As a mental health clinician, diagnosis is the cornerstone of your patient care. To make an accurate diagnosis of any mental health disorder, you need the most up-to-date information available in the DSM. The most recent DSM is the fifth edition, which introduced a host of changes from the previous version. Understanding the updates is essential to providing correct diagnoses and selecting appropriate treatment.
Table of Contents
- What Is DSM?
- What Have Been the Major Changes of DSM-5?
- New and Updated Diagnoses
- DSM-5 Codes and ICD-10-CM
- Strengths and Weaknesses of DSM-5
- Viability for Research
- Developments for the Next DSM
What Is DSM?
The Diagnostic and Statistical Manual of Mental Disorders, fifth edition, also known as DSM-5, is the handbook currently used by U.S. behavioral and mental healthcare professionals to make diagnoses. The DSM is often referred to as the "bible" of the mental healthcare field, providing descriptions and classifications of mental disorders, including their symptoms and other criteria required for diagnosis.
DSM gives clinicians a common language to use when communicating information about patients, and researchers a common basis to study disorders and recommend potential revisions. The DSM has been instrumental in driving advanced research on every aspect of mental and behavioral health.
DSM was first published in 1952 and has undergone multiple revisions as more information on mental disorders has been uncovered. DSM-5 arrived in 2013, bringing multiple updates to mental illness classification that have, in some cases, stirred controversy in the field. The revision process that created DSM-5 lasted nearly a decade and involved nearly 400 scientists from around the world, as well as more than 160 renowned clinicians and researchers.
All proposed changes were approved by the American Psychiatric Association (APA) and evaluated by a Scientific Review Committee of experts. The Committee reviewed the strength of the evidence of each change with the use of a template of validators.
What Have Been the Major Changes of DSM-5?
The overhaul of the DSM can be broadly explained through five overarching changes meant to make diagnostics easier and more accurate for clinicians — these changes include:
- Developmental focus: DSM-5 places disorders according to the age at which they are most likely to appear, starting in childhood and ending with disorders that usually occur in old age. Descriptions of disorders also include the different ways they might present according to age.
- New diagnostic criteria: Criteria for some disorders will change, including the addition of new disorders and removal of subtypes of schizophrenia.
- Dimensional measures: DSM-5 includes measures of how severe a disorder is, in order to help clinicians think about what dimensions of disorders are similar. This is intended to benefit patients with multiple diagnoses by providing more nuanced insight into their continuum of symptoms.
- Culture and gender emphasis: There is a multitude of cultural and social factors that can impact diagnosis. DSM-5 has a new section describing cultural syndromes, their potential causes and how they are expressed.
- Further research: The DSM now contains a section that describes conditions that need further research to be fully incorporated into the manual. The conditions in this section may or may not be added based on the results of ongoing research, and do not have ICD codes clinicians can use to diagnose patients and receive reimbursement from insurance companies.
New and Updated Diagnoses
The latest DSM classifications include updates and additions for many mental disorders. Some classifications have been eliminated, and some have been combined. The following 12 mental disorders are new or updated in DSM-5:
- Social communication disorder: This addition allows clinicians to diagnose speech and language issues that aren't connected to reduced cognitive ability or autism.
- Disruptive mood dysregulation disorder: This is a diagnosis for children under 18 who display extreme rages and frequent outbursts, eliminating the classification of childhood bipolar disorder.
- Premenstrual dysphoric disorder: This extremely controversial addition affects up to five percent of premenopausal women.
- Hoarding disorder: This condition, depicted in multiple TV shows, is now an official diagnosis listed under obsessive-compulsive disorders.
- Caffeine withdrawal: Another divisive addition, caffeine withdrawal has moved from the appendix of DSM-IV to "Caffeine-Related Disorders" in DSM-5.
- Cannabis withdrawal: The proliferation of legal cannabis led to a pronounced increase in people experiencing cannabis withdrawal, which is now listed under "Substance-Related and Addictive Disorders."
- Excoriation disorder: This diagnosis addresses chronic scratching and picking at the skin, and is listed under "Obsessive-Compulsive and Related Disorders."
- Binge eating disorder: Binge eating even once a week now qualifies a patient for this diagnosis, rather than biweekly.
