Understanding the DSM-5 Crystal Weaver, CRC, MT-BC
Slide 2
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
Slide 3
Part One: The History of the DSM
Slide 4
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 DSMs 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
Slide 5
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
Slide 6
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 19 th and early 20 th 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
Slide 7
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
Slide 8
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
Slide 9
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
Slide 10
International Statistical Classification In 1948, the 6 th
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
Slide 11
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
Slide 12
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
Slide 13
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
Slide 14
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
Slide 15
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
Slide 16
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 Kraepelins 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
Slide 17
Neo-Kraepelinians (cont) Kraepelins 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
Slide 18
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
Slide 19
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
Slide 20
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
responsibilityThe efficacy of various treatment modalities can be
compared only if patient groups are described using diagnostic
terms that are clearly defined.
Slide 21
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
Slide 22
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
Slide 23
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
Slide 24
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
Slide 25
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
Slide 26
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 DSM- IV-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
Slide 27
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
Slide 28
Diagnostic and Statistical Manual of Mental Disorders, Fifth
Edition Predictions (cont) Other proposed changes for the DSM-5:
Autistic disorder, Aspergers 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)
Slide 29
Part Two: The DSM-5
Slide 30
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
Slide 31
The Basics The DSM-5 was released at the American Psychiatric
Associations 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
Slide 32
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
Slide 33
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
Slide 34
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
Slide 35
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
Slide 36
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
Slide 37
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
Slide 38
Neurodevelopmental Disorders Category includes: Intellectual
Disability Global Developmental Delay (under age 5) Communication
Disorders Autism Spectrum Disorder ADHD Specific Learning Disorder
Motor Disorders
Slide 39
Autism Spectrum Disorder (ASD) Aspergers disorder is now
absorbed into Autism Spectrum Disorder (ASD) Aspergers, Childhood
Disintegrative Disorder, Retts 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
Slide 40
Autism Spectrum Disorder (cont) People with a well-established
DSM-IV diagnosis of ASD, Aspergers, 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)
Slide 41
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
(RRBs)
Slide 42
Autism Severity (Severity specifiers should not be used to
determine eligibility for services) Severity LevelSocial
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
Slide 43
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 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
Slide 46
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)
Slide 47
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
Slide 48
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
Slide 49
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
Slide 50
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
Slide 51
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 symptom- free Can not diagnosis before age 6
or after age 18
Slide 52
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
Slide 53
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)
Slide 54
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%
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
Slide 57
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
Slide 58
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
Slide 59
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
Slide 60
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
Slide 61
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
Slide 62
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
Slide 63
Substance Use and Addictive Disorders (cont) Severity: Mild =
2-3 symptoms Moderate = 4-5 symptoms Severe = 6 or more
symptoms
Slide 64
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 brains 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
Slide 65
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
Slide 66
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
Slide 67
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