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International Journal of Clinical and Health Psychology (2014) 14, 221---231

International Journalof Clinical and Health Psychology

www.elsevier.es/ijchp

THEORETICAL STUDY

From DSM-IV-TR to DSM-5: Analysis of some changes

Juan Francisco Rodríguez-Testala,∗, Cristina Senín-Calderónb, Salvador Perona-Garcelána

a Universidad de Sevilla, Spainb Universidad de Cádiz, Spain

Received 22 May 2014; accepted 10 June 2014Available online 9 July 2014

KEYWORDSDiagnosis;Classification;DSM-5;DSM-IV-TR;Theoretical study

Abstract The publication of the fifth edition of the DSM has intensified a debate begun sometime agowith the announcement of the changes in diagnostic criteria proposed by the APA. Thisarticle analyzes some of these modifications. Some interesting points where it is right, such asthe inclusion of dimensionality in both diagnostic classes and in some disorders, the inclusion ofan obsessive-compulsive spectrum, and the disappearance of subtypes of schizophrenia. It alsoanalyzes other more controversial points, such as the consideration of the attenuated psychosissyndrome, the description of a persistent depressive disorder, reorganization of the classicsomatoform disorders as somatic symptom disorders, or maintenance of three large clusters ofpersonality disorders, always unsatisfactory, along with an announced, but marginal, suggestionof the dimensional perspective of personality impairments. The new DSM-5 classification opensmany questions about the diagnostic validity which it attempts to improve, this time taking anapproach nearer to neurology and genetics than to clinical psychology.© 2014 Asociación Espanola de Psicología Conductual. Published by Elsevier España, S.L. Allrights reserved.

PALABRAS CLAVEDiagnóstico;Clasificación;DSM-5;DSM-IV-TR;

Del DSM-IV-TR al DSM-5: análisis de algunos cambios

Resumen La publicación de la quinta edición del DSM ha avivado un debate iniciado tiempoatrás, desde el anuncio de los cambios en los criterios de diagnóstico propuestos por la APA.En este artículo se analizan algunas de estas modificaciones. Se plantean aspectos interesantes

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Estudio teórico y acertados, como la inclusión de la dimensionalidad tanto en las clases diagnósticas como enalgunos trastornos, la incorporación de un espectro obsesivo-compulsivo o la desaparición delos subtipos de esquizofrenia. También se analizan otros aspectos más controvertidos comola consideración del síndrome de psicosis atenuada, la descripción de un trastorno depre-sivo persistente, la reordenación en trastornos de síntomas somáticos los clásicos trastornossomatoformes, o el mantenimiento de los tres grandes grupos de trastornos de la personalidad,

∗ Corresponding author at: Department of Personality, Psychological Evaluation and Treatment, University of Seville, C/Camilo José Celas/n, 41018 Seville (Spain).

E-mail address: testal@us.es (J.F. Rodríguez-Testal).

http://dx.doi.org/10.1016/j.ijchp.2014.05.0021697-2600/© 2014 Asociación Espanola de Psicología Conductual. Published by Elsevier España, S.L. All rights reserved.

222 J. F. Rodríguez-Testal et al.

siempre insatisfactorios, junto con un planteamiento anunciado, pero marginal, de la perspec-tiva dimensional de las alteraciones de la personalidad. La nueva clasificación del DSM-5 abrenumerosos interrogantes acerca de la validez que se pretende mejorar en el diagnóstico, enesta ocasión, asumiendo un planteamiento más cercano a la neurología y la genética que a lapsicopatología clínica.© 2014 Asociación Espanola de Psicología Conductual. Publicado por Elsevier España, S.L. Todoslos derechos reservados.

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To judge by the success of its sales (Blashfield, Keeley,lanagan, & Miles, 2014), the publication of a new editionf the DSM has immediately become an event. This studys intended to analyze some aspects that the fifth editionf the DSM (American Psychiatric Association APA, 2013b)ontributes. It is materially impossible to consider all itsections, at the same time that it requires aneducationalffort for its explanation: disappearance of hypochondria orf concepts such as somatization, substance dependence,ppearance of spectra, new disorders, etc. Therefore, aelection has been made of what might be the most out-tanding from a clinical, psychopathological viewpoint.

The Manual’s presentation states its intention of improv-ng the validity of previous editions and of being based onesearch. However, the sources to which it alludes are fromeuroscience and genetics. Although the text considers psy-hological (and social) factors, it is not this type of researchhat structures the DSM-5. In fact, future contributions fromhe Research Domain Criteria (RDoC),the principles of whichre directed at understanding mental disorders as cerebralisorders, dysfunctions of brain circuitry evaluable by thenstruments of cognitive neuroscience, and of developinghe biological basis for symptoms,are proposed for inclusionInsel, 2013; Insel et al., 2010).

Needless to say, the DSM is not a psychopathology text,lthough, as it is a Manual that has to guide diagnosisstill clinical), treatment and research, it is quite relevanto underline the obvious: that the biologicist perspec-ive (Adam, 2013) conditions the subject of study. As aatter of fact, we could starttalking about a NeuroDSM,

iven the proliferation of the prefix: Neurodevelopmentalisorders, Neurocognitive disorders, or Functional neu-ological symptom disorder. This seems to minimize oriscard any contribution of psychological research from thetart.

