Mental Health Disorders Redefined

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is the 2013 update to the American Psychiatric Association's (APA) classification and diagnostic tool.

The DSM-5 was published on May 18, 2013, superseding the DSM-IV-TR, which was published in 2000. In most respects DSM-5 is not greatly changed from DSM-IV-TR, however some changes are worth noting.

Notable changes include:

  • Dropping Asperger syndrome as a distinct classification.
  • Loss of subtype classifications for variant forms of schizophrenia.
  • Dropping the “bereavement exclusion” for depressive disorders.
  • Revised treatment and naming of gender identity disorder to gender dysphoria.
  • Removing the A2 criterion for posttraumatic stress disorder (PTSD) because its requirement for specific emotional reactions to trauma did not apply to combat veterans and first responders with PTSD.

Listed below is a summary of the changes from DSM-IV to DSM-5. If a specific disorder (or set of disorders) do not appear, it means that the diagnostic criteria for those disorders did not change significantly from DSM-IV to DSM-5.

Neurodevelopmental Disorders

  • “Mental retardation” has a new name: “intellectual disability (intellectual developmental disorder).”
  • Phonological disorder and stuttering are now called communication disorders—which include language disorder, speech sound disorder, childhood-onset fluency disorder, and a new condition characterized by impaired social verbal and nonverbal communication called social (pragmatic) communication disorder.
  • Autism spectrum disorder incorporates Asperger disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (PDD-NOS) –
  • A new sub-category, motor disorders, encompasses developmental coordination disorder, stereotypic movement disorder, and the tic disorders including Tourette syndrome.

Schizophrenia Spectrum and other Psychotic Disorders

  • All subtypes of schizophrenia were removed from the DSM-5 (paranoid, disorganized, catatonic, undifferentiated, and residual).
  • A major mood episode is required for schizoaffective disorder (for a majority of the disorders duration after criterion A [related to delusions, hallucinations, disorganized speech or behavior, and negative symptoms such as avolition] is met).
  • Criteria for delusional disorder changed, and it is no longer separate from shared delusional disorder.
  • Catatonia in all contexts requires 3 of a total of 12 symptoms. Catatonia may be a specifier for depressive, bipolar, and psychotic disorders; part of another medical condition; or of another specified diagnosis.

Bipolar and Related Disorders

  • New specifier “with mixed features” can be applied to bipolar I disorder, bipolar II disorder, bipolar disorder NED (not elsewhere defined, previously called “NOS”, not otherwise specified) and MDD.
  • Allows other specified bipolar and related disorder for particular conditions.
  • Anxiety symptoms are a specifier (called “anxious distress”) added to bipolar disorder and to depressive disorders (but are not part of the bipolar diagnostic criteria).

Depressive disorders

  • The bereavement exclusion in DSM-IV was removed from depressive disorders in DSM-5.
  • New disruptive mood dysregulation disorder (DMDD)[9] for children up to age 18 years.
  • Premenstrual dysphoric disorder moved from an appendix for further study, and became a disorder.
  • Specifiers were added for mixed symptoms and for anxiety, along with guidance to physicians for suicidality.
  • The term dysthymia now also would be called persistent depressive disorder.

Anxiety Disorders

  • For the various forms of phobias and anxiety disorders, DSM-5 removes the requirement that the subject (formerly, over 18 years old) “must recognize that their fear and anxiety are excessive or unreasonable”. Also, the duration of at least 6 months now applies to everyone (not only to children).
  • Panic attack became a specifier for all DSM-5 disorders.
  • Panic disorder and agoraphobia became two separate disorders.
  • Specific types of phobias became specifiers but are otherwise unchanged.
  • The generalized specifier for social anxiety disorder (formerly, social phobia) changed in favor of a performance only (i.e., public speaking or performance) specifier.
  • Separation anxiety disorder and selective mutism are now classified as anxiety disorders (rather than disorders of early onset).

