or body dysmorphic disorder with absent insight/delusional beliefs”. (American Psychiatric Association, 2013 b)
“DSM-5 no longer separates delusional disorder from shared delusional dis-order. If criteria are met for delusional disorder then that diagnosis is made. If the diagnosis cannot be made but shared beliefs are present, then the diagnosis ‘other specified schizophrenia spectrum and other psychotic disorder’ is used.” (American Psychiatric Association, 2013 b)
Bipolar Disorders
Bipolar disorders are now given a section separate from depressive or unipolar disorders. They were previously listed under mood disorders along with major depressive disorder.
In order to enhance the accuracy of diagnosis and facilitate earlier detection in clinical settings, the primary criteria for manic and hypomanic episodes (Criterion A) now includes an emphasis on changes in activity and energy as well as mood: the DSM-5 mentions core symptoms of increased energy/activity for both hypomanic and manic episodes. The diagnosis can be made on the basis of a set of criteria that is consistent across the life span, despite arguments that the criteria are too stringent for children and adolescents. (Kaplan, 2012).
The DSM-IV diagnosis of bipolar I disorder, mixed episode, requiring that the individual simulta¬neously meet full criteria for both mania and major depressive episode, has been removed. Instead, a new specifier, “with mixed features,” has been added that can be applied to episodes of mania or hy¬pomania when depressive features are present. It can also be applied to episodes of depression – such as in the context of major depressive disorder or bipolar disorder – when features of mania/hypomania are present.
Thirty years of data indicating that comorbid severe anxiety is a risk factor for suicide across depression and bipolar disorders led to the addition of an anxiety specifier: anxious distress (Moran, 2013 a). “This specifier is intended to identify patients with anxiety symptoms that are not part of the bipolar diagnostic criteria.” (American Psychiatric Association, 2013 b) The rationale for this addition is that anxiety is a serious complication of bipolar disorder and must be addressed.
Also, a mixed state specifier replaces the fully mixed type of bipolar disorder, which was rarely seen. The mixed state specifier applies to individuals who have major depression along with three manic symptoms, and to individuals who have mania along with three depressive symptoms. (Halter et al., 2013 a)
The areas on the anxiety scale of the DSM-5 are: feeling “keyed up,” feeling unusually restless, difficulty concentrating because of worries, dread, and an acute fear of loss of control. Two or more of these symptoms on most days are considered “anxious distress”.
Bipolar disorder should not be used as a diagnosis, when a manic or hypermanic episode appears to result from ECT or antidepressant treatment, has been reversed.
Other Specified Bipolar and Related Disorder
“DSM-5 allows the specification of particular conditions for other specified bipolar and related disorder, including categorization for individuals with a past history of a major depressive disorder who meet all criteria for hypomania except the duration criterion (i.e., at least 4 consecutive days). A second condi¬tion constituting an other specified bipolar and related disorder is that too few symptoms of hypoma¬nia are present to meet criteria for the full bipolar II syndrome, although the duration is sufficient at 4 or more days.” (American Psychiatric Association, 2013 b)
In the chapter on depressive disorders, a new specifier for anxious distress is delineated. (American Psychiatric Association, 2013 b)
Disruptive Mood Dysregulation Disorder
Disruptive mood dysregulation disorder (DMDD) is a newcomer that addresses presentations of persistent, severe, and non-episodic irritability and frequent episodes of extreme behavioral dyscontrol, that has contributed to an upsurge of pediatric bipolar disorders (Brunk, 2013).
For most of the DSM’s existence, bipolar disorder was considered primarily an illness of adulthood, but over the past two decades there has been a 40-fold increase in the diagnosis of childhood bipolar disorder (Tracy, 2013). Persistent foul temper punctuated by bursts of rage was considered diagnostic of bipolar disorder (onset before age 10). This new trend outraged a large segment of the psychiatric community. Most of the so-called bipolar kids – some of whom subsequently took mood stabilizers and antipsychotics with serious side effects – did not have a form of bipolar disorder, many psychiatrists argued. (Jabr, 2013)
Therefore disruptive mood dysregulation disorder is viewed as an alternative to assigning a lifelong diagnosis of bipolar disorder, which often was accompanied by early and powerful treatment prescriptions of untested and unapproved medications. (Margulies, Weintraub, Basile, Grover, & Carlson, 2012)
To meet the criteria of DMDD, a child between six and 18 must “exhibit persistent irritability and frequent episodes of behavior outbursts three or more times a week for more than a year.” The diagnosis applies to 6- to 18-year-olds who have outbursts that are out of proportion to what is happening in the environment. Symptoms overlap with oppositional defiance disorder but are considered more severe.
Major Depressive Disorder
“Neither the core criterion symptoms applied to the diagnosis of major depressive episode nor the req¬uisite duration of at least 2 weeks has changed from DSM-IV. Criterion A for a major depressive episode in DSM-5 is identical to that of DSM-IV, as is the requirement for clinically significant distress or impair¬ment in social, occupational, or other important areas of life, although this is now listed as Criterion B rather than Criterion C.
