Download Understanding the DSM-5

Understanding the DSM-5
Crystal Weaver, CRC, MT-BC
Terms
 Nosology: the branch of medical science dealing with the
classification of diseases
 Demarcating: separate or distinguish from
 Empirical: based on, concerned with, verifiable by observation or
experience rather than theory or pure logic
 Positivistic: a doctrine contending that sense perceptions are the
only admissible basis of human knowledge and precise thought
 Psychodynamics: the interaction of various conscious and
unconscious mental or emotional processes, especially as they
influence personality, behavior, and attitudes
 ICD: The International Classification of Diseases (ICD) is the
standard diagnostic tool for epidemiology, health management and
clinical purposes. ICD-10 was endorsed by the Forty-third World
Health Assembly in May 1990 and came into use in WHO Member
States in 1994. The 11th revision of the classification has already
started and will continue until 2015
Part One: The History of the DSM
Why Learn the History of the DSM?
 Understanding the history of the DSM can help
practitioners and researchers:
 Better understand the diagnostic language they are using
 Identify future directions for an improved nosology
 Better understand the DSM’s strengths and limitations
 For example, many of the diagnostic criteria are not based on
empirical research but on expert consensus and, in some cases,
political appeasement
Before the DSM
 Numerous nosologies in North America preceded the
development of the first edition of the Diagnostic and
Statistical Manual of Mental Disorders (DSM)
 Having divergent classification systems impeded
communication between researchers and practitioners
 A standardized classification system was needed to:
 Minimize confusion
 Create a consensus among the field
 Help mental health professionals communicate using a
common diagnostic language
Precursor to the DSM
 The advent of institutionalization provided substantial
opportunity to collect data and learn about mental disorders
in clinical contexts
 Mental disorder began to be viewed through a medical lens
 Individual nosologies put forth by psychiatrists in the late
19th and early 20th centuries had the advantage of being
holistic and centered on the individual
 Challenges of different nosologies:
 Different diagnostic languages were spoken, impeding
communication between psychiatrists
 Prevalence rates of mental disorders could not be determined
 Great confusion and variability in diagnoses of mental disorders
Precursor to the DSM (cont)
 In 1917, the Committee on Statistics of the American
Medico-Psychological Association (now the American
Psychiatric Association) recommended a uniform
classification system of mental disease
 This committee feared that having a disordered way of
classifying mental diseases would discredit the field of
psychiatry
 Published the Statistical Manual for the Use of Institutions
for the Insane
 This manual separated mental disorders into 22 groups
 This manual went through 10 editions until 1942
Opponents To A Psychiatric Nosology
 Adolf Meyer, former president of the APA
 Opposed to a nosology demarcating a one-word diagnosis
marking the individual
 Viewed mental illness in holistic terms and was a proponent
of understanding the life histories of patients to understand
the etiologies of mental disorders
 Believed each psychiatric case was unique and should be
studied on its own terms
World War II
 A significant shift in psychiatric nosology occurred in the
U.S. as a result of World War II
 Psychiatrists serving in the military found that
environmental stressors contribute to mental illness
 New terminology focused less on biological bases of behavior
and more on developmental, environmental, and relational
factors
 Therefore, further updates to the Statistical Manual for the Use of
Institutions were put on hold and the army made extensive revisions
to the standard nomenclature
International Statistical Classification
 In 1948, the 6th revision of the International Statistical
Classification (ICD) was produced
 Included a section on mental disorders
 At this time, at least three nomenclatures were widely
used in North America
 None of which were in line with the International Statistical
Classification
Diagnostic and Statistical Manual of
Mental Disorders, First Edition
 The first edition of the DSM, published in 1952, was an
important development toward a standard nosology of
mental disorders
 This manual offered:
 A new classification in conformity with newer scientific and
clinical knowledge
 Simpler structure
 Easier to use
 Virtually identical with other national
and international nomenclatures
Diagnostic and Statistical Manual of
Mental Disorders, First Edition (cont)
 DSM-I featured descriptions of 106 disorders, which were
referred to as “reactions”
 Disorders were split into two groups based on causality
 Disorders caused by or associated with impairment of brain
tissue function
 Acute brain disorders
 Chronic brain disorders
 Mental deficiency
 Disorders of psychogenic origin or without clearly defined
physical cause or structural change in the brain
 Psychotic disorders
 Psychophysiologic autonomic and visceral disorders
 Psychoneurotic disorders
 Personality disorders
 Transient situational personality disorders
Diagnostic and Statistical Manual of
Mental Disorders, First Edition (cont)
 Highly influenced by the prevalence of psychodynamic
theory in North America
 After its publication, it became necessary to coordinate
DSM with future editions of the ICD
 Proved to be a daunting task based on the different
orientation and purposes of the manuals
Diagnostic and Statistical
Manual of Mental Disorders,
Second Edition
 Both the DSM-I and the DSM-II held similar theoretical
stances, which were grounded in psychodynamics
 Noteworthy differences between the DSM-I and the
DSM-II
 In the DSM-II nomenclature was carefully selected to avoid
terms implying causality
 The term “reaction” was removed from diagnostic labels in the
DSM-II because it implied causality and referred to
psychoanalysis
 The DSM-II increased the number of disorders to 182
Between the Second and Third
Editions of the DSM
 By the 1960s, psychiatry as a profession was
predominantly psychodynamic
 Which resulted in some unrealistic thinking
 Success in returning soldiers to the front in World War II
created perhaps an unrealistic expectation of the curability of
mental illness
 The reliability of diagnosis came under scrutiny
 There was growing public contempt in the U.S.
