David J. Kupfer, MD; Emily A. Kuhl, PhD; Darrel A. Regier, MD, MPH
The next revision of psychiatry's Diagnostic and Statistical Manual of Mental Disorders (DSM-5)1 will be published in May 2013 and is the first revision of this psychiatric nomenclature in almost 2 decades. DSM-5 involved an international, multidisciplinary team of more than 400 individuals who volunteered vast amounts of their time throughout this 6-year official process, as well as many contributions from numerous international conferences that were held during the last decade.
Readers will recognize a few notable differences from DSM-IV. One distinction is DSM-5's emphasis on numerous issues important to diagnosis and clinical care, including the influence of development, gender, and culture on the presentation of disorders.2 This is present in select diagnostic criteria, in text, or in both, which include variations of symptom presentations, risk factors, course, comorbidities, or other clinically useful information that might vary depending on a patient's gender, age, or cultural background. Another distinct feature is ensuring greater harmony between this North American classification system and the International Classification of Diseases (ICD) system. For example, the chapter structure of DSM now begins with those in which neurodevelopmental influences produce early-onset disorders in childhood. This restructuring brings greater alignment of DSM-5 to the structuring of disorders in the future ICD-11 but also reflects the manual's developmental emphasis, rather than the previous edition's sequestering of all childhood disorders to a separate chapter. A similar approach to harmonizing with the ICD was taken to promote a more conceptual relationship between DSM-5 and classifications in other areas of medicine, such as the classification of sleep disorders.
Many of the revisions in DSM-5 will help psychiatry better resemble the rest of medicine, including the use of dimensional (eg, quantitative) approaches. Disorder boundaries are often unclear to even the most seasoned clinicians and underscore the proliferation of residual diagnoses (ie, “not otherwise specified” disorders) from DSM-IV. But a large proportion of DSM-5 users will not be psychiatrists; most patients, for instance, will first present to their primary care physician—not to a psychiatrist—when experiencing psychiatric symptoms. The use of definable thresholds that exist on a continuum of normality is already present throughout much of general medicine, such as in blood pressure and cholesterol measurement, and these thresholds aid physicians in more accurately detecting pathology and determining appropriate intervention.3 Thus DSM-5 provides a model that should be recognizable to nonpsychiatrists and should facilitate better diagnosis and follow-up care by such clinicians. In addition, the multiaxial system that characterized earlier editions of DSM—wherein clinicians recorded diagnoses, comorbid medical conditions, nondisorder reasons for clinical visit (eg, partner/relational problems), and ratings of disability and functioning on 5 separate axes—has been discontinued. This is largely due to its incompatibility with diagnostic systems in the rest of medicine, as well as the result of a decision to place personality disorders and intellectual disability at the same level as other mental disorders.
The above major changes represent those throughout the entire volume. What follows is a sampling from a larger summary of select recommended changes for specific disorders that will be found in the new DSM-5 manual:
Disruptive mood dysregulation disorder: In an effort to address the increase in the diagnosis of pediatric bipolar disorder among children with severe emotional and behavioral disturbance, disruptive mood dysregulation disorder will be included in DSM-5. The aim is to reduce confusion about whether severe, chronic irritability should be considered characteristic of mania in children—one of the primary reasons for the increase in pediatric bipolar diagnoses and subsequent inappropriate treatment with antipsychotic medications. In DSM-5, nonepisodic irritability is distinguished from mania as the hallmark feature of disruptive mood dysregulation disorder, whereas a diagnosis of bipolar disorder may be considered for children with an episodic course.
Posttraumatic stress disorder (PTSD) will be included in a chapter separate from anxiety disorders, obsessive-compulsive and related disorders, and dissociative disorders (which also are placed in distinct chapters). The revised criteria include expansion of DSM-IV's 3 symptom clusters into 4, with the avoidance/numbing cluster now separated into 2 clusters (avoidance and persistent negative alterations in cognitions and mood). By including an additional criteria set focused solely on symptoms in children aged 6 years and younger, diagnosis will be more developmentally sensitive and call attention to differences in presentation among young children vs adults (eg, the reexperiencing of traumatic events through play or storytelling).
Removal of bereavement exclusion: In DSM-IV, individuals meeting criteria for a major depressive episode were excluded from a diagnosis of major depressive disorder if symptoms occurred within 2 months of the death of a loved one. However, the implication that bereavement ends in only 2 months or that major depression and bereavement cannot co-occur appears false.7 Depression related to bereavement can share many of the same symptoms as nonbereavement-related depression and can accordingly respond to treatment. Similarly, major depression can share features with other forms of significant loss or stress, including job loss and natural disasters, and may be in need of intervention. To prevent the denial of diagnosis (and care) of individuals who meet full criteria for a major depressive disorder, even during bereavement or other significant loss, DSM-5 now permits such a diagnosis and includes 2 notes, within the major depressive episode criteria set, to guide clinicians in making the diagnosis in this context.
Substance use disorder is a new diagnosis in DSM-5 that combines the DSM-IV disorders of substance abuse and substance dependence. This is due in part to misuse of the term dependence to describe the normal withdrawal patterns that can occur during appropriate medication use. Criteria for substance use are largely the same as the criteria in DSM-IV for abuse and dependence, except for removal of the criterion requiring recurrent legal problems and the addition of a new criterion to address craving or strong desires or urges to use a given substance.