In view of the evidence accumulated (Blashfield et al.,014), in addition to decreasing the unspecified categories,mong the DSM-5 goals were development of clusters andimensions of disorders. Dimensionality appears in someisorder spectra, in some disorders (scales for diagnos-ic criteria of intellectual disability, autism spectrum andchizophrenia), partially in others (domains are definedn neurocognitive disorders, but the structure is categor-cal), and in determining severity (not in all diagnoses).t is curious in this sense that inspite of following con-ributions from neuroscience and genetics, and althoughhe data matchmuch wider sets of disorders depending on

heir susceptibility and pathogenesis (Craddock & Owen,010; Cross-Disorder Group of the Psychiatric Genomicsonsortium, 2013), in reality the resulting clusters are much

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ore limited (e.g., schizophrenia spectrum, but separatedrom bipolar disorders and autism spectrum). And evenithin the schizophrenia spectrum, there would be no rea-

on (by genetic criteria) for distinguishing schizophreniformisorder from schizophrenia, and by the way, harmonizinghe DSM-5 with the ICD-10.

It is not a matter of forcing a choice between categor-cal and dimensional. As Wakefield and First (2013) pointut, numerous dimensional variables end up generating aoint of inflection (points of rarity) based on which cate-ories are established. Perhaps the most difficult thing toccept is that mental disorders (or that all of them) are nat-ral classes by definition. But it is deficient in that decisionsre made in favor of some dimensions and not others whichre also backed by research (e.g., related to personality),r that do not develop one of the crucial dimensions, thene establishing the level of distress (Sandín, 2013).

One of the questions that remain under discussion abouthe diagnostic classifications and their lack of validity haso do with the definition of mental disorder itself. Althoughe are not going to concentrate our analysis on this point,

t is advisable to remember that to a large extent, diagnos-ic decisions do not depend so much on specific symptomsNone pathognomonic) (Malhi, 2013), and do on clinicallyignificant distress and impairment in areas of functioning.o the doubt arises of whether what makes a person suf-er is a mental disorder (this is where the issue relatedo bereavement arises), or whether it is a matter of pro-esses and variations not coinciding with social demands andersonal opportunities (e.g., Circadian rhythm sleep-wakeisorders) (Wakefield, 2013). In this sense, the need of find-ng the precise point at which distress and significant clinicaleterioration become unmanageable or disabling (Bolton,013) has been noted. Therefore, the new edition of theSM has lost a perfect occasion for an indispensable dimen-ion.

A first analysis of this work shows that the number ofeneral diagnostic classes of mental disorders has increasedo 21, when in the DSM-IV there were 16 (excluding thehapter on Other conditions that may be a focus of clinicalttention). This increase in diagnostic classes seems rightn some cases of disorders that have little to do with eachther (e.g., paraphilic disorder and sexual dysfunctions) orn cases like the Obsessive-compulsive disorder and relatedisorders, takenout of the Anxiety disorders.

Apart from this, an apparently minor question like theumber of diagnoses in each DSM edition mismatch in dif-

erent analyses (Blashfield et al., 2014; Mayes & Horwitz,005; Sandín, 2013; Spitzer, 2001), as it depends on whatategories are included: with description and criteria, forms

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From DSM-IV-TR to DSM-5: Analysis of some changes

with another specification or unspecified, with diagnosticcodes, with specification of severity, etc. In any case, to thecontrary of what is often published, the number of diagnoses(with criteria) is slightly lower.

The new DSM diagnostic classification proposes a schemeof diagnostic classes placed by affinity of their character-istics, and with evolutionary criteria, from manifestationsthat seem to originate in neurodevelopment to neurocog-nitive disorders. In each class, the diagnostics follow achronological criterion: whetherthey appear in childhoodand adolescence or in adulthood. Some of the major DSM-5diagnostic classes are analyzed below.

Neurodevelopmental disorders

It should be emphasized that of the neurodevelopmental dis-orders, the mental retardation concept must be replacedby Intellectual disability (intellectual development disor-der). Apart from eluding the derogatory sense of the firstterm, the concept is much more in agreement with WHOclassifications (such as the International Classification ofFunctioning, Disability and Health) (APA, 2013c).Includedin Communication disorders are Language disorder, Speechsound disorder, Childhood-onset fluency disorder (stutter-ing), and Social (pragmatic) communication disorder (andbeing able to distinguish it as such from the autism spec-trum).

The Autism spectrum disorder is a reclustering of DSM-IV-TR manifestations headed by the concept of Pervasivedevelopmental disorders: Autistic disorder (autism), Rett’sdisorder, childhood disintegrative disorder, Asperger’s dis-order, and pervasive developmental disorder not otherwisespecified. Two major domains are indicated for diagnosis(formerly divided into three): Social communication andsocial interaction, and restricted, repetitive patterns ofbehavior, interests, or activities. The genetic risk study hasnot enabledcategories to be discriminated (King, Navot,Bernier, & Webb, 2014), and it has been suggested that thenew classification gains in specificity but not in sensitivity(Volkmar & McPartland, 2014).

With respect to Attention-Deficit/Hyperactivity Disorder(ADHD), it has been questioned whether the DSM-5 maintainsthe same systematic indicators without improving precisionof the disability (reduces the number of symptoms neces-sary in adults), which it is suspected will increase falsepositives (Frances, 2010). In fact, in Criteria B and C, thepresence of impairment or distress is unnecessary and onlyCriterion D alludes to them generically, so overdiagnosisispossible (Epstein & Loren, 2013). Furthermore, the neu-roimaging study does not make it clear whether what isobserved is rather extremes of normality (Shah & Morton,2013).

