The DSM-5: Overview of Main Themes and Diagnostic Revisions

James Tobin, Ph.D. | November 2, 2013

Presented at the Symposium on DSM-5 Sponsored by OCPA and the American School of Professional Psychology/Argosy University

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Abstract

•DSM-5 represents the field’s most recent attempt at revising the DSM-IV-TR diagnostic nomenclature. In this presentation, I will outline the primary efforts of the DSM-5 Task Force and the major diagnostic changes that were incorporated in the new manual, with an emphasis on the disorders of adulthood.

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Abstract

•The most promising changes are the organization of mental illness as a spectrum, the addition of dimensionality to specifier descriptions, lifespan/development and cultural refinements, and the articulation of a new hybrid model of mental illness.

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Abstract

•In the context of these gains, I also will provide a summary of the major controversies surrounding the DSM-5, including misgivings about lower thresholds to qualify for numerous diagnoses and the related concern that we may now run the risk of pathologizing “normal” human functioning.

Part I. Introduction

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Acknowledgements

•Zur Institute (2013). DSM-5 – friend or foe? A comprehensive breakdown of changes and controversies. CE Online Course. Retrieved from http://www.zurinstitute.com/dsm5course.html.

•Nevid, J. (2013, April 4). Getting ready for DSM-5. Retrieved from http://www.youtube.com/watch?v=3akfbnmhOM8.

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Acknowledgements

•Dingle, A. (2013, July 30). The new DSM-5. Retrieved from http://www.youtube.com/watch?v=C9pru53UcbA.

•American Psychiatric Publishing (2013): Fact sheet: Highlights of changes from DSM-IV-TR to DSM-5. Retrieved from http://www.psychiatry.org/practice/dsm/dsm5.

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DSM-IV, -IV-TR, and -5 Publication Dates and Page Lengths

•DSM-IV-TR: First issued in 1994 (968 pages).

•DSM-IV-TR: Revised in 2000 (988 pages).

•DSM-5:Update initiated in 1999 and finally published on May 17, 2013 (947 pages).

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DSM-5: Sections of the Manual

•Section I: Introduction and information on how to use the manual.

•Section II: Diagnostic criteria and codes.•Section III: Emerging measures and

models, conditions that require further research, a glossary, cultural concepts of distress, and names of persons involved in the manual’s development.

•Appendix.

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How Was the DSM-5 Developed?

•APA organized groups of experts in distinct areas to assess diagnostic categories and disorders;

•Came up with consensus viewpoints on symptomatic descriptors;

•Field-tested new descriptors to determine revised diagnostic criteria (cluster sets and thresholds).

•Presented to APA Board Trustees for sign-off.

Part II. Primary Goals of DSM-5 and 10 Major Changes

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Primary Goals of DSM-5 Task Force in Creating the New Manual •Increase cultural sensitivity;•Deepen the clinician’s understanding of

the client;•Increase awareness of the neurobiology

underpinning mental disorders;•Appraise the role of social and contextual

factors associated with psychiatric symptoms.

From Zur Institute (2013)

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Change #1. Make More User-Friendly

•The multiaxial system has been abandoned.

•Axes I, II, and III have been combined.•All clinical disorders are simply listed in

order of priority (no real hierarchy of axes implied).

•No more GAF (people tended to use very idiosyncratically, and did not follow the symptom severity x impairment rating codes).

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Change #2. Incorporate a Spectrum Perspective

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Change #2. Incorporate a Spectrum Perspective•Based on two emerging realizations in the

field (Zur Institute, 2013):(1) There is not much evidence that disorders are actually categorically distinct from one another (both

within and across diagnostic categories).

(2) The distinction between “normal” and “abnormal” behavior is, ultimately, arbitrary.

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Change #2. Incorporate a Spectrum Perspective•Example: OCD is removed from the

“Anxiety Disorders” category (DSM-IV-TR) and repositioned in a new category called “Obsessive-Compulsive and Related Disorders” (DSM-5).

• The beam of light going into the prism (underlying core factor of anxiety)splits into several separate but related diagnostic categories.

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Change #2. Incorporate a Spectrum Perspective•The 20 newly-refined diagnostic categories

of mental disorders depict updated groupings of all disorders, with each grouping sharing similar characteristics.

•Has resulted in a fair amount of reshuffling of the deck, e.g., “Neurodevelopmental Disorders” (includes Autism Spectrum Disorder, ADHD, and other disorders reflecting abnormal brain development).

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Change #3. Incorporate Dimensionality

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Change #3. Incorporate Dimensionality •Diagnostic thresholds

(categorical/qualitative) are now supplemented by the degree to which the diagnosis is present (dimensional/quantitative).

