DSM-5

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5)
Author American Psychiatric Association
Country United States
Language English
Series Diagnostic and Statistical Manual of Mental Disorders
Subject Classification and diagnosis of mental disorders
Published May 18, 2013
Media type Print (hardcover, softcover); e-book
Pages 947
ISBN 978-0-89042-554-1
OCLC 830807378
616.89'075
LC Class RC455.2.C4
Preceded by DSM-IV-TR

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is the 2013 update to the American Psychiatric Association's (APA) classification and diagnostic tool. In the United States the DSM serves as a universal authority for psychiatric diagnosis. Treatment recommendations, as well as payment by health care providers, are often determined by DSM classifications, so the appearance of a new version has significant practical importance.

The DSM-5 was published on May 18, 2013, superseding the DSM-IV-TR, which was published in 2000. The development of the new edition began with a conference in 1999, and proceeded with the formation of a Task Force in 2007, which developed and field-tested a variety of new classifications. In most respects DSM-5 is not greatly changed from DSM-IV-TR. Notable changes include dropping Asperger syndrome as a distinct classification; loss of subtype classifications for variant forms of schizophrenia; dropping the "bereavement exclusion" for depressive disorders; a revised treatment and naming of gender identity disorder to gender dysphoria, and removing the A2 criterion for posttraumatic stress disorder (PTSD) because its requirement for specific emotional reactions to trauma did not apply to combat veterans and first responders with PTSD.

Various authorities criticized the fifth edition both before and after it was formally published. Critics assert, for example, that many DSM-5 revisions or additions lack empirical support; inter-rater reliability is low for many disorders; several sections contain poorly written, confusing, or contradictory information; and the psychiatric drug industry unduly influenced the manual's content. Various scientists have argued that the DSM-5 forces clinicians to make distinctions that are not supported by solid evidence, distinctions that have major treatment implications, including drug prescriptions and the availability of health insurance coverage. General criticism of the DSM-5 ultimately resulted in a petition, signed by many mental health organizations, which called for outside review of DSM-5.[1]

Changes

This part of the article summarizes changes from DSM-IV to DSM-5. DSM-5 is divided into three Sections, using Roman numerals to designate each Section. The same organizational structure is used in this overview, e.g., Section I (immediately below) summarizes relevant changes discussed in DSM-5, Section I.

Note that if a specific disorder (or set of disorders) cannot be seen, e.g., enuresis and other elimination disorders, mentioned in Section II: diagnostic criteria and codes (below), it means that the diagnostic criteria for those disorders did not change significantly from DSM-IV to DSM-5.

Section I

Section I describes DSM-5 chapter organization, its change from the multiaxial system, and Section III's dimensional assessments.[2] The DSM-5 deleted the chapter that includes "disorders usually first diagnosed in infancy, childhood, or adolescence" opting to list them in other chapters.[2] A note under Anxiety Disorders says that the "sequential order" of at least some DSM-5 chapters has significance that reflects the relationships between diagnoses.[2]

This introductory section describes the process of DSM revision, including field trials, public and professional review, and expert review. It states its goal is to harmonize with the ICD systems and share organizational structures as much as is feasible. Concern about the categorical system of diagnosis is expressed, but the conclusion is the reality that alternative definitions for most disorders is scientifically premature.

The new version replaces the NOS categories with two options: other specified disorder and unspecified disorder to increase the utility to the clinician. The first allows the clinician to specify the reason that the criteria for a specific disorder are not met; the second allows the clinician the option to forgo specification.

DSM-5 has discarded the multiaxial system of diagnosis (formerly Axis I, Axis II, Axis III), listing all disorders in Section II. It has replaced Axis IV with significant psychosocial and contextual features and dropped Axis V (Global Assessment of Functioning, known as GAF). The World Health Organization's (WHO) Disability Assessment Schedule is added to Section III (Emerging measures and models) under Assessment Measures, as a suggested, but not required, method to assess functioning.[3]

