This is a critical evaluation of DSM

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2. ALL OVER THE GLOBE !!!!!
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4. ICD DSM
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5. CRITICAL
EVALUATION OF
DSM V
DR. PAVITHRA ARUNACHALEESWARAN
JR, DEPARTMENT OF PSYCHIATRY, SSIMSRC.
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6. CONTENTS
 HISTORY
 EVOLUTION OF DSM
 DSM 5 DIMENSIONS
 INTEGRATION OF DIMENSIONS
 NEW ADDITIONS
 REMOVAL & CHANGES
 THE CRITIC
 CONCLUSION
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7. PROTOTYPE TO CHECKLIST:
A brief history
 Psychiatry diagnosis usually started as prototype based
approach:
 Clinical picture with narrative description of different forms of
psychopathology.
 Clinical vignettes based on which clinician evaluated the giver
persons problems to match those described in literature.
 A checklist method of diagnosing as in DSM focusses
on:
 individual symptoms and signs with independent diagnostic
criteria
 These are additive in nature  reflected in DSM 5’s severity
assessment.
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8.  However the 1st 2 ed. Of DSM provided only a prototypical
description
 Poorly elaborated description
 Lacking in references
 American psychiatrists believed in:
 HOLISTIC MENTAL HEALTH CONCEPT: were precipitated by a combination of
psychological and environmental factors mediated by predisposition
 Focus on patient rather than illness
SO THEN, WHY THIS CHANGE ?
PROTOTYPE TO CHECKLIST:
A brief history
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9.  In order to make population overviews of different
psychiatric conditions, they needed straight-foward,
clearly delineated disorder categories that could be
assessed easily
 Serious interest in psychiatric statistics in the mid
nineteenth century  large scale census  need to
develop standardized classification system.
 Hence a growing desire to develop a standard
nomenclature for psychiatric disorders motivated these
revisions.
PROTOTYPE TO CHECKLIST:
A brief history
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10. EVOLUTION OF DSM
DSM I adopted in 1950s – brief prototypic
description
DSM II 1968 coprised 182 disorders dint differ
much in the prototypical approach
DSM III 1980 dropped the elementary
based approach for a checklist – based system
Attempts to make psychiatry more strongly as a medical
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TEMERLIN
ROSENHAM

11. DSM IV adopted in 1994
DSM IV TR in 2000
TheDSM-IV-TRwas organized into a five-
part axial system.
DSM V – 347 mental disorders in 22 chapters.
Released on May 18th 2013
Discontinued the 5 Axis system of diagnosis
HARMONIZATION with ICD 10 was attempted
EVOLUTION OF DSM
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12. DSM 5 DIMENSIONS
NEW ORGANIZATIONAL STRUCTURE
• The linear structure of this organization is
intended to better reflect the relative
strength of relationships between disorder
groups.
• the internal organization of disorder groups
is intended to reflect more of a child-adult
developmental perspective.
• Grouping based more so on
neuroscience and less on symptom
expression
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13. DIMENSIONAL ASPECT OF DIAGNOSIS
Largely dependent on a “yes or no” decision.
use of:
specifiers,
subtypes,
severity ratings
cross-cutting symptom assessments help
clinicians better capture gradients of a disorder
DSM 5 DIMENSIONS
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14. DSM 5 CLASSIFICATIONS
INTEGRATION OF DIMENSIONS
ASD and ADHD are now grouped
together in neurodevelopmental
disorders, with some of the former DSM-
IV “disorders first diagnosed in infancy,
childhood, or adolescence”
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15. COMBINED TO FORM SPECTRUM DISORDER
AUTISM SPECTRUM DISORDER
includes symptoms that characterize previous DSM- IV
because of the presence of very poor reliability data, that
failed to validate their continued separation
• Autism disorder,
• Asperger’s disorder,
• Child disintegrative disorder,
• Pervasive developmental disorder NOS
describes all of these presentations under one rubric,
specifiers are provided to account for ASD variations,
including specifiers for
- intellectual impairment
- structural language impairment
- co-occurring medical conditions
- loss of established skills.
e.g
DSM IV - Asperger’s disorder
DSM-5 with ASD, with the specifiers “without intellectual
impairment” and “without structural language impairment.
DSM 5 CLASSIFICATIONS
INTEGRATION OF DIMENSIONS
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16. DSM 5 CLASSIFICATIONS
INTEGRATION OF DIMENSIONS
• The subtypes of schizophrenia (i.e., paranoid,
disorganized, catatonic, undifferentiated, and
residual types) are eliminated due to their
limited diagnostic stability, low reliability, and
poor validity.
• Instead, a dimensional approach to rating
severity for the core symptoms of schizophrenia
.
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17. DSM 5 CLASSIFICATIONS
INTEGRATION OF DIMENSIONS
The numbers of specifiers and sub- types in the
DSM-5 has been expanded to account for efforts to
dimensionalize disorders more so than in the DSM-
IV.
Within the depressive disorders and bipolar and
related disorders, a specifier of “with mixed
features” replaces the diagnosis of bipolar I, mixed
episode in the DSM-IV
The “with mixed features” Specifier, therefore, now
applies to unipolar as well as bipolar conditions.
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18. DSM-IV’s anxiety disorders too are distributed into
separate chapters of fear circuitry:
• based anxiety disorders (e.g., phobias);
• anxiety disorders related to obsessions and
compulsions (e.g., obsessive-compulsive
disorder)
• those that arise from trauma or extreme stress
(e.g.PTSD);
• those characterized by dissociation (e.g.,
dissociative amnesia).
