DSM - 5
An overview.
Dr.Cijo Alex
PG Trainee,
SMVMCH , Puducherry

Conte nt s
• Background
• Changes in DSM-5
• Critical analysis of DSM-5

N o s o l o g y
Nosology or taxonomy is a branch of medical science
that deals with classification of diseases.
Most disciplines of medicine follow etiological
classification.
Since etiology is still obscure in most of the psychiatric
illnesses , our classifications are primarily based on
symptomatology rather than on etiology.

What is the need for classification systems?
To distinguish one psychiatric diagnosis from
another, so that clinicians can offer the most
effective treatment;
To provide a common language among health care
professionals;
And to explore the still unknown causes of many
mental disorders.

Systems of classifications in Psychiatry.
- ICD by WHO
- DSM by APA
- Chinese Classification of Mental Disorders [CCMD]
- Latin American Guide for Psychiatric Diagnosis.
- The Research Domain Criteria [RDoC] by NIMH

Acceptance of various classification systems.
ICD-10 is the official classification system used in Europe and most parts of the
world.
All categories used in DSM-IV-TR are found in ICD-10, but not all ICD-10
categories are in DSM-IV-TR.
DSM-IV-TR is the official US nomenclature.
All terminology used standard textbooks conforms to DSM nomenclature.
As per international agreements ,the deadline for the United States to begin
using ICD-10-Clinical Modification (CM) is currently October 1, 2014.

The DSM classification.
In 1952, the APA published the DSM.
DSM-II (1968); DSM-III (1980); DSM-III-R (1987); DSM-IV
(1994); and DSM-IV-TR (2000).

The DSM - 5
Research started in 1999.
Released May 2013.

I n s i d e D SM- 5
Divided into three sections.
Section I - DSM 5 basics
Section II - Diagnostic criterion and codes
Section III - Emerging measures and models
and an
Appendix.

Section I – DSM -5 basics.
Harmonization with ICD system.
Non axial documentation of diagnosis.
Dimensional assessment.
Changes in diagnostic criterions.

Harmonization with the ICD system has been done to
avoid unwanted hindrances in both scientific
research and patient care.
Most importantly the salient differences between ICD
and DSM does not have any scientific basis rather
they reflect historical byproducts of various
committee meetings.

DSM-5 have moved towards non-axial system of
diagnosis [formerly Axis I,II and III] with separate
notations for important psychosocial and contextual
factors [formerly Axis IV] and disability
[formerly Axis V]

Sect ion I I - Diagnost ic cr i ter ion and codes

Section III - Emerging measures and models
Alternative DSM-5 model of Personality disorders.
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.

Conditions for further study
Proposed criterion sets have been described for following
conditions in which further research is encouraged.
Attenuated Psychosis Syndrome
Depressive episodes with short duration hypomania
Persistent complex bereavement disorder
Caffeine use disorder
Internet gaming disorder
Neurobehavioral disorder associated with prenatal alcohol
exposure
Suicidal behavior disorder
Nonsuicidal self injury

Psychosis like condition but in which symptoms are below the
threshold to be clinically diagnosed as Psychosis.
Symptoms are usually transient and insight is good.

A p p e n d i x
Highlights of changes from DSM-IV to DSM-5.

Neurodevelopmental disorders
Intellectual disability
New term introduced for Mental Retardation.
Diagnostic criterion emphazise the need for assessment of both
cognitive capacity [IQ] & adaptive functioning.
Severity is determined by adaptive functioning rather than IQ
score.

Communication disorders
New term for phonological disorders & stuttering.
Speech sound disorder – previously phonological disorder.
Childhood onset fluency disorder – new term for
stuttering.
Social communication disorder – new condition for for
persistent difficulties in the social uses of verbal and
nonverbal communication.

Autism spectrum disorder
New disorder encompassing previously called
Autism + Aspergers disorder + Retts disorder + Childhood
disintegrative disorder + pervasive developmental disorder
NOS.
The new criteria describe two principal symptoms: “deficits
in social communication and social interaction” and
“restrictive and repetitive behavior patterns”.

ADHD
Several changes to diagnostic criterion.
The onset criterion has been changed from
“symptoms that caused impairment were present
before age 7 years” to “several inattentive or
hyperactive-impulsive symptoms were present prior
to age 12”;
Co morbid diagnosis with Autism spectrum
disorders allowed.

Specific learning disorde
Combines DSM –IV diagnoses of reading disorder ,
mathematics disorder , disorders of written expression and
learning disorders NOS.

Schizophrenia spectrum and other Psychotic disorders.
Schizophrenia
Elimination of the special attribution of bizarre
delusions and Schneiderian first-rank auditory
hallucinations (e.g., two or more voices conversing).
The second change is the addition of a requirement in
Criterion A that the individual must have at least one of
these three symptoms: delusions, hallucinations, and
disorganized speech. At least one of these core
“positive symptoms” is necessary for a reliable
diagnosis of schizophrenia

The DSM-IV 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.

schizoaffective disorder
The primary change to schizoaffective disorder is the
requirement that a major mood episode be present for
a majority of the disorder’s total duration
[after Criterion A has been met].
It makes schizoaffective disorder a longitudinal instead
of a cross-sectional diagnosis—more comparable to
schizophrenia, bipolar disorder, and major depressive
disorder, which are bridged by this condition.

