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Abstract

The authors report on the use of the DSM-III, several years after its introduction, in the clinical diagnosis of 154 subjects with first onset psychosis. Clinicians usually assigned Axis I diagnoses but used the remainder of the multiaxial system less than one time in three; if a standard recording form was in place, the multiaxial system was used more often. Trainees used the DSM-III most, followed by psychiatrists affiliated with a university and community based clinicians. Agreement between researchers and clinicians on diagnoses was fair to poor. The authors discuss the implications of the acceptance of the complex diagnostic system in routine clinical practice.

Since its publication in 1980, the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) (1) has had a major impact on psychiatric research (2). However, as Klerman noted, “in the long run, the acceptance of DSM-III by clinical practitioners will be the main determinant of its impact, independently of scholarly and research activities” (3). In recent surveys, American and Canadian psychiatrists have reported that they routinely use DSM-III terminology and two or more of the five axes (–). However, no publications to date have recorded the actual acceptance, as opposed to reported acceptance of the DSM-III multiaxial system in clinical practice. The accuracy with which the system is used in routine practice also remains an important area of inquiry. In this paper, we report patterns of use of DSM-III diagnoses in everyday clinical practice.

Method

The population chosen for this study consisted of 175 subjects from the University of British Columbia Markers and Predictors (MAP) study, all of whom experienced their first episode of psychosis during the two year period from 1982 to 1984. Details of the patient’s characteristics and the recruitment process used in the prospective cohort study are reported elsewhere (). A research clinician conducted a semi-structured clinical interview, the Present State Examination (PSE) Ninth Edition (9), with each subject. In addition, research assistants obtained extensive information from each subject, from significant others and from referral sources. Data were evaluated by at least two clinicians using a “best estimate” approach () to record the presence or absence of all the criteria relevant to each possible DSM-III diagnosis. Then, using a strict application of DSM-III rules, diagnoses were assigned to each subject. Research diagnoses were not communicated to the treating staff.

Typically, our research subjects encountered several treatment agencies during the first episode of their illness. For example, an initial assessment in a hospital emergency room was followed by transfer to an inpatient setting and finally by discharge to a community agency. In each of these settings, the patient probably received an admission and discharge assessment, thus generating a great many diagnoses during the episode, although these were not necessarily independent of one another. All hospital and community mental health agency records of the initial illness were obtained for 154 of the 175 MAP subjects. Charts were unavailable or could not be located for 21 subjects. Each admission and discharge diagnosis found on these charts was recorded. All diagnoses obtained in this manner were examined by the principal author to determine whether or not they could be classified into DSM-III categories and how systematically the multiaxial system was employed. Criteria used to arrive at these judgements were generous. For example, if it was unclear whether the principal diagnosis was made using the ICD-9 or the DSM-III, the diagnosis was assumed to reflect a DSM-III category. Any indication of use, including a notation of “no diagnosis” on an axis, was counted as an instance of use of the axis.

In addition to determining the frequency of use of the DSM-III, the clinical diagnoses recorded on 147 of the 154 subjects were used to assess agreement with the researchers’ diagnoses. For seven of the subjects, no DSM-III diagnosis was recorded. For this evaluation, we assumed that the researchers’ diagnoses represented the best possible application of DSM-III criteria, i.e., diagnoses arrived at by an extensive accumulation of data and strict adherence to DSM-III guidelines. Community based clinicains’ diagnoses were compared to the researchers’ assessments.

We also gathered information about diagnosticians and the settings in which the diagnoses were made. By checking diagnostician names against published professional listings, we established characteristics such as age, sex, professional background, level of training and whether or not the diagnostician was affiliated with a university. One of the hospitals introduced a standardized form to record DSM-III diagnoses mid-way through the intake period of the MAP study. This made possible a comparison of DSM-III use before and after the form was instituted in this particular setting.

Over half the diagnosticians were psychiatric residents and senior medical student interns in a clerkship rotation in psychiatry. All residents and medical students were based at university teaching hospitals: 43% were females and almost all were under age 40. In contrast, the majority of the practising psychiatrists who made diagnoses were over 40 years of age, only 15% were female and many worked in community or non university settings. Compared with psychiatrists affiliated with a university, those without university appointments were older, more likely to have been in practice longer and to have completed their psychiatric training outside North America. Almost all were working in clinical settings not affiliated with the university. A small number of diagnoses were made by nurses, social workers and psychologists.

Results

There were 587 opportunities (at admission, transfer and discharge) for the 154 patients in this study to receive a diagnosis. Clinicians actually recorded diagnoses on 523 occasions (89.1%). Table I examines the extent to which the DSM-III was used by the person diagnosing the subject — for example, all diagnoses made by psychiatrists in practice who had university appointments are arranged in column 1 and so forth. There were significant differences between groups of diagnosticians recording Axis I diagnoses. Residents, medical students and psychiatrists with a university affiliation almost always used DSM-III Axis I. In contrast, about one-third of the diagnoses made by psychiatrists without faculty appointments and by clinicians (usually nurses) in the “other” category either recorded no diagnosis or used another classification system, such as the ICD-9 or an idiosyncratic “impression”.

Table I

Overall Use of the DSM-III and its Multiaxial Systems by Type of Diagnostician

In the 523 cases where Axis I was apparently used, we examined the diagnosticians’ use of each of the axes independent of their use of the DSM-III as a whole. Thus, the denominator for the Axis II to V comparisons is the number of times the DSM-III was used, i.e., the number of Axis I diagnoses recorded.

Overall, diagnosticians used Axis II in less than one-third of the cases and Axis III just over one-quarter of the time. Axes IV and V were used less than one time in five. Medical students as a group most frequently used the multiaxial system, recording on Axes II through V over twice as often as psychiatrists with a university appointment. Psychiatrists not affiliated with a university and other clinicians rarely used any axis other than Axis I.