The coexistence within a major depressive episode of at least three manic symptoms (insufficient to satisfy criteria for a manic episode) is now acknowledged by the specifier ‘with mixed features’. The presence of mixed features in an episode of major depressive disorder increases the likelihood that the illness exists in a bipolar spectrum; however, if the individual concerned has never met criteria for a manic or hypomanic episode, the diagnosis of major depressive disorder is retained.” (American Psychiatric Association, 2013 b)
Persistent Depressive Dis¬order (Dysthymia)
What was referred to as dysthymia in DSM-IV now falls under the category of persistent depressive dis¬order, which includes both chronic major depressive disorder and the previous dysthymic disorder. “An inability to find scientifically meaningful differences between these two conditions led to their combi¬nation with specifiers included to identify different pathways to the diagnosis and to provide continuity with DSM-IV.” (American Psychiatric Association, 2013 b)
Premenstrual Dysphoric Disorder
Premenstrual dysphoric disorder is formally listed as a mood disorder for the first time. Based on strong scientific evidence, this disorder has been elevated from DSM-IV Appendix B to the depressive disorders section of DSM-5. (Brunk, 2013)
Its symptoms, including mood disturbance, are more severe than those identified in the previous manual. According to the DSM-5, a diagnosis of premenstrual dysphoric disorder should only be considered in women whose symptoms cause clinically significant distress, or interfere with work, school, usual activities and relationships.
“Controversy about this diagnosis 20 years ago was heated. Opponents suggested women’s hormones were being blamed for mental illness and that the social implications were dangerous (Tavris, 1993). For this revision, controversy has been nearly absent.” (Halter et al., 2013 b)
Removal of bereavement exclusion
If a person displays 5 out of the 9 symptoms of major depressive disorder – such as low mood and energy, insomnia, feelings of worthlessness, loss of pleasure and change in weight – most of the time, for 2 weeks or longer, they meet the criteria for this diagnosis.
Earlier editions of DSM stipulated that someone who has lost a loved one should not receive a diagnosis of depression unless the relevant symptoms last longer than one year (DSM-III) or longer than two months (DSM-IV) following the death. The idea was that, in these cases, what looks like major depression is probably bereavement, a typical and transient response to loss that does not require medication. (Jabr, 2013)
In the DSM-5, the bereavement provision has been replaced by several footnotes describing the differences between grief and depression as well as an admonition to clinicians that careful examination and clinical judgment is required to differentiate bereavement from a bereavement-induced major depressive disorder. “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.” (American Psychiatric Association, 2012 a) This essentially requires providers to diagnose a grieving individual with major depression 2 weeks after the loss.
The American Psychiatric Association omitted this exclusion in the DSM-5 for several reasons:
Specifiers for Depressive Disorders
People who are suicidal are a public mental health concern. Therefore a new specifier is available that helps shed light on suicidality factors in someone who is depressed. (Grohol, 2013 b)
“Suicidality represents a critical concern in psychiatry. Thus, the clinician is given guidance on assess¬ment of suicidal thinking, plans, and the presence of other risk factors in order to make a determination of the prominence of suicide prevention in treatment planning for a given individual. A new specifier to indicate the presence of mixed symptoms has been added across both the bipolar and the depressive disorders, allowing for the possibility of manic features in individuals with a diagnosis of unipolar de¬pression. A substantial body of research conducted over the last two decades points to the importance of anxiety as relevant to prognosis and treatment decision making. The ‘with anxious distress’ specifier gives the clinician an opportunity to rate the severity of anxious distress in all individuals with bipolar or depressive disorders.” (American Psychiatric Association, 2013 b)
In the DSM-5, obsessive-compulsive disorder and posttraumatic stress disorder are set off into their own diagnostic categories, removing them from the family of anxiety disorders. Longitudinal outcomes, comorbidities, familial aggregations, and underlying biology suggest the conditions are different from anxiety disorders. However, the sequential order of these chapters reflects the close relationships among them. (American Psychiatric Association, 2013 b)
“This new approach also makes sense because the disorders that are left in the anxiety category – generalized, social, separation, panic, and phobic anxieties – are pretty much treated the same way.” (Otto, 2013).
Anxiety disorders are now organized in a dedicated chapter separate from other anxiety-related disorders. “With panic attacks” is a specifier for any mental disorder, and panic disorder and agoraphobia have become unlinked. (Brunk, 2013)
Separation Anxiety Disorder
Separation anxiety disorder now includes adults. Adults may be at greater risk than children for the disorder, with a lifetime prevalence estimate of 6.6% compared to 4.1% for children (Shear, Ruscio, Walters, & Kessler, 2006).
“The core features remain mostly unchanged, although the wording of the criteria has been modified to more adequately represent the expression of separation anxiety symptoms in adulthood. For example, at¬tachment figures may include the children of adults with separation anxiety disorder, and avoidance behaviors may occur in the workplace as well as at school.
Also, in contrast to DSM-IV, the diagnostic criteria no longer specify that age at onset must be before 18 years, because a substantial number of adults report onset of separation anxiety after age 18. Also, a duration criterion – ‘typically lasting for 6 months or more’ – has been added for adults to minimize overdiagnosis of transient fears.” (American Psychiatric Association, 2013 b)
Selective Mutism
“In DSM-IV, selective mutism was classified in the section “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence.” It is now classified as an anxiety disorder, given that a large majority of children with selective mutism are anxious. The diagnostic criteria are largely unchanged from DSM-IV.” (American Psychiatric Association, 2013 b)
Agoraphobia, Specific Phobia, and Social Anxiety Disorder (Social Phobia)
“Changes in criteria for agoraphobia, specific phobia, and social anxiety disorder (social phobia) include deletion of the requirement that individuals over age 18 years recognize that their anxiety is excessive or unreasonable.
