DSM-5

DSM-5 (formerly known as DSM-V) is the fifth edition of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders.

It was published on May 18, 2013, superseding the DSM-IV, which was last revised in 2000.

The fifth edition has been criticized by the National Institute of Mental Health and Dr. Allen Frances, who cautioned physicians to "use the DSM-5 cautiously, if at all".

New and changed diagnoses

The DSM-5 deleted the chapter that includes "all diagnoses usually first made in infancy, childhood, or adolescence", opting to list them in other sections.

Section II: diagnostic criteria and codes

Neurodevelopmental Disorders

• "mental retardation" has a new name: "intellectual disability (intellectual developmental disorder)"
• phonological disorder and stuttering are now called communication disorders -- which include language disorder, speech sound disorder, childhood-onset fluency disorder, and a new condition characterized by impaired social verbal and nonverbal communication called social (pragmatic) communication disorder
• autism spectrum disorder incorporates Asperger disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (PDD-NOS) see Diagnosis of Asperger syndrome#Proposed changes to DSM-5

Schizophrenia Spectrum and Other Psychotic Disorders

• All subtypes of schizophrenia were deleted (paranoid, disorganized, catatonic, undifferentiated, and residual).
• A major mood episode is required for schizoaffective disorder (for a majority of the disorder's duration after criterion A is met).
• Criteria for delusional disorder changed, and, in DSM-5, delusional disorder is no longer separate from shared delusional disorder.
• In DSM-5, catatonia in all contexts requires 3 of a total of 12 symptoms. Catatonia may be a specifier for depressive, bipolar, and psychotic disorders; part of another medical condition; or an other specified diagnosis.

Bipolar and Related Disorders

• New specifier "with mixed features" can be applied to bipolar I disorder, bipolar II disorder, bipolar disorder NED (previously called "NOS") and MDD
• Allows other specified bipolar and related disorder for particular conditions.
• Anxiety symptoms are a specifier added to bipolar disorder and to depressive disorders (but are not part of the bipolar diagnostic criteria).

Depressive Disorders

• The bereavement exclusion in DSM-IV was removed from depressive disorders in DSM-5.
• New Disruptive Mood Dysregulation Disorder (DMDD) for children up to age 18 years
• Premenstrual dysphoric disorder moved from an appendix for further study, and became a disorder.

Anxiety Disorders

• For the various forms of phobias and anxiety disorders, DSM-5 removes the requirement that the subject (formerly, over 18 years old) "must recognize that their fear and anxiety are excessive or unreasonable".

Obsessive-Compulsive and Related Disorders

• a new chapter on obsessive-compulsive and related disorders includes four new disorders: excoriation (skin-picking) disorder, hoarding disorder, substance-/medication-induced obsessive-compulsive and related disorder, and obsessive-compulsive and related disorder due to another medical condition

Trauma- and Stressor-Related Disorders

• posttraumatic stress disorder (PTSD) is now included in a new chapter titled "Trauma- and Stressor-Related Disorders." Furthermore, a fourth diagnostic cluster (in addition to Criteria B, C, and D) capturing behavioral symptoms has been added see Posttraumatic stress disorder#DSM-5 proposed diagnostic criteria changes. Certain criteria were changed or eliminated for acute stress disorder and PTSD. Two new disorders that were formerly subtypes were named: reactive attachment disorder and disinhibited social engagement disorder.

Dissociative Disorders

• Depersonalization disorder is now called depersonalization/derealization disorder.
• In DSM-5, criteria were expanded in dissociative identity disorder to include "possession-form phenomena and functional neurological symptoms" and to say that "transitions in identity may be observable by others or self-reported".

Somatic Symptom and Related Disorders

• somatoform disorders are now called somatic symptom and related disorders. Diagnoses of somatization disorder, hypochondriasis, pain disorder, and undifferentiated somatoform disorder were deleted in DSM-5. "Psychological factors affecting other medical conditions" (formerly found in the DSM-IV chapter "Other Conditions That May Be a Focus of Clinical Attention") is termed a new mental disorder.