DSM 5 CLASSIFICATIONS
INTEGRATION OF DIMENSIONS
Trichotillomania has been moved from impulse control to
OCD spectrum
Separation Anxiety now classified under anxiety disorder
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19. Somatic symptom disorder largely takes the place of DSM
IV’s
somatization disorder,
hypochondriasis  illness anxiety disorder
pain disorder,
undifferentiated somatoform disorder,
DSM 5 CLASSIFICATIONS
INTEGRATION OF DIMENSIONS
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20. Breathing-related sleep disorder subtypes - DSM IV
independent disorders with separate criteria
obstructive sleep apnea
hypopnea syndrome
central sleep apnea
sleep- related hypoventilation
DSM 5 CLASSIFICATIONS
INTEGRATION OF DIMENSIONS
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21. Vaginismus + Dyspareunia
Genito – pelvic pain /Penetration disorder
DSM 5 CLASSIFICATIONS
INTEGRATION OF DIMENSIONS
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22. New diagnostic class.
Removed from Sexual and gender Identity
Disorders, to separate diagnosis from sexual
dysfunctions & paraphilias
DSM 5 CLASSIFICATIONS
INTEGRATION OF DIMENSIONS
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23. DMDD disruptive Mood Dysregulation
Disorder
children with extreme behavioral dyscontrol but
non-episodic irritability no longer qualify for a
diagnosis of bipolar disorder in the DSM-5 and
instead would be considered for DMDD.
DSM 5 CLASSIFICATIONS
INTEGRATION OF DIMENSIONS
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24. Substance
abuse
Substance use
disorder
Substance
dependence
+
With addition of Severity scaling
DSM 5 CLASSIFICATIONS
INTEGRATION OF DIMENSIONS
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25. DEMENTIA
Major
Neurocognitive
disorder
MILD COGNITIVE
IMPAIRMENT
Ten etiological subtypes are now provided, with
separate criteria and text for each.
DSM 5 CLASSIFICATIONS
INTEGRATION OF DIMENSIONS
Mild Neurocognitive
disorder
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26. DSM 5 CLASSIFICATIONS
INTEGRATION OF DIMENSIONS
• Alternative approach to diagnosis developed for further
study and can be found in section 3.
• Moderate level of impairment in personality functioning required
now.
• Personality disorder, trait unspecified replaces NOS.
A typical patient meeting a criterion for a DSM-IV
personality disorder often qualifies for another personality
disorder too. So an alternative model have been introduced.
Antisocial, Avoidant, Borderline ,Narcissistic ,Obsessive –
Compulsive and Schizotypal PD can be diagnosed and
Personality Disorder –Trait Specific can be diagnosed if
the criterion is not met , but if PD is suspected.
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27. DSM 5 CLASSIFICATIONS
INTEGRATION OF DIMENSIONS
• Addition of course specifiers:
• in a controlled environment
• in remission
• Differences between paraphilias and paraphilic
disorders:
–Disorder is a paraphilia that is currently causing
distress or impairment to the individual
–Paraphilia alone does not automatically justify or
require clinical intervention
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28. NEW ADDITIONS
 Hoarding disorder
 Binge eating disorder
 Premenstrual dysphoric disorder
 Restless leg syndrome
 REM sleep behaviour disorder
 Social (pragmatic) communication disorder
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29. REMOVALS & CHANGES in
NAMES
 Bereavement exclusion removed from MDD
 Mental retardation  Intellectual development disorder
 Substance abuse/dependence  substance use
disorders
 Not otherwise specified (DSM IV)  other specified &
unspecified (ICD)
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30. THE CRITIC:
 AllenJ.Frances(born 1942 in Thessaloniki, Greece)is an American
psychiatrist best known for chairing the task force that produced the DSM-IV
and for his critique of the current version, DSM-5.
 Hewarnsthat the expandingboundaryof psychiatryiscausinga
diagnostic inflation that isswallowingupnormality andthat the over-
treatment of the "worried well" is distractingattention fromthe core
missionof treating the moreseverelyill.
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31. DEFICITS
 In aDecember2, 2012 blog post in Psychology Today, Franceslists the ten "mostpotentially
harmful changes"toDSM-5:
 DisruptiveMood DysregulationDisorder,for tempertantrums
 Major DepressiveDisorder,includesnormalgrief
 Minor NeurocognitiveDisorder,for normalforgettinginoldage
 AdultAttention Deficit Disorder,encouragingpsychiatricprescriptionsof stimulants
 BingeEatingDisorder,for excessiveeating
 Autism,definingthedisordermorespecifically,possiblyleadingtodecreasedratesofdiagnosisandthedisruptionof
schoolservices
 Firsttimedruguserswillbelumpedinwithaddicts
 BehavioralAddictions,makinga"mentaldisorderofeverythingweliketodoalot.”
 GeneralizedAnxietyDisorder,includeseverydayworries
 Post-traumaticstressdisorder,changesopening"thegateevenfurthertothealreadyexistingproblemof
misdiagnosisofPTSDinforensicsettings." 31-10-2019
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32. CONCLUSION
 Though DSM was designed for use primarily in clinical
practice, it must be applicable for a wide variety of context.
 DSM has been used by clinicians and researchers from a
different orientation, all whom strive for a common
language to communicate the essential characteristics of
mental disorders presented by their patients.
 The information is useful for all health care professionals
 Use in collecting accurate public health statistics
 Though DSM remains a categorical classificatory system,
there are continuous attempts to integrate a dimensional
approach to stimulate new clinical perspectives and
promote revisions to enhance use across all settings.
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33. THANK YOU
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