As noted, a standardized form for recording multiple axes of DSM-III was introduced in one of the settings. Use of Axes I and II or more increased from 27% (n = 12) to 55% (n = 18) after introduction of the form (chi-square = 6.31, df = 1, p < 0 .005). At the same time, use of Axis I without other axes decreased from 73% (n = 33) to 45% (n = 15).

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One estimate of the accuracy of DSM-III use is the frequency of appropriate recordings on each axis. Frequency of inappropriate use was 22.9% (n = 120) for Axis I, 5.4% (n = 9) for Axis II, 2.9% (n = 4) for Axis III, 29.0% (n = 27) for Axis IV and 14.6% (n = 13) for Axis V. Examples of inappropriate use of Axis I were terms such as “psychosis NYD” (psychosis not yet diagnosed) and “paranoid psychosis,” usually followed by a differential diagnosis using conventional DSM-III terminology. On Axes II through V, occasionally diagnoses belonging to other axes were recorded, for example, alcohol abuse on Axis III. Axes IV and V frequently contained lists of stressors and level of functioning respectively without any ratings. This was not considered inappropriate use in this study.

DSM-III Axis I is intended to be used for multiple recordings such as schizophrenic disorder or substance abuse (1). However, clinicians rarely made such additional diagnoses, even when a “substance-induced psychosis” was recorded in the differential diagnosis.

We compared the frequency with which major diagnostic categories were recorded by clinicians with the MAP researchers’ diagnoses. Results, presented in Table II, suggest that in routine clinical practice, the diagnosis of schizophrenia is assigned more often than in a research setting with strict adherence to DSM-III criteria, whereas the researchers diagnosed affective disorder more often.

Table II

We also examined the level of agreement between community based clinicians’ diagnoses and researchers’ diagnoses. Because most patients had an inpatient hospital stay and were referred to the MAP project during that admission, DSM-III discharge diagnoses from those settings were selected as most comparable to the research diagnoses. Since all patients had had a psychotic episode, the four major categories of psychotic disorders were analyzed. Clinicians’ diagnoses in each category were compared with researchers’ diagnoses. Agreement was assessed using the kappa statistic (). Results are presented in Table III. For comparison, we also present kappa coefficients obtained in field trials of the DSM-III and reported in the DSM-III handbook (1).

Table III

There was not much agreement between the clinicians and the researchers diagnoses and there was considerable variability among major diagnostic classes. The reliability of the clinicians’ assessments of Axis I affective disorders was fair (k = 0.53). However, it was poor for schizophrenic disorders and very poor for psychotic disorders not elsewhere classified and paranoid disorders. The interrater reliability was also poor for Axes II and III. Kappa coefficients were not calculated for Axes IV and V because of their low numbers.

Discussion

Our findings suggest that clinicians use the multiaxial DSM-III system in their practices far less than they claim when surveyed. In clinical practice Axes II and III are used in less than one-third of the Axis I diagnoses, and Axes IV and V are rarely used. The frequency of Axes II to V use could be artificially lowered if many diagnoses assumed to be Axis I were actually ICD-9 diagnoses. However, maximum values from this study for use of multiple axes would still only be in the 55% to 60% range. A recent study of an Oregon state hospital reports a similar frequency for use of Axis III ().

Clinicians in this study used non DSM-III generic labels such as “psychosis NYD” quite frequently. This is comparable to those in surgical specialties employing the term “abdominal pain NYD,” a widely used but discouraged practice of identifying the primary complaint instead of the diagnosis. More distressing was the frequent omission of important additional diagnoses such as alcohol abuse (). Treece () has suggested a separate assessment for each patient on substance related disorders. Instead of adding an axis, however, a standard DSM-III recording form might help overcome this problem by prompting the clinician to consider such additional diagnoses.

Mezzich () proposed a standard recording form for the DSM-III in 1982. Our study results suggest provision of a form does increase routine use of the DSM-III, as predicted by Williams () and implied in a recent article (). The recording form serves as a prompt and encourages the use of the multiaxial system.

The estimates of reliability were better for affective disorders than for schizophrenic disorders and psychosis not elsewhere classified. This could be because patients with affective disorders present with more clear-cut or recognizable symptom profiles, or that clinicians find the criteria for DSM-III affective disorders easier to use than for other psychotic conditions. Our results are consistent with other studies (6,) which report that patients are often assigned diagnoses even if they do not satisfy all the necessary criteria. Traditionally, it has been difficult to obtain a consensus when defining schizophrenia (,). This study suggests that clinicians may be having difficulties using the DSM-III operational criteria intended for schizophrenic disorders. This is an even greater problem with atypical psychotic disorders having less established criteria. For example, schizophreniform disorder was a new classification in the DSM-III and the criteria probably needed refining for the DSM-III-R listing (20,). Kappa coefficients for Axes II and III were also low.

Several factors limit the extent to which the findings of this study can be generalized. First, the estimate of the extent of use could be inflated because of the methods employed. When it was unclear whether a recorded diagnosis was made using the DSM-III or the ICD-9, it was assumed to have been the DSM-III. Diagnoses made subsequent to the initial recording may have been based on that first diagnosis. Inflated results could also be affected by the fact that these were all cases of first episode psychosis, a situation in which one might expect clinicians to exert the greatest care and attention when making a diagnosis. On the other hand, these results may underestimate current use, since they are from 1982 to 1984, when administrators in many community settings still expected psychiatrists to use the ICD-9. This study may reflect clinical preference of the multiaxial system, the use of which is reinforced in many settings.