 Particularly over conflicting testimonies of psychiatrists in
insanity defense pleas
Neo-Kraepelinians
 The profession of psychiatry underwent significant
theoretical changes toward an empirical, positivistic
orientation
 The field reverted to an orientation based on the ideas of
Emil Kraepelin
 Kraepelin’s core ideas include:
 Relating psychiatry with medicine
 Using descriptive language
 Observing psychiatry through an empirical lens
 Biology and genetics play a key role in mental disorders
 Distinguishing between schizophrenia and bipolar disorder
Neo-Kraepelinians (cont)
 Kraepelin’s influence on psychiatry reemerged in the 1960s,
about 40 years after his death, with a small group of
psychiatrists at Washington University in St. Louis, MO, who
were dissatisfied with psychodynamically oriented American
psychiatry
 They were dissatisfied with:
 The lack of clear diagnoses and classification
 Low interrater reliability among psychiatrists
 Blurred distinction between mental health and illness
 To address these fundamental concerns and to avoid
speculating on etiology, these psychiatrists advocated
descriptive and epidemiological work in psychiatric diagnosis
 In 1972, John Feighner and his “neo-Kraepelinian”
colleagues published a set of diagnostic criteria based on a
synthesis of research, pointing out that the criteria were not
based on opinion or tradition
Diagnostic and Statistical Manual of
Mental Disorders, Third Edition
 The DSM-III appeared to adopt a neo-Kraepelinian
standpoint and in the process revolutionized psychiatry
in North America
 The DSM-III, published in 1980, dropped the
psychodynamic perspective in favor of empiricism
 The DSM-III expanded to 494 pages with 265 diagnostic
categories
Diagnostic and Statistical Manual
of Mental Disorders, Third Edition
(cont)
 The DSM-III:
 Presented psychiatry in a medical model
 Emphasized follow-up
 Emphasized family histories
 Sought to increase the reliability of diagnosis
 Sought to facilitate communication among mental health
professionals
Diagnostic and Statistical Manual of
Mental Disorders, Third Edition
(cont)
 The introduction of the DSM-III emphasizes the
importance of having a common diagnostic language:
 “Clinicians and researchers must have a common language
with which to communicate about the disorders for which
they have professional responsibility…The efficacy of various
treatment modalities can be compared only if patient
groups are described using diagnostic terms that are clearly
defined.”
