Understanding the changes in DSM-5

The latest revision of the diagnostic manual does away with the complex multiaxial organization in favor of a simpler chapter listing of disorders.

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was unveiled at the annual American Psychiatric Association (APA) meeting in San Francisco in May 2013. After nearly a decade of multilevel scientific, clinical, and public-health review, the new guidelines are ready for immediate use by the APA and in your own clinical practice. The original DSM was published in 1952, with a fourth revision in 1994, and a text revision in 2000. To incorporate new research and advances in knowledge since the last revision, the APA recruited a task force and various study groups consisting of top researchers and clinicians worldwide.

The new guidelines became eligible for application in May 2013. The complete transition is slated for December 31, 2013, allowing for delays as insurance companies update claim forms and reporting diagnoses and codes. DSM-5 is compatible with the World Health Organization's International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes for immediate use. Transition to use of the ICD-10-CM is currently set for October 1, 2014. The transition to ICD-10-CM is required by the Health Insurance Portability and Accountability Act of 1996. To accommodate differing DSM-5 and ICD-10-CM disorder names, the DSM diag- nosis should always be documented in medical records in addition to the ICD code. National board examinations generally take two to three years to incorporate new guidelines.

DSM-5 has been restructured to consist of three sections in addition to the preface, the classification of coding portion, and the appendix. The new manual has removed the multiaxial organization (Axes I-V) of disorders by combining the first three DSM-IV-TR axes into a single developmental list. The nonaxial documentation includes all mental and personal- ity disorders, including intellectual disability, with separate scales for measuring symptom severity and disability. The noteworthy changes address the names of disorders, enhance criteria to align all providers in accurately assessing patients, and identify the impact a diagnosis has on daily functioning.

This brief review of the new three-part structure outlined below contains some of the key changes in DSM-5 that may impact your clinical practice.

Section 1: DSM-5 basics

The introductory section of the new volume outlines the changes in the order in which they appear.

Section 2: Diagnostic criteria and codes

The previous multiaxial structure is now divided into topics with subtopics. The nonaxial documentation for diagnosis will combine the former Axes I, II, and III, with separate notations for psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V).

Substantial changes were made to the following disorders:

Intellectual disability. The federal law (Rosa's Law) signed by President Obama on October 5, 2010, replaced the term "mental retardation" with "intellectual disability." DSM-5 will adopt this diagnostic term to align with the rest of the medi- cal, educational, and advocacy communities. Intellectual dis- ability is based on clinical assessment and standardized testing of intelligence. DSM-5 emphasizes that intelligence should be assessed across three domains of adaptive functioning: (1) conceptual domain (language, reading, math); (2) social domain (social judgment, interpersonal communication); and (3) practical domain (personal care, job responsibilities). The intelligence quotient (IQ) will no longer be used as a diagnostic criterion but is still recommended for assessment. Intellectual disability is suggested for individuals with an IQ score of approximately 70 or below (two standard deviations below the population). Severity can be specified as mild, moderate, severe, or profound. Severity is determined by adaptive functioning rather than cognitive capacity (i.e., IQ).

Autism spectrum disorder (ASD). A graded scale now combines the former four autism-related disorders: autistic, Asperger, childhood disintegrative, and pervasive developmental. In DSM-5, ASD is a collective condition that reflects severity of symptoms encompassing deficits in social communication and interaction and restricted repetitive behaviors (RRBs), interests, and activities. (Note: If RRBs are not present, the diagnosis of social communication disorder is suggested.)

The new criteria will allow for variation in symptoms and behaviors between individuals. Placing a patient on a spectrum rather than providing an individual diagnosis prevents inconsistency between clinicians and reduces the risk of misdiagnosis. DSM-5 requires symptoms to be present from early childhood even if ASD is not assessed or diagnosed until later in life. A recent study found that 91% of children diagnosed with ASD using DSM-5 criteria were also diagnosed with one of the four DSM-IV autism-related disorders.1 This study shows that most children will retain a diagnosis of ASD when converting to the new guidelines.