While there are no relevant changes in the categorythat clusters Specific learning disorders (reading, writtenexpression and mathematics disorders), several disordersthat were scattered in the DSM-IV-TR, such as motor dis-orders, have beenreclustered: Developmental coordinationdisorder, stereotypic movement disorder, and the variouscategories referring to tic disorders (mainly Tourette’s dis-

order, persistent (chronic) motor or vocal tic disorder,temporary tic disorder).

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chizophrenia spectrum and other psychoticisorders

his chapter concentrates a series of relevant changes. Onne hand, research has shown a more uniform view of thisiagnostic class, qualifying it in this sense as a spectrumGarety & Freeman, 2013), including Schizotypal personalityisorder.

In schizophrenia, as already claimed, diagnostic sub-ypes (catatonic, disorganized, paranoid, undifferentiatednd residual types) had to be eliminated due to limitediagnostic stability, low reliability, and poor validity (APA,013c). The relevance given in diagnostic criteria to Schnei-erian first-rank symptoms and the consideration of bizarreelusions, traditionally linked to schizophrenia, has dis-ppeared, thereby gaining in specificity (Keshavan, 2013).here are no changes in the consideration of the minimumf indicators for Criterion A (at least two symptoms), but it ismphasized that at least one has to be a positive symptom:allucinations, delusions, and/or disorganized speech.

On the other hand, dimensions are included in the diag-osis (Barch et al., 2013). In the previous version of the DSM,

proposal was made concentrating on the three dimensionallusters of symptoms: psychotic (hallucinations/delusions),isorganized, and negative (deficit) dimensions. The ideahen was to improve precision in identifying schizophreniaubtypes. The current proposal concentrates on symptomimensions for reporters (or the patient himself), and aboutymptom severity (Likert-type scale from 0-4) (APA, 2013a)other scales may be found in the official APA website). Aeparate mention should be made of the scale directed athe patient or informant, since of the two questions aboutsychotic symptoms, the one that has to do with delusionslludes to manifestations typical of Schneider’s first rankymptoms. If, as mentioned, these symptoms are unspecific,nd no instrument is dedicated exclusively to schizophreniaut to psychosis in general, there are doubts that it woulde a useful tool.

In schizoaffective disorder, mood is made preponderantver disorder duration (including prodromes and resid-al phase), complying with Criterion A for schizophrenia.lthough it is pointed out that it would gain in reliability, itiminishes the frequency of its diagnosis (Malaspina et al.,013). What would have to be asked is whether the diagnosisf schizophrenia will then increase.

Concerning delusional disorder, one outstanding pointtems from the possibility of including bizarre contentn delusions (a specification). This question is on targetonsidering the set of symptoms that accompanies suchhought content, especially if there is no deteriorationn functioning, nor any disorganized or bizarre behavior.ut it is contradictory if the reasons given for exclusionf bizarreness in the case of delusions are considered inchizophrenia. It would be sufficient to mention this possi-ility for both diagnoses, or else, indicate it in the detailedescription of this manifestation and not as a specification.

It is also foreseeable that the diagnosis of delusional dis-

ty can be identified without requiring a double diagnosis (asn the DSM-IV-TR).

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24

One of the most noteworthy inclusions in the DSM-5 Man-al is the separation of catatonia from the specifications ofther disorders. It is clarified that this is not an independentiagnostic class (p. 119), but it is given a privileged position,s it is identified as a specifier with the codes and sectionf a separate disorder. We do not know whether this reloca-ion responds to its presence being as high as stated (10%)Sienaert, Dhossche, & Gazdag, 2013), the definitive delim-tation of its etiology (and stimulus for development of newrugs), or because better diagnostic precision is requiredTandon et al., 2013).

Shared psychotic disorder loses its classic name of Folie deux and is relocated as the latest form of the residualategory of Other specified schizophrenia spectrum and psy-hotic disorders, with the label ‘‘Delusional Symptoms in theartner of an individual with a delusional disorder’’. Apartrom the term applied to this disorder not being very opera-ive (think of the clinician making his report), and althought must be acknowledged that it is not a frequent diagnosis,t remains limited to cases in which the origin comes fromersons with a delusional disorder.

Attenuated psychosis syndrome has been the subjectf enormous controversy. It is cursorily placed within theide category of Other specified schizophrenia spectrumnd psychotic disorders. The arguments that support thisoncentrate on its diagnosis being situated in the contextf asking for help. Most of these persons show identifiableymptomology of anxiety, depression or substance abuse.he fact that help is requested for these symptoms justi-es their being treated symptomatically and thereby avoidshese persons confronting the more traumatic diagnosis ofchizophrenia (Tsuang et al., 2013).

The heart of the issue with respect to this new diagnosticategory is that it means increasing the number of diagnosesade without absolute certainty of what the consequencesay be (e.g., stigma), but above all, because there is no cer-

ainty that antipsychotics will prevent the development ofsychosis, although there is that atypical neuroleptics favoreight gain (Frances, 2010).

Emphasis has been placed on the significant probabil-ty of transition to psychosis (from 9 to 33%, depending onriteria and time lapse) based on the identification of ‘‘high-isk mental states’’ (high-risk or ultra-high-risk criteria):ttenuated psychotic symptoms; brief limited intermittentsychotic symptoms, and trait-state risk factors (Schultze-utter, Schimmelmann, Ruhrmann, & Michel, 2013). It haslso been highlighted that in some initiatives the presencef suicide has been reduced, although there is no provenoncrete treatment (Carpenter & van Os, 2011).

