DSM - 5 An overview.

Dr.Cijo Alex

PG Trainee,

SMVMCH , Puducherry

C o n t e n t s

• Background

• Changes in DSM-5

• Critical analysis of DSM-5

N o s o l o g y

Nosology or taxonomy is a branch of medical science that deals with classification of diseases.

Most disciplines of medicine follow etiological classification.

Since etiology is still obscure in most of the psychiatric illnesses , our classifications are primarily based on

symptomatology rather than on etiology.

What is the need for classification systems?

To distinguish one psychiatric diagnosis from another, so that clinicians can offer the most

effective treatment;

To provide a common language among health care professionals;

And to explore the still unknown causes of many mental disorders.

Systems of classifications in Psychiatry.

- ICD by WHO

- DSM by APA

- Chinese Classification of Mental Disorders [CCMD]

- Latin American Guide for Psychiatric Diagnosis.

- The Research Domain Criteria [RDoC] by NIMH

Acceptance of various classification systems.

ICD-10 is the official classification system used in Europe and most parts of the world.

All categories used in DSM-IV-TR are found in ICD-10, but not all ICD-10 categories are in DSM-IV-TR.

DSM-IV-TR is the official US nomenclature.

All terminology used standard textbooks conforms to DSM nomenclature.

As per international agreements ,the deadline for the United States to begin using ICD-10-Clinical Modification (CM) is currently October 1, 2014.

The DSM classification.

In 1952, the APA published the DSM.

DSM-II (1968); DSM-III (1980); DSM-III-R (1987); DSM-IV (1994); and DSM-IV-TR (2000).

The DSM - 5

Research started in 1999.

Released May 2013.

I n s i d e D S M - 5

Divided into three sections.

Section I - DSM 5 basics

Section II - Diagnostic criterion and codes

Section III - Emerging measures and models

and an

Appendix.

Section I – DSM -5 basics.

Harmonization with ICD system.

Non axial documentation of diagnosis.

Dimensional assessment.

Changes in diagnostic criterions.

Harmonization with the ICD system has been done to avoid unwanted hindrances in both scientific

research and patient care.

Most importantly the salient differences between ICD and DSM does not have any scientific basis rather

they reflect historical byproducts of various committee meetings.

DSM-5 have moved towards non-axial system of diagnosis [formerly Axis I,II and III] with separate

notations for important psychosocial and contextual factors [formerly Axis IV] and disability

[formerly Axis V]

Section I I - Diagnostic cr iterion and codes

Section III - Emerging measures and models

Alternative DSM-5 model of Personality disorders.

A typical patient meeting a criterion for a DSM-IV personality disorder often qualifies for another

personality disorder too. So an alternative model have been introduced.

Antisocial, Avoidant, Borderline ,Narcissistic ,Obsessive –Compulsive and Schizotypal PD can be diagnosed and Personality Disorder –Trait Specific can be diagnosed if

the criterion is not met , but if PD is suspected.

Conditions for further study

Proposed criterion sets have been described for following conditions in which further research is encouraged.

Attenuated Psychosis SyndromeDepressive episodes with short duration hypomania

Persistent complex bereavement disorderCaffeine use disorder

Internet gaming disorderNeurobehavioral disorder associated with prenatal alcohol

exposureSuicidal behavior disorder

Nonsuicidal self injury

Psychosis like condition but in which symptoms are below the threshold to be clinically diagnosed as Psychosis.

Symptoms are usually transient and insight is good.

A p p e n d i x

Highlights of changes from DSM-IV to DSM-5.

Neurodevelopmental disorders

Intellectual disability

New term introduced for Mental Retardation.

Diagnostic criterion emphazise the need for assessment of both cognitive capacity [IQ] & adaptive functioning.

Severity is determined by adaptive functioning rather than IQ score.

Communication disorders

New term for phonological disorders & stuttering.

Speech sound disorder – previously phonological disorder.

Childhood onset fluency disorder – new term for stuttering.

Social communication disorder – new condition for forpersistent difficulties in the social uses of verbal and

nonverbal communication.

Autism spectrum disorder

New disorder encompassing previously called

Autism + Aspergers disorder + Retts disorder + Childhood disintegrative disorder + pervasive developmental disorder

NOS.

The new criteria describe two principal symptoms: “deficits in social communication and social interaction” and

“restrictive and repetitive behavior patterns”.

ADHD

Several changes to diagnostic criterion.

The onset criterion has been changed from “symptoms that caused impairment were present

before age 7 years” to “several inattentive or hyperactive-impulsive symptoms were present prior

to age 12”;

Co morbid diagnosis with Autism spectrum disorders allowed.

Specific learning disorde

Combines DSM –IV diagnoses of reading disorder , mathematics disorder , disorders of written expression and

learning disorders NOS.

Schizophrenia spectrum and other Psychotic disorders.

Schizophrenia

Elimination of the special attribution of bizarre delusions and Schneiderian first-rank auditory

hallucinations (e.g., two or more voices conversing).

The second change is the addition of a requirement in Criterion A that the individual must have at least one of these three symptoms: delusions, hallucinations, and

disorganized speech. At least one of these core “positive symptoms” is necessary for a reliable

diagnosis of schizophrenia

The DSM-IV subtypes of schizophrenia (i.e., paranoid, disorganized, catatonic, undifferentiated,

and residual types) are eliminated due to their limited diagnostic stability, low reliability, and poor

validity.