Secondly, since the study is based on one Canadian centre, we may not be able to generalize results to other areas of Canada or the United States. While the Canadian Psychiatric Association does not officially endorse any one diagnostic classification system, survey results indicate DSM-III is the preferred system by Canadian psychiatrists (6,). DSM-III manuals were widely distributed throughout Canada and the US from 1980 on. The University of British Columbia Department of Psychiatry embraced the DSM-III wholeheartedly in 1980, teaching only this system of classification to medical students and residents. The findings in this study reflect this, as the DSM-III has had its most noticeable impact on the diagnostic practices of medical students and residents, a result consistent with survey reports from the United States () and Canada (6).

The comparison of the clinicians’ discharge diagnoses with the researchers diagnoses is limited by several considerations. Since research and clinical assessments did not take place at exactly the same time, clinicians and research teams may not have exactly the same data available upon which to base judgements. Differences in interviewer qualities are also known to be important factors in interrater reliability (). Standard interviews were not used in clinical settings. Without standard interviews, Spitzer () has suggested that residents’ diagnoses are probably not accurate enough for research purposes, and it is likely this is also true for practising psychiatrists (). Some of the clinicians preferred diagnoses, assumed to be Axis I, could actually have been ICD-9 diagnoses. Each of these factors compromises interrater reliability.

Clinicians working in university affiliated settings use the DSM-III more often than clinicians in other settings. Perhaps over time there will be a fanning-out effect beginning with academics, progressing to clinicians affiliated with a university, and finally to practitioners in the community. Two to four years after the introduction of a new diagnostic manual may be too early for clinicians based in the community to embrace the system. Since this study was done, psychiatrists trained in university programs have taken key administrative positions in non university settings in greater Vancouver. These clinicians have encouraged the use of the DSM-III classification system for all patients. It is likely that an increased rate of use of the multiaxial system in non academic settings would be evident if this study were to be repeated now.

A majority of psychiatrists have indicated the multiaxial system is too complex or time consuming for day-to-day practice (6). Lack of knowledge about the clinical value of the information recorded on the multiaxial system may contribute to the low rate of use. Recent studies (,) suggest the Axis V rating is strongly correlated with decisions about hospital admissions and is a valuable predictor of future functioning in patients with a schizophreniform disorder. There is a widely held belief that a comprehensive approach to evaluation, such as the multiaxial system, is clinically useful (2,). However, there is a need for more research to assess the actual value of each axis (1,).

The primary goal of a diagnostic classification system in a clinical setting is to communicate information useful in making treatment and management decisions about patients. Despite drawbacks, the DSM-III is by common consensus the most comprehensive diagnostic system yet devised and the one most likely to improve the reliability of diagnosis and the clarity of communication. However, if busy clinicians are to adopt a complex system of diagnosis and use it consistently and appropriately, they must learn to use it, have confidence in its clinical value and have a standard recording form or compact visual reminder summarizing its intricacies. Our results indicate lower than expected rates of use and accuracy of the DSM-III, considering the high level of acceptance of the system in the academic setting. This suggests that, for the DSM-III to be clinically useful, the operational criteria and the multiaxial system need to be simplified.

We recommend replication of this study in other North American clinical settings. Future studies will be complicated by the recent introduction of the DSM-III-R (). However, DSM-III-R retains the basic structure of the multiaxial diagnostic system. It remains important to determine how widely accepted the DSM-III format is for routine clinical practice and to estimate the time it takes for a new classification system to gain acceptance by clinicians in the community. Such data would undoubtedly be helpful in the planning of the DSM-IV, especially if major structural changes are proposed for the ever-evolving psychiatric nosological system.

Acknowledgments

The authors thank Janice Husted and Janet B.W. Williams for comments on the manuscript.

References

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is the 2013 update to the Diagnostic and Statistical Manual of Mental Disorders, the taxonomic and diagnostic tool published by the American Psychiatric Association (APA). In the United States, the DSM serves as the principal authority for psychiatric diagnoses. Treatment recommendations, as well as payment by health care providers, are often determined by DSM classifications, so the appearance of a new version has significant practical importance.

The DSM-5 was published on May 18, 2013, superseding the DSM-IV-TR, which was published in 2000. The development of the new edition began with a conference in 1999 and proceeded with the formation of a Task Force in 2007, which developed and field-tested a variety of new classifications. In most respects, the DSM-5 is not greatly modified from the DSM-IV-TR; however, some significant differences exist between them. Notable changes in the DSM-5 include the reconceptualization of Asperger syndrome from a distinct disorder to an autism spectrum disorder; the elimination of subtypes of schizophrenia; the deletion of the 'bereavement exclusion' for depressive disorders; the renaming of gender identity disorder to gender dysphoria, along with a revised treatment plan; the inclusion of binge eating disorder as a discrete eating disorder; the renaming and reconceptualization of paraphilias to paraphilic disorders; the removal of the axis system; and the splitting of disorders not otherwise specified into other specified disorders and unspecified disorders. In addition, the DSM-5 is the first DSM to use an Arabic numeral instead of a Roman numeral in its title, as well as the first 'living document' version of a DSM.^[1]

Various authorities criticized the fifth edition both before and after it was formally published. Critics assert, for example, that many DSM-5 revisions or additions lack empirical support; inter-rater reliability is low for many disorders; several sections contain poorly written, confusing, or contradictory information; and the psychiatric drug industry unduly influenced the manual's content. Many of the members of work groups for the DSM-5 had conflicting interests, including ties to pharmaceutical companies.^[2] Various scientists have argued that the DSM-5 forces clinicians to make distinctions that are not supported by solid evidence, distinctions that have major treatment implications, including drug prescriptions and the availability of health insurance coverage. General criticism of the DSM-5 ultimately resulted in a petition, signed by many mental health organizations, which called for outside review of the DSM-5.^[3]

• 1Changes
  • 1.2Section II: diagnostic criteria and codes
  • 1.3Section III: emerging measures and models
• 5Criticism

Changes[edit]

This part of the article summarizes changes from the DSM-IV to the DSM-5. The DSM-5 is divided into three Sections, using Roman numerals to designate each Section. The same organizational structure is used in this overview, e.g., Section I (immediately below) summarizes relevant changes discussed in the DSM-5, Section I.

