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DSM-5
David Mays, MD PhD
[email protected]
A Brief History of the Diagnostic and
Statistical Manual
• DSM-I was introduced in 1952, an evolution of
a system developed by military psychiatrists. It
was issued in conjunction with ICD
(International Classification of Disease). Both
were medical models of disease. The
American Psychiatric Association held the
franchise. No one else wanted it.
DSM I History
• The APA sent questionnaires to 10% of its
membership and asked for suggestions. Three
categories were set up: organic brain
syndromes, functional disorder, and mental
deficiency. The descriptions were very vague,
and based on the theoretical orientation of a
handful of academic psychiatrists.
DSM II
• DSM-II was introduced in 1968. Neither DSM-I
or DSM-II had much impact on mental health
practice.
On Being Sane in Insane Places
• In February 1969, David Rosenhan (a
psychology professor) went to a psychiatric
hospital in Pennsylvania, complaining that
he heard the words “empty”, “thud”, and
“hollow.” He had no other symptoms. He
was immediately admitted to this hospital
and diagnosed with schizophrenia. Over the
next 3 years, seven of his friends and
students repeated the same exercise in 11
other hospitals. They were medicated and
held in hospitals between 8-52 days. The
resulting book claimed that psychiatrists had
no valid way to diagnose mental illness.
DSM-III
• DSM-III, in 1980, introduced the use of
“criteria sets,” and operationalized diagnosis.
The DSM became a guideline for insurance
coverage.
• DSM-III-R (1987) and DSM-IV (1994) and DSMIV-TR (2000) continued this tradition,
emphasizing empirical evidence to justify
diagnosis.
Problems with DSM-IV
• 1) Problems with frequent comorbidities:
anxiety/depression, antisocial/ADHD/substance
abuse, personality disorders
• 2) Discrete categories vs. spectrum disorders
• 3) Increased use of the NOS category. There are
no criteria for an NOS category.
DSM-5: “Repair the plane while
keeping it flying.”
• DSM-5 represents the first major overhaul in
30 years. But you can’t just start over.
• DSM-5 is due for publication in May 2013.
Presumably, there will be a print version and
an electronic version that will be continually
updated (DSM 5.1, 5.2, etc..)
Controversies
• Who owns it? Non-psychiatrists are
disgruntled
• Is it too revolutionary? There are objections to
removing diagnoses (Asperger’s) and making
fundamental changes in process (substance
use disorders.)
• Is it revolutionary enough? Where’s the
biology?
The Process
• A DSM-5 Research Planning Conference was held in 1999
(before DSM-IV-TR). Six workgroups were formed:
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Nomenclature
Neuroscience and Genetics
Developmental Issues and Diagnosis
Personality and Relational Disorders
Mental Disorders and Disability
Cross-Cultural Issues
• Three other groups included:
– Gender
– Geriatrics
– Infants and Young Children
The Process
• There have been a series of invitation only
conferences. A task force of 27 members
oversees the process. They represent
researchers, clinicians, consumer and family
advocates, and other scientists. All members have
been required to disclose any conflicts of interest.
Several members have been removed.
(Nonetheless, reportedly 70% have for-profit
industry ties. 56% of DSM-IV task force members
had industry ties.)
The Process
• On February 20, the proposed revisions were
posted the APA website. Comments were
solicited and changes posted. This process is
now over.
• All in all, the website received 50,000,000 hits.
8,600 comments were submitted. All these
have been reviewed and field trials are
underway. So what are they thinking?...
Overview
• Various diagnoses have been merged or
renamed.
• There is an assumption that everyone’s mental
status falls on a spectrum that stretches from
typical to pathological. Consequently, there is
an effort to introduce a dimensional scale for
virtually all disorders e.g. mild, moderate,
severe. Some scales cut across diagnoses (e.g.
anxiety, suicide)
Overview
• Disorders are no longer clustered as major mental
illnesses, personality disorders, and medical problems
related to mental illness (Axis I, II, III.)
• The organization is different in order to correspond
better to ICD and to reflect a developmental
perspective.
• There are three sections:
– 1) Introduction and instructions
– 2) The Disorders
– 3) Conditions requiring further research, cultural
formulations, dimensional scales, other stuff
Overview
• Although no biological markers are used in
any diagnosis (except sleep disorders,) the text
will include genetic risk factors and some
proposed biological findings.
DSM-5
• Neurodevelopmental Disorders Highlights
– Intellectual Disability (Intellectual Development
Disorder)
– Communication Disorders
– Autism Spectrum Disorders
– Attention-Deficit/ Hyperactivity Disorder
– Specific Learning Disorder
– Motor Disorders
Psych News, 2/3/2012
Neurodevelopmental Disorders
Specifics
• Intellectual Disability
– (Intellectual Development Disorder) ICD 11
• While generally reflecting an IQ<70, any descriptors of
mild, moderate, severe or profound are based on ability
to function, rather than on IQ scores. IQ scores become
fairly meaningless below 70.