From all of the above, it is understood that a generalisk syndrome should rather be discussed (McGorry, 2010),ne of the possibilities of which is psychosis (in particular,chizophrenia) but not the only one (Fusar-Poli, Carpenter,oods, & McGlashan, 2014; Fusar-Poli, Yung, McGorry, &

an Os, 2014; Van Os, 2013). So it is a premature category,nd we think it is correctly included in proposals for furtheresearch.

ipolar and related disorders

his is proposed as a bipolar spectrum. Even though therere shared specifiers and episodes in bipolar and depressive

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isorders, in addition to much research data showing theroximity of the two diagnostic groups, they appear sepa-atelyin the DSM-5. In the DSM-IV-TR, they were both underhe wide Mood Disorders diagnostic class.

From the viewpoint of the description of hypomanicpisodes with respect to Cyclothymic disorder, it is sug-ested that numerous periods of hypomanic symptoms doot meet the criteria of a hypomanic episode (or depres-ive). This was not expressly stated in the DSM-IV-TR andesolves a contradiction present in bipolar disorders nottherwise specified (p. 401). Among thespecifiers given,he most novel are anxious distress, mixed features, mood-ongruent and incongruent psychotic features.

In the DSM-IV-TR, there was a mixed episode, applica-le exclusively to bipolar disorders. The importance of theixed symptoms specifier has to be seen in its historical

ontext (not exclusively bipolar). Classic mixed depressions observed in manifestations of early onset, with heavieramily history loading, and clearer diagnosis of Bipolar Dis-rder II than Major Depressive Disorder (Benazzi, 2007). Theraepelian idea is that recurrent depression is in reality inhe bipolar sphere, although the DSM-III set this proposalside when it included polarity (Ghaemi, 2013). Therefore,he mixed symptom specifier is a common area between twolasses, which from this perspective, should be together. Ifhis is coherent with this starting point, the error in theSM-5 is in considering that the symptoms of this specifierre euphoria, impulsive behavior and grandeur, when theyhould really be irritability or reactivity (Koukopoulos, Sani,Ghaemi, 2013).

One question that has been brought up is that anon-etspecifier, such as in the Persistent depressive disorder,s lacking. This is especially relevant, since about a thirdf the severest cases (more suicides, psychotic symptoms)egin before 18 years of age with wide comorbidity (Colom

Vieta, 2009).

epressive disorders

ne of the outstanding changes in this class of disorders ishe incorporation of the specifier ‘‘with anxious distress’’,hich is a clear acknowledgment of the anxio-depressivemotional combination (and perhaps makes up for the defini-ive withdrawal of the mixed anxiety depressive disorder,hich in the DSM-IV-TR was under unspecified anxiety disor-ers).

Disruptive mood dysregulation disorder is described toimit overdiagnosis and treatment of bipolar disorder inhildren. Severe, non-episodic irritability is the organizingore compared to typically bipolar euphoria and grandios-ty (and also brevity and recurrence; Axelson et al., 2011;owbin, Axelson, Leibenluft, & Birmaher, 2013). This chronicrritability often overlaps with ADHD, and up to 85% withppositional defiant disorder (in which temper outbursts areescribed, but the opposite is much less coincident (Axelsont al., 2011).It is also suggested that this disorder mayeally be an acute version of Oppositional defiant disorder

Dougherty et al., 2014) (in Disruptive, impulse-control, andonduct disorders).

In the classic category of Major depressive disorderMDD), the differentiation between the single and recurrent

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From DSM-IV-TR to DSM-5: Analysis of some changes

episode disappears. It is based on the premise that bothmanifestations were etiologically different, with differentvulnerabilities, although all the recurrent forms are not nec-essarily chronic. Priority is given to course, so chronic formsof MDD (over two years of continuous symptomatology) andDysthymic disorder (DD) are integrated in the new Persis-tent depressive disorder (Dysthymia) (PDD). Regardless ofits already having been known that most of those who metthe diagnostic criteria for DD were also diagnosed with dou-ble depression (MDD plus DD), this reorganization brings upseveral problems. On one hand, MDD then becomes a pro-visional diagnosis (depending on whether the symptomologybecomes chronic or not), and in fact, Criterion D does notexclude PDD. It is in the specification where it indicateswhether to treat dysthymia (pure dysthymic syndrome), apersistent major depressive episode, or two intermittenttypes depending on whether the major depressive episodeis present at the time of assessment.

On the other hand, DD showed favorable coursein theDSM-IV-TR in up to 50% of cases (even if it was doubledepression), so very heterogeneous conditions have beenassembled under the sign of the PDD which impedes its study(Rhebergen & Graham, 2014). To summarize, the formerconcept of dysthymia has little time left (which is why itappears in parentheses), and the point on which this newdisorder turns is the chronicity of the depressive manifesta-tion, which is why all the specifiers available, most of whichare inapplicable to pure dysthymic syndrome, are added. Sodo we then definitely reject study of depressive personality,the origin of DD?

Premenstrual dysphoric disorder already widens the firstline of mental disorders (in the DSM-IV-TR, it was amongthe unspecified forms and research criteria). Argumentshave been made against its inclusion, in the sense that itwill point to and harm women and that it is a manifes-tation fabricated by pharmaceutical companies (Hartlage,Breaux, & Yonkers, 2014). What is true is that researchhas not been sufficiently conclusive, that overvaluing ofmany indicators is favored (Gómez-Márquez, García-García,Benítez-Hernández, Bernal-Escobar, & Rodríguez-Testal,2007), and that criteria that the symptoms appear in atleast two cycles, but not consecutive, will increase diagnosisunnecessarily.