Note that if a specific disorder (or set of disorders) cannot be seen, e.g., enuresis and other elimination disorders, mentioned in Section II: diagnostic criteria and codes (below), it means that the diagnostic criteria for those disorders did not change significantly from DSM-IV to DSM-5.

Section I[edit]

Section I describes DSM-5 chapter organization, its change from the multiaxial system, and Section III's dimensional assessments.^[4] The DSM-5 deleted the chapter that includes 'disorders usually first diagnosed in infancy, childhood, or adolescence' opting to list them in other chapters.^[4] A note under Anxiety Disorders says that the 'sequential order' of at least some DSM-5 chapters has significance that reflects the relationships between diagnoses.^[4]

This introductory section describes the process of DSM revision, including field trials, public and professional review, and expert review. It states its goal is to harmonize with the ICD systems and share organizational structures as much as is feasible. Concern about the categorical system of diagnosis is expressed, but the conclusion is the reality that alternative definitions for most disorders are scientifically premature.

The new version replaces the NOS (Not Otherwise Specified) categories with two options: other specified disorder and unspecified disorder to increase the utility to the clinician. The first allows the clinician to specify the reason that the criteria for a specific disorder are not met; the second allows the clinician the option to forgo specification.

DSM-5 has discarded the multiaxial system of diagnosis (formerly Axis I, Axis II, Axis III), listing all disorders in Section II. It has replaced Axis IV with significant psychosocial and contextual features and dropped Axis V (Global Assessment of Functioning, known as GAF). The World Health Organization's (WHO) Disability Assessment Schedule is added to Section III (Emerging measures and models) under Assessment Measures, as a suggested, but not required, method to assess functioning.^[5]

Section II: diagnostic criteria and codes[edit]

Neurodevelopmental disorders[edit]

• 'Mental retardation' has a new name: 'intellectual disability (intellectual developmental disorder)'.^[6]
• Phonological disorder and stuttering are now called communication disorders—which include language disorder, speech sound disorder, childhood-onset fluency disorder, and a new condition characterized by impaired social verbal and nonverbal communication called social (pragmatic) communication disorder.^[6]
• Autism spectrum disorder incorporates Asperger disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (PDD-NOS)—see Diagnosis of Asperger syndrome § DSM-5 changes.^[7]
• A new sub-category, motor disorders, encompasses developmental coordination disorder, stereotypic movement disorder, and the tic disorders including Tourette syndrome.^[8]

Schizophrenia spectrum and other psychotic disorders[edit]

• All subtypes of schizophrenia were removed from the DSM-5 (paranoid, disorganized, catatonic, undifferentiated, and residual).^[4]
• A major mood episode is required for schizoaffective disorder (for a majority of the disorder's duration after criterion A [related to delusions, hallucinations, disorganized speech or behavior, and negative symptoms such as avolition] is met).^[4]
• Criteria for delusional disorder changed, and it is no longer separate from shared delusional disorder.^[4]
• Catatonia in all contexts requires 3 of a total of 12 symptoms. Catatonia may be a specifier for depressive, bipolar, and psychotic disorders; part of another medical condition; or of another specified diagnosis.^[4]

Bipolar and related disorders[edit]

• New specifier 'with mixed features' can be applied to bipolar I disorder, bipolar II disorder, bipolar disorder NED (not elsewhere defined, previously called 'NOS', not otherwise specified) and MDD.^[9]
• Allows other specified bipolar and related disorder for particular conditions.^[4]
• Anxiety symptoms are a specifier (called 'anxious distress') added to bipolar disorder and to depressive disorders (but are not part of the bipolar diagnostic criteria).^[4]

Depressive disorders[edit]

• The bereavement exclusion in DSM-IV was removed from depressive disorders in DSM-5.^[10]
• New disruptive mood dysregulation disorder (DMDD)^[11] for children up to age 18 years.^[4]
• Premenstrual dysphoric disorder moved from an appendix for further study, and became a disorder.^[4]
• Specifiers were added for mixed symptoms and for anxiety, along with guidance to physicians for suicidality.^[4]
• The term dysthymia now also would be called persistent depressive disorder.

Anxiety disorders[edit]

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• For the various forms of phobias and anxiety disorders, DSM-5 removes the requirement that the subject (formerly, over 18 years old) 'must recognize that their fear and anxiety are excessive or unreasonable'. Also, the duration of at least 6 months now applies to everyone (not only to children).^[4]
• Panic attack became a specifier for all DSM-5 disorders.^[4]
• Panic disorder and agoraphobia became two separate disorders.^[4]
• Specific types of phobias became specifiers but are otherwise unchanged.^[4]
• The generalized specifier for social anxiety disorder (formerly, social phobia) changed in favor of a performance only (i.e., public speaking or performance) specifier.^[4]
• Separation anxiety disorder and selective mutism are now classified as anxiety disorders (rather than disorders of early onset).^[4]

Obsessive-compulsive and related disorders[edit]