This change is based on evidence that individuals with such disorders often overesti¬mate the danger in “phobic” situations and that older individuals often misattribute “phobic” fears to aging. Instead, the anxiety must be out of proportion to the actual danger or threat in the situation, af¬ter taking cultural contextual factors into account. In addition, the 6-month duration, which was limited to individuals under age 18 in DSM-IV, is now extended to all ages. This change is intended to minimize overdiagnosis of transient fears.” (American Psychiatric Association, 2013 b)
The anxiety must be out of proportion to the actual threat or danger the situation poses, after taking into account all the factors of the environment and situation. The symptoms must also last at least 6 months for all ages. This change is intended to help minimize the over-diagnosis of occasional fears.
Besides the above-mentioned changes, the “generalized” specifier has been deleted for social anxiety disorder and replaced with a “performance only” specifier. The DSM-IV generalized specifier was problematic in that “fears include most social situ¬ations” was difficult to operationalize. Individuals who fear only performance situations (i.e., speaking or performing in front of an audience) appear to represent a distinct subset of social anxiety disorder in terms of etiology, age at onset, physiological response, and treatment response. (American Psychiatric Association, 2013 b)
Agoraphobia is now a freestanding disorder and not necessarily a subset of panic disorder.
“This change recognizes that a substantial number of individuals with agoraphobia do not experience panic symptoms. The diagnostic criteria for agoraphobia are derived from the DSM-IV descriptors for agora¬phobia, although endorsement of fears from two or more agoraphobia situations is now required, be¬cause this is a robust means for distinguishing agoraphobia from specific phobias. Also, the criteria for agoraphobia are extended to be consistent with criteria sets for other anxiety disorders (e.g., clinician judgment of the fears as being out of proportion to the actual danger in the situation, with a typical duration of 6 months or more).” (American Psychiatric Association, 2013 b)
Panic Attack
“The essential features of panic attacks remain unchanged, although the complicated DSM-IV terminol¬ogy for describing different types of panic attacks (i.e., situationally bound/cued, situationally predis¬posed, and unexpected/uncued) is replaced with the terms unexpected and expected panic attacks.
Panic attacks function as a marker and prognostic factor for severity of diagnosis, course, and comor¬bidity across an array of disorders, including but not limited to anxiety disorders. Hence, panic attack can be listed as a specifier that is applicable to all DSM-5 disorders.” (American Psychiatric Association, 2013 b)
Generalized Anxiety Disorder
Changes to generalized anxiety disorder garnered the most interest within this category. The DSM-5 includes a reduction of symptom duration from 6 to 3 months, and a reduction of the number of symptoms from three to one. (American Psychiatric Association, 2013 b)
Obsessive-Compulsive and Related Disorders
Since the DSM-5 chapter on anxiety disorder no longer includes obsessive-compulsive disorder, this disorder is now included with the obsessive-compulsive and related disorders.
“The chapter on obsessive-compulsive and related disorders, which is new in DSM-5, reflects the in¬creasing evidence that these disorders are related to one another in terms of a range of diagnostic validators, as well as the clinical utility of grouping these disorders in the same chapter.” (American Psychiatric Association, 2013 b)
In previous editions of the DSM, some of the disorders within this new obsessive-compulsive and related disorders category were listed across several other diagnostic groups. While obsessive-compulsive disorder was formerly included in anxiety disorders, body dysmorphic disorder was a somatoform disorder, and hair-pulling disorder (previously trichotillomania) was listed under impulse control disorders not else¬where classified.
New disorders include hoarding disorder, excoriation (skin-picking) disorder, substance/medication-induced obses¬sive-compulsive and related disorder, and obsessive-compulsive and related disorder due to another medical condition. All disorders in this category have the core symptom of abnormal and obsessive fixations.
Specifiers for Obsessive-Compulsive and Related Disorders
“The ‘with poor insight’ specifier for obsessive-compulsive disorder has been refined in DSM-5 to allow a distinction between individuals with good or fair insight, poor insight, and ‘absent insight/delusional’ obsessive-compulsive disorder beliefs (i.e., complete conviction that obsessive-compulsive disorder beliefs are true).
Analogous “insight” specifiers have been included for body dysmorphic disorder and hoarding disorder. These specifiers are intended to improve differential diagnosis by emphasizing that individuals with these two disorders may present with a range of insight into their disorder-related be¬liefs.
The ‘tic-related’ specifier for obsessive-compulsive disorder reflects a growing literature on the diagnostic validity and clinical utility of identifying individuals with a current or past comorbid tic disorder, because this comorbidity may have important clinical implications. (American Psychiatric Association, 2013 b)
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, consistent with data indicating the prevalence and importance of this symptom.