Diagnostic and Statistical Manual of
Mental Disorders, Third Edition
(cont)
 The DSM-III featured a multiaxial format, which
addressed:
 Mental disorder
 Personality
 Medical causes
 Environmental factors
 General functioning in diagnoses
 Contrary to a neo-Kraepelinian standpoint, expert
consensus was often used to inform diagnostic criteria
 Empirical research was used when possible, but much of the
categorization was based on clinical judgment
Diagnostic and Statistical Manual
of Mental Disorders, Third Edition
(cont)
 A revised edition of the DSM-III was published in 1987,
which included:
 Some revised descriptions of diagnostic criteria
 Descriptions of field trials assessing the validity and
reliability of disorders
 An appendix of “Proposed Diagnostic Categories Needing
Further Study”
Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition
 The structure and theoretical orientation of the DSM-IV
was largely unchanged from the DSM-III
 The number of mental disorders increased to more than
300 in the DSM-IV
 The threshold for approval or a diagnosis in the DSM-IV was
more conservative, requiring more empirical backing
 The DSM-IV-TR was published to ensure that information
in the DSM-IV remained up-to-date
 No substantive changes were made to the
diagnostic criteria set out in the DSM-IV
 No new disorders nor new subtypes
were considered
The DSM-IV-TR and the ICD
 The DSM-IV-TR and ICD-10 represented the dominant
diagnostic languages in the world
 Traditionally, revisions to the DSMs and ICDs have occurred
relatively independently
 Most disorders in both manuals have differences between
them
 21% having conceptually based differences
 Differences in these two manuals can undermine the
credibility of the field of psychiatry,
and having two different classification
systems can impede international
collaboration effects
Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition
Predictions
 The initial phase of the DSM-5 planning process began in
1999 with a series of conference cosponsored by APA
and the National Institute of Mental Health
 Task force of 28 people
 Work groups had over 130 people in 13 workgroups
 400 advisors
 Strong international representation (39 countries)
 Harmonization of the DSM and ICD was identified as an
important goal of the revisions of both manuals
 One step that had been proposed for the DSM-5 was the
amalgamation of Axes I, II, and III into one axis that
contains all psychiatric and general medical conditions
 This would bring the DSM more in line with ICD approach
Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition
Predictions (cont)
 Perhaps the most revolutionary idea is to adopt a
dimensional rather than categorical approach to
classification
 In contrast with the categorical approach used in the DSMIV-TR, where dichotomous diagnostic decisions regarding
the presence/absence of a disorder are made based on
meeting a certain number/pattern of criteria, a dimensional
approach would involve quantitative ratings of patients on
characteristics or features of the disorder
 Using this method, important clinical information can be
communicated for patients above and below current diagnostic
thresholds
Diagnostic and Statistical Manual
of Mental Disorders, Fifth Edition
Predictions (cont)
 In February 2010, the APA released Proposed Draft
Revisions to DSM Disorders and Criteria. Many of these
proposed changes reflected a shirt toward etiologically
based, dimensional diagnoses
 One proposed change was the inclusion of an anxiety
dimension across all mood disorders
 In the categorical approach in DSM-III and DSM-IV, anxiety is
identified as a separate and distinct construct from other mood
disorders, whereas the proposed changes in DSM-5 suggest that
anxiety may be a common underlying factor
Diagnostic and Statistical Manual
of Mental Disorders, Fifth Edition
Predictions (cont)
 Other proposed changes for the DSM-5:
 Autistic disorder, Asperger’s disorder, and PDD-not
otherwise specified (NOS) were distinct categories in the
DSM-IV-TR. The proposed changes would eliminate these
categories and place these disorders within the classification
“autism spectrum disorder”
 With Personality Disorders, diagnoses may be based on
underlying traits (which requires a dimensional approach)
Part Two: The DSM-5
Why Are Clients Diagnosed?
 To provide better treatment for the client
 To obtain reimbursement
 To stimulate research
 To guide treatment
 To better understand the client
The Basics
 The DSM-5 was released at the American Psychiatric
Association’s annual conference in San Francisco in May,
2013
 There are criticisms and controversies surrounding the
DSM-5
 Pathology-based, not strengths-based
 Concerns about overprescribing medications
 No treatment suggestions
 Electronic version available
Development
 Task force of 28 people
 Work groups had over 130 people in 13 workgroups
 400 advisors
 International representation (39 countries)
 Process began in 1999
Goals and Purpose
 Goals:
 Improve diagnostic accuracy
 Add severity scales
 Add dimensional assessments
 Reduce not otherwise specified (NOS) usage
 Align with ICD (International Classification of Diseases)
 Purpose:
 Tool for clinicians
 Educational resource for students
 Reference for researchers
 Provide a common language
 Assist in compiling public health statistics
 Help assess people objectively
Defining Mental Disorder
 The definition of mental disorder is essentially the same
as the DSM-IV definition:
 A syndrome of clinically significant disturbance in cognition,
emotion regulation, or behavior, that is associated with
distress, disability, or significant impairment in important
areas of functioning
 Several categories give the option of medication-induced
__________ disorder or substance-induced __________
disorder
Guidance on Use
 A diagnosis should not be made for behaviors that are
an expected or culturally sanctioned response to a
particular event
 Consider cultural context: Section 3 has a chapter on
cultural formulation with a structured interview
 These are conditions a person may have but the
conditions should not define the person
 These disorders are often early life coping or defense
mechanisms that are now dysfunctional and causing
distress
 Conditions may or may not be medical or biological
illnesses
No More Multiaxial System
 No more Axis I- V
 No more GAF
 No listing of psychosocial and environmental problems
 No listing of contributing medical conditions
Diagnostic Groupings
1.