Instead, a dimensional approach to rating severity for the core symptoms of schizophrenia.

schizoaffective disorder

The primary change to schizoaffective disorder is the requirement that a major mood episode be present for

a majority of the disorder’s total duration [after Criterion A has been met].

It makes schizoaffective disorder a longitudinal instead of a cross-sectional diagnosis—more comparable to

schizophrenia, bipolar disorder, and major depressive disorder, which are bridged by this condition.

Delusional disorder

Criterion A for delusional disorder no longer has the requirement that the delusions must be nonbizarre.

Catatonia

In DSM-5, catatonia may be diagnosed as a specifierfor depressive, bipolar, and psychotic disorders

B i p o l a r a n d r e l a t e d d i s o r d e r s

Criterion A for manic and hypomanic episodes now includes an emphasis on changes in activity and energy as well as

mood.

The DSM-IV diagnosis of bipolar I disorder, mixed episode, requiring that the individual simultaneously meet full criteria

for both mania and major depressive episode, has been removed. Instead, a new specifier, “with mixed features,” has

been added that can be applied to episodes of mania or hypomania when depressive features are present, and to episodes of depression in the context of major depressive

disorder or bipolar disorder when features of mania/hypomania are present.

Other Specified Bipolar and Related Disorder

A category for individuals with a past history of a major depressive disorder who meet all criteria for

hypomania except the duration criterion (i.e., at least 4 consecutive days).

A second condition constituting an other specified bipolar and related disorder is that too few symptoms of hypomania are present to meet criteria for the full

bipolar II syndrome, although the duration is sufficient at 4 or more days.

D e p r e s s i v e d i s o r d e r s

Disruptive Mood Dysregulation Disorder – New diagnosis to include children upto 18 years of age with persistent irritability

and extreme dyscontrol.

Premenstrual Dysphoric Disorder – promoted from appendix to main body.

Persistent depressive disorder – New term for dysthymia and chronic MDD

No more berevement exclusion for diagnosing MDD. Bereavement is now recognized as a severe psychosocial stressor that can

precipitate a major depressive episode in a vulnerable individual

A n x i e t y d i s o r d e r s

OCD and PTSD have been omitted and made into separate categories.

Separation anxiety and selective mutism are included in anxiety disorders.

Anxiety disorders no longer need age >18 for diagnosis.

Panic disorder and Agoraphobia are unlinked

Panic attacks can be listed as a specifier to ALLDSM-5 diagnoses.

Obsessive Compulsive and related disorders

New chapter.

New disorders include

hoarding disorder, excoriation(skin picking)disorder , Substance/Medication induced obsessive –

compulsive and related disorders And obsessive-compulsive disorders due to another medical

condition.

Detailed specifiers introduced for insight viz fair , poor and absent.

Trauma and Stressor related disorders

Qualifying traumatic events are now explicit as to whether they were experienced directly , witnessed or

experienced indirectly.

Four symptom clusters instead of three

-Re-experiencing

-Arousal

-Avoidance

-Persistent negative alterations in cognition and mood.

Dissociative disorders

Dissociative fugue is now a specifier of dissociative amnesia rather than a specific diagnosis.

Somatic symptom and related disorders

New name for somatoform disorders.To avoid problematic overlap , many subcategories have been

omitted including .-Somatization disorder-Hypochondriasis-Pain disorder-Undifferentiated somatoform disorder

Criterion for conversion disorder have been revised to emphasize importance of neurological examination and the fact that psychosocial stressor may not be demonstrable at

the time of diagnosis.

Feeding and eating disorders

Includes many conditions found in DSM-IV chapter “disorders usually first diagnosed during

Infancy,Childhood or Adolescence” like pica.

Anorexia nervosa diagnosis does not need amenorrhea as a criterion.

Slight changes to Bulimia nervosa criterion too

Sexual dysfunctions

Female sexual desire and arousal disorders combined into one disorder “female sexual interest/arousal disorder”

Vaginismus and Dyspareunia combined to form Genito pelvic pain/Penetration disorder .

Substance related and addictive disorders

Gambling disorder , Cannabis withdrawal and Caffeine withdrawal are new conditions introduced

No more substance abuse and dependence , only substance use disorders

Neurocognitive Disorders

Mild NCD , newly introduced condition to cover milder forms of memory impairment (?MCI)

Personality Disorders

No change in criterion as such but new approach to diagnosis.

C r i t i c a l A n a l y s i s o f D S M - 5

1) Disruptive Mood Dysregulation Disorder may turn temper tantrums into a mental disorder.

2) Normal grief may become Major Depressive Disorder.

3) The everyday forgetting characteristic of old age will now be misdiagnosed as Minor Neurocognitive Disorder.

4) DSM 5 will likely trigger a fad of Adult Attention Deficit Disorder leading to widespread misuse of stimulant drugs for performance

enhancement and recreation.

5) Excessive eating 12 times in 3 months is no longer just a manifestation of gluttony but it is a psychiatric illness called Binge

Eating Disorder.

6) The changes in the DSM 5 definition of Autism will result in lowered rates- perhaps by 50% according to outside research groups.

7) First time substance abusers will be lumped in definitionaly in with hard core addicts despite their very different treatment needs and prognosis and the stigma this will cause.

8) Behavioral Addictions that eventually can spread to make a mental disorder of everything we like to do a lot. Eg; New proposed internet addiction

9) DSM 5 obscures the already fuzzy boundary been Generalized Anxiety Disorder and the worries of everyday life.

10) DSM 5 has opened the gate even further to the already existing problem of misdiagnosis of PTSD in forensic settings.

Thank you