Obsessive-Compulsive and Related Disorders

  • A new chapter on obsessive-compulsive and related disorders includes four new disorders: excoriation (skin-picking) disorder, hoarding disorder, substance-/medication-induced obsessive-compulsive and related disorder, and obsessive-compulsive and related disorder due to another medical condition.
  • Trichotillomania (hair-pulling disorder) moved from “impulse-control disorders not elsewhere classified” in DSM-IV, to an obsessive-compulsive disorder in DSM-5.
  • A specifier was expanded (and added to body dysmorphic disorder and hoarding disorder) to allow for good or fair insight, poor insight, and “absent insight/delusional” (i.e., complete conviction that obsessive-compulsive disorder beliefs are true).
  • Criteria were added to body dysmorphic disorder to describe repetitive behaviors or mental acts that may arise with perceived defects or flaws in physical appearance.
  • The DSM-IV specifier “with obsessive-compulsive symptoms” moved from anxiety disorders to this new category for obsessive-compulsive and related disorders.
  • There are two new diagnoses: other specified obsessive-compulsive and related disorder, which can include body-focused repetitive behavior disorder (behaviors like nail biting, lip biting, and cheek chewing, other than hair pulling and skin picking) or obsessional jealousy; and unspecified obsessive-compulsive and related disorder.

Trauma- and Stressor-Related Disorders

  • Posttraumatic stress disorder (PTSD) is now included in a new section titled “Trauma- and Stressor-Related Disorders.”
  • The PTSD diagnostic clusters were reorganized and expanded from a total of three clusters to four based on the results of confirmatory factor analytic research conducted since the publication of DSM-IV.
  • Separate criteria were added for children six years old or younger.
  • For the diagnosis of acute stress disorder and PTSD, the stressor criteria (Criterion A1 in DSM-IV) was modified to some extent. The requirement for specific subjective emotional reactions (Criterion A2 in DSM-IV) was eliminated because it lacked empirical support for its utility and predictive validity.Previously certain groups, such as military personnel involved in combat, law enforcement officers and other first responders, did not meet criterion A2 in DSM-IV because their training prepared them to not react emotionally to traumatic events.
  • Two new disorders that were formerly subtypes were named: reactive attachment disorder and disinhibited social engagement disorder.
  • Adjustment disorders were moved to this new section and reconceptualized as stress-response syndromes. DSM-IV subtypes for depressed mood, anxious symptoms, and disturbed conduct are unchanged.

Dissociative Disorders

  • Depersonalization disorder is now called depersonalization/derealization disorder.
  • Dissociative fugue became a specifier for dissociative amnesia.
  • The criteria for dissociative identity disorder were expanded to include “possession-form phenomena and functional neurological symptoms”. It is made clear that “transitions in identity may be observable by others or self-reported”.
  • Criterion B was also modified for people who experience gaps in recall of everyday events (not only trauma).

Somatic Symptom and Related Disorders

  • Somatoform disorders are now called somatic symptom and related disorders.
  • Patients that present with chronic pain can now be diagnosed with the mental illness somatic symptom disorder with predominant pain; or psychological factors that affect other medical conditions; or with an adjustment disorder.
  • Somatization disorder and undifferentiated somatoform disorder were combined to become somatic symptom disorder, a diagnosis which no longer requires a specific number of somatic symptoms.
  • Somatic symptom and related disorders are defined by positive symptoms, and the use of medically unexplained symptoms is minimized, except in the cases of conversion disorder and pseudocyesis (false pregnancy).
  • A new diagnosis is psychological factors affecting other medical conditions. This was formerly found in the DSM-IV chapter “Other Conditions That May Be a Focus of Clinical Attention”.
  • Criteria for conversion disorder (functional neurological symptom disorder) were changed.