•Severity ratings (from minimal to more extreme levels): typically, symptom counts.

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Change #4. Reflect a Developmental Perspective• (1) Chapter structure of DSM-5 follows a

neurodevelopmental life span approach (congruent with the system used by the ICD [World Health Organization]):

Early development: Neurodevelopmental Disorders; Schizophrenia Spectrum and Other Psychotic Disorders; etc.

Adolescence/early adulthood:Depressive Disorders; Anxiety Disorders; etc.

Later life: Neurocognitive Disorders.

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Change #4. Reflect a Developmental Perspective

(2) For specific disorders, variations of symptom presentations across the lifespan are described.

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Change #5. Increase the Emphasis on Culture and Gender•Cultural information and gender differences

are included wherever relevant.•Previous cultural formulation replaced with

the Cultural Formulation Interview (CFI; pp. 750-757), a structured clinical interview that assesses the client’s subjective view of cultural factors re: the presentation of symptoms (effort is to diminish the clinician’s own cultural biases).

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Change #6. Enhance Descriptive Information for Diagnoses•Many specifiers provided. •Severity ratings provided. •Not Otherwise Specified (NOS) deleted,

but here is what they came up with instead: if not meet full criteria for the disorder use “Other Specified” (need to give a reason) or “Unspecified Disorder” (don’t need to give a reason).

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Change #7. Match the International Classification of Diseases (ICD) Codes

•DSM-5 includes equivalent ICD-9 and ICD-10 codes.

•The U.S. will adopt the ICD-10 in October, 2014; however, by that time, most of the world will already be using ICD-11.

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Change #8. Reinvent DSM To Be a “Living” Document•DSM-5 (Arabic numeral) vs. DSM-IV-TR

(Roman numeral).

•More readily incorporate advances generated by new research, neuroscience, and investigations re: the genetics of psychiatric illness.

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Change #9. Introduce the Potential of the So-called “Hybrid” Model in Subsequent DSMs

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Change #9. Introduce the Potential of the So-called “Hybrid” Model • The Personality Disorders (PDs) essentially remain

the same in DSM-5 as in DSM-IV-TR. • However, in Section III of DSM-5 they introduce a

hybrid (category and dimensional synthesized) model of PDs:

Level of impairment of personality functioning (dimensional) with ....

An evaluation of personality traits (categorical)

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Change #9. Introduce the Potential of the So-called “Hybrid” Model •Five broad domains of personality traits:

(1) Negative Affectivity(2) Detachment(3) Antagonism(4) Disinhibition(5) Psychoticism

•As a field, we are moving closer to defining what the core elementsof psychiatric health/personality actually are.

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Change #10. Use Biologically-based Diagnostic Criteria•For some disorders, DSM-5 employs

objective measures (genetic work-ups, neuroimaging, neurochemistry) into the criteria sets.

•David Kupfer, M.D., the co-chair of the DSM-5 Task Force, indicated a keen interest in genetic tests/brain scanning/biomarkers/laboratory tests, but admitted that the field is not quite there yet.

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Part III. A Select Review of Revised Diagnostic Categories and Disorders in DSM-5

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“Neurodevelopmental Disorders”

•Intellectual Disabilities •Communication Disorders•Autism Spectrum Disorder•Attention-Deficit/Hyperactivity Disorder•Specific Learning Disorder •Motor Disorders •Other Neurodevelopmental Disorders

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“Neurodevelopmental Disorders”: ShiftsDisorder Name Used To Be In (DSM-IV-

TR)Now In (DSM-5):

Separation Anxiety “Disorders Usually First Diagnosed in Infancy, Childhood and Adolescence”

“Anxiety Disorders”

Selective Mutism “Disorders Usually First Diagnosed in Infancy, Childhood and Adolescence”

“Anxiety Disorders”

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“Schizophrenia Spectrum and Other Psychotic Disorders”• Schizotypal (Personality) Disorder• Delusional Disorder• Brief Psychotic Disorder• Schizophreniform Disorder• Schizophrenia• Schizoaffective Disorder • Substance/Medication-Induced Psychotic Disorder• Psychotic Disorder Due to Another Medical

Condition • Catatonia • Other/Unspecified

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“Schizophrenia Spectrum and Other Psychotic Disorders”: Shifts Disorder Name Used To Be In

(DSM-IV-TR)Now In (DSM-5)

Schizotypal (Personality) Disorder

Axis II Personality Disorders

“Schizophrenia Spectrum and Other Psychotic Disorders” and “Personality Disorders”

Schizophrenia Subtypes include Paranoid, Disorganized, Catatonic, Undifferentiated, and Residual

Subtypes removed

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“Schizophrenia Spectrum and Other Psychotic Disorders”: Criteria/Notes

• Delusions, hallucinations, disordered thinking (speech), and grossly disorganized or abnormal motor behavior (including catatonia) maintained.

