Notes on the DSM-5 Changes

Back in 1999, research priorities for the development of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) were set at a conference sponsored jointly by the American Psychiatric Association (APA) and the National Institute of Mental Health (NIMH).  After more than a dozen tumultuous years, the APA Board of Trustees approved the final diagnostic criteria for the DSM-5.

Since the announcement, the community has been abuzz with forecasts of disaster from critics along with accolades from supporters and wishes for better things to come. Although some had hoped for major changes from the DSM-IV, David J. Kupfer, MD, Chair of the DSM-5 Task Force stated: “We have sought to be very conservative in our approach to revising.”  That restraint may prove to be a wise decision, because with so many other changes taking place in the world of behavioral healthcare and healthcare in general, the effects of these will already be felt profoundly by the more than 300,000 mental health professionals who use the Diagnostic and Statistical Manual to make decisions every year.  Here is a partial summary of the changes:

• The 20 chapters of the DSM will be restructured based on the apparent relation of disorders to one another, as reflected by similarities in the disorders’ underlying vulnerabilities and symptom characteristics.
• The DSM-5 will move to a nonaxial documentation of diagnosis, combining the former Axes I, II, and III, with separate notations for psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V).
• One of the more controversial changes is the reshuffling and renaming of Autistic Disorder to include the diagnostic labels of “Autistic Disorder,” “Asperger’s Disorder,” and “PDD-NOS” under one umbrella term: Autism Spectrum Disorder.
• Binge Eating Disorder will be moved from the DSM-IV’s Appendix B: Criteria Sets and Axes Provided for Further Study to the DSM-5’s Section 2—formal recognition of Binge Eating Disorder as a mental disorder.
• Another oft-discussed change is that Disruptive Mood Dysregulation Disorder will be included in the DSM-5 to diagnose children who exhibit persistent irritability and frequent episodes of behavior outbursts three or more times a week for more than a year. The change addresses a belief that there is the potential over-diagnosis and overtreatment of Bipolar Disorder in children. Time will tell if this changes diagnostic practices.
• Excoriation (skin-picking) Disorder is new to the DSM-5, and will be included in the Obsessive-Compulsive and Related Disorders chapter.
• Hoarding Disorder has been added as a discrete disorder, removing it from OCD.
• Pedophilic Disorder criteria will remain unchanged from DSM-IV, but the disorder name will be revised from pedophilia to pedophilic disorder.
• DSM-5 will maintain the categorical model and criteria for the 10 personality disorders included in DSM-IV and will include the new trait-specific methodology in a separate area of Section 3
• PTSD will be included in a new chapter in DSM-5 on Trauma- and Stressor-Related Disorders. DSM-5 will pay more attention to the behavioral symptoms that accompany PTSD and includes  four distinct diagnostic clusters
• The bereavement exclusion criterion in DSM-IV applied to people experiencing depressive symptoms lasting less than two months following the death of a loved one has been removed and replaced by notes to help differentiate grief and depression.
• Specific learning disorder has an expanded criterion to represent distinct disorders which interfere with the acquisition of academic skills.
• Substance abuse and substance dependence will be combined into one overarching disorder; Substance Use Disorder.  The criteria have also been strengthened.

The DSM-5 will be published in Spring 2013. A complete list of approved changes to date can be downloaded from the American Psychiatric Association website here.