• A new chapter on obsessive-compulsive and related disorders includes four new disorders: excoriation (skin-picking) disorder, hoarding disorder, substance-/medication-induced obsessive-compulsive and related disorder, and obsessive-compulsive and related disorder due to another medical condition.^[4]
• Trichotillomania (hair-pulling disorder) moved from 'impulse-control disorders not elsewhere classified' in DSM-IV, to an obsessive-compulsive disorder in DSM-5.^[4]
• A specifier was expanded (and added to body dysmorphic disorder and hoarding disorder) to allow for good or fair insight, poor insight, and 'absent insight/delusional' (i.e., complete conviction that obsessive-compulsive disorder beliefs are true).^[4]
• Criteria were added to body dysmorphic disorder to describe repetitive behaviors or mental acts that may arise with perceived defects or flaws in physical appearance.^[4]
• The DSM-IV specifier “with obsessive-compulsive symptoms” moved from anxiety disorders to this new category for obsessive-compulsive and related disorders.^[4]
• There are two new diagnoses: other specified obsessive-compulsive and related disorder, which can include body-focused repetitive behavior disorder (behaviors like nail biting, lip biting, and cheek chewing, other than hair pulling and skin picking) or obsessional jealousy; and unspecified obsessive-compulsive and related disorder.^[4]

Trauma- and stressor-related disorders[edit]

• Posttraumatic stress disorder (PTSD) is now included in a new section titled 'Trauma- and Stressor-Related Disorders.'^[12]
• The PTSD diagnostic clusters were reorganized and expanded from a total of three clusters to four based on the results of confirmatory factor analytic research conducted since the publication of DSM-IV.^[13]
• Separate criteria were added for children six years old or younger.^[4]
• For the diagnosis of acute stress disorder and PTSD, the stressor criteria (Criterion A1 in DSM-IV) was modified to some extent. The requirement for specific subjective emotional reactions (Criterion A2 in DSM-IV) was eliminated because it lacked empirical support for its utility and predictive validity.^[13] Previously certain groups, such as military personnel involved in combat, law enforcement officers and other first responders, did not meet criterion A2 in DSM-IV because their training prepared them to not react emotionally to traumatic events.^[14][15][16]
• Two new disorders that were formerly subtypes were named: reactive attachment disorder and disinhibited social engagement disorder.^[4]
• Adjustment disorders were moved to this new section and reconceptualized as stress-response syndromes. DSM-IV subtypes for depressed mood, anxious symptoms, and disturbed conduct are unchanged.^[4]

Dissociative disorders[edit]

• Depersonalization disorder is now called depersonalization/derealization disorder.^[17]
• Dissociative fugue became a specifier for dissociative amnesia.^[4]
• The criteria for dissociative identity disorder were expanded to include 'possession-form phenomena and functional neurological symptoms'. It is made clear that 'transitions in identity may be observable by others or self-reported'.^[4] Criterion B was also modified for people who experience gaps in recall of everyday events (not only trauma).^[4]

Somatic symptom and related disorders[edit]

• Somatoform disorders are now called somatic symptom and related disorders.
• Patients that present with chronic pain can now be diagnosed with the mental illness somatic symptom disorder with predominant pain; or psychological factors that affect other medical conditions; or with an adjustment disorder.^{[4][18][19][20][21]}
• Somatization disorder and undifferentiated somatoform disorder were combined to become somatic symptom disorder, a diagnosis which no longer requires a specific number of somatic symptoms.^[4]
• Somatic symptom and related disorders are defined by positive symptoms, and the use of medically unexplained symptoms is minimized, except in the cases of conversion disorder and pseudocyesis (false pregnancy).^[4]
• A new diagnosis is psychological factors affecting other medical conditions. This was formerly found in the DSM-IV chapter 'Other Conditions That May Be a Focus of Clinical Attention'.^[4]
• Criteria for conversion disorder (functional neurological symptom disorder) were changed.^[4]

Feeding and eating disorders[edit]

• Criteria for pica and rumination disorder were changed and can now refer to people of any age.^[4]
• Binge eating disorder graduated from DSM-IV's 'Appendix B -- Criteria Sets and Axes Provided for Further Study' into a proper diagnosis.^[22]
• Requirements for bulimia nervosa and binge eating disorder were changed from 'at least twice weekly for 6 months to at least once weekly over the last 3 months'.
• The criteria for anorexia nervosa were changed; there is no longer a requirement of amenorrhea.
• 'Feeding disorder of infancy or early childhood', a rarely used diagnosis in DSM-IV, was renamed to avoidant/restrictive food intake disorder, and criteria were expanded.^[4]

Elimination disorders[edit]

• No significant changes.^[4]
• Disorders in this chapter were previously classified under disorders usually first diagnosed in infancy, childhood, or adolescence in DSM-IV. Now it is an independent classification in DSM 5.^[4]

Sleep–wake disorders[edit]

• 'Sleep disorders related to another mental disorder, and sleep disorders related to a general medical condition' were deleted.^[4]
• Primary insomnia became insomnia disorder, and narcolepsy is separate from other hypersomnolence.^[4]
• There are now three breathing-related sleep disorders: obstructive sleep apnea hypopnea, central sleep apnea, and sleep-related hypoventilation.^[4]
• Circadian rhythm sleep–wake disorders were expanded to include advanced sleep phase syndrome, irregular sleep–wake type, and non-24-hour sleep–wake type.^[4]Jet lag was removed.^[4]
• Rapid eye movement sleep behavior disorder and restless legs syndrome are each a disorder, instead of both being listed under 'dyssomnia not otherwise specified' in DSM-IV.^[4]

Sexual dysfunctions[edit]

• DSM-5 has sex-specific sexual dysfunctions.^[4]
• For females, sexual desire and arousal disorders are combined into female sexual interest/arousal disorder.^[4]
• Sexual dysfunctions (except substance-/medication-induced sexual dysfunction) now require a duration of approximately 6 months and more exact severity criteria.^[4]
• A new diagnosis is genito-pelvic pain/penetration disorder which combines vaginismus and dyspareunia from DSM-IV.^[4]
• Sexual aversion disorder was deleted.^[4]
• Subtypes for all disorders include only 'lifelong versus acquired' and 'generalized versus situational' (one subtype was deleted from DSM-IV).^[4]
• Two subtypes were deleted: 'sexual dysfunction due to a general medical condition' and 'due to psychological versus combined factors'.^[4]