One of the most debated questions refers to bereave-ment and possible risk of overdiagnosis in what has beencalled medicalization of bereavement (Frances, 2010). TheDSM-IV-TR was clear in excluding bereavement from majordepressive episode (Criterion E). There was a possibility thata diagnosis of MDD was indicated if the symptoms werelasting (persisting for longer than two months) and espe-cially, with aggravation of symptoms (e.g., suicidal ideationor marked psychomotor retardation) (APA, 2000; p. 741).More so, on page 373, it was suggested that MDD could takeplace starting with a severe psychosocial stressor, such asthe death of a loved one or divorce, which made bereave-ment equivalent to other stressors. Therefore, bereavementis not a disorder and is diagnosed when the symptomologyis severe and characteristic of MDD.

But the heart of the problem is that in major depressiveepisode the DSM-5 does not specify the exclusion of bereave-ment, which gives us to understand that the figures for MDDidentification will increase (Maj, 2013), when in reality, the

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ymptomology comes from a normal reaction of bereave-ent (and even though bereavement is expressly excluded

n the definition of a mental disorder, p. 20).In the DSM-5 section on conditions for further study, crite-

ia are given for a Persistent complex bereavement disorder.he essence of this proposal stems from suffering for theeath of someone with whom he or she had a close relation-hip, with presence of clinically significant symptomologyn more days than not, and which persists for at least 12onths in adults (and at least six months in children). Thereould therefore be some continuity from the DSM-IV-TR (in

he sense of dealing with a diagnosable condition), length-ning the time span (APA, 2013c). Some data suggest thatround 10% of bereavements would fit in the description of aisorder (violent deaths, or traumatic, such as the death of

child) (Bryant, 2013). The problem comes from the DSM-5riteria themselves: Reactive distress to the death, per-istent yearning/longing for the deceased, social/identityisruption, which break with the idea of the previous editionf the DSM and pose terms of doubtful diagnostic validityince they refer rather to a process of bereavement thatan be lengthy, but not pathological.

nxiety disorders

hildhood characteristics such as selective mutism or sep-ration anxiety disorder are studied in the diagnostic classelated to Anxiety disorders. In this one, it is clearly speci-ed by its possible presence in adults, although in reality theSM-IV-TR did not exclude its diagnosis (p. 123). Perhaps the

imitation of the previous edition is that it forced the onseto be before 18 years of age. Research shows that in somedults, onset is later (Bögels, Knappe, & Clark, 2013). In viewf this, transitions between the various Anxiety disorders tohich it can lead, as well as its relationship with Dependentersonality disorder, question the validity of this category.

In the case of Specific phobia, and given the changes thatnclude Illness anxiety disorder in another of the diagnosticlasses, it is very deficient in that there are no explanationsbout it, e.g., in differential diagnosis for classic nosopho-ia.

The classic concept of Social phobia will disappear inuture classifications due to the term used in the literature,ocial anxiety disorder, with the specification of whethert refers exclusively to performance anxiety (talking orddressing a group).

Panic disorder and agoraphobia remain in this classifica-ion as independent disorders. Although it is true that byoing this it is desired to acknowledge that the origin ofgoraphobia is not always panic, it is no less true that nowhere will be two frequent comorbid diagnoses.

In general terms, the role of panic attacks as a spec-fier, in reality an authentic subsyndrome present in allsychopathology, would have to be emphasized. It is nowimited to two forms: expected and unexpected (APA, 2013c)instead of unexpected, situationally bound (cued), and sit-ationally predisposed in the DSM-IV-TR).

Generally, indicating over six months of symptomologyo avoid overdiagnosis in Anxiety disorders may be an ade-uate measure. Precisely because of it, the role of Limitedymptom attacks (fewer than four indicators out of a total

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26

f 13) must be shown in the forms of anxiety with anotherpecification, and that seems to stabilize it as another riskyndrome.

bsessive-compulsive and related disorders

onsideration of manifestations about the concept ofbsession-compulsion may be acknowledged as true. It isound to a tradition that began in the nineteen-ninetiesHollander, 1998; Hollander, Kim, Braun, Simeon, & Zohar,009; Hollander & Rosen, 2000), and was suggested as apectrum that spans from the most compulsive to impul-ive.It includes,e.g., impulse-control disorders, addictions,ating disorders, and hypochondria (Abramowitz, McKay,

Taylor, 2007; Phillips et al., 2010). This diagnosticlass, half-way between anxiety and depressive disor-ers, is now made up of: Obsessive-compulsive disorderOCD), Body dysmorphic disorder (BDD), Hoarding disorderHD), Trichotillomania (which announces the following termroposal: hair-pulling disorder), Excoriation disorder (skin-icking), and so forth (e.g.,Obsessional jealousy).

The specification insight (good or fair insight, poornsight, and absent insight/delusional beliefs) is introducedor OCD, BDD and HD. In BDD in particular, it was observedhat there were few differences among cases with or with-ut delusions, and identical response to drugs, so it wasreferable to specify insight than give an additional diag-osis in the psychotic spectrum (Phillips, Hart, Simpson, &tein, 2014). The specification With muscle dysmorphia islso added for this disorder, and those who show objec-ive defects in appearance are placed in Other specifiedbsessive-compulsive and related disorders.