- Rapid eye movement sleep behavior disorder: This disorder causes people to act out dreams in potentially dangerous ways, and is now separate from the parasomnia category it occupied in the previous DSM.
- Restless leg syndrome: Previously classified as a form of dyssomnia, restless leg syndrome now has full DSM status as its own diagnosis.
- Major neurocognitive disorder with Lewy body disease: This classification differentiates major and mild neurocognitive disorders, allowing for more specific treatment.
- Disinhibited social engagement disorder: This classification was previously categorized with reactive attachment disorder, but given a separate classification because children with it do not necessarily lack attachment.
Classifications With New DSM-5 Criteria
In addition to the diagnoses added to DSM-5, several diagnoses have been appointed new criteria, including:
- Autism spectrum disorder: One of the most important changes that involves collapsing diagnoses deals with autism spectrum disorder. In DSM-IV, there were four categories: Autism, Asperger's, childhood disintegrative disorder and pervasive developmental disorder. All four have been collected under the umbrella of autism spectrum disorder in DSM-5.
- ADHD: Revisions have been made to the ADHD diagnosis, broadening the criteria to allow for adult-onset cases. Because adult brains are more developed and adults have better impulse control, they can be diagnosed with fewer symptoms than children.
- PTSD: Due to the new research on PTSD available, the detail on this diagnosis has been expanded in DSM-5. The new criteria adds more information on diagnosing children and creates four separate classes of symptoms: Arousal, avoidance, flashbacks and negative impacts on mood and thought patterns.
- Mental retardation: The collection of issues called "mental retardation" has now been reclassified as "Intellectual Development Disorder" to reflect changes in common language. This is a result of the new focus on cultural relevance in DSM-5. The criteria for diagnosis has also shifted to focus more on level of function, instead of relying so heavily on IQ score.
DSM-5 Codes and ICD-10-CM
The DSM and the World Health Organization's International Classification of Disease (ICD) are companion publications. The DSM contains diagnostic criteria, while the ICD codes are needed to monitor mortality and morbidity statistics, as well as for insurance reimbursement.
There are no DSM codes. Instead, the numbers you will find next to diagnoses in the manual are ICD codes. The manual contains ICD-9 codes in bold and new ICD-10 codes in parentheses. Many codes stayed the same between ICDs, but it is important to note any changes between ICD codes, as clinicians had to switch to using ICD-10 in 2015.
Strengths and Weaknesses of DSM-5
There is always some disagreement between professionals on the best diagnostic and treatment approaches, and continuing research brings more information that drives revisions to the DSM. Many of the new classifications in DSM-5 have been greeted enthusiastically by some clinicians, while others insist the same changes are detrimental. Some of the largest controversies and problems with DSM-5 include:
1. Grief and Major Depression
The previous DSM had a bereavement exclusion for major depressive disorder. In DSM-IV, people who have recently experienced a loved one's death could not be diagnosed with depression unless:
- Symptoms lasted longer than two months.
- Symptoms produced functional impairment.
- The patient had a morbid preoccupation with worthlessness.
- There was suicidal ideation, psychotic symptoms or psychomotor retardation.
In DSM-5, the bereavement exclusion has been replaced with a note that simply provides further guidance on how to tell grief apart from major depression. There is now another guide for recording reactions to a loved one's death, found in the chapter "Other Conditions That May Be a Focus of Clinical Attention."
Clinicians who oppose the elimination of the bereavement exclusion are concerned that removing it will lead to people with normal grief being inappropriately diagnosed with depression.
2. Oppositional Defiant Disorder
Oppositional defiant disorder (ODD) was highly controversial when added to DSM-IV, and the outcry has continued as it remains a diagnosis in DSM-5. The condition is characterized by:
- Using obscene language
- Angry outbursts
- Frequent resentment
- Intentionally irritating or hurting others
- Being easily angered
- Refusing to follow instructions or rules
- Throwing temper tantrums repeatedly
The DSM-5 stipulates that these behavioral patterns must last for at least six months and not be the result of a different mental health issue. The controversy here is that the relatively loose criteria may lead to over-diagnosis of what may just be bad behavior. It can be quite damaging to label a child or teen "mentally ill" when they may not be.