Attention deficit hyperactivity disorder (ADHD). The DSM-5 criteria divide the 18 diagnostic symptoms from DSM-IV into inattention and hyperactivity. Key changes include the addition of examples to help identify the disorder across the life span and the facts that: symptoms are now required to be present before age 12 years rather than age 7 years; a diagnosis of both ADHD and ASD is now permitted; the symptom threshold for ADHD in adults has been lowered to five symptoms (six for those younger); and ADHD is now listed as a neurodevel- opmental disorder rather than a disruptive disorder.

Specific learning disorder. All previous learning disorders are now combined into a single diagnosis, which acknowledges the fact that academic deficits commonly occur together. A coding specifier can be added to designate deficits in reading, mathematics, written expression, and learning disorder not otherwise specified.

Catatonia. This diagnosis now requires three out of 12 catatonic symptoms for all contexts. Diagnosis can be made separately or as a specifier for bipolar, psychotic, or depres- sive disorder.

Disruptive mood dysregulation disorder. This new diagnosis identifies children experiencing persistent irritability and extreme changes in mood without bipolar disorder. This change addresses and prevents overdiagnosis and treatment of bipolar in patients aged 6 to 18 years. Diagnostic criteria include persistent irritability and frequent behavior outbursts occurring at least three times per week for over a year.

Major depressive disorder (MDD). No modifications have been made to the core symptom criteria or length of symptoms for diagnosis (at least two weeks). However, a bereavement exclusion modification removes the exemption of diagnosing MDD when grief is present within two months of the death of a loved one. This change reflects the belief that bereave- ment can be a stressor precipitating depression soon after a loss and that grief can last up to two years. Bereavement now does not exempt one from being diagnosed with MDD, and guidance is given regarding how to differentiate grief from depressive disorders. In cases of grief, self-esteem is usually preserved, and painful feelings present in waves mixed with positive memories. Cases of depressive disorders commonly feature feelings of worthlessness and self-loathing and constant negative thoughts. Depression both related and unrelated to bereavement responds to the same or similar treatment options.

Persistent depressive disorder. This new diagnosis, which includes chronic MDD and the previous dysthymic disorder, was formed after an inability to scientifically find meaning- ful differences between dysthymia and chronic depression.

Suicide risk assessment scales. Two new suicide risk assess- ment scales-one for adolescents and one for adults-help identify individuals with suicidal risk factors, gives clinical guidance, and recommend assessment of suicidal thinking and plans. The goal is to implement suicide prevention while devising treatment plans.

Premenstrual dysphoric disorder (PMDD). PMDD is a state of extremely high tension, anxiety, and aggression. Criteria for this diagnosis include five or more symptoms during most menstrual cycles with presence in the week prior to menses onset, improvement of symptoms a few days after menses, and absence in the week following menses. The symptoms must cause clinically significant distress affecting work, school, social activities, or relationships.

Obsessive-compulsive and related disorders. This new chapter adds hoarding disorder (including specifiers for personal insight into the problematic nature of the hoarding-related beliefs [i.e., good/fair, poor, or absent insight]), excoria- tion (i.e., skin picking), substance- or medication-induced obsessive-compulsive and related disorder including specifiers for onset of the disorder (i.e., during intoxication, with- drawal, or after medication use), and obsessive-compulsive and related disorder due to another medical condition.2

Other specified and unspecified obsessive-compulsive and related disorders. This diagnosis is reserved for conditions that do not fit into a designated category. Such conditions include body- focused repetitive behavior disorder-such recurrent behaviors as cheek-chewing, lip-biting, and nail-biting that the patient has repeatedly and unsuccessfully tried to stop-and obsessional jealousy (nondelusional obsessions of a partner's infidelity).

Body dysmorphic disorder. Preoccupation with physical appearance resulting in such repetitive behaviors or acts as looking in a mirror and reassurance-seeking is now added to the manual. Specifiers include degree of insight into the individual's beliefs of appearing "ugly or deformed" and the option to add "with muscle dysmorphia" for individuals preoccupied with insufficient muscularity.

