Psychologists are preparing for major changes in the fifth edition of the “Diagnostic and Statistical Manual of Mental Disorders” (DSM-5), to be published in May.
The American Psychiatric Association Board of Trustees approved the final diagnostic criteria after a decade-long revision process.
Licensed psychologist Craig W. Knapp, Ph.D., president elect of the Vermont Psychological Association, who will give an upcoming conference presentation on DSM-5, says the whole system is changing. “DSM-5 is probably the most substantial revision that’s been done” and he foresees both benefits and challenges.
“The good news is that one of the promised thrusts of the new manual is to be more descriptive and less theoretical,” he says. DSM-5 is organized in three sections – introductory; the main body including criteria for disorders; and a section with assessment measures, cultural formulation and conditions for further study. “I think it is certainly beneficial to try to be as descriptive as you can be and the intent has been to utilize the most current information available through research and neuroscience to more accurately describe conditions that are problems for people and that certainly is a benefit,” Knapp says.
Knapp expects one challenge to be a change in the diagnostic process. DSM-5 removes the multiaxial system and moves to a nonaxial documentation of diagnosis, combining the former Axes I, II and III, with separate notations for psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V).
“That’s a radical change that will require people to rethink, ‘How do I go about making the diagnosis in the first place’?” Knapp says.
Practitioners who use electronic case files may also face challenges, as systems need updating or replacement. This situation follows another technological issue that began in January when the American Medical Association behavioral health CPT codes changed.
“That is a problem that will affect mental health professionals, as we have to transition from one system to another system, where the whole diagnostic process is changed and the medical record – if it was electronic – has to be updated or replaced, and then we have to learn how to use it,” Knapp says.
Among DSM-5 changes in Section 2 Disorders:
- Autism spectrum disorder criteria incorporates several DSM-IV diagnoses – autistic disorder, Asperger’s disorder, childhood disintegrative disorder and pervasive developmental disorder (not otherwise specified) – under a single umbrella
- Disruptive mood dysregulation disorder will be included to diagnose children whoexhibit persistent irritability and frequent episodes of behavior outbursts
- Hoarding disorder is new
- DSM-5 will maintain the categorical model and criteria for the 10 personality disorders included in DSM-IV and will include the new trait-specific methodology in a separate area of Section 3 to encourage further study of how this could be used to diagnose personality disorders in clinical practice
- Removal of bereavement exclusion: the exclusion criterion in DSM-IV applied to people experiencing depressive symptoms lasting less than two months following the death of a loved one and will be replaced by several notes within the text delineating the differences between grief and depression
- The DSM-5 chapter on Anxiety Disorders no longer includes obsessive-compulsive disorder (which is included in DSM-5 in Obsessive-Compulsive and Related Disorders) or posttraumatic stress disorder and acute stress disorder (now under Trauma- and Stressor-Related Disorders)
Gordon Street, Ph.D., clinical psychologist, and partner of Anxiety Solutions of Northern New England, PLLC, in Maine, says that while he understands the reasons for reclassifying DSM-IV Anxiety Disorders into three separate categories in DSM-5, it seems odd from a clinical standpoint. “Not only has clinical research so clearly shown that exposure-based CBTs are particularly effective in the treatment of all three of these DSM-5 categories, but also so much of what we have learned about improving treatments for the rest of the DSM-IV anxiety disorders has come from what we have learned about what is effective in treating OCD,” Street says.
“However, no one is suggesting that anxiety is no longer to be considered a key symptom of OCD and PTSD (and related disorders), just that the anxiety experienced may have a different etiology and be secondary to that etiology,” Street says.
For example, in PTSD (and what have been called the adjustment disorders), the key etiological factor seems to be a significant experiential trauma or stressor, he says.
“For now, what is most important to us clinically is that – until/unless dividing these disorders into separate categories leads to significant differences in treatments – all three categories continue to be characterized by significantly excessive, distressing, and/or impairing anxiety and all three categories continue to be more likely to benefit from exposure-based CBTs (especially adaptations of ERP) than other psychological treatments,” Street says.
Concerns about DSM-5 have sparked an international effort to alert professionals and the public.
In late 2011, the American Psychological Association’s Society for Humanistic Psychology (Division 32), affiliated with the British Psychological Society, sponsored an open letter/petition that garnered more than 14,000 signatures and support from 50-plus organizations. Concerns included the lowering of diagnostic thresholds of existing disorders; emphasis on the biomedical basis of disease, which could encourage the use of pharmaceutical treatment and possibly increase the stigma of issues that might be temporary in normal human development; and a lack of transparency in the process.
As a follow-up to the open letter, Brent Dean Robbins, Ph.D., president-elect of Division 32 and co-chair of the division’s DSM-5 Response Committee, says the committee has been gathering organizational support and consensus to post a statement of concern and additional information in late March, directed at mental health professionals and consumers.
“At this point, we’re moving beyond attempting to reform the DSM-5 and trying to alert the public to what we see as problems that haven’t been resolved,” Robbins says.
Robbins says some DSM-5 changes run the risk of creating opportunities to expand diagnosis categories that would pathologize normal, transient behavior.
Specific concerns include the removal of the bereavement exclusion, which Robbins says could lead to an over-diagnosis of depression among people who are experiencing normal processes when faced with the death of a loved one.
“There’s a general consensus that grief is normal,” Robbins says. “When you look at some of this grieving, it’s virtually indistinguishable from the symptoms of major depressive disorder. So if you remove the exclusion criteria, you seriously increase the risk that people going through normal, transient grief will be saddled with the diagnosis of major depressive disorder, which will follow them for life.”
Robbins says the criteria changes in generalized anxiety disorder could also be applicable to a larger population and lead to people becoming identified with a psychiatric diagnosis in situations whereas they otherwise might have adapted to their circumstances.
David Kupfer, M.D., chair of the DSM-5 Task Force, says, “Rather than lowering diagnostic thresholds, our work was aimed at more accurately defining mental disorders that have a real impact on people’s lives.
“Based on results from the DSM-5 Field Trials, we do not expect revisions to diagnostic criteria to drastically raise the prevalence rates. In other words, we do not expect that the number of people receiving a mental disorder diagnosis will increase significantly,” Kupfer says.
By Pamela Berard