An Overview and Clinical Implications: DSM-5

DSM: A brief history

• First published in 1844 as a descriptor of conditions of patients in mental institutions– Also used as a component of the U.S. Census

• DSM has gone through 4 iterations since World War II– Evolved into a diagnostic classification system of mental disorders widely

used by psychiatrists, physicians and other healthcare professionals• DSM 5 builds on its predecessors of providing guidelines for

diagnoses that can inform clinical care– Meant to be used as a clinical manual

DSM 5 Revision Process

• Did we need DSM 5?• The ideal for diagnosing: objective criteria and measurable biological markers, we are

far from this in psychiatry • Some argue that there have been insufficient advances in pathophysiologic,

phenomenologic, and therapeutic understanding of mental illness to warrant a new DSM • The Insel argument for a biologically based nosology for mental illness classification• Research Domain Criteria: Relies on genetics, imaging studies, and other biologically based

criteria for diagnosis• Revised classifications are to be based on brain structure and function implicating specific domains of

cognition, emotion, and behavior

• Currently, DSM and ICD are the contemporary consensus standards for diagnosis and treatment of mental disorders

• As the field changes, DSM must be periodically updated

DSM 5: Organizational Structure

• Section 1 Use of the Manual• Section 2 Diagnostic Criteria and Codes– Includes ICD-9 Codes– Cross-walked to ICD-10

• Section 3 Emerging Measures and Models

Harmonization with ICD-11• Reasons to harmonize:• Two different major classifications of mental disorders hinders:• Collection and use of national health statistics• Standardization of design of clinical trials that try to develop new treatments• Lack of harmonization is associated with lack of global applicability of results

by international regulatory agencies• Complicates attempts to replicate scientific results across national boundaries• Code order for ICD-10 codes in DSM 5 are not sequential as DSM 5 has been

correlated to the order of diagnoses and codes in the ICD-11 Chapter 5 Mental and behavioral disorders

The Multiaxial System

• Removed from DSM 5• DSM combines Axis I, II, III

• Multiple diagnoses can be recorded• Separate notations for psychosocial factors (former Axis IV) and disability (former Axis V)• Dimensional approach allows the rating of disorders by severity• Eliminates most of the need for a ‘not otherwise specified’ category; now termed ‘not elsewhere defined’• How to Record Diagnoses:

• Diagnosis(es) including medical illnesses related to psychiatric condition• Check diagnostic category: include descriptors of severity and note ICD-10 coding instructions by diagnosis• E.g.: Substance-related disorders: ICD-10 code for Opioid Withdrawal: F11.23• F11.20 is the ICD-10 code for opioid use disorder, moderate to severe, the 4th digit (3) indicates the opioid withdrawal state• This reflects that opioid withdrawal does not occur in someone with a mild opioid use disorder (F11.1)

• Old Axis IV (Psychosocial Stressors) is replaced by V codes and new Z codes that are part of ICD-10 and were developed specifically to describe stressors/problems that may occur in those with mental health issues

• Axis V (GAF): removed; found to be unreliable as a metric of impairment; global measure of disability now recommended (but not required) is WHODAS (included in Section 3 (further study))

Use of Other Specified and Unspecified Disorders

• NOS replaced with:• Other specified disorder: allows a clinician to communicate the specific reason

why the clinical presentation does not meet full criteria for any specific category within a diagnostic class

• E.g.: for a disorder that is depressive, but not severe enough to meet criteria for MDD:

• Diagnose as: Other specified depressive disorder, depressive episode with insufficient symptoms

• If the clinician does not specify the reason that the full diagnostic criteria were not met for a specific disorder; then the term ‘unspecified depressive disorder’ is used

Diagnosis: A Dimensional Approach• Previous DSM classification: narrow diagnostic categories that did not fit many clinical

presentations• Substantial use of NOS categories• Many with related ‘comorbidities’

• Widespread sharing of symptoms and risk factors between conditions• DSM 5 acknowledges overlap of symptoms between some conditions and expresses

these as a continuum (e.g.: affective disorders: depressive symptoms in mania, manic symptoms in depression: use of ‘mixed mood’ specifier now possible)

• DSM 5 organized on developmental and lifespan considerations:• Section 2:• Starts with consideration of disorders that occur early in life and moves through disorders of

adolescence/early adulthood, adulthood and older age

DSM Revision Process

• Committee members examined DSM-IV criteria on the basis of longitudinal research