Neurodevelopmental Disorders
2.
Schizophrenia Spectrum and Other Psychotic Disorders
3.
Bipolar and Related Disorders
4.
Depressive Disorder
5.
Anxiety Disorders
6.
Obsessive-Compulsive and Related Disorders
7.
Trauma and Stressor-Related Disorders
8.
Dissociative Disorders
9.
Somatic Symptom and Related Disorders
10. Feeding and Eating Disorders
11. Elimination Disorders
12. Sleep-Wake Disorders
13. Sexual Dysfunctions
14. Gender Dysphoria
15. Disruptive, Impulse Control, and Conduct Disorders
16. Substance-Related and Addictive Disorders
17. Neurocognitive Disorders
18. Personality Disorders
19. Paraphilic Disorders
Neurodevelopmental Disorders
 Category includes:
 Intellectual Disability
 Global Developmental Delay (under age 5)
 Communication Disorders
 Autism Spectrum Disorder
 ADHD
 Specific Learning Disorder
 Motor Disorders
Autism Spectrum Disorder (ASD)
 Asperger’s disorder is now absorbed into Autism
Spectrum Disorder (ASD)
 Asperger’s, Childhood Disintegrative Disorder, Rett’s
Disorder, and Pervasive Developmental Disorder (PDD) are
gone
 The reliability and validity of these disorders are very poor
 There is no evidence to support their continued separation
Autism Spectrum Disorder (cont)
 People with a well-established DSM-IV diagnosis of ASD,
Asperger’s, or PDD will probably qualify for the diagnosis
of ASD
 If the person does not meet criteria, an evaluation for
Social (Pragmatic) Communication Disorder may be done
 Dramatic rise in the prevalence of ASD:
 2007 (1 in 150)
 2009 (1 in 110)
 2013 (1 in 88)
Autism Spectrum Disorder (cont)
 Three domains in DSM-IV will become two domains in
the DSM-5:
 DSM-IV
1. Qualitative impairment in social interaction
2. Qualitative impairment in communication
3. Restricted repetitive and stereotyped patterns of behavior,
interests, and activities
 DSM-5
1. Social and communication deficits
2. Restricted repetitive behaviors, interests, and activities (RRB’s)
Autism Severity
(Severity specifiers should not be used to
determine eligibility for services)
Severity Level
Social
Communication
Restricted
Interests,
Repetitive
Behaviors
Level 3
Requiring very
substantial support
Severe deficits in verbal
and nonverbal
communication, limited
social interaction
Preoccupations interfere
with functioning in all
areas. Distress when
rituals are interrupted
Level 2
Requiring substantial
support
Marked deficits even
with supports, limited
initiation of social
interactions, abnormal
responses
Rituals appear
frequently enough that
a casual observer
notices. Some
interference with
function
Level 1
Requiring support
Without support,
deficits cause
impairment. Difficulty
with social interaction
Repetitive behaviors
interfere with some
functioning. Resists
redirection
Autism Spectrum Disorder (cont)
 Typical presentation includes:
 Inappropriate responses in conversation
 Misreading nonverbal interactions
 Difficulty building friendships appropriate to age
 Overly dependent on routines
 Highly sensitive to changes in environment
 Intensely focused on inappropriate items
 Core features are usually obvious by age 2
 Regression or plateau in language or social development is
present in 20-30% by age 2
 There is no blood test or biological marker
Autism Spectrum Comorbidities
 71%: Oppositional Defiant Disorder (ODD)
 62%: Anxiety
 50-73%: Significant motor delays (especially handwriting)
 40-85%: Sleep problems (10x higher rate of insomnia)
 41%: ADHD
 37%: Obsessive-Compulsive Disorder (OCD)
 22-70%: GI complaints
 13%: Depression
 10%: Speech problems
 9%: Tourette’s/tic disorders
Autism Spectrum Disorder (cont)
 70% have one other mental health diagnosis
 41% have two or more other mental health diagnoses
 Parents may have increased stress and poorer health
 Siblings may have more anxiety and depression
 There is no link between vaccines and autism
 Conclusive studies done by:
 Centers for Disease Control and Prevention
 Food and Drug Administration
 Institute for Medicine
 World Health Organization
 American Academy of Pediatrics
Depressive Disorder
 Category includes:
 Disruptive Mood Dysregulation Disorder (new)
 Major Depressive Disorder
 Symptom list has not changed
 Persistent Depressive Disorder (new)
 Premenstrual Dysphoric Disorder (new)
Anxious Distress Specifier

Depression/anxiety link:
 29% have history of panic attacks