Gender dysphoria[edit]

• DSM-IV gender identity disorder is similar to, but not the same as, gender dysphoria in DSM-5. Separate criteria for children, adolescents and adults that are appropriate for varying developmental states are added.
• Subtypes of gender identity disorder based on sexual orientation were deleted.^[4]
• Among other wording changes, criterion A and criterion B (cross-gender identification, and aversion toward one's gender) were combined.^[4] Along with these changes comes the creation of a separate gender dysphoria in children as well as one for adults and adolescents. The grouping has been moved out of the sexual disorders category and into its own. The name change was made in part due to stigmatization of the term 'disorder' and the relatively common use of 'gender dysphoria' in the GID literature and among specialists in the area.^[23] The creation of a specific diagnosis for children reflects the lesser ability of children to have insight into what they are experiencing and ability to express it in the event that they have insight.^[24]

Disruptive, impulse-control, and conduct disorders[edit]

Free xexmenu download without jtag 2016 - full version. Some of these disorders were formerly part of the chapter on early diagnosis, oppositional defiant disorder; conduct disorder; and disruptive behavior disorder not otherwise specified became other specified and unspecified disruptive disorder, impulse-control disorder, and conduct disorders.^[4]Intermittent explosive disorder, pyromania, and kleptomania moved to this chapter from the DSM-IV chapter 'Impulse-Control Disorders Not Otherwise Specified'.^[4]

• Antisocial personality disorder is listed here and in the chapter on personality disorders (but ADHD is listed under neurodevelopmental disorders).^[4]
• Symptoms for oppositional defiant disorder are of three types: angry/irritable mood, argumentative/defiant behavior, and vindictiveness. The conduct disorder exclusion is deleted. The criteria were also changed with a note on frequency requirements and a measure of severity.^[4]
• Criteria for conduct disorder are unchanged for the most part from DSM-IV.^[4] A specifier was added for people with limited 'prosocial emotion', showing callous and unemotional traits.^[4]
• People over the disorder's minimum age of 6 may be diagnosed with intermittent explosive disorder without outbursts of physical aggression.^[4] Criteria were added for frequency and to specify 'impulsive and/or anger based in nature, and must cause marked distress, cause impairment in occupational or interpersonal functioning, or be associated with negative financial or legal consequences'.^[4]

Substance-related and addictive disorders[edit]

• Gambling disorder and tobacco use disorder are new.^[4]
• Substance abuse and substance dependence from DSM-IV-TR have been combined into single substance use disorders specific to each substance of abuse within a new 'addictions and related disorders' category.^[25] 'Recurrent legal problems' was deleted and 'craving or a strong desire or urge to use a substance' was added to the criteria.^[4] The threshold of the number of criteria that must be met was changed^[4] and severity from mild to severe is based on the number of criteria endorsed.^[4] Criteria for cannabis and caffeine withdrawal were added.^[4] New specifiers were added for early and sustained remission along with new specifiers for 'in a controlled environment' and 'on maintenance therapy'.^[4]

DSM-5 substance dependencies include:

• 303.90 Alcohol dependence
• 304.00 Opioid dependence
• 304.10 Sedative, hypnotic, or anxiolytic dependence (including benzodiazepine dependence and barbiturate dependence)
• 304.20 Cocaine dependence
• 304.30 Cannabis dependence
• 304.40 Amphetamine dependence (or amphetamine-like)
• 304.50 Hallucinogen dependence
• 304.60 Inhalant dependence
• 304.80 Polysubstance dependence
• 304.90 Phencyclidine (or phencyclidine-like) dependence
• 304.90 Other (or unknown) substance dependence
• 305.10 Nicotine dependence

There are no more polysubstance diagnoses in DSM-5; the substance(s) must be specified.^[26]

Neurocognitive disorders[edit]

• Dementia and amnestic disorder became major or mild neurocognitive disorder (major NCD, or mild NCD).^[4][27] DSM-5 has a new list of neurocognitive domains.^[4] 'New separate criteria are now presented' for major or mild NCD due to various conditions.^[4]Substance/medication-induced NCD and unspecified NCD are new diagnoses.^[4]

Personality disorders[edit]

• Personality disorder (PD) previously belonged to a different axis than almost all other disorders, but is now in one axis with all mental and other medical diagnoses.^[28] However, the same ten types of personality disorder are retained.^[28]
• There is a call for the DSM-5 to provide relevant clinical information that is empirically based to conceptualize personality as well as psychopathology in personalities. The issue(s) of heterogeneity of a PD is problematic as well. For example, when determining the criteria for a PD it is possible for two individuals with the same diagnosis to have completely different symptoms that would not necessarily overlap.^[29] There is also concern as to which model is better for the DSM - the diagnostic model favored by psychiatrists or the dimensional model that is favored by psychologists. The diagnostic approach/model is one that follows the diagnostic approach of traditional medicine, is more convenient to use in clinical settings, however, it does not capture the intricacies of normal or abnormal personality. The dimensional approach/model is better at showing varied degrees of personality; it places emphasis on the continuum between normal and abnormal, and abnormal as something beyond a threshold whether in unipolar or bipolar cases.^[30]

Paraphilic disorders[edit]

• New specifiers 'in a controlled environment' and 'in remission' were added to criteria for all paraphilic disorders.^[4]
• A distinction is made between paraphilic behaviors, or paraphilias, and paraphilic disorders.^[31] All criteria sets were changed to add the word disorder to all of the paraphilias, for example, pedophilic disorder is listed instead of pedophilia.^[4] There is no change in the basic diagnostic structure since DSM-III-R; however, people now must meet both qualitative (criterion A) and negative consequences (criterion B) criteria to be diagnosed with a paraphilic disorder. Otherwise they have a paraphilia (and no diagnosis).^[4]

Section III: emerging measures and models[edit]

Alternative DSM-5 model for personality disorders[edit]

An alternative hybrid dimensional-categorical model for personality disorders is included to stimulate further research on this modified classification system.^[32]

Conditions for further study[edit]

These conditions and criteria are set forth to encourage future research and are not meant for clinical use.