A ‘with muscle dysmorphia’ specifier has been added to reflect a growing literature on the diagnostic validity and clini¬cal utility of making this distinction in individuals with body dysmorphic disorder. The delusional vari¬ant of body dysmorphic disorder (which identifies individuals who are completely convinced that their perceived defects or flaws are truly abnormal appearing) is no longer coded as both delusional disor¬der, somatic type, and body dysmorphic disorder; in DSM-5 this presentation is designated only as body dysmorphic disorder with the absent insight/delusional beliefs specifier.” (American Psychiatric Association, 2013 b)
Hoarding disorder
The addition hoarding disorder to the DSM-5 is supported by extensive scientific research on this disorder. This devastating problem has been showcased on prime-time television and become part of common language. People who amass huge quantities of belongings and have extreme and persistent problems in parting with or discarding them regardless of their actual value may receive this diagnosis. Typically, the individual and the family suffer from chronic emotional, social, physical, financial, and even legal problems as a result of the hoarding. (American Psychiatric Association, 2012 b)
The DSM-IV listed hoarding as one of the possible symptoms of obsessive-compulsive personality disorder and noted that extreme hoarding may also occur in obsessive-compulsive disorder. However, available data do not indicate that hoarding is a variant of obsessive-compulsive disorder or another mental disorder. (American Psychiatric Association, 2013 b)
Consequently, many hoarders do not have any other symptoms of OCD and hoarding may be more common than OCD in the general population. Investigations have also suggested that although OCD and hoarding can co-occur, they are genetically and neurologically distinct. Parents and siblings of hoarders show higher rates of hoarding than do first-degree relatives of people with OCD, for instance, and hoarding seems to be inherited as a recessive trait, whereas the compulsive checking and organizing that characterizes OCD is dominant. (Jabr, 2013)
Neuroimaging studies have revealed that when hoarders make decisions about what to keep and what to throw out, their brain activity is markedly different from that of people with OCD and people without a mental disorder. (Jabr, 2013)Therefore, there is evidence for the diagnostic validity and clinical utility of a separate diagnosis of hoarding disorder. Hoarding disorder may have unique neurobiological correlates, is associated with significant impairment, and may respond to clinical intervention. (American Psychiatric Association, 2013 b)
The official recognition of hoarding as an important neuropsychic disorder will increase screening, detection, diagnosis, and treatment. This diagnosis is one of major public health significance, because every department of public health in every county in the country has to deal with a hoarding issue, whether it’s animal-related or other forms of excessive acquisition. (Brunk, 2013) The new diagnosis is already inspiring pharmaceutical companies to think about doing trials specifically for hoarding disorder. (Krumboltz, 2013)
Excoriation (skin-picking) disorder
This disorder is new to DSM-5 and results in noticeable physical damage, emotional distress, and attempts to conceal the behavior (Odlaug & Grant, 2010)
Substance/Medication-Induced Obsessive-Compulsive and Related Disorder and Obsessive-Compul¬sive and Related Disorder Due to Another Medical Condition
DSM-IV included a specifier “with obsessive-compulsive symptoms” in the diagnoses of anxiety disor¬ders due to a general medical condition and substance-induced anxiety disorders.
Given that obses¬sive-compulsive and related disorders are now a distinct category, DSM-5 includes new categories for substance/medication-induced obsessive-compulsive and related disorder and for obsessive-compul¬sive and related disorder due to another medical condition. This change is consistent with the intent of the new manual, because it reflects the recognition that substances, medications, and medical conditions can pres¬ent with symptoms similar to primary obsessive-compulsive and related disorders. (American Psychiatric Association, 2013 b)
Trauma- and Stressor-Related Disorders
This category is new and all disorders share abnormal responses to external trauma and stress. (Friedman et al., 2011) Posttraumatic stress disorder and acute stress disorder are now included with the trauma- and stressor-related disorders.
Reactive Attachment Disorder and Disinhibited Social Engagement Disorder
“The DSM-IV childhood diagnosis reactive attachment disorder had two subtypes: emotionally with¬drawn/inhibited and indiscriminately social/disinhibited.
In DSM-5, these subtypes are defined as distinct disorders: reactive attachment disorder and disinhibited social engagement disorder. Both of these disorders are the result of social neglect or other situations that limit a young child’s opportunity to form selective attachments. Although sharing this etiological pathway, the two disorders differ in important ways.
Because of dampened positive affect, reactive attachment disorder more closely re¬sembles internalizing disorders; it is essentially equivalent to a lack of or incompletely formed preferred attachments to caregiving adults. In contrast, disinhibited social engagement disorder more closely resembles ADHD; it may occur in children who do not necessarily lack attachments and may have es-tablished or even secure attachments. The two disorders differ in other important ways, including cor¬relates, course, and response to intervention, and for these reasons are considered separate disorders.” (American Psychiatric Association, 2013 b)
The diagnosis of disinhibited social engagement disorder is used when children demonstrate no normal fear of strangers, seem unfazed in response to separation from a primary caregiver, and are unusually willing to go off with people who are unknown to them.