Feeding and Eating Disorders

  • Criteria for pica and rumination disorder were changed and can now refer to people of any age.
  • Binge eating disorder graduated from DSM-IV’s “Appendix B — Criteria Sets and Axes Provided for Further Study” into a proper diagnosis.
  • Requirements for bulimia nervosa and binge eating disorder were changed from “at least twice weekly for 6 months to at least once weekly over the last 3 months”.
  • The criteria for anorexia nervosa were changed; there is no longer a requirement of amenorrhea.
  • “Feeding disorder of infancy or early childhood”, a rarely used diagnosis in DSM-IV, was renamed to avoidant/restrictive food intake disorder, and criteria were expanded.

Sleep–Wake Disorders

  • “Sleep disorders related to another mental disorder, and sleep disorders related to a general medical condition” were deleted.
  • Primary insomnia became insomnia disorder, and narcolepsy is separate from other hypersomnolence.
  • There are now three breathing-related sleep disorders: obstructive sleep apnea hypopnea, central sleep apnea, and sleep-related hypoventilation.
  • Circadian rhythm sleep–wake disorders were expanded to include advanced sleep phase syndrome, irregular sleep–wake type, and non-24-hour sleep–wake type. Jet lag was removed.
  • Rapid eye movement sleep behavior disorder and restless legs syndrome are each a disorder, instead of both being listed under “dyssomnia not otherwise specified” in DSM-IV.

Sexual Dysfunctions

  • DSM-5 has sex-specific sexual dysfunctions.
  • For females, sexual desire and arousal disorders are combined into female sexual interest/arousal disorder.
  • Sexual dysfunctions (except substance-/medication-induced sexual dysfunction) now require a duration of approximately 6 months and more exact severity criteria.
  • A new diagnosis is genito-pelvic pain/penetration disorder which combines vaginismus and dyspareunia from DSM-IV.
  • Sexual aversion disorder was deleted.
  • Subtypes for all disorders include only “lifelong versus acquired” and “generalized versus situational” (one subtype was deleted from DSM-IV).
  • Two subtypes were deleted: “sexual dysfunction due to a general medical condition” and “due to psychological versus combined factors”.

Gender Dysphoria

  • DSM-IV gender identity disorder is similar to, but not the same as, gender dysphoria in DSM-5. Separate criteria for children, adolescents and adults that are appropriate for varying developmental states are added.
  • Subtypes of gender identity disorder based on sexual orientation were deleted.
  • Among other wording changes, criterion A and criterion B (cross-gender identification, and aversion toward one’s gender) were combined. Along with these changes comes the creation of a separate gender dysphoria in children as well as one for adults and adolescents.
  • The grouping has been moved out of the sexual disorders category and into its own.The name change was made in part due to stigmatization of the term “disorder” and the relatively common use of “gender dysphoria” in the GID literature and among specialists in the area.
  • The creation of a specific diagnosis for children reflects the lesser ability of children to have insight into what they are experiencing and ability to express it in the event that they have insight.

Disruptive, Impulse-Control, and Conduct Disorders

  • Some of these disorders were formerly part of the chapter on early diagnosis, oppositional defiant disorder; conduct disorder; and disruptive behavior disorder not otherwise specified became other specified and unspecified disruptive disorder, impulse-control disorder, and conduct disorders.
  • Intermittent explosive disorder, pyromania, and kleptomania moved to this chapter from the DSM-IV chapter “Impulse-Control Disorders Not Otherwise Specified”.
  • Antisocial personality disorder is listed here and in the chapter on personality disorders (but ADHD is listed under neurodevelopmental disorders).
  • Symptoms for oppositional defiant disorder are of three types: angry/irritable mood, argumentative/defiant behavior, and vindictiveness. The conduct disorder exclusion is deleted. The criteria were also changed with a note on frequency requirements and a measure of severity.
  • Criteria for conduct disorder are unchanged for the most part from DSM-IV. A specifier was added for people with limited “prosocial emotion”, showing callous and unemotional traits.
  • People over the disorder’s minimum age of 6 may be diagnosed with intermittent explosive disorder without outbursts of physical aggression. Criteria were added for frequency and to specify “impulsive and/or anger based in nature, and must cause marked distress, cause impairment in occupational or interpersonal functioning, or be associated with negative financial or legal consequences”.

