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.

Final form announced

Its final form was announced on December 1, 2012, by the APA.

The ten personality disorders in DSM-IV will remain, (Paranoid personality disorder, Schizoid personality disorder, Schizotypal personality disorder, Antisocial personality disorder, Borderline personality disorder, Histrionic personality disorder and Narcissistic personality disorder), the multiaxial system will be dropped in favor of a system evaluating psychosocial and contextual factors and will use a new trait-specific diagnostic method.

Asperger's disorder will be merged into Autism, and new disorders added, such as Disruptive mood dysregulation disorder (for children to reduce reliance on a Bipolar disorder diagnosis), Excoriation (skin-picking) disorder, and Hoarding disorder. Disorders not accepted include Anxious depression, Hypersexual disorder, Parental alienation syndrome, and Sensory processing disorder. Pedophilia is retained as is but renamed to Pedophilic disorder.

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 will oversee the development of DSM-5. The DSM-5 Task Force consists 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.

Owing to criticism over the perceived proliferation of diagnoses in the current edition of the DSM, David Kupfer, M.D., who is the DSM-5 Task Force chair and is shepherding the DSM's revision, said in an interview: "One of the raps against psychiatry is that you and I are the only two people in the U.S. without a psychiatric diagnosis."

First draft diagnostic criteria

The first draft diagnostic criteria for DSM-5 has now been released. Revisions include the following:

1. The recommendation of new categories for learning disorders and a single diagnostic category, "autism spectrum disorders" that will incorporate the current diagnoses of autistic disorders, Asperger syndrome, childhood disintegrative disorder and pervasive developmental disorder (not otherwise specified). Work group members have also recommended that the diagnostic term "mental retardation" be changed to "intellectual disability," bringing the DSM criteria into alignment with terminology used by other disciplines.
2. Eliminating the current categories substance abuse and dependence, replacing them with the new category "addiction and related disorders." This will include substance use disorders, with each drug identified in its own category. Eliminating the category of dependence will better differentiate between the compulsive drug-seeking behavior of addiction and normal responses of tolerance and withdrawal that some patients experience when using prescribed medications that affect the central nervous system.
3. Creating a new category of "behavioral addictions," in which gambling will be the sole disorder. Internet addiction was considered for this category, but work group members decided there was insufficient research data to do so, so they recommended it be included in the manual's appendix instead, with a goal of encouraging additional study.
4. New suicide scales for adults and adolescents to help clinicians identify those individuals most at risk, with a goal of enhancing interventions across a broad range of mental disorders; the scales include research-based criteria such as impulsive behavior and heavy drinking in teens.
5. Consideration of a new "risk syndromes" category, with information to help clinicians identify earlier stages of some serious mental disorders, such as neurocognitive disorder (dementia) and psychosis.
6. A proposed new diagnostic category, temper dysregulation with dysphoria (TDD), within the Mood Disorders section of the manual. The new criteria are based on a decade of research on severe mood dysregulation, and may help clinicians better differentiate children with these symptoms from those with bipolar disorder or oppositional defiant disorder.
7. New recognition of binge eating disorder and improved criteria for anorexia nervosa and bulimia nervosa, as well as recommended changes in the definitions of some eating disorders now described as beginning in infancy and childhood to emphasize that they may also develop in older individuals.

Dimensional assessments
In addition to proposed changes to specific diagnostic criteria, the APA proposed that "dimensional assessments" be added to diagnostic evaluations of mental disorders. These would permit clinicians to evaluate the severity of symptoms, as well as take into account "crosscutting" symptoms.

Careful consideration of gender, race and ethnicity
The process for developing the proposed diagnostic criteria for DSM-5 has included careful consideration of how gender, race and ethnicity may affect the diagnosis of mental illness.

Proposed changes to DSM-IV diagnoses

Asperger syndrome

Main article: Diagnosis of Asperger syndrome § Proposed changes to DSM-5

Asperger syndrome will be eliminated as a separate disorder, and merged under autism spectrum disorders (ASD). Under the new classification, clinicians would rate the severity of clinical presentation of ASD as severe, moderate or mild. This change has been met with resistance amongst Asperger Syndrome specialists such as Tony Attwood and Simon Baron-Cohen.

Attention deficit hyperactivity disorder

Further information: Attention deficit hyperactivity disorder

There has been a proposal to increase the diagnostic criteria for the age when symptoms became present. The proposal would change the diagnostic criteria from symptoms being present before seven years of age to symptoms being present before twelve years of age. The new diagnostic criteria would read: "B. Several noticeable inattentive or hyperactive-impulsive symptoms were present by age 12."

