An Overview of the DSM-5

Version Year Number of diagnoses

1952 102
DSM-I
1968 182
DSM-II
1980 265
DSM-III
1987 292
DSM-III-R
1994 297
DSM-IV
2000 365
DSM-IV-TR
2013 157
DSM-5
 DSM-5
• DSM-5 Editor: David Kupfer
• Mainly incremental changes from DSM-IV
• No more Roman numerals
Problems with DSM-IV Addressed by DSM-5

• High rates of co-morbidity

• High use of Not Otherwise specified (NOS)
category
• Concerns about reliability and validity
 DSM-5 Structure
• Section I: Basics
• Section II: Diagnostic Criteria and Codes
• Section III: Emerging Measures and Models
• Appendix
 Section I: Basics
• Introduction
• Use of the Manual
• Cautionary Statement for Forensic Use
 Section I: Basics: Introduction
• DSM-5 has better reliability than DSM-IV.
• Research to validate diagnoses continues.
• DSM-5 accommodates dimensional
approaches to mental disorders.
• Many mental disorders are on a spectrum
with related disorders that have shared
symptoms.
• Disorder categories in earlier DSMs were
overly narrow, resulting in the widespread use
of Not Otherwise Specified (NOS) diagnoses.
• DSM-5 removes the NOS diagnosis. It adds
Other Specified Disorder (criteria vary by
disorder)
Unspecified Disorder (for use when there is
insufficient information to be more specific)
• For example, suppose a client has significant
depressive symptoms but does not meet all
the criteria for a major depressive episode.
• The diagnosis would be “Other specified
depressive disorder, depressive episode with
insufficient symptoms.”
 Organization of Disorders
• Disorders are organized on developmental and
lifespan considerations.
• DSM-5 begins with diagnoses that manifest
early in life, then adolescence and young
adulthood, then adulthood and later life.
 Cultural Issues
• Culture shapes the experience and expression
of the symptoms, signs, and behaviors that are
criteria for diagnosis.
• Section III contains a Cultural Formulation.
• The Appendix contains a Glossary of Cultural
Concepts of Distress.
 DSM-5 is Non-Axial
• DSM-IV axes I, II, and III have been combined.
• Continue to list relevant medical conditions.
• The Global Assessment of Functioning, in
DSM-IV has been eliminated. Instead, use the
World Health Organization Disability
Assessment Schedule (WHODAS).
•
 Section I: Basics: Use of the Manual
• Clinical Case Formulation
– Making diagnoses requires clinical judgment, not
just checking off the symptoms in the criteria.
– The client’s cultural and social context must be
considered.
 Definition of a Mental Disorder
A mental disorder is a syndrome
characterized by clinically significant disturbance
in an individual’s cognition, emotion regulation,
or behavior that reflects a dysfunction in the
psychological, biological, or developmental
processes underlying mental functioning.
There is usually significant distress or
disability in social or occupational activities.
• The diagnosis of a mental disorder should
have clinical utility; it should help clinicians to
determine prognosis and treatment plans.

• Until etiological or pathophysiological

mechanisms are identified to validate specific
disorders, the most important standard for the
disorder criteria will be their clinical utility.
• In the absence of clear biological markers for
mental disorders, it has not been possible to
completely separate normal and pathological
symptom expressions contained in diagnostic
criteria.
• Therefore, a generic diagnostic criterion is
“the disturbance causes clinically significant
distress or impairment . . . .”
• Diagnoses are made on the basis of
– The clinical interview
– DSM-5 text descriptions
– DSM-5 criteria
– Clinician judgment
 Section I: Basics: Cautionary Statement for
Forensic Use of DSM-5
• The diagnosis of a mental disorder does not
imply that the person meets legal criteria for
the presence of a mental disorder or a specific
legal standard for competence, criminal
responsibility, disability, etc.
• Having a diagnosis does not imply that the
person is (or was) unable to control his or her
behavior at a particular time.
Section II: Diagnostic Criteria and Codes

