After Debate, Feedback, and Revision, DSM-5 Arrives, With Some Surprising Changes
I was at the annual conference of the American Psychiatric Association (APA) in San Francisco when it released its much-anticipated DSM-5 on May 18. Publication of the Diagnostic and Statistical Manual “marked the end of more than a decade’s journey in revising the criteria for the diagnosis and classification of mental disorders,” notes APA’s DSM-5 Task Force Chair David Kupfer, MD, and Co-Chair Darrel Regier, MD, MPH.
I attended a number of DSM-5 sessions at the conference, including an all-day workshop led by each of the DSM-5 workgroup chairs. Amazingly, the workshop
handout packet contained 350 slides, and each one was covered in the presentation.
The program reviewed the major changes and provided opportunities for the more than 400 participants to ask questions. It was interesting hearing the various stories about how these changes came about, including how these workgroup members had devoted about six years of their professional lives to this endeavor.
The buzz at the APA conference was fairly positive, but some contentious questions were raised. Most of the participants were psychiatrists, but some, like myself, were from other disciplines. I had a number of good conversations with those who sat around me and found the atmosphere very collegial. Later in the afternoon of the workshop, I had my first opportunity to obtain the DSM-5 manual itself and, finally, to crack it open.
SECTION I — Practical Issues
The first of the manual’s three major sections, Section I, deals with introductory comments and practical issues in writing a diagnosis and using the manual. The multi-axial system has been discontinued and replaced by a single-axis system on which former Axis I-III disorders are coded. The only remnant of Axis IV is the option of using V-codes, which can be used as way of noting situational or contextual factors.
SECTION II — Codes and Criteria Sets
Section II contains the codes and criteria sets for all of the disorders. There are 20 chapters and roughly the same number of disorders as in DSM-IV-TR, but the chapter organization and names of some the disorders may seem foreign. For example, the former anxiety disorders chapter has been divided into three chapters, Anxiety Disorders (e.g., phobias, Panic Disorder, and Generalized Anxiety Disorder), Obsessive-Compulsive and Related Disorders (e.g., OCD, Hoarding Disorder, Excoriation Disorder), and Trauma- and Stressor-Related Disorders (e.g., PTSD, Adjustment Disorder). The rationale for the change was that research evidence suggested that this was a more accurate way of clustering these disorders.
SECTION III — Tools to Enhance Diagnosis
Section III provides information and tools that can enhance the diagnostic process. Included are assessment inventories for broadband screening of various symptoms, and the WHODAS 2.0 to assess disability and specific severity measure for symptoms such as psychosis. These inventories are available online.
A Change That Might Surprise You About the DSM-5
Even if you’ve been scanning the Internet commentary about the DSM-5, you probably never have heard of what I consider one of its biggest contributions: The manual devotes considerably more attention than DSM-IV-TR did to developmental, gender, and cultural factors. Of these, the infusion of developmental factors throughout the manual is the most significant.
It’s Not Just a Revision
These changes mark a real transformation of the manual. It has been referred to as a paradigm shift, not without reason. Some critics of the manual, including psychiatrist Allen Frances, MD—chair of the DSM-IV Task Force and professor emeritus of Duke University School of Medicine—believe that the DSM-5 effort should have been more conservative.
7/27/2017 » 7/29/2017
2017 AMHCA Annual Conference