With much fanfare and no small amount of controversy the American Psychiatric Association (APA) released the 5th version of the Diagnostic and Statistics manual, DSM-5 in May of this year. Since its release it has been a consistent best seller and is still ranked #19 of all books on Amazon in October 2013. Planning for the edition dates back to at least 2003, and that process alone has generated over 200 journal articles and involved hundreds of researchers and clinicians, many of whom live and practice outside the United States. Coming in at 947 pages the DSM-5 is bit larger than the 129-page first edition, but it is actually 41 pages shorter than the its immediate predecessor. The total number of discrete disorders has also dropped a bit from 172 to 157, obtained by the elimination of 2, the addition of 15, and the consolidation, many of them in the substance use categories, of 28 disorders.
Interestingly criticism of the DSM-5 has come from both directions. It has been categorized as a collection of relatively minor adjustments to DSM- IV which has not fully tracked research developments or the new emphasis on brain circuitry as captured by the Research Domain Criteria (RDoC) system currently being advanced by the NIMH as a framework for funding and promoting research activities. (See the NIH’s Dr. Thomas Insel’s April blog comments ( http://www.nimh.nih.gov/about/director/2013/transforming-diagnosis.shtml ) and his May joint statement with the APA President for more information (http://www.nimh.nih.gov/news/science-news/2013/dsm-5-and-rdoc-shared-interests.shtml )). Alternately, it has been criticized for the wholesale repackaging of certain disorders, e.g. autism and related disorders, substance abuse/dependence, and as a book that advances the medicalization and treatment of normalcy, e.g. the elimination of the bereavement exclusion from the diagnosis of depression.
It is simply not possible to summarize all of the changes in this edition of the DSM in the limited space of this column, so I will highlight a few things of note and recommend to the reader a synopsis found at (http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf).
Actually, one of the biggest conceptual changes is the reorganization of the chapters, or metastructure to better track with the International Classification of Disease (ICD)10 and the upcoming ICD 11. The reorganization tries to better group the spectrum of disorders we encounter and their progression across the lifespan. In addition, it will allow for better tracking of the DSM disorders to the ICD codes, which practitioners are mandated to use when submitting claims for billing purposes.
The multi-axial diagnostic system has ended. There is no longer a separation of personality disorders form the rest of psychiatric diagnosis and there is no mandate to use the Global Assessment of Functioning (GAF) and list all psychosocial stressors in the diagnosis. This aligns psychiatry with the rest of the house of medicine. Comprehensive medical and psychiatric care should always reflect patient function and pertinent life issues, and these factors should be reflected in the care plan, but it is not part of a diagnosis.
Substance Use and Addictive disorders: Gone are the 2 distinct categories of abuse and dependence, as they have been combined into a single substance use disorder, with a severity rating across a continuum that includes mild, moderate, or severe substance use. The 2 categories had been “invented” in a previous edition of the DSM and there is no compelling scientific data to support the separation. This tracks well with the experience of clinicians who have long known that one can be physically dependent without abusing a substance and one can heavily abuse a substance with life destroying consequences and never be physically dependent. The “legal consequences” diagnostic criteria has been removed as the legal difficulty associated with drug use may be more related to social standing and residence than the degree of use/impairment. Many would point to stop and frisk statistics in NYC as an example of this disparity. And the criteria of craving was added, a key feature of the pathology that was missing from the previous definitions.
Gambling Disorder has now been added as the first behavioral addictive disorder, having been moved from the impulse disorder categories. Found in the DSM’s section 3 “are “conditions for further study” that are promising candidates for future inclusion, but which lack enough scientific evidence to support full recognition at this time. Both Caffeine Use Disorder and Internet Gaming Disorder have been included in Section 3.
Schizophrenia: The various subtypes of schizophrenia have been removed as they have not been shown to have sufficient stability or predictive outcome value. In addition, the special treatment of bizarre delusions and “special;” hallucinations are also removed, and finally criteria have been clarified that at some point a patient has to have had delusions, hallucinations, or disorganized speech to receive the diagnosis.
Autism Spectrum Disorder: A single spectrum diagnosis replaces autistic disorder, Asperger disorder, Childhood Disintegrative Disorder, Rett’s Disorder and pervasive developmental disorder not otherwise specified. This decision was strongly supported by the scientific literature that demonstrated that our previous distinctions could not be supported. There was significant controversy mainly centered on a fear of loss of eligibility for special education and other programs. As DSM5 specifically allows the inclusion of all persons already diagnosed under DSM-IV it is likely this fear during the transition from IV to 5 is overblown.
Intellectual Disability (Intellectual Developmental Disorder): This disorder now replaces the outmoded term mental retardation. The diagnosis is now longer strictly driven by IQ but takes into account other areas of functioning.
Depression: One significant change includes the elimination of the so-called bereavement exclusion, so it is now possible to diagnosis someone with depression even if they recently suffered the loss of a loved one. There is a very real effort in the supporting text to provide guidance to clinicians to distinguish depression from normal grieving. The change was made to recognize that loss, like any major stressor can trigger a pathologic response, depression, which may need specialized and focused treatment. There have also been modifications to the diagnosis of dysthymia and its overlap with depression by the introduction of persistent depression. The anxious features of depression are now pulled out for special attention as an independent specifier in the diagnosis as it may predict higher rates of suicide and poorer outcome.
And finally, no discussion of DSM-5 can be complete without highlighting the fact that the authors and the APA are very aware that the DSM will continue to need to be modified and refined, and more frequently than every 20 years or so. The challenge will be to find the right balance between introducing important empirically supported change, and maintaining stability in the field for billing, clinical and long term follow up research purposes. Updates on that process, current FAQs refining diagnostic criteria and addressing insurance and billing issues, errata, as well as an online form to complete to ask questions or suggest improvements are all available at www.Dsm5.org.
Dr. Glenn Martin, MD, DFAPA, a practicing psychiatrist, is the President of the New York State Psychiatric Association and is the Recorder of the Assembly of the American Psychiatric Association. He chaired the Assembly Committee on DSM-5.