• DSM-5 minimizes importance of negative symptoms; emphasis is more on positive symptoms.

• Can now specify severity (how many symptoms the person has): see dimensional rating scale “Clinician-Rated Dimensions of Psychosis Symptom Severity” in Section III of the DSM-5 Manual (pp. 742-744).

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“Bipolar and Related Disorders”

•Bipolar I Disorder•Bipolar II Disorder•Cyclothymic Disorder•Substance/Medication-Induced Bipolar

and Related Disorder•Bipolar and Related Disorder Due to

Another Medical Condition •Other and Unspecified

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“Bipolar and Related Disorders”: Shifts

•Depressive Disorders and Bipolar Disorders no longer listed under the umbrella category of “Mood Disorders” (as was the case in DSM-IV-TR).

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“Bipolar and Related Disorders”: Criteria/Notes

•The primary criteria for manic and hypomanic episodes now include an emphasis on changes in activity and energy as well as mood.

•More specifiers added (p. 127):

e.g., “With anxious distress”: capture anxiety symptoms.

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“Depressive Disorders”

•Disruptive Mood Dysregulation Disorder •Major Depressive Disorder•Persistent Depressive Disorder

(Dysthymia)•Premenstrual Dysphoric Disorder•Substance/Medication-Induced

Depressive Disorder •Other and Unspecified

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“Depressive Disorders”: ShiftsDisorder Name Used To Be In (DSM-IV-

TR) Now In (DSM-5)

Disruptive Mood Dysregulation Disorder

-- “Depressive Disorders”

Premenstrual Dysphoric Disorder

Disorders in Need of Further Research

“Depressive Disorders”

Persistent Depressive Disorder (Dysthymia)

“Dysthymic Disorder” in the “Depressive Disorders” subcategory of Mood Disorders

“Depressive Disorders”

Bereavement V62.82 Major Depressive Disorder (MDD could not be diagnosed if symptoms were due to loss)

MDD diagnosed even if symptoms are related to grief

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“Depressive Disorders”: Criteria/Notes

•MDD: essentially the same criteria set. •A major depressive episode with at least 3

manic symptoms is now coded with the specifier “with mixed features” (see pg. 162).

•Persistent Depressive Disorder (Dysthymia): what used to be known as “double depression” (refractory major depressive episodes along with chronic sub-threshold depressive symptoms).

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“Depressive Disorders”: Controversies•DMDD: Are we fostering the

pathologizing of temper outbursts?•Removal of the bereavement exclusion for

MDD: Are we over-pathologizing the normal bereavement process?

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“Anxiety Disorders”

•Separation Anxiety •Selective Mutism•Specific Phobia•Social Anxiety Disorder (Social Phobia)•Panic Disorder •Agoraphobia•Generalized Anxiety Disorder •Substance/Medication-Induced Anxiety

Disorder•Other and Unspecified

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“Anxiety Disorders”: ShiftsDisorder Name Used To Be In (DSM-IV-TR) Now In (DSM-5)

Separation Anxiety Disorder

“Disorders Usually First Diagnosed in Infancy, Childhood and Adolescence”

“Anxiety Disorders”

Selective Mutism “Disorders Usually First Diagnosed in Infancy, Childhood and Adolescence”

“Anxiety Disorders”

Agoraphobia Panic Disorder Without Agoraphobia and Agoraphobia With or Without Panic Disorder in “Anxiety Disorders”

Panic Disorder and Agoraphobia de-linked but still fall under “Anxiety Disorders”

OCD “Anxiety Disorders” “Obsessive Compulsive and Related Disorders”

Acute Stress Disorder “Anxiety Disorders” “Trauma and Stressor-Related Disorders”

PTSD “Anxiety Disorders” “Trauma and Stressor-Related Disorders”

Body Dysmorphic Disorder

“Somatoform Disorders” “Obsessive Compulsive and Related Disorders”

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“Anxiety Disorders:” The Controversy of the New GAD Criteria

•Symptom duration lowered from 6 to 3 months.

•Associated symptoms of anxiety and worry lowered from 3 to 1 symptoms needed.

•Aaron Beck has indicated this will result in a rise of “false positive” GAD diagnoses.

