DSM-5 Cleared For Takeoff

In case you missed the big news, last weekend, the American Psychiatric Association’s Board of Trustees voted on and approved the final diagnostic criteria for the fifth edition of the Diagnostic and Statistical Manual, or DSM-5, paving the way for publication next year.

I know, you are shocked. The DSM-5 has been 14 years in the making, with more than 1,500 expert reviewers, multiple committees, work groups, meetings, revisions, and $25 million spent when all is said and done. So, there was little surprise when the board met on Dec. 1 and made the final approvals for publication in May 2013. I am on the APA Assembly, which is its deliberative body. We met in November to vote affirmatively on the recommendations of the Assembly DSM-5 Task Force to approve the new manual to date. At that time, most of the criteria sets had been finalized.

The scientific reviews began in 1999 across 13 NIH-supported conferences, followed by a prelude to the DSM-5 website in 2004 for additional input and development. Specific work groups began meeting 5 years ago for more focused reviews, and in 2010 the first draft was publicly released, with two subsequent revisions leading up to the present. In addition to the extensive scientific review, there were reviews based on effects on clinical practice, public health, and forensics.

I won’t provide an exhaustive review of the DSM-5 changes; you will get plenty of these in the months leading up to the May publication date. I will share the aspects that stand out for me so far.

First, you will notice that the multi-axial system is going away. No more dividing things up into Axis I (mental illness), Axis II (personality and developmental), Axis III (“medical”), Axis IV (essentially social problems), and Axis V (global assessment of functioning or GAF). This system was the embodiment of the “biopsychosocial” formulation.

In today’s era of integration of psychiatry into mainstream medicine and attempts to destigmatize, it makes sense to me to include mental illnesses among all the other conditions a person might have rather than setting them off in their own special section. I found the GAF to not be very useful, as it had turned into an unreliable metric for many reasons.

The number of diagnoses will remain about the same, but some of the names, organization, and criteria will have been revised based on the latest research and conceptualizations. Newly distilled diagnoses include autism spectrum disorder, binge eating disorder, hoarding disorder, and skin-picking disorder. The dementia diagnoses have been reworked.

The old diagnoses of substance abuse and substance dependence were restructured and combined into substance use disorder. I found that differentiation between abuse and dependence was not terribly useful, and that these things existed along a spectrum that changes over time for each specific person.

The new, broader diagnosis emphasizes impairment combined with elements of abuse, including overuse, trouble quitting, craving, negative consequences, dangerous use, tolerance, and withdrawal. A modifier can indicate whether physiological dependence is present. Severity modifiers based on number of symptoms have replaced the less useful prior modifiers of episodic and continuous.

Disruptive mood dysregulation disorder has simultaneously been criticized as pathologizing temper tantrums in kids and lauded as a mechanism to reduce the growing percentage of kids with a bipolar diagnosis. The criteria do specify that the outbursts must be inconsistent with developmental level, so that should mute the above criticism, although it will be helpful to know what are the levels of “severe recurrent temper outbursts” that are consistent with a given developmental level. This is probably a bell-shaped curve so an agreed-upon cut point will be required.

There have some changes to the mood disorders. Dysthymia has been renamed persistent depressive disorder. Major depression has some notable changes. Separate diagnoses of Single episode and Recurrent have been reduced to modifiers, while a new modifier of Persistent (greater than 2 years) was added. Another modifier, “with anxious distress,” was added to help identify comorbid anxiety symptoms, rather than create a separate diagnosis called “anxious depression,” which was considered but rejected.

Previously, there was a brighter line between depressive symptoms accountable to loss-related grief versus major depression, whereas now it is left more to clinical judgment. A very useful footnote goes into detail about how to think this through.

There has been some controversy regarding the interrater reliability of diagnosing major depression. The field trials for this diagnosis showed a much lower level of agreement when two clinicians examine the same person. This was brought up as one of the main points of contention during the Assembly discussion. My impression is that this diagnosis has become used with less attention to the criteria over the years, with this effect spilling over into the field trial results. But I’d like to hear what the depression experts have to say about this problem.

Overall, the DSM-5 has been long-awaited and will be out in a few months. Instead of having such long periods between DSM revisions, we will see shorter periods with bite-size revisions, for example, DSM-5.1, 5.2, 5.3, etc. This will make it more of a living document that can change more frequently based on new research and conceptualizations.

—Steven Roy Daviss, M.D., DFAPA

DR. DAVISS is chair of the department of psychiatry at the University of Maryland’s Baltimore Washington Medical Center, policy wonk for the Maryland Psychiatric Society, chair of the APA Committee on Electronic Health Records, and co-author of Shrink Rap: Three Psychiatrists Explain Their Work, published by Johns Hopkins University Press. In addition to @HITshrink on Twitter, he can be found on the Shrink Rap blog and drdavissATgmail.com.

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