Posttraumatic stress disorder (PTSD)
Moved from anxiety disorders to this new chapter in the DSM-5 on trauma- and stressor-related disorders, criteria for posttraumatic stress disorder differ significantly from those in the DSM-IV. (American Psychiatric Association, 2013 b)
One change is the removal of the A2 criteria, which was that an individual not only has to be exposed to an overwhelming stress but they have to react with horror or disgust. “What was happening is that soldiers who are trained to immediately deal with horrendous experiences would say that their training ‘kicked in.’ They didn’t have the reaction – the A2 criteria – yet they subsequently would have clear criteria for PTSD. There was a need to eliminate that criteria.” (Brunk, 2013)
The exposure to actual or threatened death, serious injury or sexual violation is central to the definition of PTSD, with media exposure being explicitly excluded unless it is work-related.
The revised manual pays more attention to the behavioral symptoms that accompany PTSD than the DSM-IV. Because the avoidance/numbing cluster has been divided into two distinct clusters, avoidance and persistent negative alterations in cognition and mood, four (instead of three) clusters of symptoms now define posttraumatic stress disorder:
The new cluster of negative cognitions and mood includes estrangement from others, a persistent and distorted sense of blame of self/others, diminished interest in activities, and inability to remember key aspects of the event. The arousal cluster includes more aggression-related symptoms than it did in the DSM-IV.
Three symptoms are new:
Direct exposure or exposure of a close friend or relative to a traumatic event, or repeated exposure to the aversive details of trauma, such as that experienced by disaster workers or first responders, meets the criteria for a PTSD diagnosis.
Because small children develop PTSD at the same rate as adults, a developmental subtype of PTSD was added to address the needs of children younger than 6 who have been subjected to traumatic events. (Jagodzinski, 2011) Previous criteria for PTSD aren’t appropriate for children, no matter how bright or verbally expressive a young child may be. Therefore, diagnostic thresholds have been lowered for children and adolescents. New research details what PTSD looks like in young children and finds that treatment for these young sufferers can be effective. (“Psychiatry ‘Bible’ DSM-5 to Add PTSD for Preschoolers,” 2013)
Another subtype for individuals with prominent dissociative symptoms is called “dissociative”.
Acute Stress Disorder
In the DSM-5, the stressor criterion (Criterion A) for acute stress disorder is changed from the DSM-IV. The criterion requires being explicit as to whether qualifying traumatic events were experienced directly, witnessed, or experienced indirectly. Also, the DSM-IV Criterion A2 regarding the subjective reaction to the traumatic event (e.g., “the person’s response involved intense fear, helplessness, or horror”) has been eliminated.
Based on evidence that acute posttraumatic reactions are very heterogeneous and that the DSM-IV’s emphasis on dissociative symptoms was overly restrictive, individuals may meet diagnostic criteria in the DSM-5 for acute stress disorder if they exhibit any 9 of 14 listed symptoms in these catego¬ries: intrusion, negative mood, dissociation, avoidance, and arousal. (American Psychiatric Association, 2013 b)
Adjustment Disorders
The DSM-IV saw adjustment disorders as a residual category for individuals who exhibit clinically significant distress without meeting the criteria for a more discrete disorder.
In the DSM-5, adjustment disorders are re-conceptualized as a heterogeneous array of stress-response syndromes that occur after exposure to a distressing (traumatic or non-traumatic) event. The DSM-IV subtypes marked by depressed mood, anxious symp¬toms, or disturbances in conduct have been retained, unchanged. (American Psychiatric Association, 2013 b)
Dissociative disorders are purposefully listed immediately after Trauma and Stressor-Related Disorders due to the link with trauma and disorganized attachment (Boysen, 2011). The manual maintains the two disorders as separate categories because research indicates that patients with dissociative disorders do not respond well to standard exposure-based treatments designed for PTSD and that they leave treatment prematurely. (Bland et al., 2012).
Major changes in dissociative disorders in DSM-5 include the following:
Dissociative Identity Disorder
Several changes to the criteria for dissociative identity disorder have been made in the DSM-5.
Other text modifications clarify the nature and course of identity disruptions. (American Psychiatric Association, 2013 b)
Somatic Symptom and Related Disorders
Somatic symptom and related disorders were formerly known as somatoform disorders. Diagnoses of somatization disorder, hypochondriasis, the 3 variants of pain disorder, and undifferentiated somatoform disorder were regrouped into somatic symptom disorder and illness anxiety disorder. (Dimsdale, 2013)
Since the word “somatization” refers to psychological stress that manifests in the form of physical symptoms, a person’s physical symptoms are traceable to a mental or emotional cause rather than to a physical one. “DSM-IV criteria overemphasized the importance of an absence of a medical explanation for the somatic 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).” (American Psychiatric Association, 2013 b)
Medically unexplained symptoms do remain a key fea¬ture in conversion disorder and pseudocyesis because it is possible to demonstrate definitively in such disorders that the symptoms are not consistent with medical pathophysiology.” (American Psychiatric Association, 2013 b)
Somatic Symptom Disorder (SSD)
Somatic symptom disorder has been added to the DSM-5 to better recognize the complexity of the interface between psychiatry and medicine. These disorders are primarily seen in medical settings. Non-psychiatric physicians found somatoform diagnoses problematic to use. (American Psychiatric Association, 2013 b)
The DSM-IV emphasized “medically unexplained symptoms” as the key feature of somatoform disorders. The Somatic Symptoms Workgroup stated that patients feel that their complaints are viewed as inauthentic, doctors can’t agree about what is or is not medically unexplained, and that the reliability of “medically unexplained symptoms” is limited. Grounding a diagnosis on the absence of an explana¬tion is problematic and reinforces mind-body dualism, which is more consonant with the 17th century than the 21st.