• Incorporated data based on the apparent relatedness of some disorders with one another– Similarities in underlying vulnerabilities, symptom characteristics,

disease trajectories, genetics (e.g.: shared SNPs)• Most diagnostic criteria remain the same, but updates are

significant

DSM 5 Field Trials

• 2246 patients of varying diagnoses/comorbidities• 279 clinicians of varying specialties with training thought to be

similar to what clinicians in the field will receive• Each patient Interviewed twice (by two different clinicians) on

basis of DSM 5 criteria• Criteria tested for 23 diagnoses: 15 adult; 8 child/adolescent

DSM 5 Field Trials

Inter-rater reliability measured:E.g.: 85% agreement: kappa of .46 (good)

Schizophrenia, conduct disorder– 5 Diagnoses “very good”

kappa 0.60-0.79– Major neurocognitive disorder– Posttraumatic stress disorder– Complex somatic symptom

disorder revised– Autism spectrum disorder– ADHD

• 12 diagnoses “good” kappa 0.40-0.59• Bipolar I disorder• Hoarding disorder• Binge eating disorder• Borderline Personality disorder• Schizoaffective disorder• Schizophrenia• Mild cognitive disorder• Alcohol Use Disorder• Bipolar II disorder• Avoidant/ restrictive food intake disorder• Conduct disorder• Oppositional defiant disorder

DSM 5 Field Trials

Questionable range: kappa 0.20-0.396 diagnoses

• Mild traumatic brain injury• Obsessive compulsive personality

disorder• Major depressive disorder• Antisocial personality disorder• Generalized anxiety disorder• Disruptive mood regulation

disorder

Unacceptable range: kappa < 0.202 diagnoses (removed)

• Mixed anxiety depressive disorder

• Non-suicidal self injury

DSM 5 Field Trials

• Criticisms:– Lack of inter-rater reliability for major depression and GAD–Acceptance of lower kappas than for other studies–Wide variability between sites on diagnosis reliability–Recent study shows that clinicians and patients thought DSM

5 was clinically useful and easy to use (Mościcki, EK et al. Psychiatric Services, 2013)

DSM 5: The ChangesSection 2: Diagnostic Criteria and Codes

Neurodevelopmental Disorders

• Mental retardation = Intellectual developmental disorder• Attempt to destigmatize diagnosis

• Phonological Disorder and Stuttering =Communication Disorders• Includes language disorder, speech sound disorder, childhood onset fluency disorder and a new disorder:

social (pragmatic) communication disorder characterized by impaired social verbal and non verbal communication

• ADHD• Specific Learning Disorders• Motor disorders• New Autism Spectrum Disorders• The section attempts to group disorders thought to develop in childhood and adolescence and

thought to be due to abnormal neural circuit development causing dysfunction in cognition, learning, communication, and behavior

Section 2: Diagnostic Criteria and Codes Neurodevelopmental Disorders: Autism Spectrum Disorders

• Substitutes a single category for the former: Autistic disorder, Asperger disorder, childhood disintegrative disorder, and pervasive developmental disorder, NOS

• Takes into account the dimensional approach to categorizing psychopathology

• Patients will be diagnosed across a spectrum of pathology with indicators of different severity of symptoms

• Field trials show that those with former autism and Asperger’s disorder will not be adversely affected and will benefit by the more explicit definitions and symptom descriptions

Section 2: Neurodevelopmental Disorders: ADHD• Diagnostic criteria have not changed– Inattention and hyperactivity/impulsivity remain the domains

• Age criteria (onset of symptoms before age 7) changed to:• Several inattentive or hyperactivity-impulsive symptoms were

present prior to age 12• Comorbid autism spectrum diagnosis now allowed• Symptom threshold (6 symptoms) has been lowered to 5 for adults• Concerns have been expressed about overdiagnosis and increasing

use/abuse of stimulants

Section 2: Diagnostic Criteria and Codes Feeding and Eating Disorders: Binge Eating Disorder

• Moved from DSM-IV TR category of disorders to be studied• Allows for description of broader range of eating disorders (in

addition to AN, BN, and eating disorder NOS)• Unlike bulimia nervosa, there are no compensatory behaviors

following a binge episode• Recognizes that binge eating may be a psychiatric underpinning of

some obesity• Criticism: could overlap with nonpathologic problem eating; could

be a manifestation of other medical disorders (e.g.: diabetes)

