This document provides an overview of the main themes and diagnostic revisions in the DSM-5. It outlines 10 major changes incorporated in the new manual, including making it more user-friendly, incorporating a spectrum perspective, adding dimensionality, reflecting a developmental perspective, increasing emphasis on culture and gender, enhancing diagnostic information, matching ICD codes, reinventing it as a living document, introducing a hybrid diagnostic model, and using more biologically-based criteria. It also reviews revisions to several diagnostic categories such as neurodevelopmental disorders, schizophrenia spectrum disorders, bipolar disorders, depressive disorders, anxiety disorders, and trauma-related disorders.
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The DSM-5: Overview of Main Themes and Diagnostic Revisions
1. 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. 2
Abstract
⢠DSM-5 represents the fieldâs 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. 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. 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 ânormalâ
human functioning.
6. 6
Acknowledgements
⢠Zur Institute (2013). DSM-5 â 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. 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. 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. 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
manualâs development.
⢠Appendix.
10. 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.
12. 12
Primary Goals of DSM-5 Task Force in
Creating the New Manual
⢠Increase cultural sensitivity;
⢠Deepen the clinicianâs 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. 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).
15. 15
Change #2. Incorporate a Spectrum
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 ânormalâ
and âabnormalâ behavior is, ultimately,
arbitrary.
16. 16
Change #2. Incorporate a Spectrum
Perspective
⢠Example: OCD is removed from the âAnxiety
Disordersâ category (DSM-IV-TR) and
repositioned in a new category called
âObsessive-Compulsive and Related Disordersâ
(DSM-5).
⢠The beam of light going into the prism
(underlying core factor of anxiety)
splits into several separate but
related diagnostic categories.
17. 17
Change #2. Incorporate a Spectrum
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., âNeurodevelopmental Disordersâ
(includes Autism Spectrum Disorder,
ADHD, and other disorders reflecting
abnormal brain development).
19. 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. 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. 21
Change #4. Reflect a Developmental
Perspective
(2) For specific disorders, variations of symptom
presentations across the lifespan are described.
22. 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 clientâs subjective view of cultural
factors re: the presentation of symptoms (effort
is to diminish the clinicianâs own cultural
biases).
23. 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 âOther
Specifiedâ (need to give a reason)
or âUnspecified Disorderâ
(donât need to give a reason).
24. 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. 25
Change #8. Reinvent DSM To Be a
âLivingâ 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. 26
Change #9. Introduce the Potential of the
So-called âHybridâ Model in Subsequent
DSMs
27. 27
Change #9. Introduce the Potential
of the So-called âHybridâ 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. 28
Change #9. Introduce the Potential
of the So-called âHybridâ 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. 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. 30
Part III. A Select Review of Revised
Diagnostic Categories and Disorders in
DSM-5
32. 32
âNeurodevelopmental Disordersâ: Shifts
Disorder Name
Used To Be In (DSM-IVTR)
Now In (DSM-5):
Separation Anxiety
âDisorders Usually First
Diagnosed in Infancy,
Childhood and Adolescenceâ
âAnxiety Disordersâ
Selective Mutism
âDisorders Usually First
Diagnosed in Infancy,
Childhood and Adolescenceâ
âAnxiety Disordersâ
33. 33
âSchizophrenia Spectrum and Other
Psychotic Disordersâ
â˘
â˘
â˘
â˘
â˘
â˘
â˘
â˘
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. 34
âSchizophrenia Spectrum and Other
Psychotic Disordersâ: Shifts
Disorder Name
Used To Be In (DSMIV-TR)
Now In (DSM-5)
Schizotypal
(Personality)
Disorder
Axis II Personality
Disorders
âSchizophrenia Spectrum
and Other Psychotic
Disordersâ and âPersonality
Disordersâ
Schizophrenia
Subtypes include
Paranoid, Disorganized,
Catatonic,
Undifferentiated, and
Residual
Subtypes removed
35. 35
âSchizophrenia Spectrum and Other
Psychotic Disordersâ: 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
âClinician-Rated Dimensions of Psychosis
Symptom Severityâ in Section III of the DSM5 Manual (pp. 742-744).
36. 36
âBipolar and Related Disordersâ
â˘
â˘
â˘
â˘
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. 37
âBipolar and Related Disordersâ:
Shifts
⢠Depressive Disorders and Bipolar Disorders no
longer listed under the umbrella category of
âMood Disordersâ (as was the case in DSM-IVTR).
38. 38
âBipolar and Related Disordersâ:
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., âWith anxious distressâ: capture
anxiety symptoms.
39. 39
âDepressive Disordersâ
â˘
â˘
â˘
â˘
â˘
Disruptive Mood Dysregulation Disorder
Major Depressive Disorder
Persistent Depressive Disorder (Dysthymia)
Premenstrual Dysphoric Disorder
Substance/Medication-Induced Depressive
Disorder
⢠Other and Unspecified
40. 40
âDepressive Disordersâ: Shifts
Disorder Name
Used To Be In (DSM-IVTR)
Now In (DSM-5)
Disruptive Mood
Dysregulation Disorder
--
âDepressive Disordersâ
Premenstrual Dysphoric
Disorder
Disorders in Need of Further
Research
âDepressive Disordersâ
Persistent Depressive
Disorder (Dysthymia)
âDysthymic Disorderâ in the
âDepressive Disordersâ
subcategory of Mood
Disorders
âDepressive Disordersâ
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. 41
âDepressive Disordersâ: Criteria/Notes
⢠MDD: essentially the same criteria set.
⢠A major depressive episode with at least 3 manic
symptoms is now coded with the specifier âwith
mixed featuresâ (see pg. 162).