Feeding and Eating Disorders

• binge eating disorder graduated from DSM-IV's Appendix B -- Criteria Sets and Axes Provided for Further Study Requirements for bulimia nervosa and binge eating disorder were changed from "at least twice weekly for 6 months to at least once weekly over the last 3 months". Anorexia nervosa no longer has a requirement of amenorrhea. What in DSM-IV was called "feeding disorder of infancy or early childhood" and rarely used, is now called avoidant/restrictive food intake disorder with expanded criteria.

Sleep-Wake Disorders

• In DSM-5, there are three breathing-related sleep disorders: obstructive sleep apnea hypopnea, central sleep apnea, and sleep-related hypoventilation. Circadian rhythm sleep-wake disorders were expanded to include advanced sleep phase syndrome, irregular sleep-wake type, and non-24-hour sleep-wake type. Jet lag was removed. Listed under "dyssomnia not otherwise specified" in DSM-IV, rapid eye movement sleep behavior disorder and restless legs syndrome are each a disorder in DSM-5.

Sexual Dysfunctions

• New in DSM-5 is genito-pelvic pain/penetration disorder which combines vaginismus and dyspareunia from DSM-IV.
• DSM-IV had a subtype "due to psychological factors versus due to combined factors" which is omitted in DSM-5.

Gender Dysphoria

• Among other wording changes, criterion A and and criterion B (cross-gender identification, and aversion toward one’s gender) were combined.

Substance-Related and Addictive Disorders

• substance abuse and substance dependence have been combined into single substance use disorders specific to each substance of abuse within a new "addictions and related disorders" category.

Neurocognitive Disorders

• neurocognitive disorder added. categorical classification system for personality disorders unchanged

Paraphilic Disorders

• distinguishes between paraphilic behaviors, or paraphilias, and paraphilic disorders

Section III: emerging measures and models

Alternative DSM-5 model for personality disorders

An alternative hybrid dimensional-categorical model for personality disorders is included to stimulate further research on this modified classification system

Conditions for further study

• Attenuated Psychosis Syndrome
• Depressive Episodes With Short-Duration Hypomania
• Persistent Complex Bereavement Disorder
• Caffeine Use Disorder
• Internet Gaming Disorder
• Neurobehavioral Disorder Associated With Prenatal Alcohol Exposure
• Suicidal Behavior Disorder
• Non-suicidal self-injury

Development

In 1999, a DSM–5 Research Planning Conference; sponsored jointly by APA and the National Institute of Mental Health (NIMH), was held to set the research priorities. Research Planning Work Groups produced "white papers" on the research needed to inform and shape the DSM-5 and the resulting work and recommendations were reported in an APA monograph and peer-reviewed literature. There were six workgroups, each focusing on a broad topic: Nomenclature, Neuroscience and Genetics, Developmental Issues and Diagnosis, Personality and Relational Disorders, Mental Disorders and Disability, and Cross-Cultural Issues. Three additional white papers were also due by 2004 concerning gender issues, diagnostic issues in the geriatric population, and mental disorders in infants and young children. The white papers have been followed by a series of conferences to produce recommendations relating to specific disorders and issues, with attendance limited to 25 invited researchers.

On July 23, 2007, the APA announced the task force that would oversee the development of DSM-5. The DSM-5 Task Force consisted of 27 members, including a chair and vice chair, who collectively represent research scientists from psychiatry and other disciplines, clinical care providers, and consumer and family advocates. Scientists working on the revision of the DSM have experience in research, clinical care, biology, genetics, statistics, epidemiology, public health, and consumer advocacy. They have interests ranging from cross-cultural medicine and genetics to geriatric issues, ethics and addiction. The APA Board of Trustees required that all task force nominees disclose any competing interests or potentially conflicting relationships with entities that have an interest in psychiatric diagnoses and treatments as a precondition to appointment to the task force. The APA made all task force members' disclosures available during the announcement of the task force. Several individuals were ruled ineligible for task force appointments due to their competing interests. Future announcements will include naming the workgroups on specific categories of disorders and their research-based recommendations on updating various disorders and definitions.

The DSM-5 field trials included "test-retest reliability" which involved different clinicians doing independent evaluations of the same patient—a new approach to the study of diagnostic reliability.