Psychiatric symptoms and general medical symptoms can and do coexist. Patients think and feel with their brains and are affected by life experience and the cellular milieu that they live in. (American Psychiatric Association, 2013 b)
“The DSM-5 diagnosis of somatic symptom disorder represents an attempt to correct these problems in DSM IV. The DSM-5 diagnosis does not question the reality of patients’ suffering and emphasizes instead that psychiatric disorders are more properly diagnosed on the basis of features such as disproportionate and excessive thoughts, feelings, and behaviors, rather than by negative features like ‘medically unexplained symptoms’.” (Dimsdale, et al., 2013 b) In other words, a patient’s suffering is now considered authentic, whether or not it is medically explained. (Tagore, 2013)
The diagnosis of somatic symptom disorder subsumes the former diagnoses of somatization disorder, hypochondriasis, undifferentiated somatoform disorder, and pain disorder. There was significant problematic overlap across the somatoform disorders and a lack of clarity about their boundaries. (American Psychiatric Association, 2013 b)
People can be diagnosed with SSD if, for at least six months, they have had one or more physical symptoms that are distressing and/or disruptive to their daily life, and if they have one of the following three reactions:
Individuals with somatic symptoms plus abnormal thoughts, feelings, and behaviors may or may not have a diagnosed medical condition.
Individuals previously diag¬nosed with somatization disorder usually meet the DSM-5 criteria for somatic symptom disorder if they have the above-mentioned criteria that define the disorder, in addition to their somatic symptoms. (American Psychiatric Association, 2013 b)
Hypochondriasis and Illness Anxiety Disorder
Hypochondriasis has been eliminated as a disorder, in part because the name was perceived as pejora¬tive and not conducive to an effective therapeutic relationship. Most individuals who would previously have been diagnosed with hypochondriasis have significant somatic symptoms in addition to their high health anxiety, and therefore receive now a DSM-5 diagnosis of somatic symptom disorder. In the DSM-5, indi¬viduals with high health anxiety without somatic symptoms receive a diagnosis of illness anxiety disorder (unless their health anxiety was better explained by a primary anxiety disorder, such as gener¬alized anxiety disorder). (American Psychiatric Association, 2013 b)
Pain Disorder
In the DSM-IV, the pain disorder diagnoses assume that some pains are associated solely with psychological factors, some with medical diseases or injuries, and some with both. Somatic Symptom Disorder Workgroup saw a lack of evidence that such distinctions can be made with reliability and validity, because a large body of research has demonstrated that psycho¬logical factors influence all forms of pain. Most individuals with chronic pain attribute their pain to a combination of factors, including somatic, psychological, and environmental influences. In the DSM-5, some individuals with chronic pain should therefore be appropriately diagnosed as having somatic symptom disorder, with predominant pain. For others, psychological factors affecting other medical conditions or an ad¬justment disorder are more appropriate. (American Psychiatric Association, 2013 b)
Psychological Factors Affecting Other Medical Conditions and Factitious Disorder
The DSM-IV included “Psychological Factors Affecting Medical Condition” (PFAMC) in the part of the manual reserved for conditions that may be of interest to clinicians, even though they are explicitly not to be considered mental disorders (“Other Conditions That May Be a Focus of Clinical Atten¬tion”).
In the DSM-5, “this disorder and factitious disorder are placed among the somatic symptom and related disor¬ders because somatic symptoms are predominant in both disorders, and both are most often encoun¬tered in medical settings.” (American Psychiatric Association, 2013 b) The variants were reduced from 2 to 1. The 6 subtypes were entirely eliminated in favor of one diagnosis.
PFAMC might describe someone’s stress precipitating a stroke, a patient’s noncompliance with treatment, type A personality traits that are a risk factor for heart attack, a sedentary lifestyle predisposing to obesity, or unsafe sexual practices. (Frances, 2013 c)
Conversion Disorder (Functional Neurological Symptom Disorder)
Criteria for conversion disorder (functional neurological symptom disorder) have been modified to emphasize the essential importance of the neurological examination, and in recognition that relevant psychologi¬cal factors may not be demonstrable at the time of diagnosis.
This category was formerly known as Eating Disorders. It includes several problems originally listed among Disorders of Infancy, Childhood, or Adolescence. These include pica, rumination disorder, and avoidant/restrictive food intake disorder.
Symptoms of anorexia nervosa traditionally have included amenorrhea and a fear of gaining weight. New criteria include menstruating women along with individuals who are not fixated on weight gain.
The twice-weekly binge and purge criterion previously required for a diagnosis of bulimia nervosa has been reduced to once per week.