 62% have moderate anxiety

Anxious Distress Specifier:
 Keyed up/tense
 Unusually restless
 Decreased concentration
 Fear of something awful happening
 Fear of losing control

Depression with Anxious Distress Specifier:
 Takes longer to recover from
 Greater suicide risk
 More complaints of medication side effects
 Greater recurrence
 Greater impairment
Bereavement Exclusion
 Beginning in DSM-III, if someone is grieving the loss of a
loved one, they can not be diagnosed with depression for
the first 2 months
 Prognosis is bad if someone has bereavement and major
depression at the same times
 Bereavement can induce great suffering, but does not
typically induce major depression
 Grief vs. Depression:
 Less psychomotor retardation
 Less worthlessness or self-loathing
 Less suicidal ideation
 Fewer symptoms
 People see symptoms as normal and expected given the loss
Bereavement Exclusion (cont)
 Grief:
 Painful feelings come in waves, often mixed with positive
memories of the deceased
 Prominent feelings of emptiness and loss
 Person feels that symptoms are due to the loss
 Depression:
 Mood and ideation are almost constantly negative
 Mood is persistently depressed with an inability to anticipate
happiness or pleasure
 Person may not have any idea why they feel so bad
Disruptive Mood Dysregulation
Disorder (DMDD)
 New diagnosis
 Similar to Bipolar Disorder with extreme temper and
rage
 Prevalence: 2-5% more in males than females
 Similar to Oppositional Defiant Disorder (ODD), but
more severe:
 DMDD requires impairment across two settings, once of
which is severe
 DMDD has higher symptom threshold than ODD
Disruptive Mood Dysregulation
Disorder (cont)
 Severe recurrent temper outbursts:
 Verbal or behavioral
 Inconsistent with developmental level
 Mood between outbursts is persistently irritable or angry
 Present in a least 2 settings, severe in at least one
 Frequency: at least 3 times weekly
 Duration: 12 months, no more than 3 months symptomfree
 Can not diagnosis before age 6 or after age 18
Anxiety Disorders
 Post-Traumatic Stress Disorder (PTSD) and Obsessive
Compulsive Disorder (OCD) are no longer in this category
 “Panic attack” is now just a specifier, not a diagnosis
 Category includes:
 Separation Anxiety Disorder
 Can diagnose with adult onset
 Selective Mutism
 Specific Phobia
 Social Anxiety Disorder
 Panic Disorder
 Agoraphobia
 Now a stand-along diagnosis, does not need to be linked with Panic
Disorder
 Generalized Anxiety Disorder
Obsessive-Compulsive and
Related Disorders
 Obsessive-Compulsive Disorder (OCD) is a stand alone
category
 Category includes:
 OCD
 Body Dysmorphic Disorder (now listed under OCD instead
of Somatoform Disorders)
 Hoarding Disorder (new)
 Trichotillomania
 Excoriation (new)
Obsessive-Compulsive and
Related Disorders (cont)
 Insight specifier with OCD, Hoarding, and Body
Dysmorphic Disorder
 DSM-IV required the person with OCD to realize the
obsessions and compulsions were unreasonable, that is not
required in the DSM-5
 30% have a Tic Disorder
 25% of OCD starts by age 14
 Suicide and OCD:
 Ideation in 50%
 Attempts in 25%
Trauma and Stressor-Related
Disorders
 Category includes:
 Reactive Attachment Disorder
 Disinhibited Social Engagement Disorder
 Post-Traumatic Stress Disorder (PTSD)
 Acute Stress Disorder
 Adjustment Disorders
Post Traumatic Stress Disorder
(PTSD)
 Specifically includes sexual violence as a trigger event
 PTSD no longer requires that an individual have a
subjective experience of fear or horror
 Well-trained emergency workers and military personnel
often do not report subjective feelings of fear and horror
 At one year, 14% have dissociative symptoms
 Military leaders through that the word “disorder” made
military people resistant to asking for help
 they wanted to rename PTSD to “Post-Traumatic Stress
Injury”
 The task force felt that “injury” was imprecise and that the
military environment needs to change
PTSD:
Symptom Clusters
 DSM-IV: 3 symptom clusters
 Re-experiencing and intrusive symptoms
 Avoidance and numbing
 Arousal and reactivity
 DSM-5: 4 symptom clusters
 Re-experiencing and intrusive symptoms
 Avoidance and numbing
 Arousal and reactivity
 Negative alterations in cognitions and mood
PTSD:
Symptom Clusters (cont)
 Negative cognitions and mood:
 Inability to remember important aspects of the trauma