Criticism

Robert Spitzer, the head of the DSM-III task force, has publicly criticized the APA for mandating that DSM-5 task force members sign a nondisclosure agreement, effectively conducting the whole process in secret: "When I first heard about this agreement, I just went bonkers. Transparency is necessary if the document is to have credibility, and, in time, you're going to have people complaining all over the place that they didn't have the opportunity to challenge anything." Allen Frances, chair of the DSM-IV Task Force, expressed a similar concern.

Although the APA has since instituted a disclosure policy for DSM-5 task force members, many still believe the Association has not gone far enough in its efforts to be transparent and to protect against industry influence. In a recent Point/Counterpoint article, Lisa Cosgrove, PhD and Harold J. Bursztajn, MD noted that "the fact that 70% of the task force members have reported direct industry ties---an increase of almost 14% over the percentage of DSM-IV task force members who had industry ties---shows that disclosure policies alone, especially those that rely on an honor system, are not enough and that more specific safeguards are needed."

David Kupfer, MD, chair of the DSM-5 task force, and Darrel A. Regier, MD, MPH, Vice Chair of the task force, whose industry ties are disclosed with those of the task force, countered that "collaborative relationships among government, academia, and industry are vital to the current and future development of pharmacological treatments for mental disorders." They asserted that the development of DSM-5 is the "most inclusive and transparent developmental process in the 60-year history of DSM." The developments to this new version can be viewed on the APA website. Perhaps as an effort towards this transparency, public input is requested for the first time in the history of the manual. During periods of public comment, members of the general public could sign up at the DSM-V website and provide feedback on the various proposed changes.

In June 2009 Allen Frances issued strongly worded criticisms of the processes leading to DSM-5 and the risk of "serious, subtle, (…) ubiquitous" and "dangerous" unintended consequences such as new "false 'epidemics'". He writes that "the work on DSM-V has displayed the most unhappy combination of soaring ambition and weak methodology" and is concerned about the task force's "inexplicably closed and secretive process.". His and Spitzer's concerns about the contract that the APA drew up for consultants to sign, agreeing not to discuss drafts of the fifth edition beyond the task force and committees, have also been aired and debated.

The appointment, in May 2008, of two of the taskforce members, Kenneth Zucker and Ray Blanchard, has led to an internet petition to remove them. According to MSNBC, "The petition accuses Zucker of having engaged in 'junk science' and promoting 'hurtful theories' during his career, especially advocating the idea that children who are unambiguously male or female anatomically, but seem confused about their gender identity, can be treated by encouraging gender expression in line with their anatomy." According to The Gay City News, "Dr. Ray Blanchard, a psychiatry professor at the University of Toronto, is deemed offensive for his theories that some types of transsexuality are paraphilias, or sexual urges. In this model, transsexuality is not an essential aspect of the individual, but a misdirected sexual impulse." Blanchard responded, "Naturally, it's very disappointing to me there seems to be so much misinformation about me on the Internet. [They didn't distort] my views, they completely reversed my views." Zucker "rejects the junk-science charge, saying there 'has to be an empirical basis to modify anything' in the DSM. As for hurting people, 'in my own career, my primary motivation in working with children, adolescents and families is to help them with the distress and suffering they are experiencing, whatever the reasons they are having these struggles. I want to help people feel better about themselves, not hurt them.'"

In 2011, psychologist Brent Robbins co-authored a national letter for the Society for Humanistic Psychology that has brought thousands into the public debate about the DSM. Approximately 13,000 individuals and mental health professionals have signed a petition in support of the letter. Thirteen other American Psychological Association divisions have endorsed the petition. In a recent article about the debate in the San Francisco Chronicle, Robbins notes that under the new guidelines, certain responses to grief could be labeled as pathological disorders, instead of being recognized as being normal human experiences. In 2012, a footnote was added to the draft text which explains the distinction between grief and depression.

DSM-5, has been criticized for purportedly saying nothing about the biological underpinnings of mental disorders.