3. Pediatric Bipolar Disorder
While ODD remained in the DSM, a diagnosis some clinicians have been asking for has been left out. Rather than adding a diagnosis for pediatric bipolar disorder, also known as child-onset bipolar disorder, DSM-5 introduced disruptive mood dysregulation disorder (DMDD).
DMDD focuses on temper tantrums and general anger rather than addressing all the symptoms of pediatric bipolar disorder, so clinicians must create a workaround. The closest thing to a diagnosis of pediatric bipolar disorder is a combination of DMDD diagnosed alongside major depression. These two diagnoses can occur together, but DMDD and bipolar cannot be combined.
Viability for Research
Although the DSM is intended to function as a common language for researchers to use, it seems that part of its mission has not been accomplished. According to many experts, the DSM-5 does not provide a strong foundation for studying mental illnesses.
The National Institute of Mental Health (NIMH) has actually rejected the DSM-5 for the purposes of research and has shifted its funding away from DSM categories to more neuroscience-based sources.
However, this announcement was not a rejection of the DSM outright. Instead, NIMH clarified that while the DSM may no longer be sufficient for use by researchers, it still remains the gold standard for clinical diagnosis.
Developments for the Next DSM
One of the biggest changes for the next DSM is the shift in revision processes. The APA recognizes the need to be able to make more timely updates to the DSM in response to breakthroughs in research. The change from the roman numerals used through DSM-IV to the Arabic numerals in DSM-5 reflects the intention to publish incremental updates. We may soon be seeing a DSM-5.1, DSM-5.2 and more until enough incremental updates necessitate a whole new edition.
The eight conditions identified as needing further study in DSM-5 are:
- Attenuated psychosis syndrome
- Caffeine use disorder
- Depressive episodes with short-duration hypomania
- Internet gaming disorder
- Neurobehavioral disorder associated with prenatal alcohol exposure
- Non-suicidal self-injury
- Persistent complex bereavement disorders
- Suicidal behavior disorder
Although these conditions do not have formal diagnoses in DSM-5, they will be the first to be considered in updates to mental illness classification. The information on them is included in the DSM to give clinicians more information that may affect the diagnosis of other conditions.
For example, someone addicted to caffeine can only be diagnosed with a substance-related and addictive disorder, but the diagnosing clinician can gain more insight into the situation by reading information in the caffeine use disorder section.
Updates to Intellectual Disability
One of the formally proposed DSM-5 updates regards the diagnostic features section of intellectual developmental disorder. At present, the criteria for diagnosing an intellectual disability are:
- Deficiency in adaptive daily life skills or functioning.
- Deficits in intelligence.
- Onset during childhood.
DSM-5 requires that the intellectual impairments must be directly related to the deficiency in adaptive functioning. However, the APA has recommended that this be replaced with a criterion that specifies a deficiency in adaptive functioning is a result of intellectual deficits.
One example given by the American Association on Intellectual and Developmental Disabilities (AAIDD) is the case of the state of Texas seeking to execute a man with an intellectual disability.
According to the state, the man's adaptive functions likely resulted from a lack of learning opportunities and were not directly related to his intellectual function, therefore, he did not actually have any intellectual disability. In 2016, the Supreme Court ruled against the state and found that the man does have an intellectual disability, and disallowed his execution.
The CEO of AAIDD, Margaret Nygren, says that experts agree intellect and adaptive behavior should not be connected or conflated because it is impossible to determine which elements of behavior are the result of educational opportunities, mental health issues or IQ. The use of the current DSM-5 language in the case of Moore v. Texas is a clear indicator that the DSM is not perfect and should be updated in this area.
ICANotes: Your Source for DSM Information
Understanding the latest DSM classifications is crucial to providing accurate diagnosis and the most appropriate course of treatment for your patients. The most recently updated ICD codes (ICD 11) were released in June 2018, and clinicians will need to become familiar with those as well since they will be required for reporting starting in 2022.
Keeping up with crucial information on the DSM and ICD codes can be time-consuming and confusing, which is why ICANotes works hard to provide up-to-date resources and information for mental and behavioral health clinicians. For additional information on DSM-5 updates and ICD changes, contact ICANotes today.