 Negative beliefs about self, others, or the world
 Persistent distorted blame of self or others
 Pervasive negative emotional state
 Diminished interest in significant activities
 Feeling detachment from others
 Inability to experience positive emotions
PTSD:
Symptom Clusters (cont)
 Re-experiencing and intrusive symptoms:
 Recurrent memories of the traumatic event
 Recurrent distressing dreams related to the trauma
 Flashbacks or other intense prolonged psychological distress
 Avoidance:
 Avoiding distressing memories, thoughts, feelings, or external
reminders of the event
 Arousal and reactivity:
 Aggressive, reckless, or self-destructive behavior
 Sleep disturbance
 Hypervigilance
 Irritability and anger
Substance Use and Addictive
Disorders
 This is by far the largest category in the DSM-5
 Only three qualifiers are used in the category
 Use (replaces both abuse and dependence)
 Intoxication
 Withdrawal
 Nicotine-related renamed tobacco use
 Polysubstance categories discontinued
 Gambling added to this category
Substance Use and Addictive
Disorders (cont)
 Substance use disorder replaces both abuse and
dependence
 Dependence was misused when describing the normal
physical reactions that can occur during appropriate
medication use, such as antidepressant discontinuation
syndrome
 Abuse was more reliably assessed than dependence
 Nicotine was changed to tobacco
 Do not want people on nicotine replacement to get confused
and think they are doing something risky
 Tobacco is the harmful agent with significant health risks
Substance Use and Addictive
Disorders (cont)
 Symptoms:
1. Taken in larger amounts or for a longer period than intended
2. Persistent desire or unsuccessful efforts to cut down or control
use
3. Great deal of time is spent obtaining, using, or recovering
4. Craving or a strong desire or urge to use
5. Recurrent use results in failure to fulfill major role obligations
at work, school, or home
6. Continued use in spite of social or interpersonal problems
7. Important activities are given up or reduced because of use
8. Recurrent use when it is physically hazardous
9. Continued use in spite of physical problems
10. Tolerance
11. withdrawal
Substance Use and Addictive
Disorders (cont)
 Severity:
 Mild = 2-3 symptoms
 Moderate = 4-5 symptoms
 Severe = 6 or more symptoms
Gambling

Moved to substance use and addictive disorders section from disruptive,
impulse control, and conduct disorders section

Only behavioral addiction in the manual

Individuals who are pathological gamblers: show tolerance, dependence,
and withdrawal

The brain’s reward system and neural circuits react in similar ways

Similar to substance use disorders in:
 Clinical expression
 Brain origin
 Comorbidity
 Frontal lobe dysfunction
 Treatment (Cognitive-Behavioral Therapy, 12-step program, motivational, brief)
 Impulse dysregulation
 Genetics
In Conclusion
 The DSM has frequently been referred to as the gold
standard for psychiatric diagnosis
 The DSM is used in clinical and research contexts
throughout the world, and few texts match its influential
power
 There are a number of factors that spurred the
development of the first edition of the DSM, with
perhaps the most important being the need for a
common diagnostic language
 From the beginning, there were fundamental differences
between the DSM and the ICD
 As international collaboration becomes increasingly more
common, continued harmonization of the DSM and ICD is
needed
In Conclusion (cont)
 The development of DSM, from beginning to present,
resembles a historic pendulum, from DSM-I on the one
hand emphasizing psychodynamics and causality to
DSM-III and DSM-IV emphasizing empiricism and logical
positivism
 Etiological- and dimensional-based classification for DSM-5
appear to represent a shift toward the center
References
Sanders, J. L. (2011). A distinct language and a historic
pendulum: The evolution of the diagnostic and statistical
manual of mental disorders. Archives of Psychiatric Nursing,
25, 394-403.
Teater, M. (2013). Using the DSM-5 for Revolutionizing
Diagnosis & Treatment. Eau Claire, Wisconsin: CMI Education.
DSM-5 Press Briefing at the APA Annual Meeting in San
Francisco
 May 18, 2013
 Speaker: DSM Task Force Chair David Kupfer, MD
American Psychiatric Association:
 www.dsm5.org
 www.psychiatry.org/dsm5