Post-traumatic stress disorder (PTSD). Stressor criteria have become more explicit in DSM-5, and symptom clusters have been increased from three to four. These clusters include:

* Re-experiencing the traumatic event (memories, dreams, flashbacks)

* Persistent avoidance of stimuli associated with the event

* Persistent negative alterations in cognitions and mood

* Marked alterations in arousal and reactivity (aggressive, reckless, or self-destructive behavior).

By lowering the threshold of criteria, DSM-5 is more sensitive for diagnosing PTSD in children and adolescents. A new subtype with separate criteria has been included for children aged 6 years or younger.

Feeding and eating disorders. This category now includes the diagnosis of binge-eating disorder, which is specified as bing- ing on food one or more times per week for three months. The criterion for bulimia nervosa has been reduced to one or more episodes of binge-eating per week (in DSM-IV, it was two episodes per week). Anorexia no longer includes the criterion of amenorrhea to prevent excluding men, women in pre-menarche, women who use contraception, and women in post-menarche.

Gender dysphoria. A transition from the previous "Sexual and gender identity disorders" reflects the variations in criteria and experiences regarding the diagnosis of gender dysphoria. Identifying with a gender different from what an individual was assigned at birth does not constitute a mental disorder; it is the stressors resulting from this dys- phoria that meet the criteria for diagnosis. Removing the term "disorder" indicates a movement toward eliminating stigma surrounding affected individuals by modifying the terminology that previously suggested the patient is "dis- ordered."3 Gender dysphoria was included in the manual to facilitate clinical care and allow access to insurance coverage that supports mental health. The concern with complete omission of gender dysphoria would be denial of medical treatments that include counseling, cross-sex hormones, gender reassignment, and legal transition. Separate criteria are provided for children and must also be present for at least six months. A post-transition specifier can be applied when an individual's post-gender transition no longer meets criteria and treatment is still needed, whether surgical, endocrinologic, or psychotherapeutic.

Substance-related and addictive disorders. The diagnosis of gambling disorder is now included under the chapter related to substance disorders, reflecting evidence that addictive behaviors (i.e., gambling) activate the brain's reward system in a manner similar to that of drugs or alcohol. DSM-5 also combines substance abuse and dependence into the overall diagnosis of substance use disorder. Criteria changes include the removal of "recurrent legal problems" and addition of "craving or a strong desire or urge to use a substance." A new diagnosis is included for cannabis withdrawal. Severity of substance use disorder is ranked by the number of symp- tom criteria: mild disorder (2-3); moderate disorder (4-5); severe (6 or more).

Communication disorders. Phonological disorder is referred to as speech sound disorder in DSM-5, and stuttering is referred to as childhood-onset fluency disorder. Social (pragmatic) communication disorder is a new diagnostic category in DSM-5. This diagnosis was created to more accurately recognize individuals who have significant problems using verbal and nonverbal communication for social purposes. This difficulty can cause impairments in the individual's ability to communicate effectively, participate socially, maintain social relationships, or otherwise perform at school or at work.

Anxious distress specifier. Individuals with the diagnosis of a depressive or bipolar disorder can have the specifier "with anxious distress" added.

Social anxiety disorder (SAD). The features of SAD, formerly termed "social phobia," are essentially the same. Changes include removing the requirement of individuals older than age 18 years to recognize their anxiety and now require all ages to have duration of symptoms for six months or longer. The only specifier offered is "performance only," which is used to identify fears regarding speaking or performing in front of an audience.

Panic attack. The optional features of describing a panic attack are replaced with the diagnosis of expected or unex- pected panic attacks. A panic attack specifier can be added to all DSM-5 disorders.

Somatic symptoms and related disorders. Previously, somatoform disorders had overlapping symptoms and lacked well-defined boundaries for diagnosis. Removal of individual disorders now falling under this diagnosis includes hypochondriasis, pain disorder, somatization disorder, and undifferentiated somatoform disorder.

