About the DSM-5
Introduction
The Diagnostic and Statistical Manual of Mental Disorders, or DSM, has been used for decades as a way for mental health professionals to use a shared language and terminology in which they could share information about patients and clients including symptoms that were common to a particular diagnosis as well as in recommending courses of treatment.
Over the years the manual has undergone significant changes. The 991 page DSM-5 was published by the American Psychiatric Association in 2013 after more than twelve years of work and collaboration and contains some significant changes and updates. For a manual of such significance and so widely used, it is not surprising that reviews have been somewhat mixed. After all, change is a process, and resistance to change is often simply a desire to hold on to the familiar.
Though certainly not perfect, the DSM-5 is a major step forward for the American Psychiatric Association, for clinicians, and for other professionals who regularly use it. This article is designed to serve as a summary of the updates found in the DSM-5 when compared to previous editions, most notably the DSM-IV-TR.
A Conceptual Revision
Not surprisingly, the new version of the Diagnostic and Statistical Manual of Mental Disorders includes updates due to current research findings, new discoveries, technological advances, and scientific breakthroughs.
As an official diagnostic manual the information contained should be based on scientifically proven data and not be merely theoretical in nature. At the same time there is an awareness that research studies and theoretical explanations alone do not create the type of diagnostic descriptions and symptom presentations that often exist in the real world, which is full of extraneous variables.
Thus one of the goals in developing the DSM-5 was to provide a more fluid and less rigid and complex means of diagnosis, while still providing specific, objective, and scientifically validated symptom presentations. In other words, without losing accuracy the authors of the DSM wanted to make the diagnoses it contains more flexible to the natural variety that occurs in our world.
Along these lines, the manual offers a reminder that its primary purpose is to aid in summarizing common symptoms of a condition, to assist with providing a prognosis based upon the experiences of others with the same condition, and most importantly to develop an appropriate treatment plan.
The DSM-5 emphasizes that a diagnosis is not a call to treatment, nor is it a requirement of treatment. In other words, not everyone with a diagnosis must undergo treatment, not everyone who chooses to be treated must receive the same kind of treatment, nor should the absence of a formal diagnosis be an excuse to keep a person from desired treatment if there's a reasonable expectation that they would benefit from it.
The manual's introductory section also emphasizes the importance of trained professionals who can and will include a careful and thorough clinical history as part of their overall assessment as opposed to simply checking off a certain number of symptoms from a list in order to make a diagnosis.
Another goal was to make the DSM more in line with the International Classification of Diseases, a similar manual used worldwide. To have two major and essentially competing manuals was deemed to be unnecessary and confusing.
Rather the two manuals can and should compliment one another. They can do this by essentially providing research study replication for each other across national borders and acting as an alternative method for confirming a diagnosis. Another benefit of better coordinating the two systems is the improved and expanded ability to use shared diagnostic codes for insurance, billing, and other such purposes.
Finally, the authors of the manual make it a point to mention that while the DSM was designed and intended primarily for clinically trained mental health professionals such as psychiatrists, psychologists, and social workers they recognize that there are others such as those in the legal field, law enforcement, and forensics who may also rely upon the DSM in their work.
Although arguments are frequently made for and against personal responsibility in the case of a person diagnosed with a mental health disorder, the American Psychiatric Association warns that not only should non-clinically trained individuals not attempt to make clinical diagnoses, but also that due to a variety of confounding variables, the presence or absence of any particular diagnosis should not in and of itself be used as a means of demonstrating one's ability or inability to control their behavior at a particular point in time.
Put another way, even a trained mental health professional will have a difficult time accurately determining whether or not the symptoms associated with a particular diagnosis could be considered the "cause" of criminal behavior or whether or not at a particular moment in time a person was capable of distinguishing right from wrong.
A Content Revision
Developing a new version of the Diagnostic and Statistical Manual of Mental Disorders was not an easy or quick undertaking. After over a decade of work, a series of changes were made. These include eliminating old diagnoses, establishing new ones, and expanding upon and adjusting the specifics of others.
In addition to the collaborative efforts of thousands of professionals, over a dozen international planning conferences were held, field trials were used in both large academic settings and smaller clinical practices, and public opinion was sought out online. Work groups were assigned and a series of three revisions of proposed changes were developed, all before the final version was approved for publication.
Some of the more significant changes in diagnoses include the replacement of Mental Retardation with Intellectual Disability, known also as Intellectual Developmental Disorder in part to be in compliance with Rosa's Law. Hoarding Disorder and Gambling Disorder were added as new diagnoses.
Premenstrual Dysphoric Disorder was also accepted as a new diagnosis. Previously it was simply a topic of consideration and in need of additional research. Additionally, Disruptive Mood Dysregulation Disorder was added as a new condition specific to children with depressive symptoms, irritability, and behavioral issues.
