American Psychiatric Association Proposes 5 Changes to DSM-5

The American Psychiatric Association posted proposals for 5 distinct changes to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5), on their website, soliciting commentary from interested parties. The DSM Steering Committee, which offered a 30-day public comment period after the publication of the proposals, approved all proposed changes before posting.

The first proposal addresses inappropriate International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) coding options for withdrawal from opioids, sedatives, or stimulants. At this time, protocol requires that all withdrawal be coded in terms of a substance use disorder, even if the patient is undergoing withdrawal in the absence of abuse or dependence (such as that seen while under medical management using these medications). The changes reflect the notion that this is incorrect, and will allow withdrawal to be diagnosed and coded without indications of abuse, by substituting F 11.23 (“opioid dependence with withdrawal”) with F 11.93 (opioids), F 13.93 (sedatives) or F 15.93 (stimulants), indicating withdrawal without dependence.

In the second proposed change, the Steering Committee indicates the need for additional options for differential diagnosis under the definitions of “other specified/unspecified” depressive or anxiety disorders. Specifically, the exclusion of adjustment disorder as a possible diagnosis in these cases must be corrected, particularly in the face of a clearly identified stressor. Clinicians should also understand that adjustment disorder, when appropriate, takes precedence over “other specified/unspecified,” which is meant to be used only when another diagnosis is not available.

The third proposed change is meant to help resolve some of the confusion surrounding diagnoses that are similar to, but fall short of, the diagnostic criteria for either acute stress disorder or post-traumatic stress disorder (PTSD). If an adjustment disorder diagnosis is not appropriate because of timing or lack of stressors, then the practitioner should use “other specified trauma- and stressor-related disorder,” and examples in the DSM-5 should include “persistent trauma response with PTSD-like symptoms.” Also, the adjustment disorder differential diagnosis section should indicate the above choices as viable alternatives to adjustment disorder when the criteria fit.

The fourth proposed change recommends correcting the omission of “other types of hallucinations,” which should be added to the text concerning symptom severity of psychosis as rated by clinicians. At this time, all ratings and qualifications are related only to auditory hallucinations in terms of level of distress. It is important to include writing that makes clear the necessity of considering various forms of hallucination when assessing psychotic severity and effect, moving away from a voice-centric model, which has been deemed imprecise.

In the final proposal, the steering committee recommends changing the wording of criterion A for acute stress disorder; specifically, replacing “sexual violation” with “sexual violence.” Making this change would align this definition and criterion with that of PTSD, and is viewed as more accurate than the older wording.

Taken together, these proposals represent 5 key discrepancies between current DSM-5 coding and language and what the steering committee believes the coding and language should be amended to. Although the public comment period has ended, there is no indication as to when these proposed changes might take effect.

Reference

View and comment on recently proposed changes to DSM-5. American Psychiatric Association. https://www.psychiatry.org/psychiatrists/practice/dsm/proposed-changes. Published November 22, 2017. Accessed February 5, 2018.