Understanding the 
changes in DSM-5

 

Disruptive mood dysregulation disorder. This new diagnosis identifies children experiencing persistent irritability and extreme changes in mood without bipolar disorder. This change addresses and prevents over-diagnosis and treatment of bipolar in patients aged 6 to 18 years. Diagnostic criteria include persistent irritability and frequent behavior outbursts occurring at least three times per week for over a year. 


Major depressive disorder (MDD). No modifications have been made to the core symptom criteria or length in symptoms for diagnosis (at least two weeks). However, a bereavement exclusion modification removes the exemption of diagnosing MDD when grief is present within two months of the death of a loved one.

This change reflects the belief that bereavement can be a stressor precipitating depression soon after a loss and that grief can last up to two years. Bereavement does not exempt one from being diagnosed with MDD, and guidance is given on how to differentiate grief from depressive disorders.

In cases of grief, self-esteem is usually preserved, and painful feelings present in waves mixed with positive memories. Cases of depressive disorders commonly feature feelings of worthlessness and self-loathing with a constant state of negative thoughts. Depression both related and unrelated to bereavement responds to the same or similar treatment options.


Persistent depressive disorder. This new diagnosis, which includes chronic MDD and the previous dysthymic disorder, was formed after an inability to scientifically find meaningful differences between dysthymia and chronic depression. 


Suicide risk assessment scales. Two new suicide risk assessment scales—one for adolescents and one for adults—help identify individuals with suicidal risk factors, gives clinical guidance, and recommends assessment of suicidal thinking and plans. The goal is to implement suicide prevention while devising treatment plans. 


Premenstrual dysphoric disorder (PMDD). Criteria for this diagnosis include five or more symptoms during most menstrual cycles with presence in the week prior to menses onset, improvement of symptoms a few days after menses, and absence in the week following menses. The symptoms must cause clinically significant distress affecting work, school, social activities, or relationships. PMDD is a state of extremely high tension, anxiety, and aggression.


Obsessive-compulsive and related disorders. This new chapter adds hoarding disorder (including specifiers for personal insight to the problematic nature of the individual’s hoarding-related beliefs [i.e., good/fair, poor, or absent insight]), excoriation (i.e., skin picking), substance/medication-induced obsessive-compulsive and related disorder including specifiers for onset of the disorder (i.e., during intoxication, withdrawal, or after medication use), and obsessive-compulsive and related disorder due to another medical condition.² 


Other specified and unspecified obsessive-compulsive and related disorders. This diagnosis is reserved for conditions that do not fit into a designated category. Such conditions include body-focused repetitive behavior disorder—recurrent behaviors such as cheek-chewing, lip-biting, and nail-biting that the patient has repeatedly and unsuccessfully tried to stop—and obsessional jealousy (i.e., nondelusional obsessions of a partner’s infidelity). 


Body dysmorphic disorder. Preoccupation with physical appearance resulting in repetitive behaviors or acts (e.g., looking in a mirror, reassurance seeking) is now added to the manual. Specifiers include degree of insight on the individual’s beliefs of appearing “ugly or deformed” and the option to add “with muscle dysmorphia” for individuals preoccupied with insufficient muscularity. 


Post-traumatic stress disorder (PTSD). Stressor criteria have become more explicit in DSM-5, and symptom clusters have been increased from three to four. These clusters include:


• Re-experiencing the traumatic event (memories, dreams, flashbacks)

• Persistent avoidance of stimuli associated with the traumatic event

• Persistent negative alterations in cognitions and mood

• Marked alterations in arousal and reactivity (aggressive, reckless, or self-destructive behavior)


By lowering the threshold of criteria, DSM-5 is more sensitive for diagnosing PTSD in children and adolescents. A new subtype with separate criterion has been included for children aged 6 years or younger. 


Feeding and eating disorders. This category now includes the diagnosis binge-eating disorder, which is specified as binging on food one or more times per week for three months. The criterion for bulimia nervosa has been reduced to one or more episodes of binge eating per week (in DSM-IV, it was two episodes per week). Anorexia will omit the criteria of amenorrhea to prevent excluding men, women in pre-menarche, women who use contraception, and women in post-menarche. 


Gender dysphoria. A transition from the previous “Sexual and gender identity disorders” reflects the variations in criteria and experiences regarding the diagnosis of gender dysphoria. Identifying with a gender different from what an individual was assigned at birth does not constitute a mental disorder; it is the stressors resulting from this dysphoria that meet the criteria for diagnosis. Removing the term “disorder” indicates a movement toward eliminating stigma surrounding affected individuals by modifying the terminology that previously suggested the patient is “disordered.”³

Gender dysphoria was included in the manual to facilitate clinical care and allow access to insurance coverage that supports mental health. The concern with complete omission of gender dysphoria would be denial of medical treatments that include counseling, cross-sex hormones, gender reassignment, and legal transition. Separate criteria are provided for children and must also be present for at least six months.

