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

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

2

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.

3

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.

4

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.

6

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=3akfbnmhO
M8.

7

Acknowledgements
• Dingle, A. (2013, July 30). The new DSM-5.
Retrieved from
http://www.youtube.com/watch?v=C9pru53Uc
bA.
• 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.

8

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).

9

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.

10

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.

11

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

12

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)

13

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).

14

Change #2. Incorporate a Spectrum
Perspective

15

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.

16

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.

17

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).

18

Change #3. Incorporate Dimensionality

19

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.

20

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.

21

Change #4. Reflect a Developmental
Perspective
(2) For specific disorders, variations of symptom
presentations across the lifespan are described.

22

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).

23

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).

24

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.

25

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.

26

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

27

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)

28

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 elements
of psychiatric health/personality actually are.

29

Change #10. Use Biologically-based
Diagnostic Criteria
• For some disorders, DSM-5 employs objective
measures (genetic workups, 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.

30

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

31

“Neurodevelopmental Disorders”
•
•
•
•
•
•
•

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

32

“Neurodevelopmental Disorders”: Shifts
Disorder Name

Used To Be In (DSM-IVTR)

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”


33

“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

34

Psychotic Disorders”: Shifts
Disorder Name

Used To Be In (DSMIV-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

35

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 DSM5 Manual (pp. 742-744).

36

“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

37

“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-IVTR).

38

“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.

39

“Depressive Disorders”
•
•
•
•
•

Disruptive Mood Dysregulation Disorder
Major Depressive Disorder
Persistent Depressive Disorder (Dysthymia)
Premenstrual Dysphoric Disorder
Substance/Medication-Induced Depressive
Disorder

40

“Depressive Disorders”: Shifts
Disorder Name

Used To Be In (DSM-IVTR)

Now In (DSM-5)

Disruptive Mood
Dysregulation Disorder

--


Premenstrual Dysphoric
Disorder

Disorders in Need of Further
Research


Persistent Depressive
Disorder (Dysthymia)

“Dysthymic Disorder” in the
subcategory of Mood
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

41

“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).

42

“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?

43

•
•
•
•
•
•
•
•

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

44

“Anxiety Disorders”: Shifts
Disorder Name

Used To Be In (DSM-IV-TR)

Now In (DSM-5)

Separation Anxiety
Disorder

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


Selective Mutism



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


“Obsessive Compulsive and
Related Disorders”

Acute Stress Disorder


“Trauma and StressorRelated Disorders”

PTSD



Body Dysmorphic
Disorder

“Somatoform Disorders”

“Obsessive Compulsive and
Related Disorders”

45

“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.

46

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

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

47

Disorders”
Disorder Name

Used To Be In (DSM-IV-TR)

Now In (DSM-5)

Reactive Attachment
Disorder



Disinhibited Social
Engagement Disorder

--


PTSD






Adjustment Disorders

“Adjustment Disorders”


48

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.

49

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.

50

“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)

51

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.

52

Disorders”: Controversies
• “First-time substance abusers are now lumped
together with heroine addicts” (Zur Institute,
2013);
• Category has been expanded beyond
psychoactive substances:

53

“Neurocognitive Disorders”
• Delirium
• Major Neurocognitive Disorder (with Etiological
Subtypes)
Alzheimer’s Disease
Vascular Disease
Traumatic Brain Injury
HIV Infections
Parkinson’s Disease
Huntington’s Disease
Substance/Medication.

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

54

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

55

“Neurocognitive Disorders”:
Controversies
• Mild Neurocognitive Disorder: Are we
pathologizing natural aging processes?

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

56

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

57

(#1) Assessment Measures
• “Cross-cutting Symptom Measure” (see pp. 734742)

58

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

59

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

60

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

61

(#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

62

Part V. Five Major Controversies

63

Allen Frances’ Saving Normal (2013)

64

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.

65

• 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.

66

• 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.”

67

• 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.

68

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

69

#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.

70

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.

71

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

72

#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).

73

#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.

74

#5. Is the DSM Experiencing an
Identity Crisis?

75

#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).

76

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

77

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.

78

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.

79

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.

80

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

81

THE END!
Thanks for your attention!!

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

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