Section II: diagnostic criteria and codes

Neurodevelopmental disorders

Schizophrenia spectrum and other psychotic disorders

Bipolar and related disorders

Depressive disorders

Anxiety disorders

Obsessive-compulsive and related disorders

Trauma- and stressor-related disorders

Dissociative disorders

Somatic symptom and related disorders

Feeding and eating disorders

Elimination disorders

Sleep–wake disorders

Sexual dysfunctions

Gender dysphoria

Further information: Gender dysphoria

DIC Disruptive, impulse-control, and conduct disorders

Some of these disorders were formerly part of the chapter on early diagnosis, oppositional defiant disorder; conduct disorder; and disruptive behavior disorder not otherwise specified became other specified and unspecified disruptive disorder, impulse-control disorder, and conduct disorders.[2] Intermittent explosive disorder, pyromania, and kleptomania moved to this chapter from the DSM-IV chapter "Impulse-Control Disorders Not Otherwise Specified".[2]

Substance-related and addictive disorders

DSM-5 substance dependencies include:

There are no more polysubstance diagnoses in DSM-5; the substance(s) must be specified.[24]

Neurocognitive disorders

Personality disorders

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.[30]

Conditions for further study

These conditions and criteria are set forth to encourage future research and are not meant for clinical use.

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[32] and the resulting work and recommendations were reported in an APA monograph[33] and peer-reviewed literature.[34] 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.[35] 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.[35]

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 had a broad range of experience and interests. 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.[36]

The DSM-5 field trials included test-retest reliability which involved different clinicians doing independent evaluations of the same patient—a common approach to the study of diagnostic reliability.[37]

About 68% of DSM-V task-force members and 56% of panel members reported having ties to the pharmaceutical industry, such as holding stock in pharmaceutical companies, serving as consultants to industry, or serving on company boards.[38]

Revisions and updates

Beginning with the fifth edition, it is intended that diagnostic guidelines revisions will be added incrementally.[39] The DSM-5 is identified with Arabic rather than Roman numerals, marking a change in how future updates will be created. Incremental updates will be identified with decimals (DSM-5.1,DSM-5.2, etc.), until a new edition is written.[40] The change reflects the intent of the APA to respond more quickly when a preponderance of research supports a specific change in the manual. The research base of mental disorders is evolving at different rates for different disorders.[39]

Criticism

General

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."[41] Allen Frances, chair of the DSM-IV task force, expressed a similar concern.[42]

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.[43] In a 2009 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."[44]

David Kupfer, 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,[45] 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.[46] Public input was requested for the first time in the history of the manual. During periods of public comment, members of the public could sign up at the DSM-5 website[47] and provide feedback on the various proposed changes.[48]

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".[49] 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.[50]

The appointment, in May 2008, of two of the taskforce members, Kenneth Zucker and Ray Blanchard, led to an internet petition to remove them.[51] 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."[52] 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."[53] 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."[53] 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.'"[52]

In 2011, psychologist Brent Robbins co-authored a national letter for the Society for Humanistic Psychology that brought thousands into the public debate about the DSM. Approximately 13,000 individuals and mental health professionals signed a petition in support of the letter. Thirteen other American Psychological Association divisions endorsed the petition.[54] In a November 2011 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.[55] In 2012, a footnote was added to the draft text which explains the distinction between grief and depression.[56]

The DSM-5 has been criticized for purportedly saying nothing about the biological underpinnings of mental disorders.[57] A book-long appraisal of the DSM-5, with contributions from philosophers, historians and anthropologists, was published in 2015.[58]

The financial association of DSM-5 panel members with industry continues to be a concern for financial conflict of interest.[59] Of the DSM-5 task force members, 69% report having ties to the pharmaceutical industry, an increase from the 57% of DSM-IV task force members.[59]

Borderline personality disorder controversy

In 2003, the Treatment and Research Advancements National Association for Personality Disorders (TARA-APD) campaigned to change the name and designation of borderline personality disorder in DSM-5.[60] The paper How Advocacy is Bringing BPD into the Light[61] reported that "the name BPD is confusing, imparts no relevant or descriptive information, and reinforces existing stigma." Instead, it proposed the name "emotional regulation disorder" or "emotional dysregulation disorder." There was also discussion about changing borderline personality disorder, an Axis II diagnosis (personality disorders and mental retardation), to an Axis I diagnosis (clinical disorders).[62]

The TARA-APD recommendations do not appear to have affected the American Psychiatric Association, the publisher of the DSM. As noted above, the DSM-5 does not employ a multi-axial diagnostic scheme, therefore the distinction between Axis I and II disorders no longer exists in the DSM nosology. The name, the diagnostic criteria for, and description of, borderline personality disorder remain largely unchanged from DSM-IV-TR.[63]