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“Trauma- and Stressor-Related Disorders”

•Reactive Attachment Disorder•Disinhibited Social Engagement Disorder•PTSD•Acute Stress Disorder•Adjustment Disorders •Other and Unspecified

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“Trauma- and Stressor-Related Disorders”

Disorder Name Used To Be In (DSM-IV-TR) Now In (DSM-5)

Reactive Attachment Disorder

“Disorders Usually First Diagnosed in Infancy, Childhood and Adolescence”

“Trauma and Stressor-Related Disorders”

Disinhibited Social Engagement Disorder

-- “Trauma and Stressor-Related Disorders”

PTSD “Anxiety Disorders” “Trauma and Stressor-Related Disorders”

Acute Stress Disorder “Anxiety Disorders” “Trauma and Stressor-Related Disorders”

Adjustment Disorders “Adjustment Disorders” “Trauma and Stressor-Related Disorders”

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“Trauma- and Stressor-Related Disorders”: Criteria/Notes

•Adjustment Disorders no longer a residual category (DSM-IV-TR subtypes retained).

•Reactive Attachment Disorder and Disinhibited Social Engagement Disorder (resembles ADHD): both are the result of social neglect or other situations that limit a young child’s opportunity to form selective attachments.

•For PTSD, attempted to specify “trauma” as an actual or threatened death, serious injury or sexual violation.

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“Trauma- and Stressor-Related Disorders”: Controversy •New criteria (i.e., “Emotional reactions

to the traumatic event [fear, helplessness, horror]” [p. 274] no longer being necessary) may dilute what is actually deemed “traumatic.”

•Diagnosis may occur for people who have not had direct exposure but merely learned about a violent traumatic event suffered by a loved one.

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“Substance-Related and Addictive Disorders”• Substance Use Disorders• Alcohol-Related Disorders • Caffeine-Related Disorders• Cannabis-Related Disorders • Hallucinogen-Related Disorders• Inhalant-Related Disorders • Opioid-Related Disorders• Sedative-, Hypnotic-, and Anxiolytic-Related Disorders • Stimulant-Related Disorders • Tobacco-Related Disorders • Non-Substance-Related Disorders (Gambling

Disorder)

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“Substance-Related and Addictive Disorders”: Criteria/Notes •“Abuse” and “dependence” have been

collapsed into a single diagnostic category (addictions exist on a continuum: the spectrum perspective).

•Severity of diagnoses (dimensionality) rated as mild, moderate, or severe, based on the number of symptoms.

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“Substance-Related and Addictive Disorders”: Controversies•“First-time substance abusers are now

lumped together with heroine addicts” (Zur Institute, 2013);

•Category has been expanded beyond psychoactive substances:

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“Neurocognitive Disorders”

• Delirium• Major Neurocognitive Disorder (with Etiological

Subtypes) Alzheimer’s DiseaseVascular DiseaseTraumatic Brain InjuryHIV InfectionsParkinson’s DiseaseHuntington’s DiseaseSubstance/Medication.

• Mild Neurocognitive Disorder (specifiers correspond to the disease process to which the cognitive decline is due)

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“Neurocognitive Disorders”: Criteria/Notes

•Formerly categorized in the DSM-IV-TR under the diagnostic category “Delirium, Dementia, and Amnestic and Other Cognitive Disorders.”

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“Neurocognitive Disorders”: Controversies

•Mild Neurocognitive Disorder: Are we pathologizing natural aging processes?

What is the distinction between illness and average expected generative decline?

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Part IV. Section III of the DSM-5: Emerging Measures and Models

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(#1) Assessment Measures

•“Cross-cutting Symptom Measure” (see pp. 734-742)

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(#1) Assessment Measures

•“Clinician-Rated Dimensions of Psychosis Symptom Severity” (see pp. 743-744)

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(#1) Assessment Measures

World Health Organization Disability Assessment Schedule 2.0 (WHODAS)

•Understanding and communicating•Getting around•Self-care•Getting along with people•Life activities (household, work, or school)•Participation in society

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(#2) Alternate DSM-5 Model for Personality Disorders

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(#3) Conditions for Further Study

•Attenuated Psychosis Syndrome •Depressive Episodes with Short-Duration

Hypomania•Persistent Complex Bereavement Disorder•Internet Gaming Disorder•Neurobehavioral Disorder Associated with

Prenatal Alcohol Exposure•Suicidal Behavior Disorder•Nonsuicidal Self-injury

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Part V. Five Major Controversies

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Allen Frances’ Saving Normal (2013)

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Amazon Review: Jonathan Karmel • “This book, by a well-respected psychiatrist who was very

involved in the creation of the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), argues that a high percentage of people diagnosed with mental illness are actually normal. He thinks this trend of diagnostic inflation may be exacerbated and there may be diagnostic hyperinflation with the publication of DSM-5 in May 2013.