On the other hand, manifestations such as HD have beeniven backing (Mataix-Cols et al., 2010), and nevertheless, itlearly overlaps with Obsessive-compulsive personality dis-rder.The text points out that both diagnoses are possible,lthough HD is suggested for more severe cases. Therefore,nd like manifestations qualified as body-focused Repetitiveehavior disorder (nail-biting, lip-biting, or cheek chew-ng), these manifestations may not have sufficient entity andequire more research to determine whether they should beonsidered isolated disorders.

rauma and stressor-related disorders

or quite a long time it has been suggested that the clas-ic posttraumatic stress and adaptive anxiety disorders beeparated because of their different pathological mecha-isms. This class of disorders includes Disinhibited socialngagement disorder, Posttraumatic stress disorder (betterifferentiation of key symptoms of three to four indi-ators, especially for emotional response), Acute stressisorder (not only dissociative symptoms are emphasized),nd Adjustment disorders. Forms with another specificationre placed in persistent complex bereavement disorder.

issociative disorders

n this group we emphasize the inclusion of dissociativeugue as a specifier of Dissociative amnesia, and inclusion ofhe concept of possession among the criteria for Dissociative

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dentity disorder. Possession was already contemplated inhe DSM-IV-TR under the unspecified forms among versionsf the Dissociative trance disorder (Spiegel et al., 2013),ut here it is given an appropriate place in the definition ofissociated identity.

omatic symptom and related disorders

rofound transformations have been made in this chapter. Itould be said that the organizing principle has been changedrom somatization to the main reference of somatic symp-oms, whether medically explained or not. The idea is thatf it is medically unexplained, the patient’s experience iselegitimized (Dimsdale & Levenson, 2013), but the con-equences of considering anyone with at least one physicalllness asa mental disorder may not be the best idea (Frances

Nardo, 2013).Reclustering the Somatization disorder, Undifferentiated

omatoform disorder, and Pain disorder categories makesense because of the complexity of the criteria necessaryor the first diagnosis, and lassitude with respect to theecond, affecting validity of the diagnostic classification.owever, this clusteris described very ambiguously underhe name Somatic symptom disorder (SSD): At least oneomatic symptom that is distressing or results in significantisruption of daily life, with excessive thoughts, feelings, orehaviors related to the somatic symptoms, and causing dis-roportionate thoughts, high level of anxiety, or excessiveime devoted to these symptoms (p. 311). It is an impreciseefinition from including any somatic symptom to referringaguely to worry and anxiety.

Research has suggested that the total number of symp-oms is more relevant than whether they are unexplainedr not, which is related to disability and overuse of health-are services (Sharpe, 2013), even after having adjusted themotional variables and with extensive samples (Tomensont al., 2013). The importance of a larger number of indica-ors among the psychological symptoms supports the posturef the DSM-5 (Voigt et al., 2012; Wollburg, Voigt, Braukhaus,erzog, & Löwe, 2013). However, this also means that

poly presentation is more relevant than a monosymp-omatic one (it is unlikely that many symptoms respond to aeference illness) (Rief & Martin, 2014), and certain moreetailed processes could improve the diagnostic pattern:elective attention to bodily signals, dysfunctional cogni-ions as catastrophizing interpretations of bodily signals,ersistent attribution, excessive health-care use, avoidancend decreased activity, or functional impairment (Löwet al., 2008). No examples are given in the criteria, so it isasy to predict that diagnoses in this category will increase.

Another question that attracts attention is the expressention made in the differential diagnosis of SSD in which

t is stated that the presence of somatic symptoms is not suf-cient to make this diagnosis, because it excludes irritableowel syndrome or fibromyalgia (p. 314), and contradicto-ily, are later dealt with in Other conditions that may be

focus of clinical attention, such as manifestations with a

efined etiology. Some authors, even in characterizing SSD,ave suggested the presence of these disorders, as well ashronic fatigue syndrome or the forms of multiple chemicalensitivity (Rief & Martin, 2014).

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From DSM-IV-TR to DSM-5: Analysis of some changes

Although the difference between SSD and Illness anxietydisorder (IAD) concentrates on the presence or not of ill-nesses (Starcevic, 2013), there is some overlapping amongsymptoms of both entities, because of imprecision in cru-cial measurable behavioral and cognitive symptoms (e.g.,rumination) (Rief & Martin, 2014).

Another novelty of the DSM-5 is that many of the personsdiagnosed with classic hypochondria will now be identi-fied as SSD (APA, 2013b). The concept of hypochondriahas been withdrawn because in addition to being deroga-tory, it could condition the therapeutic relationship. Inthe concept of hypochondria there are two contents: thebelief in an unspecified disease (overvalued idea, even delu-sional), and fear of developing the disease (Noyes, Carney, &Langbehn, 2004). Research on IAD requires that what is con-sidered normal functioning be well defined, since presenceof hypochondria from 2-13% is recorded (Weck, Richtberg,& Neng, 2014) (5.72% life prevalence), far above 1%, andalthough it is true that classic hypochondria was infrequentand difficult to diagnose (Sunderland, Newby, & Andrews,2013), is it not like diagnosing overweight instead of obesity?In a medicalized society with strong concern for health, arewe not going to find an increase in persons who meet thediagnosis for IAD?

Medical emphasis is obvious in the Conversion disorder(Functional neurological symptom disorder), justified by alower percentage of cases in which a neurological etiol-ogy has been found. The question of whether to locateconversion among the dissociative manifestations (such asdissociative sensorimotor disorder (Spiegel et al., 2013) orin relation to somatic symptoms, where paralysis fits well,but seizures worse, goes way back.