• Non-suicidal self-injury^[33]

Development[edit]

In 1999, a DSM–5 Research Planning Conference; sponsored jointly by APA and the National Institute of Mental Health (NIMH), was held to set the research priorities. Research Planning Work Groups produced 'white papers' on the research needed to inform and shape the DSM-5^[34] and the resulting work and recommendations were reported in an APA monograph^[35] and peer-reviewed literature.^[36] There were six workgroups, each focusing on a broad topic: Nomenclature, Neuroscience and Genetics, Developmental Issues and Diagnosis, Personality and Relational Disorders, Mental Disorders and Disability, and Cross-Cultural Issues. Three additional white papers were also due by 2004 concerning gender issues, diagnostic issues in the geriatric population, and mental disorders in infants and young children.^[37] The white papers have been followed by a series of conferences to produce recommendations relating to specific disorders and issues, with attendance limited to 25 invited researchers.^[37]

On July 23, 2007, the APA announced the task force that would oversee the development of DSM-5. The DSM-5 Task Force consisted of 27 members, including a chair and vice chair, who collectively represent research scientists from psychiatry and other disciplines, clinical care providers, and consumer and family advocates. Scientists working on the revision of the DSM had a broad range of experience and interests. The APA Board of Trustees required that all task force nominees disclose any competing interests or potentially conflicting relationships with entities that have an interest in psychiatric diagnoses and treatments as a precondition to appointment to the task force. The APA made all task force members' disclosures available during the announcement of the task force. Several individuals were ruled ineligible for task force appointments due to their competing interests.^[38]

The DSM-5 field trials included test-retest reliability which involved different clinicians doing independent evaluations of the same patient—a common approach to the study of diagnostic reliability.^[39]

About 68% of DSM-5 task-force members and 56% of panel members reported having ties to the pharmaceutical industry, such as holding stock in pharmaceutical companies, serving as consultants to industry, or serving on company boards.^[40]

Revisions and updates[edit]

Beginning with the fifth edition, it is intended that diagnostic guideline revisions will be added incrementally.^[41] The DSM-5 is identified with Arabic rather than Roman numerals, marking a change in how future updates will be created. Incremental updates will be identified with decimals (DSM-5.1, DSM-5.2, etc.), until a new edition is written.^[42] The change reflects the intent of the APA to respond more quickly when a preponderance of research supports a specific change in the manual. The research base of mental disorders is evolving at different rates for different disorders.^[41]

Criticism[edit]

General[edit]

Robert Spitzer, the head of the DSM-III task force, publicly criticized the APA for mandating that DSM-5 task force members sign a nondisclosure agreement, effectively conducting the whole process in secret: 'When I first heard about this agreement, I just went bonkers. Transparency is necessary if the document is to have credibility, and, in time, you're going to have people complaining all over the place that they didn't have the opportunity to challenge anything.'^[43]Allen Frances, chair of the DSM-IV task force, expressed a similar concern.^[44]

Although the APA has since instituted a disclosure policy for DSM-5 task force members, many still believe the association has not gone far enough in its efforts to be transparent and to protect against industry influence.^[45] In a 2009 Point/Counterpoint article, Lisa Cosgrove, PhD and Harold J. Bursztajn, MD noted that 'the fact that 70% of the task force members have reported direct industry ties—an increase of almost 14% over the percentage of DSM-IV task force members who had industry ties—shows that disclosure policies alone, especially those that rely on an honor system, are not enough and that more specific safeguards are needed'.^[46]

David Kupfer, chair of the DSM-5 task force, and Darrel A. Regier, MD, MPH, vice chair of the task force, whose industry ties are disclosed with those of the task force,^[47] countered that 'collaborative relationships among government, academia, and industry are vital to the current and future development of pharmacological treatments for mental disorders'. They asserted that the development of DSM-5 is the 'most inclusive and transparent developmental process in the 60-year history of DSM'. The developments to this new version can be viewed on the APA website.^[48] Public input was requested for the first time in the history of the manual.^{[citation needed]} During periods of public comment, members of the public could sign up at the DSM-5 website^[49] and provide feedback on the various proposed changes.^[50]

In June 2009, Allen Frances issued strongly worded criticisms of the processes leading to DSM-5 and the risk of 'serious, subtle, (..) ubiquitous' and 'dangerous' unintended consequences such as new 'false 'epidemics'. He writes that 'the work on DSM-V has displayed the most unhappy combination of soaring ambition and weak methodology' and is concerned about the task force's 'inexplicably closed and secretive process'.^[51] His and Spitzer's concerns about the contract that the APA drew up for consultants to sign, agreeing not to discuss drafts of the fifth edition beyond the task force and committees, have also been aired and debated.^[52]

The appointment, in May 2008, of two of the taskforce members, Kenneth Zucker and Ray Blanchard, led to an internet petition to remove them.^[53] According to MSNBC, 'The petition accuses Zucker of having engaged in 'junk science' and promoting 'hurtful theories' during his career, especially advocating the idea that children who are unambiguously male or female anatomically, but seem confused about their gender identity, can be treated by encouraging gender expression in line with their anatomy.'^[54] According to The Gay City News, 'Dr. Ray Blanchard, a psychiatry professor at the University of Toronto, is deemed offensive for his theories that some types of transsexuality are paraphilias, or sexual urges. In this model, transsexuality is not an essential aspect of the individual, but a misdirected sexual impulse.'^[55] Blanchard responded, 'Naturally, it's very disappointing to me there seems to be so much misinformation about me on the Internet. [They didn't distort] my views, they completely reversed my views.'^[55] Zucker 'rejects the junk-science charge, saying there 'has to be an empirical basis to modify anything' in the DSM. As for hurting people, 'in my own career, my primary motivation in working with children, adolescents and families is to help them with the distress and suffering they are experiencing, whatever the reasons they are having these struggles. I want to help people feel better about themselves, not hurt them.'^[54]