Parasomnias. The independent sleep-wake disorders in DSM-5 include rapid eye movement sleep behavior disorder and restless leg syndrome. Previous research suggested that these disorders should no longer fall under the DSM-IV category "not otherwise specified."

Section 3: Emerging measures and models

Section 3 of DSM-5 includes the chapters Assessment Measures, Cultural Formulation, and Conditions for Further Study.

Assessment Measures. The World Health Organization Disability Assessment Schedule (WHO-DAS 2.0) is considered the best current measure for disability based on the International Classification of Functioning, Disability, and Health.

Conditions for Further Study. Continued research is recom- mended in determining whether criteria should be made for formal diagnosis of:

* Attenuated psychosis syndrome: This syndrome could identify an individual who shows relevant psychotic symptoms suggesting an increased risk for developing a psychotic disorder without meeting criteria for a formal diagnosis.

* Caffeine use disorder: Research indicates that the drink- ing of as few as two or three cups of coffee can trigger a withdrawal effect marked by tiredness or sleepiness.4,5 The extent of clinical impact on an individual has not been identified.

* Internet gaming disorder: This disorder reflects research and scientific findings that identify preoccupation with online gaming that causes significant clinical distress and impairment. Currently, the condition only applies to gaming and does not include online gambling, general Internet use, or social media. Studies have shown evidence in Asian countries, primarily among young males.

* Nonsuicidal self-injury: This category includes skin cutting, burning, scratching, and banging when suicide is not the intention.

What is the controversy?

The authors of the DSM-5 still have a great deal of work left to do in refining the new guidelines and continuing with research in the field of psychological disorders.6 This edition was drafted to reduce the stigma of mental illnesses, more accurately label and clarify diagnoses, and improve medical understanding. Critics believe that the new version is too broad and are concerned that nearly half of the U.S. popula- tion will meet the criteria for at least one DSM-5 diagnosis at some point7 (see "Critics question the methodology and transparency of DSM-5," on page 74). The DSM-5 changes aim to create access to clinical treatment for patients who may lack well-defined symptoms for a diagnosis. The manual is used to help determine an accurate diagnosis and repre- sents only one part of the overall care delivered to patients. Ultimately, the clinician is the key to identifying, screening, treating, and following the individual. n

The latest version of the DSM is the first full revision since 1994.

Critics question the methodology and transparency of DSM-5

WALKER HARRISON

The release of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) this in May 2013 was met with criticism within the mental health profession.

Modifications in diagnostic criteria for autism, bipolar disorder, attention-deficit hyperactivity disorder (ADHD), and other conditions have been questioned by experts. Many suspect that the manual has been influenced by the pharmaceutical industry, which could benefit from an increase in drug prescriptions for people with the aforementioned conditions.

Among the detractors are two authors of previous versions of the manual. Robert L. Spitzer, MD, head of the task force for DSM-3, expressed outrage over the fact that the creators of DSM-5 signed a nondisclosure agreement, allowing them to operate confidentially. "When I first heard about this agreement, I just went bonkers. Transparency is necessary if the document is to have credibility," said Dr. Spitzer.

Allen Frances, MD, chair of the DSM-IV task force, was also skeptical, pointing to the increasingly mild and ambiguous signs for such disorders as ADHD proposed by DSM-5 that could add to the widespread overdiagnosis of these conditions.

"The DSM-5 should buck the trend and its inclinations-it should be ending false epidemics, not starting them," said Dr. Frances, who also called the work a "most unhappy combination of soaring ambition and weak methodology."

In an effort to quantify the concern over the then upcoming DSM-5, the Massachusetts General Hospital Psychiatry Academy partnered with myCME (myCME.com) to conduct a survey of medical professionals' opinions on the matter. The survey was sent to clinicians in December 2012 and January 2013 and received 144 responses.