British Psychological Society response

The British Psychological Society stated in its June 2011 response to DSM-5 draft versions, that it had "more concerns than plaudits".[64] 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, MD,[65] wrote in an April 29, 2013 blog post:[66]

“ 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 ... Patients with mental disorders deserve better. ”

Insel also discussed an NIMH effort to develop a new classification system, Research Domain Criteria (RDoC), currently for research purposes only.[67] Insel's post sparked a flurry of reaction, some of which might be termed sensationalistic, with headlines such as "Goodbye to the DSM-V",[68] "Federal institute for mental health abandons controversial 'bible' of psychiatry", [69] "National Institute of Mental Health abandoning the DSM",[70] and "Psychiatry divided as mental health 'bible' denounced." [71] Other responses provided a more nuanced analysis of the NIMH Director's post.[72]

In May 2013, Insel, on behalf of NIMH, issued a joint statement with Jeffrey A. Lieberman, MD, president of the American Psychiatric Association,[73] that 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." Insel and Lieberman say that DSM-5 and RDoC "represent complementary, not competing, frameworks" for characterizing diseases and disorders.[73] However, epistemologists of psychiatry tend to see the RDoC project as a putative revolutionary system that in the long run will try to replace the DSM, its expected early effect being a liberalization of the research criteria, with an increasing number of research centers adopting the RDoC definitions.[74]