Borderline personality disorder controversy

The Treatment and Research Advancements National Association for Personality Disorders (TARA-APD) campaigns to change the name and designation of borderline personality disorder in DSM-5. The paper How Advocacy is Bringing BPD into the Light reports that "the name BPD is confusing, imparts no relevant or descriptive information, and reinforces existing stigma...". Instead, it proposes the name "emotional regulation disorder" or "emotional dysregulation disorder". There is also discussion about changing Borderline Personality Disorder, an Axis II diagnosis (personality disorders and mental retardation), to an Axis I diagnosis (clinical disorders).

More radical criticisms

Some authors believe that the problem is not simply of a few criteria to be deleted or modified. For example, a Kuhnian reformulation of the diagnostic debate suggested that apparently trivial problems of the DSM, like the extremely high rates of comorbidity, might fruitfully be analysed as Kuhnian anomalies leading the DSM system to a scientific crisis. As a consequence, a radical rethinking of the concept of mental disorder was proposed, addressing its constructive nature. Based on similar views, several revolutionary approaches were proposed, ranging from dimensional diagnosis to various forms of etiopathogenetic diagnosis.

The financial association of DSM-5 panel members with industry continues to be a concern for financial conflict of interest.

British Psychological Society response

The British Psychological Society in the United Kingdom stated in its June 2011 response that it had "more concerns than plaudits". It criticized proposed diagnoses as "clearly based largely on social norms, with 'symptoms' that all rely on subjective judgements... not value-free, but rather reflect[ing] current normative social expectations", noting doubts over the reliability, validity, and value of existing criteria, that personality disorders were not normed on the general population, and that "not otherwise specified" categories covered a "huge" 30% of all personality disorders.

It also expressed a major concern that "clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences... which demand helping responses, but which do not reflect illnesses so much as normal individual variation".

The Society suggested as its primary specific recommendation, a change from using "diagnostic frameworks" to a description based on an individual's specific experienced problems, and that mental disorders are better explored as part of a spectrum shared with normality:

[We recommend] a revision of the way mental distress is thought about, starting with recognition of the overwhelming evidence that it is on a spectrum with 'normal' experience, and that psychosocial factors such as poverty, unemployment and trauma are the most strongly-evidenced causal factors. Rather than applying preordained diagnostic categories to clinical populations, we believe that any classification system should begin from the bottom up – starting with specific experiences, problems or 'symptoms' or 'complaints'...... We would like to see the base unit of measurement as specific problems (e.g. hearing voices, feelings of anxiety etc)? These would be more helpful too in terms of epidemiology. While some people find a name or a diagnostic label helpful, our contention is that this helpfulness results from a knowledge that their problems are recognised (in both senses of the word) understood, validated, explained (and explicable) and have some relief. Clients often, unfortunately, find that diagnosis offers only a spurious promise of such benefits. Since – for example – two people with a diagnosis of 'schizophrenia' or 'personality disorder' may possess no two symptoms in common, it is difficult to see what communicative benefit is served by using these diagnoses. We believe that a description of a person's real problems would suffice. Moncrieff and others have shown that diagnostic labels are less useful than a description of a person's problems for predicting treatment response, so again diagnoses seem positively unhelpful compared to the alternatives.

—British Psychological Society June 2011 response

National Institute of Mental Health

National Institute of Mental Health Director Thomas R. Insel, M.D. wrote in a April 29, 2013 blog post:

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.

Dr. Insel's post sparked a flurry of reaction, some of which might be termed sensationalistic, with headlines such as "Goodbye to the DSM-V", "Federal institute for mental health abandons controversial 'bible' of psychiatry", "National Institute of Mental Health abandoning the DSM", and "Psychiatry divided as mental health 'bible' denounced." Other responses provided a more nuanced analysis of the NIMH Director's post.

On May 23, 2013 Dr. Insel, on behalf of NIMH, issued a joint statement with Jeffrey A. Lieberman, M.D., President-elect, American Psychiatric Association, which emphasized that DSM-5 "...represents the best information currently available for clinical diagnosis of mental disorders. Patients, families, and insurers can be confident that effective treatments are available and that the DSM is the key resource for delivering the best available care. The National Institute of Mental Health (NIMH) has not changed its position on DSM-5."

External links

• Official DSM-5 Development Website