– Global Developmental Delay
Neurodevelopmental Disorders
Specifics
• Communication Disorders
– Language Disorder (expressive and mixed)
– Speech Sound Disorder (phonological disorder)
– Childhood-onset Fluency Disorder (stuttering)
– Social Communication Disorder: captures young
people with autism-like communication problems,
but lack repetitive behaviors. These children were
diagnosed with PDD–NOS in DSM-IV.
Psych News 1/18/13
Neurodevelopmental Disorders
Specifics
• Autism Spectrum Disorders
• This category will include Asperger’s,
Childhood Disintegrative Disorder, and
Pervasive Developmental Disorder NOS.
(Rett’s disorder is dropped.) This is done
because the reliability and validity of these 3
disorders is very poor. There is no evidence to
support their continued separation.
Neurodevelopmental Disorders
Specifics
• Autism spectrum disorders (symptoms
present in early childhood, 3 levels of severity)
– Deficits in communication and interaction
including these 3:
• reciprocity
• nonverbal interaction
• having relationships
– Repetitive and/or restrictive behaviors
– Expanded list of specifiers (e.g. intellectual
impairment)
DSM-5 vs. DSM-IV Autism
• The DSM-5 Autism Spectrum diagnosis differs
from DSM-IV primarily in that social and
communication (language) deficits are merged
into a single domain. There is less emphasis
on the importance of language
delays/abnormalities. This allows the inclusion
of Asperger’s.
What About Asperger’s Disorder?
• DSM-IV Asperger’s Disorder
– 1) Impairment in social interaction (2 of the
following): nonverbal behaviors, no peer
relationships, lack of shared activities, lack of
social reciprocity
– 2) repetitive activities of behavior (1 of the
following): pattern of activity, rituals, motor
mannerisms, fixation on parts of objects
– 3) no delay in language
– 4) no cognitive delay
The Controversy
• Some individuals with Asperger’s do not want
to be in the same category as people with
autism.
• Some individuals fear that Asperger’s will not
meet the criteria for ASD, and they will lose
benefits.
• Mental health workers believe that Asperger’s
is a qualitatively different illness than autism.
The criteria do not capture this.
Neurodevelopmental Disorders
Specifics
• Attention Deficit/ Hyperactivity Disorder
– The onset age has been changed to “before” 12
rather than 7.
– Subtypes have been replaced with specifiers
– More symptoms are required in different settings
– Fewer symptoms are required if the person is an
adult
Mary Kearl: additudemag.com; Psych News 1/18/13
Neurodevelopmental Disorders
Specifics
• Specific Learning Disorder
– Combines reading disorder, mathematics disorder,
disorder of written expression, and learning
disorder NOS.
– Clinicians will specify the kind: reading, written
expression, mathematics, etc.
DSM-5 Depressive Disorders Highlights
• Disruptive Mood Dysregulation Disorder
• Major Depressive Episode
• Persistent Depressive Disorder (Dysthymic
Disorder)
• Premenstrual Dysphoric Disorder
• Anxious Distress Specifier (for all mood
disorders, including bipolar)
Depressive Disorders Specifics
• Disruptive Mood Dysregulation Disorder
– This diagnosis is created in an effort to diagnose
children with extreme temper dysregulation and
rage attacks who do not show manic features or
an episodic course. These children have recently
been diagnosed with bipolar disorder.
Jabr Sci Am Mind May/june 2012
ADHD
DMDD
More aggressive
BIPOLAR
More continuous
More
labile
Disruptive
Behavior
Disorders
DSM-5 Anxiety Disorders Highlights
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Separation Anxiety Disorder
Selective Mutism
Specific Phobia
Social Anxiety Disorder (Social Phobia)
Panic Attack, Panic Disorder
Agoraphobia
Generalized Anxiety Disorder
Is Obsessive-Compulsive Disorder an
Anxiety Disorder?
• In the past, OCD has variously been believed to
be a “religious melancholy”, a result of repressed
sexual drives, or a type of anxiety disorder.
• Most experts now believe that OCD is not the
result of anxiety, but rather a kind of neurological
“short circuit” that causes repetitive thoughts
and behaviors, similar to Body Dysmorphic
Disorder, Tourette’s syndrome, and
Hypochondriasis.
Moyer Sci Am Mind May/June 2011
Obsessive-Compulsive and Related
Disorders Highlights
• Obsessive-Compulsive Disorder
• Body Dysmorphic Disorder (from
Somatoform Disorders)
• Hoarding Disorder
• Trichotillomania (Hair-Pulling)
• Excoriation Disorder (Skin-Picking)
Obsessive-Compulsive and Related
Disorders Specifics
• Hoarding Disorder
– Difficulty discarding or parting with possessions
regardless of the value
– The symptoms result in the accumulation of a
large number of possessions that fill up and
clutter active living areas of the home so that
intended use is no longer possible
– The symptoms cause distress or impairment
Hoarding Disorder, Unclutterer blog
Is PTSD an Anxiety Disorder?