⢠Persistent Depressive Disorder (Dysthymia):
what used to be known as âdouble
depressionâ (refractory major depressive
episodes along with chronic sub-threshold
depressive symptoms).
42. 42
âDepressive Disordersâ: 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?
44. 44
âAnxiety Disordersâ: Shifts
Disorder Name
Used To Be In (DSM-IV-TR)
Now In (DSM-5)
Separation Anxiety
Disorder
âDisorders Usually First Diagnosed in
Infancy, Childhood and Adolescenceâ
âAnxiety Disordersâ
Selective Mutism
âDisorders Usually First Diagnosed in
Infancy, Childhood and Adolescenceâ
âAnxiety Disordersâ
Agoraphobia
Panic Disorder Without Agoraphobia and
Agoraphobia With or Without Panic
Disorder in âAnxiety Disordersâ
Panic Disorder and
Agoraphobia de-linked but
still fall under âAnxiety
Disordersâ
OCD
âAnxiety Disordersâ
âObsessive Compulsive and
Related Disordersâ
Acute Stress Disorder
âAnxiety Disordersâ
âTrauma and StressorRelated Disordersâ
PTSD
âAnxiety Disordersâ
âTrauma and StressorRelated Disordersâ
Body Dysmorphic
Disorder
âSomatoform Disordersâ
âObsessive Compulsive and
Related Disordersâ
45. 45
âAnxiety Disorders:â 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 âfalse positiveâ GAD diagnoses.
47. 47
âTrauma- and Stressor-Related
Disordersâ
Disorder Name
Used To Be In (DSM-IV-TR)
Now In (DSM-5)
Reactive Attachment
Disorder
âDisorders Usually First Diagnosed in
Infancy, Childhood and Adolescenceâ
âTrauma and StressorRelated Disordersâ
Disinhibited Social
Engagement Disorder
--
âTrauma and StressorRelated Disordersâ
PTSD
âAnxiety Disordersâ
âTrauma and StressorRelated Disordersâ
Acute Stress Disorder
âAnxiety Disordersâ
âTrauma and StressorRelated Disordersâ
Adjustment Disorders
âAdjustment Disordersâ
âTrauma and StressorRelated Disordersâ
48. 48
âTrauma- and Stressor-Related
Disordersâ: 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 childâs opportunity
to form selective attachments.
⢠For PTSD, attempted to specify âtraumaâ as
an actual or threatened death, serious
injury or sexual violation.
49. 49
âTrauma- and Stressor-Related
Disordersâ: Controversy
⢠New criteria (i.e., âEmotional reactions to
the traumatic event [fear, helplessness,
horror]â [p. 274] no longer being necessary)
may dilute what is actually deemed âtraumatic.â
⢠Diagnosis may occur for people who have not
had direct exposure but merely learned about a
violent traumatic event suffered by a loved one.
51. 51
âSubstance-Related and Addictive
Disordersâ: Criteria/Notes
⢠âAbuseâ and âdependenceâ 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. 52
âSubstance-Related and Addictive
Disordersâ: Controversies
⢠âFirst-time substance abusers are now lumped
together with heroine addictsâ (Zur Institute,
2013);
⢠Category has been expanded beyond
psychoactive substances:
53. 53
âNeurocognitive Disordersâ
⢠Delirium
⢠Major Neurocognitive Disorder (with Etiological
Subtypes)
Alzheimerâs Disease
Vascular Disease
Traumatic Brain Injury
HIV Infections
Parkinsonâs Disease
Huntingtonâs Disease
Substance/Medication.
⢠Mild Neurocognitive Disorder (specifiers
correspond to the disease process to which the
cognitive decline is due)
59. 59
(#1) Assessment Measures
World Health Organization Disability Assessment
Schedule 2.0 (WHODAS)
â˘
â˘
â˘
â˘
â˘
â˘
Understanding and communicating
Getting around
Self-care
Getting along with people
Life activities (household, work, or school)
Participation in society
64. 64
Amazon Review: Jonathan Karmel
⢠âThis 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. 65
Amazon Review: Jonathan Karmel
⢠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. 66
Amazon Review: Jonathan Karmel
⢠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.â
67. 67
Amazon Review: Jonathan Karmel
⢠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. 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 âreduced
thresholdâ problem.
⢠May lead to stigma/mislabeling of those who
would do better without a psychiatric diagnosis.
69. 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. 70
#2. Are DSM-5 Diagnoses Valid?
National Institute of Mental Health
(NIMH) director Thomas Insel
announced that it would no longer use
DSM diagnoses in research projects
due to the manualâs lack of validity.
⢠He contends the manual should be used solely
as a dictionary so that clinicians share the
same descriptions of symptoms.
71. 71
#2. Are DSM-5 Diagnoses Valid?
⢠Research indicates that 2 clinicians agree on a
diagnosis of major depression only 60 percent of
the time (Zur Institute, 2013).
72. 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. 73
#4. Are the DSM-5 Diagnoses Irrelevant to
the Cause and Treatment of
Psychological Problems?
⢠Despite changes in the DSM-5, it remains âa
topographical symptom mapâ (Zur Institute,
2013): does not capture causal pathways that
give rise to and maintain illness.
75. 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. 76
How, in What Ways, for What Patients,
under What Therapeutic Conditions Does
Diagnostic Nomenclature Help or Hinder?
77. 77
Final Words
⢠The therapeutic process remains the best
diagnostic tool, providing the clinician with a
view of the patientâs 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. 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. 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. 80
Final Words
⢠The clinician uses the diagnostic nomenclature
yet remains skeptical of its ultimate authority
and truth.