There has been a proposal that for the Inattentive type and Hyperactive/Impulsive type, a minimum of only four symptoms need to be met if a person is 17 years of age or older. The current DSM-IV-TR criteria of meeting a minimum of six symptoms for the Inattentive type or Hyperactive/Impulsive Type would still apply for those 16 years of age or younger.

Bipolar disorder

Further information: Bipolar disorder

There have been proposals to include further and more accurate sub-typing for bipolar disorder. (Akiskal and Ghaemi, 2006)

There have been proposals for more stringent criteria for the diagnosis of bipolar disorder in children with a new diagnosis temper dysregulation disorder with dysphoria proposed.

Depression

Further information: Mood disorder

While currently grief is only considered a sign of depression if two months have elapsed since the death of a loved one, the new version would allow for diagnosis within the first few weeks.

Dissociative identity disorder

Further information: Dissociative identity disorder

Proposed changes to the controversial dissociative identity disorder diagnosis include adding a new diagnostic criterion: "C. Causes clinically significant distress or impairment in social, occupational, or other important areas of functioning." This phrase, which occurs in several other diagnostic criteria, is proposed for inclusion in 300.14 as part of a proposed merger of dissociative trance disorder with DID. Criterion C would be included to "help differentiate normative cultural experiences from psychopathology". For example, professionals would be able to take shamanism, which involves voluntary possession trance states, into consideration, rather than diagnosing those who report it as having a mental disorder.

Gender identity disorder

Further information: Gender Identity Disorder

Gender Identity Disorder (GID) will be renamed "Gender Dysphoria" in the DSM 5. Along with these changes comes the creation of a separate Gender Dysphoria in Children as well as one for Adults and Adolescents. The grouping will be moved out of the Sexual Disorders category and into its own. The name change was made in part due to stigmatization of the term "disorder" and the relatively common use of "gender dysphoria" in the GID literature and among specialists in the area. The creation of a specific diagnosis for children reflects the lesser ability of children to have insight into what they are experiencing and ability to express it in the event that they have insight.

Hypersexual disorder

Further information: Hypersexual disorder

Hypersexual Disorder is proposed as a new category to be added. The diagnosis would apply when a person experiences several of the indicated symptoms (extreme amounts of time spent in the sexual activity, using the sexual activity in response to low mood or stress, failed attempts to reduce the behaviors, etc.). Moreover, it would apply only when the problem lasted six months or more, when person experienced significant distress or impairment in major life areas because of it, and when the problem was not directly caused by a medication or drugs, as well as other criteria. Under the proposal, an official diagnosis would also specify which behavior(s) are problematic in the case: masturbation, pornography use, cybersex, etc.

The label "hypersexual disorder" was reportedly chosen because it did not imply any specific theory for what causes hypersexuality, which remains unknown. A proposal to add sexual addiction to the DSM system has been rejected by the APA, as not enough evidence suggested to them that the condition is analogous to substance addictions, as that name would imply. The concept of hypersexual disorder was also challenged, as it overpathologized aspects of male sexuality, especially that of gay and bisexual men. There was discussion that hypersexual disorder would be included in a section designated for future research, but ultimately, hypersexual disorder was rejected, and will not be included in DSM5.

The DSM-IV-TR includes "Sexual Disorder—Not Otherwise Specified" (Sexual Disorder NOS), which applies to, among other conditions, "distress about a pattern of repeated sexual relationships involving a succession of lovers who are experienced by the individual only as things to be used."

Oppositional defiant disorder

Further information: Oppositional defiant disorder

It is proposed that the eight symptoms of Oppositional Defiant Disorder should be divided into the following categories: Angry/Irritable Mood; Defiant/Headstrong Behavior; and Vindictiveness. However, just as in the DSM-IV-TR, four of these symptoms need to be present to meet diagnostic criteria. The minimum four symptoms can come from all (or even just one or two) of the three categories.

It is proposed that a section be added to the diagnostic criteria for Oppositional Defiant Disorder stating that for children under 5 years of age, oppositional behavior "must occur on most days for a period of at least six months". For children 5 years or older, oppositional behavior "must occur at least once per week for at least six months". The current criteria states that four or more symptoms must be present for at least 6 months. The proposed change adds the criterion of frequency of symptoms and also delineates required frequency by the age of the child.

Personality disorders

Further information: Personality disorder

Major changes have been proposed in the assessment and diagnosis of personality disorders. These include a revamped definition of personality disorder and a dimensional rather than a categorical approach based on the severity of dysfunctional personality trait domains (negative emotionality, introversion, antagonism, disinhibition, compulsivity, and schizotypy). In addition, patients would be assessed on how much they match each of six prototypic personality disorder types: antisocial/psychopathic, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal with their criteria being derived directly from the dimensional personality trait domains.

