After Debate, Feedback, and Revision, DSM-5 Arrives, With Some Surprising Changes
Gary G. Gintner PhD, LPC
Chair, AMHCA DSM-5 Task Force
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.
DSM Comparison Chart
Compare the list of differences between the
DSM-IV-R and the DSM-5:
Download the DSM Comparison Chart.
Lori Russell–Chapin, PhD,
LCPC, ACS, CCMHC, of Bradley University.
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.
The Global Assessment of Functioning Scale has also been discontinued. Another disability rating scale will be available (World Health Organization Disability Assessment Schedule II [WHODAS 2.0]), but its use is purely optional.
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.
Another important change is the introduction of spectrum disorders such as Autism Spectrum Disorder, which combines a number of similar disorders that overlapped, according to research. In terms of the criteria sets themselves, you will see that there are more specifiers available, each of which has been tied to prognosis or treatment response.
For example, with anxious distress is a new specifier that can be used with a number of the mood disorders. It has been associated with higher suicide risk, longer duration of symptoms, and a more complicated treatment response. With peripartum onset is a new specifier that covers onset of mood symptoms from pregnancy through one month following delivery.
Overall, the diagnostic options will make for a more narrative description of features for the particular disorder. One concern I have, however, is that the additional specifiers and coding options may make the diagnostic process more cumbersome, especially for busy clinicians.
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 section on cultural factors includes a 16-item cultural interview guide to assess the impact of culture on the clinical presentation. There is also a subsection of proposed disorders that need further study, such as an alternative personality disorder model, internet gaming disorder, and nonsuicidal self-injury.
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.
The sequence of chapters and disorders within chapters are arranged developmentally. For example, the Anxiety Disorders chapter starts with Separation Anxiety Disorder and then progresses to disorders that typically appear later in life. The criteria sets and narrative portions for each disorder are much more specific than in DSM-IV-TRregarding how symptoms present for children, adolescents, and adults.
The DSM-5 also includes more gender-specific information, with many of the chapters having a separate “gender issues” section. You’ll notice a number of gender-specific disorders, such as those listed in the Sexual Dysfunctions section. New disorders are included, such as Premenstrual Dysphoric Disorder. And what was called Gender Identity Disorder in DSM-IV-TR is now called Gender Dysphoria, in hopes of reducing the stigma. Nevertheless, there is still controversy about whether it should have been included at all.
Finally, cultural issues are more prominent throughout the manual, and there is much more information about how disorders may present as a function of race, ethnicity, and culture.
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.
Time will tell, but my guess is that some of these innovations will prove valuable, while others are off the mark. One example of the latter is the introduction of Disruptive Mood Dysregulation Disorder, which tries to better identify children with severe anger outbursts and irritable mood. The data support was too thin at this point and this would have been better placed in Section III for conditions requiring further study.
One difference in the DSM process is that the American Psychiatric Association plans to modify the DSM more frequently than it has in the past, based on accumulating data. So just as you get used to the new manual, be ready for the notice that DSM-5.1 updates are ready to download.
Gary Gintner, PhD, LPC, is a nationally recognized trainer on the DSM and best practice guidelines. His 30 years of clinical experience includes inpatient care, substance abuse counseling, and outpatient mental health. A past president of AMHCA, he currently chairs its DSM-5 Task Force. He is also an associate professor and program coordinator of the Counseling Program at Louisiana State University.