Delusional disorder
Criterion A for delusional disorder no longer has the
requirement that the delusions must be nonbizarre.

Catatonia
In DSM-5, catatonia may be diagnosed as a specifier
for depressive, bipolar, and psychotic disorders

B i p o l a r a n d r e l a t e d d i s o r d e r s
Criterion A for manic and hypomanic episodes now includes
an emphasis on changes in activity and energy as well as
mood.
The DSM-IV diagnosis of bipolar I disorder, mixed episode,
requiring that the individual simultaneously meet full criteria
for both mania and major depressive episode, has been
removed. Instead, a new specifier, “with mixed features,” has
been added that can be applied to episodes of mania or
hypomania when depressive features are present, and to
episodes of depression in the context of major depressive
disorder or bipolar disorder when features of
mania/hypomania are present.

Other Specified Bipolar and Related Disorder
A category for individuals with a past history of a major
depressive disorder who meet all criteria for
hypomania except the duration criterion (i.e., at least 4
consecutive days).
A second condition constituting an other specified
bipolar and related disorder is that too few symptoms
of hypomania are present to meet criteria for the full
bipolar II syndrome, although the duration is sufficient
at 4 or more days.

D e p r e s s i v e d i s o r d e r s
Disruptive Mood Dysregulation Disorder – New diagnosis to
include children upto 18 years of age with persistent irritability
and extreme dyscontrol.
Premenstrual Dysphoric Disorder – promoted from appendix to
main body.
Persistent depressive disorder – New term for dysthymia and
chronic MDD
No more berevement exclusion for diagnosing MDD. Bereavement
is now recognized as a severe psychosocial stressor that can
precipitate a major depressive episode in a vulnerable individual

A n x i e t y d i s o r d e r s
OCD and PTSD have been omitted and made into
separate categories.
Separation anxiety and selective mutism are
included in anxiety disorders.
Anxiety disorders no longer need age >18 for
diagnosis.
Panic disorder and Agoraphobia are unlinked
Panic attacks can be listed as a specifier to ALL
DSM-5 diagnoses.

Obsessive Compulsive and related disorders
New chapter.
New disorders include
hoarding disorder, excoriation(skin picking)disorder ,
Substance/Medication induced obsessive –
compulsive and related disorders And obsessive-compulsive
disorders due to another medical
condition.
Detailed specifiers introduced for insight viz fair ,
poor and absent.

Trauma and Stressor related disorders
Qualifying traumatic events are now explicit as to
whether they were experienced directly , witnessed or
experienced indirectly.
Four symptom clusters instead of three
-Re-experiencing
-Arousal
-Avoidance
-Persistent negative alterations in cognition and mood.

Dissociative disorders
Dissociative fugue is now a specifier of dissociative
amnesia rather than a specific diagnosis.

Somatic symptom and related disorders
New name for somatoform disorders.
To avoid problematic overlap , many subcategories have been
omitted including .
-Somatization disorder
-Hypochondriasis
-Pain disorder
-Undifferentiated somatoform disorder
Criterion for conversion disorder have been revised to
emphasize importance of neurological examination and the
fact that psychosocial stressor may not be demonstrable at
the time of diagnosis.

Feeding and eating disorders
Includes many conditions found in DSM-IV chapter
“disorders usually first diagnosed during
Infancy,Childhood or Adolescence” like pica.
Anorexia nervosa diagnosis does not need amenorrhea as
a criterion.
Slight changes to Bulimia nervosa criterion too

Sexual dysfunctions
Female sexual desire and arousal disorders combined
into one disorder “female sexual interest/arousal
disorder”
Vaginismus and Dyspareunia combined to form
Genito pelvic pain/Penetration disorder .

Substance related and addictive disorders
Gambling disorder , Cannabis withdrawal and Caffeine
withdrawal are new conditions introduced
No more substance abuse and dependence , only
substance use disorders

Neurocognitive Disorders
Mild NCD , newly introduced condition to cover
milder forms of memory impairment (?MCI)

Personality Disorders
No change in criterion as such but new approach to
diagnosis.

C r i t i c a l An a l y s i s of DSM- 5

1) Disruptive Mood Dysregulation Disorder may turn temper tantrums
into a mental disorder.
2) Normal grief may become Major Depressive Disorder.
3) The everyday forgetting characteristic of old age will now be
misdiagnosed as Minor Neurocognitive Disorder.
4) DSM 5 will likely trigger a fad of Adult Attention Deficit Disorder
leading to widespread misuse of stimulant drugs for performance
enhancement and recreation.
5) Excessive eating 12 times in 3 months is no longer just a
manifestation of gluttony but it is a psychiatric illness called Binge
Eating Disorder.

6) The changes in the DSM 5 definition of Autism will result in lowered
rates- perhaps by 50% according to outside research groups.
7) First time substance abusers will be lumped in definitionaly in with
hard core addicts despite their very different treatment needs and
prognosis and the stigma this will cause.
8) Behavioral Addictions that eventually can spread to make a mental
disorder of everything we like to do a lot. Eg; New proposed internet
addiction
9) DSM 5 obscures the already fuzzy boundary been Generalized
Anxiety Disorder and the worries of everyday life.
10) DSM 5 has opened the gate even further to the already existing
problem of misdiagnosis of PTSD in forensic settings.

Thank you