Psychological factors affecting other medical conditionsis a controversial class. They wereconsidered separatelyfrom Axis I disorders as a complement to them in theDSM-IV-TR. Many subjects studied by health psychology arethus understood as a mental disorder, e.g., the relation-ship between chronic stress and hypertension or anxiety andasthma. Functional syndromes such as migraine, irritablebowel syndrome, fibromyalgia, or idiopathic medical symp-toms, such as pain, fatigue and dizziness are also locatedhere (already indicated in SSD, p. 311).

Finally, we believe it is appropriate to include Facti-tious disorder in this diagnostic class because it also usesthe body and illness as a vehicle for communicating dis-tress.

Feeding and eating disorders

This section includes Pica, Rumination disorder, andAvoidant/restrictive food intake disorder. The last needs tobe studied further to clarify its relationship with anorexia(may precede it) and conversion, given its link to conceptsof functional dysphagia and globushystericus (p. 319), or itsrelationship to anxiety (avoidance, frequent traumatic ori-gin, comorbidity).In fact, the same possibility of diagnosisis given in the description of phobias without explanation

in the differential. Furthermore, many of these expressionsmay be limited and not require intervention (Attia et al.,2013), so their usefulness is not seen, but risk of overdiag-nosis is.

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227

Adjustments have been made in Anorexia nervosa (e.g.,he requirement of amenorrhea has been withdrawn), andrequency of binges in Bulimia nervosa and Binge-eating dis-rder (they are equivalent: at least one binge per week forhree months or more) (Call, Walsh, & Attia, 2013). Sometudies concentrating on eating disorders with the new crite-ia back the modifications made (Stice, Marti, & Rohde,013), even a slight increase in binge eating (0.2% in mennd women) (Hudson, Coit, Lalonde, & Pope, 2012). It haseen proposed, however, that overvaluing shape and weighte included in this disorder, which would diminish its preva-ence (Grilo, 2013) and make the group more coherent. Itertainly seems strange that a description of a person whoinge eats, does not compensate for it, and feels ill, and iseither anorexia nor bulimia.

ubstance-related and addictive disorders

n this diagnostic class, the concept of dependence has beenithdrawn, because it is derogatory, and abuse because it

s not very reliable (it was sufficient for one indicator toe met) (Regier, Kuhl, & Kupfer, 2013). Research shows thatlthough the Substance use disorder has no natural thresh-ld, it agrees with the version in the DSM-IV-TR (Hasin et al.,013; Peer et al., 2013). Inclusion of the concept of cravingakes it possible to relate it to DSM and ICD classifications,

nd the set of changes made will differentiate compulsiveehavior in seeking a substance better (Obiols, 2012).

Diagnosis of Gambling disorder is transferred from thehapter on impulse-control disorders to the present diagno-is class (same brain reward system).Reference is made to aambling disorder (and not pathological gambling as redun-ant and stigmatizing), and Criterion 8 in the DSM-IV-TRillegal acts such as forgery, fraud, theft, etc.) disappears.iagnosis goes from at least five to ten indicators to at leastour to nine. It is suggested that although this modificationay increase prevalence (or else the DSM-IV-TR underesti-ated it), the agreement between the DSM-IV-TR and theSM-5 is over 99% (Petry, Blanco, Jin, & Grant, in press).

eurocognitive disorders

he incorporation of Minor neurocognitive disorders (mNCD)as awakened controversy. It should be recalled, however,hat it was already suggested in DSM-IV-TR, both in Appendix

(Criteria and axes provided for further study), and in theection on cognitive disorders not otherwise specified (mildeurocognitive disorder). Inclusion in the DSM-5 and its pre-entation along with Major neurocognitive disorder MNCDdue to Alzheimer’s disease, frontotemporal, with Lewy bod-es, etc.) is another example of continuation.

The problem is similar to the attenuated psychosis syn-rome described above, since it is oriented by data onransition rates, in this case toward dementia (from 6-10%er year in epidemiological studies, higher in clinical sam-les) (Petersen et al., 2009), and therefore, mNCD is takens a prodrome of dementias (mainly Alzheimer’s disease)

Gauthier et al., 2006). Other data show that heterogeneitys the norm and that transition indicators with participantsrom the community are much lower (3%) (Decarli, 2003;authier et al., 2006). Therefore, this incorporation in the

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28

SM-5 favors excessive medicalization (Frances, 2010) andonfusion between aging, cognitive deterioration associatedith aging, and the development of a neurodegenerativerocess. Research must find a way to make a precise dis-inction between decline and deterioration. But the mostuestionable, from a psychopathological viewpoint is that aNCD is identified without any functional impairment, with-

ut any interference in the activities of daily life (Criterion). In addition to its arguable validity for a diagnostic classi-cation of mental disorders, what personal, social and even

egal implications does this have?We do consider appropriate the domains proposed for

he study of NCD (Complex attention, executive function,earning and memory, expressive and receptive language,erceptual-motor, social cognition), adoption of a charac-eristic neuropsychological language (possible or probablellness), and integration of the classic amnesic disorder inCD.

ersonality disorders

he chapter on personality disorders (PD) is mentioned asn example of incorporation of dimensionality in the DSM-. However, this novelty has become a step taken withoutonviction, a sort of yes but no. On one hand, the previ-us categorical classification was not backed by researchneither disorders nor their clusters) (Livesley, 2011; Pull,014; Tyrer, Crawford, & Mulder, 2011), and nevertheless,heir basic criteria remain unchanged. On the other hand,he dimensional contribution appears in Section III of theanual (among the emerging measures and models), so

t is complementary and probably not secondary in thelinic.

