World of Psychology
DSM-5 Released: The Big Changes
In the meantime, here is an overview of the big changes. We sat in on a conference call that the American Psychiatric Association (APA) had in order to introduce the new version of the diagnostic reference manual used primarily by clinicians in the U.S. to diagnose mental disorders. It is called the Diagnostic and Statistical Manual of Mental Disorders and is now in its fifth major revision (DSM-5).
James Scully, Jr., MD, CEO of the APA, kicked off the call by remarking that the DSM-5 will be a “critical guidebook for clinicians” — a theme echoed by the other speakers on the call.
Why has it taken on such a large “role [both] in society as well as medicine?” he asked. Dr. Scully believes it’s because of the prevalence of mental disorders in general, touching most people’s lives (or someone we know).
The APA has published three separate drafts of the manual on their website, and in doing so received over 13,000 comments from 2010 – 2012, as well as thousands of emails and letters. Every single comment was read and evaluated. This was an unprecedented scale of openness and transparency never before seen in the revision of a diagnostic manual.
“The manual is first and foremost a guidebook for clinicians,” reiterated David Kupfer, M.D., DSM-5 task force chair, who walked us through the major changes detailed below.
1. Three major sections of the DSM-5
I. Introduction and clear information on how to use the DSM.
II. Provides information and categorical diagnoses.
III. Section III provides self-assessment tools, as well as categories that require more research.
2. Section II – Disorders
Organization of chapters is designed to demonstrate how disorders are related to one another.
Throughout the entire manual, disorders are framed in age, gender, developmental characteristics.
Multi-axial system has been eliminated. “Removes artificial distinctions” between medical and mental disorders.
DSM-5 has approximately the same number of conditions as DSM-IV.
3. The Big Changes in Specific Disorders
Autism
There is now a single condition called autism spectrum disorder, which incorporates 4 previous separate disorders. As the APA states:
ASD now encompasses the previous DSM-IV autistic disorder (autism), Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified.ASD is characterized by 1) deficits in social communication and social interaction and 2) restricted repetitive behaviors, interests, and activities (RRBs). Because both components are required for diagnosis of ASD, social communication disorder is diagnosed if no RRBs are present.
Disruptive Mood Dysregulation Disorder
Childhood bipolar disorder has a new name — “intended to address issues of over-diagnosis and over-treatment of bipolar disorder in children.” This can be diagnosed in children up to age 18 years who exhibit persistent irritability and frequent episodes of extreme behavioral dyscontrol (e.g., they are out of control).
ADHD
Attention deficit hyperactivity disorder (ADHD) has been modified somewhat, especially to emphasize that this disorder can continue into adulthood. The one “big” change (if you can call it that) is that you can be diagnosed with ADHD as an adult if you meet one less symptom than if you are a child.
While that weakens the criteria marginally for adults, the criteria are also strengthened at the same time. For instance, the cross-situational requirement has been strengthened to “several” symptoms in each setting (you can’t be diagnosed with ADHD if it only happens in one setting, such as at work).
The criteria were also relaxed a bit as the symptoms now have to had appeared before age 12, instead of before age 7.
Bereavement Exclusion Removal
In the DSM-IV, if you were grieving the loss of a loved one, technically you couldn’t be diagnosed with major depression disorder in the first 2 months of your grief. (I’m not sure where this arbitrary 2 month figure came from, because it certainly reflects no reality or research.). This exclusion was removed in the DSM-5. Here are the reasons they gave:
The first is to remove the implication that bereavement typically lasts only 2 months when both physicians and grief counselors recognize that the duration is more commonly 1–2 years. Second, bereavement is recognized as a severe psychosocial stressor that can precipitate a major depressive episode in a vulnerable individual, generally beginning soon after the loss. When major depressive disorder occurs in the context of bereavement, it adds an additional risk for suffering, feelings of worthlessness, suicidal ideation, poorer somatic health, worse interpersonal and work functioning, and an increased risk for persistent complex bereavement disorder, which is now described with explicit criteria in Conditions for Further Study in DSM-5 Section III. Third, bereavement-related major depression is most likely to occur in individuals with past personal and family histories of major depressive episodes. It is genetically influenced and is associated with similar personality characteristics, patterns of comorbidity, and risks of chronicity and/or recurrence as non–bereavement-related major depressive episodes. Finally, the depressive symptoms associated with bereavement-related depression respond to the same psychosocial and medication treatments as non–bereavement-related depression. In the criteria for major depressive disorder, a detailed footnote has replaced the more simplistic DSM-IV exclusion to aid clinicians in making the critical distinction between the symptoms characteristic of bereavement and those of a major depressive episode.
PTSD
More attention is now paid to behavioral symptoms that accompany PTSD in the DSM-5. It now includes four primary major symptom clusters:
- Reexperiencing
- Arousal
- Avoidance
- Persistent negative alterations in cognitions and mood
“Posttraumatic stress disorder is now developmentally sensitive in that diagnostic thresholds have been lowered for children and adolescents. Furthermore, separate criteria have been added for children age 6 years or younger with this disorder.”
Major and Mild Neurocognitive Disorder
Major Neurocognitive Disorder now subsumes dementia and the amenstic disorder.
But a new disorder, Mild Neurocognitive Disorder, was also added. “There was concern we may have added a disorder that wasn’t ‘important’ enough.”
“The impact of the decline was noticeable, but clinicians lacked a diagnosis to give patients,” noted Dr. Kupfer. There were two reasons for this change: “(1) Opportunity for early detection. The earlier the better for patients with these symptoms. (2) It also encourages an early effective treatment plan, ” before dementia sets in.
Other New & Notable Disorders
Both binge eating disorder and premenstrual dysphoric disorder and now official, “real” diagnoses in the DSM-5 (they were not prior to this, although still commonly diagnosed by clinicians). Hoarding disorder is also now recognized as a real disorder, separate from OCD, “which reflects persistent difficulty dis-carding or parting with possessions due to a perceived need to save the items and distress associated with discarding them. Hoarding disorder may have unique neurobiological correlates, is associated with significant impairment, and may respond to clinical intervention.”
Jeffrey Lieberman, MD, President-Elect of the APA reminded us that the DSM-5 is not a pop-psychology book intended for consumers: “[It is] a guide, an aide to assist clinicians to … help facilitate treatment.”
The APA also noted that a large number of sessions — 21 — will be dedicated to the DSM-5 this weekend at the APA’s annual meeting.
Commenting on the swirling controversy regarding the DSM-5, that perhaps the diagnostic system isn’t good enough, Dr. Lieberman said, “It can’t create the knowledge, it reflects the current state of our knowledge.”
“We can’t keep waiting for such breakthroughs,” (in reference to biomarkers and laboratory tests). “Clinicians and patients need the DSM-5 now.
“How it’s applied reflects critical practice… it’s not necessarily because of the criteria [themselves]. It’s because of the way the criteria are applied.”
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