Highlights of Specific Disorder

Revisions
 Schizophrenia Spectrum and Other
Psychotic Disorders
• Schizophrenia
– Elimination of special treatment of bizarre delusions
and special hallucinations in Criterion A.
– At least one of two required symptoms to meet
Criterion A must be delusions, hallucinations, or
disorganized speech.
– Specific subtypes were deleted due to poor reliability
and validity.
• Catatonia
– Now exists as a specifier for many mental disorders.
 Bipolar and Related Disorders
• Mania and Hypomania
– Criterion A now includes increased energy/activity
as a required symptom.
– “Mixed episode” is replaced with a “with mixed
features” specifier.
– “With anxious distress” was added as a specifier
for bipolar and depressive disorders.
 Depressive Disorders
• Disruptive Mood Dysregulation Disorder
(DMDD) was added.
– For children with extreme behavioral dyscontrol
but persistent rather than episodic irritability.
– This should decrease the number of children
diagnosed with bipolar disorder.
– Dysthymic Disorder was renamed Persistent
Depressive Disorder.
 Anxiety Disorders
• no longer includes obsessive-compulsive
disorder (which is included with the obsessive-
compulsive and related disorders)
• posttraumatic stress disorder and acute stress
disorder (which is included with the trauma-
and stressor-related disorders).
• Panic attacks was added as a specifier .
 Obsessive-Compulsive & Related Disorders

• Hoarding Disorder was added.

• Excoriation (Skin-Picking) Disorder was added.

• Body Dysmorphic Disorder (BDD) was moved

from the chapter on somatic disorders to the
chapter on OCD & Related disorders.

A “delusional” specifier was added for both OCD

and BDD.
 Dissociative Disorders
• Text was added to support Criterion D
(exclusion based on cultural or religious
practices).
– This is to emphasize that possession states do not
necessarily indicate the presence of Dissociative
Identity Disorder if the possession state is
recognized in the client’s culture or subculture.
 Dissociative Disorders
• Dissociative fugue was removed as an
independent disorder but was added as a
specifier for any dissociative disorder.
 Somatic Symptom and Related Disorders

• The emphasis is placed on disproportionate

thoughts, feelings, and behaviors that
accompany symptoms, rather than on
whether the symptoms are medically
unexplained.
• Somatic Symptom Disorder replaces
somatoform disorder, hypochondriasis, and
the pain disorders.
 Personality Disorders
• All 10 PDs in DSM-IV remain intact in DSM-5.
• Note that “Axis II” in DSM-IV no longer exists.
• Section III of the DSM-5 contains an alternate,
trait-based approach to assessing personality.
It helps with the diagnosis of people who
meet the core criteria for a PD but do not
meet the criteria for a specific type of PD.
 Section III: Emerging Measures and Models

• Assessment Measures
– Level 1 Cross-Cutting Symptom Measure
• To measure depression, anger, mania, anxiety, etc.
• To screen for important symptoms; self-administered
by patient; brief (1-3 questions per symptom domain).
– Level 2 Cross-Cutting Symptom Measure
• To be done when a Level 1 item is endorsed at the level
of “mild” or greater.
 Emerging Measures, cont.
• Diagnosis-Specific Severity Measures
– To document the severity of a specific disorder.
– Some are clinician-rated, some are patient-rated.
 Emerging Measures, cont.
• WHO Disability Assessment Schedule 2.0
• Replaces the GAF Scale in DSM-IV
• Is recommended but not required.
• Has 36 self-administered questions.

• Cultural Formulation
– Outline for Cultural Formulation
– Cultural Formulation Interview
 Conditions for Further Study
• Attenuated Psychosis Syndrome
• Persistent Complex Bereavement Disorder
• Caffeine Use Disorder
• Internet Gaming Disorder
• Suicidal Behavior Disorder
• Nonsuicidal Self-Injury
 Suicidal Behavior Disorder
• A suicide attempt within the past 24 months.
• The act is not non-suicidal self-injury.
• Suicidal ideation does not qualify.
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 Non-suicidal Self-Injury
• In the last year the person has, on 5 or more
days, engaged in intentional self-inflicted
damage to the surface of his or her body . . .
with the expectation that the injury will lead
to only minor or moderate physical harm (i.e.
there is no suicidal intent).
• Five additional criteria.
 Similarities DSM- V & ICD-10
• Shared Definitions - ICD and DSM share several similar codes for
diagnosis. However, the specificity of defining each condition is where
they differ. For example codes for social pragmatic communication
disorder, and alcohol use disorder (AUD), etc. are similar in both the
classification system
• Classification - DSM and ICD are code sets which are nearly identical in
many ways and permits classifying the diagnosis for healthcare and
insurance processing processes
• Code Crosswalking - Both DSM and ICD allow crosswalking from old to
new versions. This allows the new version to have some definitions from
the former versions
• Formulation - The criteria for DSM and ICD are not decided based on
factual evidence, but they are approved by medical experts for research
after reaching a consensus
Differences