Binge Eating Disorder
Binge eating disorder is moved from the DSM-IV’s Appendix B: “Criteria Sets and Axes Provided for Further Study” to the DSM-5 Section 2 as an actual disorder. “The change is intended to better represent the symptoms and behaviors of people with this condition.” (American Psychiatric Association, 2012 b)
Criteria for binge-eating disorder are:
Affected individuals report that they eat too rapidly, feel too full, and eat when they are not hungry. Eating alone is common due to embarrassment. (Halter et al., 2013 a)
Avoidant/Restrictive Food Intake Disorder
This disorder describes people who are particularly uninterested in eating or are restrictive or phobic in their food choices. They must also suffer resulting weight loss, nutritional deficiency, or social problems. (Frances, 2013 e)
This category, formerly known as Sleep Disorders, has had a nearly complete overhaul in the DSM-5. The reworking of this category will make sleep problems easier for professionals to diagnose and discriminate between different sleep disorders. The term “primary” was dropped, with the previously named primary insomnia disorder listed simply as insomnia disorder (Reynolds, 2011) Dimensional measures gauge severity and identify other contributing factors. (Halter et al., 2013 a)
Primary and commonly diagnosed sleep disorders are now organized into three major categories:
The DSM-5 allows professionals to choose among sub-types in each category, as can be done with many other major disorders in the manual.
Sexual dysfunctions were formerly classified along with Sexual and Gender Identity Disorders.
This category was also formerly listed under the category of Sexual and Gender Identity Disorders. This meant, for example, that a man who believed he was destined to be a woman was considered mentally ill.
The DSM-5 eliminated the term gender identity disorder, long considered stigmatizing by mental health specialists and lesbian, gay, bisexual and transgender activists. “For years, advocates lobbied the APA to redefine or remove gender identity disorder as a psychiatric diagnosis. Their work has been rewarded. To receive the new diagnosis and qualify for insurance coverage, one must experience a sense of mismatch between biological gender and personal gender identification and must experience related distress (dysphoria).” (Halter et al., 2013 a)
In other words: when the new manual refers to gender dysphoria, it focuses the attention on only those who feel distressed by their gender identity.
Disruptive, Impulse Control, and Conduct Disorders
This category now contains disorders that previously were included across diagnostic categories. Oppositional defiant disorder and conduct disorder were formerly classified alongside attention-deficit/hyperactivity disorder as disruptive behavior disorders. Intermittent explosive disorder was classified as an impulse control disorder NEC (not elsewhere classified), and antisocial personality disorder was classified exclusively under personality disorders where it remains as a cross-listed diagnosis in the DSM-5. (Halter et al., 2013 a)
Substance-Related and Addictive Disorders
“The DSM-5 is the first to include the word ‘addiction’. But this change is largely cosmetic, appearing only in the title of the section ‘Addiction and Related Disorders’. Previous versions shied away from this charged word.” (Dahr, 2013).
In the new category of “behavioral addictions,” gambling is the sole disorder, which was previously called “pathological gambling” and listed under “Impulse-Control Disorder Not Elsewhere Classified”. The APA based its decision in part on recent evidence that compulsive behaviors and compulsive substance use create similar subjective experiences, follow the same clinical pattern, may derive from the same neural network, and respond to similar treatments. The brains of people who are addicted to gambling change in similar ways to the brains of drug addicts and that both drug addicts and pathological gamblers benefit from group therapy and gradual weaning. (Jabr, 2013)
“Addiction is a disorder of the brain reward system, and it doesn’t matter whether the system is repeatedly activated by gambling or alcohol or another substance. … In functional brain imaging – whether with gamblers or drug addicts – when they are showed video or photograph cues associated with their addiction, the same brain areas are activated.” (Moran, 2013)
Internet addiction was considered for this category, but work group members decided there was insufficient research data to do so. Therefore Internet gaming disorder is included in the manual’s appendix instead, with a goal of encouraging additional study. (Nauert, 2010)
Substance Use Disorder
The previous manual discussed substance abuse and substance dependence. Many critics contended that this was a poor choice. (Jabr, 2013) The distinction between abuse and dependence has never made much clinical sense and did little to enhance understanding or guide treatment. (Lembke, 2013) To many clinicians, they appeared to be the same disorder but on a continuum of abuse. The APA agreed and considered the term “abuse” as clinically meaningless. (Moran, 2013) They also pointed out the misuse of the term “dependence” to describe the normal withdrawal patterns that can occur during appropriate medication use. (Kupfer et al., 2013) Therefore, substance-related and addictive disorders combine the DSM-IV categories of substance abuse and substance dependence.
There are two major changes to the new DSM-5 criteria for substance use disorder:
The threshold for substance use disorder diagnosis is set at two or more criteria. This is a change from the DSM-IV, where substance abuse required a threshold of one or more criteria be met, and substance dependence required a threshold of three or more. (Grohol, 2013 c)
The severity of the diagnosis depends on how many of the six criteria apply. More criteria means greater severity:
Rather than dividing the world into “alcoholics” and “non-alcoholics,” for example, the new “alcohol disorder” spectrum includes everyone at levels from “mild” (your “normal” college binge drinker) to “severe” (someone whose drinking is out of control and who meets all six criteria). One can even be “almost” alcoholic, with four criteria. Previously, the milder “substance use” required only one symptom while the DSM-5’s mild “alcohol use disorder” disorder requires two to three symptoms. (Dhar, 2013 a)
Since this change supports treatment according to severity, or stage, of illness, people with different degrees of severity and treatment response are expected to receive treatment specifically tailored to their needs. (Willenbring, 2013) The new criteria are also expected to support early interventions in order to hinder the addiction problem, to reduce or halt physical problems, and to save money by reducing long-term disability. (Halter et al., 2013 a)
The introduction of the severity scale is meant to help addiction treatment fall in line with physical medicine, with its numerically precise diagnostics like blood pressure and cholesterol levels. (Dahr, 2013)
The DSM-5 removed the physiological subtype, as well as the diagnosis for polysubstance dependence. Early remission from a substance use disorder is defined as at least 3 but less than 12 months without substance use disorder criteria (except craving), and sustained re-mission is defined as at least 12 months without criteria (except craving). Additional specifiers include “in a controlled environment” and “on maintenance therapy”.