Responses were split into physicians (36.8%) and nonphysicians (63.2%). Almost all nonphysicians (94.6%) were nurse practitio- ners or physician assistants. More than 75% of respondents had more than 10 years of practice experience, and 91.6% were in the field of psychiatry.

Nonphysicians appeared to be more interested in the release of DSM-5 than were physicians: 88% of the former expressed at least moderate anticipation about the new manual, compared with 70.6% of the latter. Meanwhile, 11.3% of physicians were indiffer- ent to the release, and 15.1% said they would only pay attention once it impacted their practice, compared with 4.4% and 6.6%, respectively, for nonphysicians.

In general, clinicians expressed anxiety about understanding the changes made to diagnostic criteria. A large majority (84%) were at least "somewhat concerned" that implementing the revi- sions would be complicated, with just over half (50.7%) reporting high levels of concern. Moreover, only 14.6% of participants felt "very confident" that they would be able to put the changes into practice. Nonphysicians were more optimistic than physi- cians about the prospects of DSM-5, as 67% reported at least moderate confidence in incorporating the changes, compared with 47.2% for physicians.

When clinicians were asked to specify what exactly con- cerned them about DSM-5, the most common answers were the time required and available to understand the new manual, access to education on the new guidelines, and insurance- and reimbursement-related issues.

Therapeutic areas of DSM-5 that troubled clinicians most were bipolar disorder (59.0%), autism spectrum disorders (47.9%), depression (47.2%), substance abuse disorders (45.8%), and post- traumatic stress disorder (41.0%).

With regard to actually educating themselves, 87.8% of partici- pants said they would seek to do so either right away or soon after the release of DSM-5, while almost half (49.3%) planned on primarily using the Internet to learn about the revised manual.

While there are certainly some clinicians who are not fretting about DSM-5, the general trends of the survey seem to indicate high levels of doubt surrounding the manual and reflect the overall anxious mood of practitioners in the related fields.

Symptoms of premenstrual dysphoric disorder must cause clinically significant distress affecting work, school, social activities, or relationships.

The independent sleep-wake disorders include rapid eye movement sleep behavior disorder and restless leg syndrome.

"I hear it's because we're right and they're wrong."

"Being falsely accused on social media has left my life largely unchanged."

References

1. Huerta M, Bishop SL, Duncan A, et al. Application of DSM-5 criteria for autism spectrum disorder to three samples of children with DSM-IV diagnoses of pervasive developmental disorders. Am J Psychiatry. 2012;169:1056-1064. Available at ajp.psychiatryonline.org/article. aspx?articleid=1367813.

2. Psychiatric News. DSM-5 updates depressive, anxiety, and OCD criteria. Available at psychnews.psychiatryonline.org/newsArticle. aspx?articleid=1653568.

3. Kuhl EA, Kupfer DJ, Regier DA. Patient-centered revisions to the DSM-5. Virtual Mentor. 2011;13:873-879. Available at virtualmentor .ama-assn.org//2011/12/stas1-1112.html.

4. Monthly Prescribing Reference. Caffeine withdrawal syndrome -an official diagnosis? Available at www.empr.com/caffeine-withdrawal -syndrome-an-official-diagnosis/article/296408/.

5. Medscape. Caffeine withdrawal recommended for inclusion in DSM-5. Available at www.medscape.com/viewarticle/755557.

6. Kraemer HC, Kupfer DJ, Narrow WE, et al. Moving toward DSM-5: the field trials. Am J Psychiatry. 2010;167:1158-1160. Available at ajp.psychiatry- online.org/article.aspx?articleid=102483.

7. Kupfer DJ, Regier DA. Why all of medicine should care about DSM-5. JAMA. 2010;303:1974-1975.

All electronic documents accessed November 15, 2013.

FEATURE: AMBER WHITMORE, PA-C

Mr. Harrison is a freelance medical writer in New York City.

Ms. Whitmore is an assistant professor at the University of Florida School of Physician Assistant Studies in Gainesville.