Section 2: Diagnostic Criteria and Codes Depressive Disorders: Disruptive Mood Dysregulation Disorder

• New diagnosis:• Chronological or developmental age of at least 6 years; onset before age 10• Persistent irritability with severe behavioral outbursts at least 3/wk for at least one year and

dysphoric mood in between episodes• DMDD is meant to be used for very irritable children and to avoid over-diagnosis of Bipolar I

disorder in very young children• Criticism: paucity of research showing DMDD as a valid disorder; may result in overdiagnosis of

mental disorders in children possibly with exposure to psychotropic medications• Diagnosis challenged as not able to be delineated from conduct disorder or oppositional defiant

disorder, and not associated with parental history of mood or anxiety disorders, nor associated with future development of such disorders in the child

• It is hoped that behavioral, psychosocial and family interventions will be used with this diagnosis rather than psychotropics

Section 2: Diagnostic Criteria and Codes Depressive Disorders: Premenstrual Dysphoric Disorder

• Moved from DSM-IV Criteria Sets for Further Study• Captures mood disorder with clinically meaningful distress or

impairment in 1 week prior to menses which improves within several days of onset, followed by symptom free period until approximately 1 week before the next menstrual period

• Present for most menstrual cycles in a 1 year time frame; documented with daily prospective symptom ratings in two separate cycles (if this has not been done; diagnosis is coded “provisional”)

Section 2: Gender Dysphoria

• Replaces DSM-IV Gender Identity Disorder• Emphasizes ‘gender incongruence’ rather than cross-gender

identification• Diagnosis is made by mental health providers, but treatment is

endrocrinological or surgical• Symptoms resolve with medical treatment; post-transition specifier can

be used due to need for ongoing therapies to facilitate life in the desired gender

• Controversy over whether this should be classified as a mental disorder

DSM 5: New Chapter in Section 2 Obsessive Compulsive Spectrum Disorders

• Includes OCD, Body Dysmorphic Disorder• Adds conditions previously classified as ‘impulse control disorders not elsewhere

classified’ and Trichotillomania• New diagnoses:• Excoriation (skin picking) disorder—compulsive skin picking with tissue damage• Hoarding disorder-inability to part with possessions regardless of value (or not)• Some possible symptom overlap between OCD and the ICDs, but growing

evidence that these are separate disorders:• Differences in cerebral glucose metabolism between OCD and hoarding; differences in

responses to treatment between OCD and hoarding or skin picking; many hoarders do not have other symptoms of OCD

Section 2: Diagnostic Criteria and Codes: Personality Disorders

• All 10 personality disorders from DSM IV were retained• Only borderline personality disorder has good interrater reliability; some question

whether this is a manifestation of bipolar illness-research recommended• OCPD and ASP were in the questionable range• All other PDs in field trials were in too few in number to do analysis• With DSM 5, personality disorders would be diagnosed in the same fashion as

other mental disorders; no Axis II• The DSM team proposed removal of categorical diagnoses in favor of trait-based,

dimensional system with 6 categories of personality disorder—this was put in Section 3 for more study

Section 2: Diagnostic Criteria and Codes: Posttraumatic Stress Disorder

• Removed from Anxiety Disorders and placed with Trauma and Stressor Related Disorders• A fourth diagnostic symptom cluster capturing behavioral symptoms has been added

(Section E):• Reckless/self-destructive behavior • Angry outbursts with little to no provocation that can be verbal or physical

• The 6 diagnostic criteria were maintained and 2 added:• Negative alterations in cognition and mood associated with the traumatic event beginning or

worsening after the event• The disturbance is not attributable to the direct physiologic effects of a substance or another

medical condition• Diagnostic subtype to include preschool children added• DSM 5 further defines traumatic events, criteria more culturally applicable; prior

distinction between acute and chronic PTSD removed

Section 2: Diagnostic Criteria and Codes: Removal of bereavement exclusion from MDD

• DSM IV had excluded a diagnosis of MDD for periods of bereavement of less than 2 months

• DSM 5 removes the exclusion calling bereavement a severe stressor that may cause MDD even shortly after a death occurs