In 2011, psychologist Brent Robbins co-authored a national letter for the Society for Humanistic Psychology that brought thousands into the public debate about the DSM. Approximately 13,000 individuals and mental health professionals signed a petition in support of the letter. Thirteen other American Psychological Association divisions endorsed the petition.^[56] In a November 2011 article about the debate in the San Francisco Chronicle, Robbins notes that under the new guidelines, certain responses to grief could be labeled as pathological disorders, instead of being recognized as being normal human experiences.^[57] In 2012, a footnote was added to the draft text which explains the distinction between grief and depression.^[58]

The DSM-5 has been criticized for purportedly saying nothing about the biological underpinnings of mental disorders.^[59] A book-long appraisal of the DSM-5, with contributions from philosophers, historians and anthropologists, was published in 2015.^[60]

The financial association of DSM-5 panel members with industry continues to be a concern for financial conflict of interest.^[61] Of the DSM-5 task force members, 69% report having ties to the pharmaceutical industry, an increase from the 57% of DSM-IV task force members.^[61]

A 2015 essay from an Australian university criticized the DSM-5 for having poor cultural diversity, stating that recent work done in cognitive sciences and cognitive anthropology is still only accepting western psychology as the norm.^[62]

Borderline personality disorder controversy[edit]

In 2003, the Treatment and Research Advancements National Association for Personality Disorders (TARA-APD) campaigned to change the name and designation of borderline personality disorder in DSM-5.^[63] The paper How Advocacy is Bringing BPD into the Light^[64] reported that 'the name BPD is confusing, imparts no relevant or descriptive information, and reinforces existing stigma.' Instead, it proposed the name 'emotional regulation disorder' or 'emotional dysregulation disorder.' There was also discussion about changing borderline personality disorder, an Axis II diagnosis (personality disorders and mental retardation), to an Axis I diagnosis (clinical disorders).^[65]

The TARA-APD recommendations do not appear to have affected the American Psychiatric Association, the publisher of the DSM. As noted above, the DSM-5 does not employ a multi-axial diagnostic scheme, therefore the distinction between Axis I and II disorders no longer exists in the DSM nosology. The name, the diagnostic criteria for, and description of, borderline personality disorder remain largely unchanged from DSM-IV-TR.^[66]

Chart 5011 Latest Edition Of Dsmx

British Psychological Society response[edit]

The British Psychological Society stated in its June 2011 response to DSM-5 draft versions, that it had 'more concerns than plaudits'.^[67] It criticized proposed diagnoses as 'clearly based largely on social norms, with 'symptoms' that all rely on subjective judgements.. not value-free, but rather reflect[ing] current normative social expectations', noting doubts over the reliability, validity, and value of existing criteria, that personality disorders were not normed on the general population, and that 'not otherwise specified' categories covered a 'huge' 30% of all personality disorders.

It also expressed a major concern that 'clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences.. which demand helping responses, but which do not reflect illnesses so much as normal individual variation'.

The Society suggested as its primary specific recommendation, a change from using 'diagnostic frameworks' to a description based on an individual's specific experienced problems, and that mental disorders are better explored as part of a spectrum shared with normality:

National Institute of Mental Health[edit]

National Institute of Mental Health director Thomas R. Insel, MD,^[68] wrote in an April 29, 2013 blog post about the DSM-5:^[69]

Insel also discussed an NIMH effort to develop a new classification system, Research Domain Criteria (RDoC), currently for research purposes only.^[70] Insel's post sparked a flurry of reaction, some of which might be termed sensationalistic, with headlines such as 'Goodbye to the DSM-V',^[71] 'Federal institute for mental health abandons controversial 'bible' of psychiatry',^[72] 'National Institute of Mental Health abandoning the DSM',^[73] and 'Psychiatry divided as mental health 'bible' denounced'.^[74] Other responses provided a more nuanced analysis of the NIMH Director's post.^[75]

In May 2013, Insel, on behalf of NIMH, issued a joint statement with Jeffrey A. Lieberman, MD, president of the American Psychiatric Association,^[76] that emphasized that DSM-5 '.. represents the best information currently available for clinical diagnosis of mental disorders. Patients, families, and insurers can be confident that effective treatments are available and that the DSM is the key resource for delivering the best available care. The National Institute of Mental Health (NIMH) has not changed its position on DSM-5.' Insel and Lieberman say that DSM-5 and RDoC 'represent complementary, not competing, frameworks' for characterizing diseases and disorders.^[76] However, epistemologists of psychiatry tend to see the RDoC project as a putative revolutionary system that in the long run will try to replace the DSM, its expected early effect being a liberalization of the research criteria, with an increasing number of research centers adopting the RDoC definitions.^[77]

See also[edit]

References[edit]

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2. ^Welch, Steven; Klassen, Cherisse; Borisova, Oxana; Clothier, Holly (2013). 'The DSM-5 controversies: How should psychologists respond?'. Canadian Psychology. 54 (3): 166–175. doi:10.1037/a0033841.
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External links[edit]

• 'DSM-V The Future Manual'. American Psychiatric Association. Archived from the original on November 19, 2008.
• 'DSM-5 Update: Supplement to Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition'(PDF). PsychiatryOnline. American Psychiatric Association Publishing. September 2016.