The American Psychiatric Association (APA) released the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in May 2013. Like the DSM-IV-TR, which it replaced, the DSM-5 provides diagnostic criteria – descriptions and symptoms – for every known mental disorder. It is considered the leading resource for making psychiatric diagnoses and is used by psychiatrists, psychologists, social workers, nurses, and other mental health workers. It provides standardized criteria and a common language with which to diagnose and treat mental illness. It is also used by researchers, the insurance industry, pharmaceutical companies, and policy makers to define and describe the mental disorders of both children and adults. While treatment is often guided by DSM diagnoses, as is insurance reimbursement, the DSM manual itself does not provide specific treatment recommendations.
Called by some “the bible of psychiatry,” the DSM is not without its critics. It has been praised both for creating a system that was easily used by all types of mental health workers and criticized for creating a subjective guide based on the expertise of a much smaller group of psychiatrists. Some have argued that DSM lacks validity and reliability, while others reply that there is plenty of evidence to support the classification system. To some extent, the controversy stems from the fact the DSM describes signs and symptoms of mental disorders rather than causes. In fact, for many mental disorders, we still know very little about what causes a specific individual to develop a certain psychiatric condition.
First published in 1952, the DSM has undergone a number of revisions. Prior to the new DSM-5, the DSM-IV-TR was published in 2000. Since that time, we have learned a great deal more about mental illness and this new knowledge helped to guide development of DSM-5. That is, the DSM was revised to take into account what we have learned about the brain and mental illness from studies in the fields of neurology, genetics, and human behavior, including research about brain structure and function, the prevalence of mental disorders, and the lifelong effects of genes and the environment on an individual’s health and behavior. In addition, advances in scientific technologies have enabled us to analyze these disorders in new and more sophisticated ways.
Revisions in the diagnostic criteria for the DSM-5 took a long time, with the first Task Force discussions taking place in 1999. The work began in earnest in 2002 with the “Research Agenda for the DSM-5” (APA). The effort was coordinated by the DSM-5 Task Force and 13 work groups, made up of experts from around the world in research and/or treatment for different psychiatric disorders. The goal of the Task Force for the DSM-5 was to create a manual that would have maximum utility for both clinicians and patients. Further, the Task Force sought to find balance between new research evidence and the maintenance of continuity with the previous DSM-IV-TR. Their goal was to minimize disruptions to clinicians and researchers while making necessary changes in areas where new research can inform psychiatric diagnoses. More systemic changes were also made to address problem areas in the DSM-IV-TR. Specifically, the DSM-5 addresses symptom severity, an area that received little attention in earlier versions. It also discusses symptoms that tend to co-occur, like schizophrenia and insomnia. Finally, the DSM-5 contains fewer disorders labeled “Not Otherwise Specified.”
Further changes appearing in the DSM-5 include the following:
- Hoarding, classified as an independent mental disorder separate from obsessive-compulsive disorder; this change was noncontroversial and well supported in the research literature.
- Drug addiction, which replaces “substance abuse” and “substance dependence,” and is classified under the heading of “substance use disorders” in a chapter titled “Substance Related and Addictive Disorders.” The criteria contributing to a diagnosis of drug addiction has been revised from the DSM-IV-TR and also consolidated, bearing severity ratings of mild, moderate, or severe.
- Gambling disorder is now included in this chapter, as well.
- Binge eating disorder was approved as its own category of eating disorder.
- Disruptive mood dysregulation disorder is now used as the diagnosis for children and adolescents who exhibit persistent irritability with explosions of rage and physical violence instead of bipolar disorder.
- Autism spectrum disorders encompass autistic disorder, Asperger’s, and childhood disintegrative disorders which were listed as distinct disorders in the DSM-IV-TR; the criteria for diagnosing a patient with autism have also become much stringent to minimize concerns with over-diagnosis.
- In the DSM-5, it is possible to assign a diagnosis of depression even within the first two months following a person’s loss of a loved one. This is in contrast to the earlier nosology where symptoms had to persist for more than two months (the so-called “bereavement exclusion”) prior to diagnosis.
The impact of these changes is potentially staggering as millions of people are treated for disorders based on DSM categories, and treatment for these disorders costs our country billions of dollars each year. The changes will influence such diverse areas as which treatments get covered by insurance and which students are eligible for special services.
Jerilyn Schweitzer is a freelance writer in Bethesda, MD