Substance-Related and Addictive Disorders

  • Gambling disorder and tobacco use disorder are new.
  • Substance abuse and substance dependence from DSM-IV-TR have been combined into single substance use disorders specific to each substance of abuse within a new “addictions and related disorders” category. “Recurrent legal problems” was deleted and “craving or a strong desire or urge to use a substance” was added to the criteria.
  • The threshold of the number of criteria that must be met was changed and severity from mild to severe is based on the number of criteria endorsed. Criteria for cannabis and caffeine withdrawal were added.
  • New specifiers were added for early and sustained remission along with new specifiers for “in a controlled environment” and “on maintenance therapy”.

DSM-5 substance dependencies include:

  • Alcohol dependence
  • Opioid dependence
  • Sedative, hypnotic, or anxiolytic dependence (including benzodiazepine dependence and barbiturate dependence)
  • Cocaine dependence
  • Cannabis dependence
  • Amphetamine dependence (or amphetamine-like)
  • Hallucinogen dependence
  • Hallucinogen dependence
  • Inhalant dependence
  • Polysubstance dependence
  • Phencyclidine (or phencyclidine-like) dependence
  • Other (or unknown) substance dependence
  • Nicotine dependence

There are no more polysubstance diagnoses in DSM-5; the substance(s) must be specified.

Neurocognitive Disorders

  • Dementia and amnestic disorder became major or mild neurocognitive disorder (major NCD, or mild NCD). DSM-5 has a new list of neurocognitive domains. “New separate criteria are now presented” for major or mild NCD due to various conditions. Substance/medication-induced NCD and unspecified NCD are new diagnoses.

Paraphilic Disorders

  • New specifiers “in a controlled environment” and “in remission” were added to criteria for all paraphilic disorders.
  • A distinction is made between paraphilic behaviors, or paraphilias, and paraphilic disorders. All criteria sets were changed to add the word disorder to all of the paraphilias, for example, pedophilic disorder is listed instead of pedophilia. There is no change in the basic diagnostic structure since DSM-III-R; however, people now must meet both qualitative (criterion A) and negative consequences (criterion B) criteria to be diagnosed with a paraphilic disorder. Otherwise they have a paraphilia (and no diagnosis).

Personality Disorders

  • Personality disorder (PD) previously belonged to a different axis than almost all other disorders, but is now in one axis with all mental and other medical diagnoses. However, the same ten types of personality disorder are retained.
  • There is a call for the DSM-5 to provide relevant clinical information that is empirically based to conceptualize personality as well as psychopathology in personalities.
  • The issue(s) of heterogeneity of a PD is problematic as well. For example, when determining the criteria for a PD it is possible for two individuals with the same diagnosis to have completely different symptoms that would not necessarily overlap.There is also concern as to which model is better for the DSM – the diagnostic model favored by psychiatrists or the dimensional model that is favored by psychologists. The diagnostic approach/model is one that follows the diagnostic approach of traditional medicine, is more convenient to use in clinical settings, however, it does not capture the intricacies of normal or abnormal personality.The dimensional approach/model is better at showing varied degrees of personality; it places emphasis on the continuum between normal and abnormal, and abnormal as something beyond a threshold whether in unipolar or bipolar cases.

The following conditions have been listed for further research and documenting:

  • Attenuated psychosis syndrome.
  • Depressive episodes with short-duration hypomania.
  • Persistent complex bereavement disorder.
  • Caffeine use disorder.
  • Internet gaming disorder.
  • Neurobehavioral disorder associated with prenatal alcohol exposure.
  • Suicidal behavior disorder.
  • Non-suicidal self-injury.

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