Pica

Further information: Pica (disorder)

It is proposed that Pica be reclassified from the "Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence" classification to the "Eating Disorders" classification.

It is proposed that the wording of "non-food substances" be added alongside the current DSM-IV-TR wording of "non-nutritive substances". "Non-food" was added to further clarify that items consumed are not just merely lacking nutrients (diet soda, according to the DSM-V committee, is an example of a non-nutritive substance), but are actual non-foodstuffs.

Posttraumatic stress disorder

Main article: Posttraumatic stress disorder § DSM-5 proposed diagnostic criteria changes

Various criteria changes are proposed.

Schizophrenia

Further information: Schizophrenia

The following Schizophrenia subtypes are proposed for removal from DSM-5. :

• 295.30 Schizophrenia - Paranoid Type
• 295.10 Schizophrenia - Disorganized Type
• 295.20 Schizophrenia - Catatonic Type
• 295.90 Schizophrenia - Undifferentiated Type
• 295.60 Schizophrenia - Residual Type

Somatoform disorder

Further information: Somatoform disorder

Additional proposed somatoform disorders are:

• Abridged somatization disorder - at least 4 unexplained somatic complaints in men and 6 in women
• Multisomatoform disorder - at least 3 unexplained somatic complaints from the PRIME-MD scale for at least 2 years of active symptoms

These disorders have been proposed because the recognized somatoform disorders are either too restrictive or too broad. In a study of 119 primary care patients, the following prevalences were found:

• Somatization disorder - 1%
• Abridged somatization disorder - 6%
• Multisomatoform disorder - 24%
• Undifferentiated somatoform disorder - 79%

Proposed new diagnoses

The proposed DSM-5 new diagnoses include the following:

• Complex post-traumatic stress disorder - not accepted
• Post-traumatic embitterment disorder - not accepted
• Depressive personality disorder - not accepted
• Compulsive hoarding - added
• Olfactory Reference Syndrome - not accepted
• Passive–aggressive personality disorder (in Appendix of DSM-IV-TR) is redefined, clarified and added as Negativistic personality disorder - not accepted
• Relational disorder - not accepted
• Skin Picking Disorder - added as Excoriation (skin-picking) disorder in the Obsessive-Compulsive and Related Disorders chapter.
• Sluggish cognitive tempo - not accepted
• Binge Eating disorder will be moved from the appendix to Section 2.

Olfactory Reference Syndrome and Skin Picking Disorder may be added to the Appendix for Further Research in the DSM-V.

Two proposed diagnoses were dropped. They were attenuated psychosis syndrome and mixed anxiety depressive disorder.

Conditions proposed by outside sources

The following conditions have been proposed by outside sources for inclusion in the DSM-5:

• Apathy Syndrome
• Body Integrity Identity Disorder
• Complicated Grief Disorder
• Developmental Trauma Disorder
• Disorders of Extreme Stress Not Otherwise Specified
• Fetal Alcohol Syndrome
• Internet Addiction Disorder - added as Internet use gaming disorder
• Male-to-Eunuch Gender Identity Disorder
• Melancholia
• Parental Alienation Syndrome - not accepted
• Seasonal Affective Disorder
• Sensory Processing Disorder - not accepted

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 saying nothing about the biological underpinnings of mental disorders. Previous DSMs would also have this criticism.

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

The head of the National Institute of Mental Health, Thomas Insel, withdrew support for the DSM-5 in his statement on April 29, 2013, stating, "the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure." Insel's criticism was not specific to the new manual, but rather as a general criticism of the DSM as it has always existed, acknowledging that "the final product involves mostly modest alterations of the previous edition, based on new insights emerging from research since 1990 when DSM-IV was published."

"The goal," he explained, "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." While Insel acknowledges the strengths of the DSM in its reliability, ensuring that all members of the field use the same definitions, the biggest weakness has always been "its lack of validity".

In their effort to resolve their issues with the new DSM, the NIMH launched the Research Domain Criteria Project (RDoC), based on four assumptions:

• A diagnostic approach based on the biology as well as the symptoms must not be constrained by the current DSM categories,
• Mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior,
• Each level of analysis needs to be understood across a dimension of function,
• Mapping the cognitive, circuit, and genetic aspects of mental disorders will yield new and better targets for treatment.

Insel stressed that the RDoC is not designed as diagnostic criteria to replace the DSM, but rather as a research framework, for future development.

Their argument is centered around the claim that, "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." As a result of this position, the NIMH is no longer using the DSM as the criteria upon which they will evaluate funding of future clinic trials.

External links

• Official DSM-5 Development Website
• Topic Center from Psychiatric Times: DSM-V