A post-transition specifier can be applied when an individual’s post-gender transition no longer meets criteria and treatment is still needed whether surgical, endocrinologic, or psychotherapy. 


Substance-related and addictive disorders. The diagnosis of gambling disorder is now included under the chapter related to substance disorders, reflecting evidence that addictive behaviors (i.e., gambling) activate the brain’s reward system in a manner similar to that of drugs or alcohol. DSM-5 also combines substance abuse and dependence into the overall diagnosis of substance use disorder.

Criteria changes include the removal of “recurrent legal problems” and addition of “craving or a strong desire or urge to use a substance.” A new diagnosis is included for cannabis withdrawal. Severity of substance use disorder is ranked by the number of symptom criteria: mild disorder (2-3); moderate disorder (4-5); severe (6 or more). 


Communication disorders. Phonological disorder will be referred to as speech sound disorder in DSM-5, and stuttering will be referred to as childhood-onset fluency disorder. Social (pragmatic) communication disorder is a new diagnostic category in DSM-5.

This diagnosis was created to more accurately recognize individuals who have significant problems using verbal and nonverbal communication for social purposes. This difficulty can cause impairments in the individual’s ability to effectively communicate, participate socially, maintain social relationships, or otherwise perform at school or at work.


Anxious distress specifier. Individuals with the diagnosis of a depressive or bipolar disorder can have the specifier “with anxious distress” added.


Social anxiety disorder (SAD). The features of SAD, formerly termed “social phobia,” are essentially the same. Changes include removing the requirement of individuals older than age 18 years to recognize their anxiety and now require all ages to have duration of symptoms for six months or longer. The only specifier offered is “performance only,” which is used to identify fears regarding speaking or performing in front of an audience. 


Panic attack. The optional features of describing a panic attack are replaced with the diagnosis of expected or unexpected panic attacks. A panic attack specifier can be added to all DSM-5 disorders.


Somatic symptom and related disorders. Previously, somatoform disorders had overlapping symptoms and lacked well-defined boundaries for diagnosis. Removal of individual disorders now falling under this diagnosis includes hypochondriasis, pain disorder, somatization disorder, and undifferentiated somatoform disorder.


Parasomnias. The independent sleep-wake disorders in DSM-5 include rapid eye movement sleep behavior disorder and restless leg syndrome. Previous research suggested that these disorders should no longer fall under the DSM-IV category “not otherwise specified.” 


Section 3: Emerging measures and models


Section 3 of DSM-5 includes the chapters Assessment Measures, Cultural Formulation, and Conditions for Further Study. 


Assessment measures. The World Health Organization Disability Assessment Schedule (WHO-DAS 2.0) is considered the best current measure for disability based on the International Classification of Functioning, Disability, and Health.


Conditions for further study. Continued research is recommended in determining if criteria should be made for formal diagnosis of:


• Attenuated psychosis syndrome: This syndrome could identify an individual who shows relevant psychotic symptoms suggesting an increased risk for developing a psychotic disorder without meeting criteria for a formal diagnosis.

• Caffeine use disorder: Research indicates that as little as two or three cups of coffee can trigger a withdrawal effect marked by tiredness or sleepiness.^4,5 The extent of clinical impact on an individual has not been identified. 

• Internet gaming disorder: This disorder reflects research and scientific findings that identify preoccupation with online gaming that causes significant clinical distress and impairment. Currently, the condition only applies to gaming and does not include online gambling, general Internet use, or social media. Studies have shown evidence in Asian countries, primarily among young males. 

• Nonsuicidal self-injury: This category includes skin-cutting, burning, scratching, and banging when suicide is not the intention. 





What is the controversy?


The authors of the DSM-5 still have a great deal of work left to do in refining the new guidelines and continuing with research in the field of psychological disorders.⁶ This edition was drafted to reduce stigma of mental illnesses, more accurately label and clarify diagnoses, and improve medical understanding. Critics believe that the new version is too broad and are concerned that nearly half of the U.S. population will meet the criteria for at least one DSM-5 diagnosis during their lifetime (see “Critics question methodology and transparency of DSM-5,” on page xx).⁷

The DSM-5 changes aim to create access to clinical treatment for patients that may lack well defined symptoms for a diagnosis. The manual is used to help determine an accurate diagnosis and is only one part of the overall care delivered to patients. Ultimately, the clinician is the key to identifying, screening, treating, and following the individual.

Amber Whitmore, PA-C, is an assistant professor at the University of Florida School of Physician Assistant Studies in Gainesville. 


This article originally appeared on Clinical Advisor