• Careful study of clinical, biochemical, and
fMRI data has lead investigators to conclude
that PTSD is not a fear and anxiety-based
disorder. PTSD is one of a wide array of
disorders that arise in response to traumatic
events. The disorders are characterized by
symptoms of avoidance, and negative
alterations of mood.
Negative Alterations in Mood or
Cognition
• Several of the following:
– Inability to remember important aspects of the
trauma
– negative expectations of the self, others, or the world
– persistent distorted blame of the self
– pervasive negative emotional state
– diminished interest in significant activities
– feeling detachment from others
– inability to experience positive emotions
DSM-5 Trauma and Stressor-Related
Disorders (Moran Psych News 4/6/12)
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Reactive Attachment Disorder of Infancy
Disinhibited Social Engagement Disorder
Posttraumatic Stress Disorder
Acute Stress Disorder
Adjustment Disorder (moved from its own
category in DSM-IV)
– Bereavement related
– Acute stress (depressed mood, anxiety, PTSD-like)
DSM-5 Trauma and Stressor-Related
Disorders Specifics
• Posttraumatic Stress Disorder
– Trauma does not include witnessing events on TV
or other electronic media
– PTSD no longer requires that an individual have a
subjective experience of fear or horror, since that
has not been useful in determining who develops
PTSD. Well-trained emergency workers, for
instance, often do not show emotions during the
crisis, but may develop PTSD.
DSM-5 PTSD Highlights
• The 3 symptom clusters of DSM-IV
– re-experiencing
– avoidance and numbing
– arousal
• become 4 symptom clusters in DSM-5
– re-experiencing
– avoidance
– negative alterations in mood and cognition
– arousal
DSM-IV Substance Use Disorders
• Substance Abuse: 1 or more of the following
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Failure to fulfill role obligations
Physically hazardous
Legal problems
Recurrent social or interpersonal problems
• Substance Dependence: 3 or more of the following
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Tolerance
Withdrawal
More use than intended
Unsuccessful efforts to cut down
Much time spent trying to obtain substance
Social, occupational, or recreational activities given up
Continued use despite physical or mental health problems
• Specifiers: with or without physiologic dependence
Substance Related and Addictive
Disorders Specifics
• DSM-5 combines abuse and dependence into a single
disorder graded by severity. The disorder requires 2
criteria, with 2-3 criteria indicating moderate and 4+
criteria indicating severe. Specifiers for physiologic
dependence and course remain.
• Some clinicians believe this is losing a crucial
distinction between dependence and abuse.
• The task force argues that reliability of diagnosing
substance abuse is low, and that there is substantial
evidence showing abuse and dependence as a
continuum.
DSM-5 Substance Use and Addictive
Disorders
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Stimulant-Related: use, intoxication, withdrawal
Tobacco-Related: use, withdrawal
Unknown Substance
Gambling Disorder
Neurobehavioral Disorder Due to Prenatal
Alcohol Exposure (Fetal Alcohol Syndrome) in
Section III
• Internet Use Disorder in Section III
Non-Suicidal Self-Injury (Section III)
• In the last year, the individual has on 5 or more days
engaged in intentional self-inflicted damage to the
surface of the body, for purposes not socially
sanctioned, but with the intention that the injury will
only lead to minor or moderate physical harm (not
suicidal.)
• The intentional injury is associated with a least 2 of:
– Negative feelings/thoughts prior to injury
– Preoccupation with the intended behavior that is difficult
to resists
– The urge occurs frequently.
– Activity is engaged in to get relief from negative feeling
Disorders Suggested by Outside
Groups
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Apathy Syndrome
Body Integrity Disorder
Developmental Trauma Disorder
Disorders of Extreme Stress
Melancholia
Parental Alienation Syndrome
Seasonal Affective Disorder
Sensory Processing Disorder
Some Other Suggestions From Me
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Public Whining Disorder
Shameless Body Display Disorder
Narcissistic Airline Seat-Reclining Disorder
DSM-5 Anticipation Disorder
Other Things…
• GAF Scale?
• V and Z codes are in Section III
• How long insurance companies will accept DSMIV? Probably a year.
• ICD-10 correlations. ICD-10 was completed in
1992. The final date for implementation of ICD-10
for CMS (Centers for Medicare and Medicaid
Services) is October 2014. There is an effort to
make DSM-5 ICD-10 and ICD-11 friendly.
• Suicide scale probably in Section III with the other
Cross-Cutting Dimensional Measures