See also

References

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  3. ↑ American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.). Arlington, VA: American Psychiatric Publishing. pp. 5–25. ISBN 978-0-89042-555-8.
  4. 1 2 "A Guide to DSM-5: Neurodevelopmental Disorders". Medscape.com. Retrieved May 26, 2013.
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  26. 1 2 "Personality Disorders" (PDF). American Psychiatric Association. 2013. Retrieved October 6, 2013.
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  28. ↑ Crocq, Marc-Antoine (2013). "Milestones in the History of Personality Disorders" (PDF). Dialogues in Clinical Neuroscience. 15 (2). Retrieved 8 August 2016.
  29. ↑ "A Guide to DSM-5: Paraphilias and Paraphilic Disorders". Medscape.com. Retrieved May 26, 2013.
  30. ↑ "A Guide to DSM-5: Personality Disorders". Medscape.com. Retrieved May 26, 2013.
  31. ↑ American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.). Arlington, VA: American Psychiatric Publishing. pp. 783–808. ISBN 978-0-89042-555-8.
  32. ↑ First, Michael B. (2002), "A Research Agenda for DSM-V: Summary of the DSM-V Preplanning White Papers Published in May 2002", DSM-V Prelude Project, American Psychiatric Association, archived from the original on April 13, 2008, retrieved May 12, 2012
  33. ↑ Kupfer, David J.; First, Michael B.; Regier, Darrel A., eds. (2002), A Research Agenda for DSM-5, Washington, D.C.: American Psychiatric Association, ISBN 9780890422922, OCLC 49518977
  34. ↑ Regier, Darrel A; Narrow, William E; First, Michael B; Marshall, Tina (2002). "The APA classification of mental disorders: future perspectives". Psychopathology. 35 (2–3): 166–170. doi:10.1159/000065139. PMID 12145504.
  35. 1 2 "DSM-5 Research Planning", DSM-V Prelude Project, American Psychiatric Association, DSM-V Research White Papers, archived from the original on April 24, 2008, retrieved May 12, 2012
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  38. ↑ Cosgrove, Lisa; Bursztajn, Harold J.; Krimsky, Sheldon (7 May 2009). "Developing Unbiased Diagnostic and Treatment Guidelines in Psychiatry". New England Journal of Medicine. 360 (19): 2035–2036. doi:10.1056/NEJMc0810237.
  39. 1 2 "About DSM-5 Frequently Asked Questions". American Psychiatric Association. Retrieved May 24, 2015.
  40. ↑ Harold, Eve (March 9, 2010). "APA Modifies DSM Naming Convention to Reflect Publication Changes" (Release No. 10-17). The American Psychiatric Association.
  41. ↑ Carey, Benedict (December 17, 2008). "Psychiatrists Revise the Book of Human Troubles". The New York Times.
  42. ↑ Psychiatrists Propose Revisions to Diagnosis Manual. via PBS Newshour, February 10, 2010 (interviews Frances and Alan Schatzberg on some of the main changes proposed to the DSM-5)
  43. ↑ Cosgrove, Lisa; Krimsky, Sheldon; Vijayaraghavan, Manisha; Schneider, Lisa (April 2006), "Financial Ties between DSM-IV Panel Members and the Pharmaceutical Industry", Psychotherapy and Psychosomatics, 75 (3): 154–160, doi:10.1159/000091772, PMID 16636630
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  47. ↑ Registration page for DSM-5 public comment Archived May 1, 2011, at the Wayback Machine., page found June 5, 2011.
  48. ↑ "Suggestions and ideas for members of the work groups were also solicited through the DSM-5 website. The proposed draft revisions to DSM-5 are posted on the website, and anyone can provide feedback to the work groups during periods of public comment."Question 4 on the DSM-5 FAQ Archived September 25, 2011, at the Wayback Machine., page found June 5, 2011.
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  50. ↑ Lane, Christopher (July 24, 2009). "The Diagnostic Madness of DSM-V". Slate.
  51. ↑ Lou Chibbaro, Jr. (May 30, 2008). "Activists alarmed over APA: Head of psychiatry panel favors 'change' therapy for some trans teens". Washington Blade.
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  53. 1 2 Osborne, Duncan (May 15, 2008). "Flap Flares Over Gender Diagnosis". Gay City News. Retrieved June 14, 2008.
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  55. ↑ Erin Allday (November 26, 2011). "Revision of psychiatric manual under fire". San Francisco Chronicle.
  56. ↑ Carey, Benedict (May 8, 2012), "Psychiatry Manual Drafters Back Down on Diagnoses", The New York Times, nytimes.com, retrieved May 12, 2012
  57. ↑ New DSM-5 Ignores Biology of Mental Illness; "The latest edition of psychiatry's standard guidebook neglects the biology of mental illness. New research may change that." May 5, 2013 Scientific American
  58. ↑ Demazeux, Steeves; Singy, Patrick (2015). The DSM-5 in Perspective: Philosophical Reflections on the Psychiatric Babel. Springer. ISBN 978-94-017-9764-1.
  59. 1 2 Cosgrove, Lisa; Drimsky Lisa (March 2012). "A comparison of DSM-iv and DSM-5 panel members' financial associations with industry: A pernicous problem persisits". PLoS Medicine. 9 (3): 1–5. doi:10.1371/journal.pmed.1001190. Retrieved November 28, 2012.
  60. ↑ Treatment and Research Advancements National Association for Personality Disorders (TARA-APD)
  61. ↑ "TARA Association for Personality Disorder". tara4bpd.org. Archived from the original on October 20, 2014. Retrieved January 29, 2015.
  62. ↑ New, Antonia; Triebwasser Joseph; Charney Dennis (October 2008). "The case for shifting borderline personality disorder to Axis I" (PDF). Biol. Psychiatry. 64 (8): 653–9. doi:10.1016/j.biopsych.2008.04.020. Retrieved May 8, 2013.
  63. ↑ American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders (Fifth ed.). Arlington, VA: American Psychiatric Publishing. pp. 663–6. ISBN 978-0-89042-555-8.
  64. ↑ British Psychological Society Response, June 2011
  65. ↑ "Director's Biography". National Institute of Mental Health. Retrieved May 22, 2013.
  66. ↑ Insel, Thomas. "Transforming Diagnosis". National Institute of Mental Health. Retrieved May 23, 2013.
  67. ↑ "NIMH Research Domain Criteria (RDoC) (Draft 3.1)". National Institute of Mental Health. June 2011. Retrieved May 26, 2013.
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    "Mental Health Researchers Reject Psychiatry's New Diagnostic 'Bible'". Time. May 7, 2013. Retrieved May 23, 2013.
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  73. 1 2 "DSM-5 and RDoC: Shared Interests". National Institute of Mental Health and American Psychiatric Association. Retrieved May 23, 2013.
  74. ↑ Aragona M. (2014) Epistemological reflections about the crisis of the DSM-5 and the revolutionary potential of the RDoC project Dialogues in Philosophy, Mental and Neuro Sciences 7: 11-20

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