In addition, many conditions and categories were adjusted in some manner. Autistic Disorder, Early Infantile Autism, Childhood Autism, Kanner's Autism, High-Functioning Autism, Atypical Autism, Pervasive Developmental Disorder Not Otherwise Specified (NOS), Childhood Disintegrative Disorder, and Asperger's Disorder are all now a part of the single diagnosis known as Autism Spectrum Disorder.
Gender Dysphoria and Sexual Dysfunctions are now separate categories. Previously they were part of a single category. Likewise, Substance Abuse and Substance Dependence have been combined into Substance Use Disorder, a move intended to avoid confusion. Furthermore, Dementia and Amnesia are now joined under Neurocognitive Disorders.
An Organizational Revision
When it came time to update the organizational structure of the Diagnostic and Statistical Manual of Mental Disorders, a few key changes stood out. Among those are the establishment of new sections of the manual, a chronological lifespan approach to the ordering of chapters, replacement of the Not Otherwise Specified option, and perhaps most notably the elimination of the multiaxial system.
The sections of the DSM-5 should not be confused with the axes of the previous version. These sections are better thought of as chapters, or groupings of content.
The first section is called DSM-5 Basics and consists of an Introductory text. Section II, Diagnostic Criteria and Codes, is the main part of the manual and is where you'll find all of the various diagnoses, descriptions, and other pertinent information. Section III is called Emerging Measures and Models and can be thought of as a collection of ideas that were considered for the current edition of the manual but not deemed ready for inclusion. These are issues that may be in future editions of the DSM. Also included are discussions on culture, personality disorders, and suggestions for researchers hoping to contribute to the ongoing development of the DSM.
The manual ends with an index and an appendix, the latter of which includes a summary of changes seen in this fifth edition of the manual, a glossary of clinical terminology, a list of culturally specific concepts of distress, and reference lists with ICD codes and DSM diagnoses.
In Section II specifically the manual lists its diagnostic categories roughly in order based upon one's typical developmental lifespan, with issues common to children listed early on and those more frequently seen in older adults towards the end of the section. A secondary level of ordering groups diagnoses into internally focused conditions such as anxiety and depressive disorders, externally focused conditions such as conduct and substance-related disorders, those with a neurocognitive component, and other or miscellaneous disorders.
Another key change was the replacement of the Not Otherwise Specified or NOS designation. It was found that with the last edition of the manual, clinicians and other professionals were relying heavily on the NOS designation to diagnose clients and patients whose symptoms didn't quite fit the specific and often overly rigid requirements to be formally diagnosed. By using the NOS designation, mental health professionals have been able to say that someone essentially had a particular diagnosis even if they didn't technically fit all of the necessary criteria.
In the fifth edition, the Not Otherwise Specified designation has been replaced with two similar but different options: Other Specified Disorder and Unspecified Disorder.
The Other Specified Disorder designation allows clinicians to explain why precisely a person comes close without fully fitting a particular diagnosis. For example, a diagnosis of Attention-Deficit/Hyperactivity Disorder requires the identification of twelve specific symptoms. If however someone presents with eleven such symptoms and otherwise fits the diagnosis a clinician might use the Other Specified Disorder designation.
By contrast the Unspecified Disorder option or designation is used when a clinician is unable or unwilling for some reason to specify why a person does not fit the full criteria for a diagnosis. This may be the case for example if a mental health professional sees an individual in a limited context or has limited information such as may happen in an emergency setting or other brief encounter.
Additionally, a provisional diagnosis may be used when a person does not yet meet the criteria for a particular diagnosis, but the clinician believes that eventually they will. Unlike the Other Specified Disorder and Unspecified Disorder designations where the full diagnostic criteria are not met or the symptoms are not fully known or available at the time, a provisional diagnosis suggests that it's just a matter of time before a person will likely be fully diagnosed.
For instance, Alcohol Use Disorder cannot be diagnosed if the symptoms have not lasted for at least twelve months. Thus if a person otherwise fit the full criteria for the diagnosis after eleven months, one might reasonably believe that in time they would be able to fully meet the diagnostic criteria for Alcohol Use Disorder. In the meantime they may receive a provisional diagnosis.
Many categories in the manual also have options that allow for diagnoses caused by medications, illicit drugs, alcohol, and/or medical conditions. It's important for example to specify whether a particular Anxiety Disorder is the result of a separate medical condition such as hyperthyroidism or not, because this would have a direct impact on how a person would be best treated.
But by far, the most prominent change in the fifth edition is the elimination of the multiaxial system. Previously clinicians were supposed to make separate indications for relevant social, medical, and other factors that would contribute to a more complete diagnosis. Personality disorders were listed separately from other disorders and an overall assessment of functioning was also required to be made.
In the DSM-5 personality disorders are no longer listed separately. Social, medical, and other such factors are also included in the primary diagnosis and the Global Assessment of Functioning or GAF Scale has been eliminated. However an alternative overall assessment instrument called the WHODAS is being considered for future use.