Cannabis withdrawal is new, as is caffeine withdrawal. These were previously included only in the DSM-IV Appendix B, “Criteria Sets and Axes Provided for Further Study”. The symptoms of withdrawal must be severe enough to cause the person substantial problems with functioning at work or in social situations – or significant impairment in functioning in other important areas. These symptoms include:
Physical symptoms of withdrawal include headache, stomach pains, increased sweating, fever, chills or shakiness. At least one of these physical symptoms must be present, and the severity of the symptom(s) must be great enough to cause substantial discomfort.
The criteria for the DSM-5 tobacco use disorder are the same as those for other substance use disorders. By contrast, the DSM-IV did not have a category for tobacco abuse.
Disorders listed in this category were formerly found under delirium, dementia, and amnestic and other cognitive disorders. Major neurocognitive disorder now subsumes dementia and the amenstic disorder. Although the problems that are addressed in this revised category remain the same, using the term neurocognitive was chosen to neutralize dementia-related stigma. (Halter et al., 2013 a)
Neurocognitive disorders are divided into major and mild types. Major neurocognitive disorders are characterized by substantial cognitive decline that results in curtailed independence and functioning among affected individuals.
Mild neurocognitive disorder was added as a new disorder. This diagnosis identifies people whose symptoms place them somewhere in a gray zone between normal cognition and those with noticeably significant cognitive deterioration. Identifying early-presenting symptoms among those individuals may aid in earlier interventions at a stage when some disease-modifying therapies may be most effective (Sperling, 2011).
The workgroup for this disorder assumed that the DSM-5 can make a significant contribution to assisting clinicians with diagnosing neurocognitive disorders. “An enormous amount of information has emerged in the area of neurocognitive disorders [in terms of] early differentiation of a probable Alzheimer’s disease versus a frontal temporal dementia diagnosis and differentiating dementia with Lewy bodies versus vascular dementia.” (Brunk, 2013)
In previous editions of the manual, personality disorders were listed on Axis II, suggesting that they were unique from Axis I. The removal of the Axis system eliminates the suggestion of a causal dichotomy between personality disorders and all other psychiatric diagnoses. (Skodol, 2012).
The DSM-5 maintains the categorical model and criteria for the 10 personality disorders included in the DSM-IV. Originally, a hybrid categorical-dimensional model was proposed. It included not only core impairments in personality functioning but also various combinations of pathological personality traits associated with these conditions. Although this proposal was endorsed by the DSM-5 Task Force, it was decided that the hybrid model required more research support before being fully adopted. Therefore, this new model was added in Section III to encourage study of how the methodology could be used to clinically diagnose personality in clinical practice.
Sex has a controversial history in the DSM. Therefore the manual has undergone significant changes over the last 50 years in how it defines healthy and unhealthy sexuality. For example, homosexuality was considered a mental disorder until 1973. Up until 1986 the manual still gave clinicians the option of declaring gay people mentally ill if their sexuality caused them distress.
The Paraphilic Disorders Section of the DSM-5 represents a significant departure from DSM-IV-TR. Paraphilias (sexual masochism, fetishism, voyeurism, transvestism, sadism, pedophilia, etc.) have been removed from the DSM. They are disorders involving the patient’s need for unusual sexual stimulation to achieve sexual arousal or orgasm. This group of disorders was listed in the Sexual and Gender Identity section of earlier versions of the DSM.
The DSM-5 defines paraphilic disorders as: “Any intense and persistent sexual interest other than sexual interest in genital stimulation or preparatory fondling with phenotypically normal, consenting human partners between the ages of physical maturity and physical decline.” The new manual added one criterion: These disorders apply if an individual feels personal distress about their interest. Remission is defined as having no distress, functional impairment, or recurring behavior for 5 years in an uncontrolled environment.
The manual lists the following noncriminal sexual disorders: Voyeuristic Disorder, Exhibitionistic Disorder, Frotteuristic Disorder, Sexual Masochism Disorder, Sexual Sadism Disorder, Pedophilic Disorder, Fetishistic Disorder, Transvestic Disorder, Other Specified Paraphilic Disorder, or Unspecified Paraphilic Disorder.
The work group assigned to this category sought to distinguish the mild and socially harmless paraphilias from the severe paraphilias, which are distressing to those afflicted and/or are potentially dangerous to others (Dreger, 2010). Therefore, risk-assessing specifiers have been developed to indicate level of threat to others posed by individuals diagnosed with a paraphilic disorder, designating whether the individual is in a controlled environment, and if the individual is in remission.
Psychiatrists have argued that by including the paraphilic disorders in the DSM, the door remains open for those individuals to seek treatment. (Keenan, 2013)
For Extended Bibliography and References, click here.