• The book begins by attempting to do something that DSM-5 fails to do: define what is normal and what is abnormal. The author concludes that there is no good definition of normal and that psychology ought to simply take a utilitarian approach: a diagnosis should exist if it is useful. What makes it useful is if it can actually be used as a tool to help people who are suffering.

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Amazon Review: Jonathan Karmel

• In retrospect, the author is glad that he was conservative and did not add many new diagnoses to DSM-IV, but he wishes he had been more aggressive about purging diagnoses which were not evidence-based. He faults DSM-IV for contributing to over-diagnosis of ADHD and autism in children.

• The author provides a number of explanations for diagnostic inflation. One is a desire for psychologists to identify symptoms indicating that a person is going to get mental illness, just like doctors are now wont to order tests and prescribe drugs to prevent the onset of physical disease. The problem is that preventative medicine is mostly a waste of money and can be harmful for both physical and mental illness.

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Amazon Review: Jonathan Karmel

• The author believes the biggest culprit is Big Pharma. As soon as the drug companies began direct to consumer marketing, advertisements convinced people that they had some form of mental illness and should "ask their doctor" about various prescription drugs.

• The author cites some very alarming statistics about the number of people taking prescription drugs, some with serious side effects, even though there is no real reason to believe the people have actual mental illness.”

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Amazon Review: Jonathan Karmel

• Finally, people have a mistaken belief that they should feel great all the time. People think that they have some kind of mental illness when they are actually just experiencing normal, bad events and/or feelings that people typically have.

• The author is a complete believer in mental health treatment and actually laments that there is not enough mental health treatment for people who truly need it. But I think the author makes a convincing case that way too many normal people are being diagnosed with mental illness.

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#1. Will We Overdiagnose with the DSM-5?•The dimensional perspective has a risk of

over-pathologizing (i.e., pathologize normal behavior and/or normalize pathologic symptoms); usually referred to as the “reduced threshold” problem.

•May lead to stigma/mislabeling of those who would do better without a psychiatric diagnosis.

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#2. Are DSM-5 Diagnoses Valid?

•Allen Frances: DSM-5 introduces new, invalid diagnoses and contends the DSM-5 Task Force is merely helping the drug companies.

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#2. Are DSM-5 Diagnoses Valid?

National Institute of Mental Health (NIMH) director Thomas Insel announced that it would no longer use DSM diagnoses in research projects due to the manual’s lack of validity.

•He contends the manual should be used solely as a dictionary so that clinicians share the same descriptions of symptoms.

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#2. Are DSM-5 Diagnoses Valid?

•Research indicates that 2 clinicians agree on a diagnosis of major depression only 60 percent of the time (Zur Institute, 2013).

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#3. Was the Process of Development of the Manual Flawed?

•Development was shrouded in secrecy; changes were not empirically supported.

•Were the work groups merely flying by seat of their pants?

•DSM-5 diagnoses are based on a consensus about clusters of clinical symptoms, not on any objective laboratory measure (in medicine: symptoms rarely indicate the best choice of treatment).

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#4. Are the DSM-5 Diagnoses Irrelevant to the Cause and Treatment of Psychological Problems?

•Despite changes in the DSM-5, it remains “a topographical symptom map” (Zur Institute, 2013): does not capture causal pathways that give rise to and maintain illness.

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#5. Is the DSM Experiencing an Identity Crisis?

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#5. Is the DSM Experiencing an Identity Crisis? • It is not clear if the DSM-5 is a diagnostic tool,

a treatment tool, a research tool, or some combination of all of these: Is the DSM a good example of Multiple Personality Disorder?

• Different groups use the DSM too loosely or too rigidly (little pragmatic consensus) (Zur Institute, 2013).

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How, in What Ways, for What Patients, under What Therapeutic Conditions Does Diagnostic Nomenclature Help or Hinder?

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Final Words

•The therapeutic process remains the best diagnostic tool, providing the clinician with a view of the patient’s regressive tendencies and relational potential.

•How psychiatric diagnosis is used between patient and therapist is a relational event that deserves careful consideration and processing.

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Final Words

•Mental illness as a spectrum will ultimately provide clinicians with greater flexibility, as the focus will not solely be on distinct syndromes but underlying etiological factors and associated symptomatic features as well.

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Final Words

•As a field, we must remain aware of our narcissistic preference for certainty vs. uncertainty, which often translates into our tendency to organize the complexities of nature prematurely or erroneously.

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Final Words

•The clinician uses the diagnostic nomenclature yet remains skeptical of its ultimate authority and truth.

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THE END!Thanks for your attention!!