• Risk of overdiagnosing MDD; pathologizing normal grief; lack of evidence base for removal of restriction

• Questions arose regarding pharma influence on the committee

Section 2: Diagnostic Criteria and Codes: Substance Use Disorder

Placed in a new category of ‘Addictions and Related Disorders’ categorySubstance Abuse and Substance Dependence have been combined into a single, substance-specific category: substance use disorder with descriptors: mild (2), moderate (3-4), severe (5 or more of 11 criteria)• Removal of legal problems criteria• Addition of ‘craving’ criteria• Concerns: greater numbers will be diagnosed for relatively minor

symptoms leading to reduced treatment access for those with more serious disorders

Section 2: Diagnostic Criteria and Codes: Mixed Mood Specifier

• New specifier ‘with mixed features’ can now be added to Bipolar I, Bipolar II, bipolar disorder not elsewhere defined, and MDD• Change was made to reflect clinical syndrome of mixed mood states that do not meet full

criteria for a mixed episode of bipolar I disorder (full mania and MDD). Predominant mood can be either depression, mania or hypomania and secondary mood can be ‘subclinical’ in that some diagnostic criteria of a mood disorder are present, but not sufficient to make a diagnosis of a full disorder.

• In DSM-IV TR, only Bipolar I could be designated ‘mixed’. The change acknowledges the continuum of affective disorders and dimensional approach of DSM 5 which allows clinicians to formally diagnose and treat subthreshold expressions of mixed depressive symptoms to mania or hypomania as well as subthreshold mania-like symptoms to depression.

• Concerns: Classification of MDD with relevant mania symptoms as MDD rather than a bipolar spectrum disorder may be misleading; treatment recommendations for those with mixed features are unclear indicating need for further research.

Section 2: Diagnostic Criteria and Codes: Neurocognitive Disorder (preferred to Dementia)

• New diagnosis includes dementia and amnestic disorder diagnoses• Recognizes specific etiologic subtypes of neurocognitive dysfunction

• Alzheimer disease• Parkinson disease• HIV infection• Lewy Body disease• Vascular disease• Mild or Major specifiers based on inability to perform ADLs

• Mild: modest cognitive decline that does not interfere with independence in daily activities• Major: significant impairment evident or reported that interferes with independence to a point that assistance is required

• With or Without Behavioral Disturbance can be specified (allows clinicians to indicate whether cognitive decline is main concern or if behavioral issues also need to be addressed)

• Changes are important to determining prognosis and therapeutic course

Section 2: Diagnostic Criteria and Codes: Paraphilias and Paraphilic Disorders

• Diagnostic criteria unchanged from DSM-IV• Distinguishes between paraphilic behaviors and paraphilic disorders• “Disorder” currently causes distress or impairment to the individual or

the behavior has resulted in personal harm, risk of or harm to others• Implications: Destigmatizes and demedicalizes unusual sexual

preferences and behaviors provided they are not distressing or harmful to self or others

• Diagnosis will require thorough history to determine if behaviors meet criteria for diagnosis

Summary• DSM 5 is an attempt to describe mental disorders in a dimensional manner rather than by strict

categories• Better describes the range of psychopathology• Enables clinicians to better describes the symptoms experienced by individual patients

• DSM 5 is correlated/harmonized to ICD-11• Will make it easier to compare diagnoses across national boundaries• Will facilitate research on mental disorders and help to standardize research protocols

• Elimination of multiaxial diagnoses will provide more information that will better describe the situation of the person being assessed and treated

• Use of standardized and validated rating scales will help to better describe impairments and help to define treatment needs

• DSM 5 has clarified some diagnoses/added others after extensive research review• To date, clinicians/patients/families reportedly find DSM 5 easy to use and in general believe it will

be more informative than DSM-IV

References• Stetka, B: A guide to DSM-5, Medscape, 2013.• American Psychiatric Association: DSM 5’s integrated approach to diagnosis and

classifications, www.psych.org, 2013• Eve K. Mościcki EK, Clarke DE, Kuramoto SJ, Kraemer HC, Narrow WE, Kupfer DJ,

Regier DA: Testing DSM-5 in Routine Clinical Practice Settings: Feasibility and Clinical Utility. Psychiatric Services 2013 http://ps.psychiatryonline.org/article.aspx?articleID=1712781