This proposal fits the Big Five factor model (Krueger Markon, 2014), and the Manual includes a com-lete version, another summarized for adults, and oneor informants (APA, 2013d, 2013e, 2013f). It consistsf five domains: negative affectivity/emotional stability,etachment/extraversion, antagonism/agreeableness, dis-nhibition/conscientiousness, psychoticism/lucidity, and 25ersonality trait facets. However, some components ana-yzed do not show acceptable reliability (see in Krueger,erringer, Markon, Watson, & Skodol, 2012), and Widiger2011) criticizes the DSM-5 for developing an own dimen-ional system when others had already been established andonsolidated. The truth is that this discourages its use.

It has often been suggested that this perspective is tooomplicated for daily use by the clinician (First, 2011;yrer et al., 2011), and however, doctors often analyze theesults of a hemogram, for example, considering differentimensions and combinations. The psychometric tradition insychology and the model of the broad factors is sufficientlyolid to be able to understand and apply a model similar tohe one described.

Another of the criticisms refers to the Manual offeringharacterization of some specific PDs (antisocial, avoidant,orderline, narcissistic, obsessive-compulsive, and schizoty-

al disorders), but not others (they did not have sufficientacking). On the other hand, it is hardly mentioned thatn the case of Antisocial personality disorder, there is apecification of psychopathic symptoms (in addition to its

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efinition), which could contribute to making the differ-nces debated for so long about the antisocial personalityoncept more precise.

inal comments

he latest edition of the DSM was started before publica-ion of the TR revision of the DSM-IV. It has been a veryublicized, elaborate and long-awaited text (first as DSM-

and finally as DSM-5). Since then, criticisms have beenaried,some coincide with past editions (e.g., tendency toeification of disorders or presence of marketing by the phar-acology industry) (Obiols, 2012; Reed, Anaya, & Evans,

012); others have addressed poorly written text and lackf clarity in some criteria, plus the signs that will favor anncrease in diagnoses with its application: the requirementsor meeting some diagnoses are lowered, new disordersre incorporated, variants of normal behavior are included,mong other arguments (Frances, 2010; George & Regier,013).

Doubtless, what exactly a risk syndrome is and how ithould be approached will have to be well explained, sincet could derive in the same treatment being applied for aisorder as its risk factor, and that says little in favor ofntervention precision. At the same time, it would requiren education to discriminate and balance prevention andtigma, a labor that compromises the science, and socialgents. In this sense, mention has been made before of thettenuated psychosis syndrome (which in the end is proposedor later study) and the mNCD. But there are other exam-les: Suicidal behavior disorder and Nonsuicidal self-injuryre proposed for further study. The first case attracts atten-ion in that it is considered difficult to observe outside of theontext of other disorders (bipolar disorders, depressive,tc.) (p. 803). In the second case, it seems that the great-st emphasis is on differentiating it from the first (Butler

Malone, 2013), although nothing indicates specific treat-ents in this sense, or that it makes sense to separate it fromisorders such as borderline personality or posttraumatictress. In fact, much of the content of the DSM-5 does notesolvedoubts about whether the descriptions contained inhe DSM-5 are valid, or whether or not the Manual’s reliabil-ty has improved, so it is difficult to take this classifications a guideline for treatment (Timimi, 2014).

One of the decisions that we think has to do not onlyith its validity, but with the clinical usefulness of a diag-ostic system, is the elimination of the multiaxial systemn the DSM-5. Regardless of comorbidity between Axes Ind II, in the daily clinic, the information from differentontents is necessary. Although it is true that a disabilitycale is included (the WHO Disability Assessment Schedule,ocated in Appendix III), there is no express reference tots application in diagnosis. It has been suggested thathere are numerous specifiers present throughout thelassification that make up for this content (Harris, 2014),ut neither does it guarantee it nor is it the same. It islso true that, as in earlier editions, the content includes

ther conditions that may be a focus of clinical attentione.g., relational problems), of strong relevance along withverything else that makes up Axis IV and which shoulderve the clinician to contextualize a problem, and research

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From DSM-IV-TR to DSM-5: Analysis of some changes

on delimiting participating variables, but there is no clearpattern combining the information.

It could be said, as a closing point, that this version of theDSM does not make anybody happy. For some, because it isobvious that the approach goes in the direction of biologicalreductionism (which does not fit in with what affects humanbeings), while for others the DSM-5 stops short, as it wouldrequire a larger number of biological markers, physiologicalrisk factors and genetic results to determine mental illnesses(Kupfer & Regier, 2011).

Although we have not reviewed all the diagnostic classes,in some, there are details of interest (such as in Sexual dys-functions) and even among the proposals for further study(such as the Internet gaming disorder), we propose somepoints that should be taken into account for the upcomingelectronic version of the DSM (ver. 5.1, now being spokenof):

The validity of the diagnoses and their clusters needsmore in-depth study (perhaps decreasing and integratingcategories) and they need to be separated them from thevariants of behavior. Just as terms are changed becausethey are derogatory, alternatives for action that minimizethe stigma associated with diagnoses must also be studiedand generated (Kapur, Cooper, O’Connor, & Hawton, 2013).It is imperative to study and dimension distress, and relate itto the characteristics of the context to offer a more integralview of human suffering. If one of the goals of the DSM-5 wasalignment with the ICD-11 (Blashfield et al., 2014), it couldbe added that they should suggest integrative dimensionalforms (Harkness, Reynolds, & Lilienfeld, 2014) from otherspheres of knowledge.

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