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The DSM-5

In May, 2013, the American Psychiatric Association (APA) plans to release the latest version of the Diagnostic and Statistical Manual of Mental Disorders, (DSM) otherwise known as the DSM-5. This event is likely to have an impact on the lives of most clinicians. Learn about the possible changes and the current status.

A Brief Look at the Future Manual for Diagnosing Mental Health Disorders LCSW
By: Mike Griffin, JD,
Staff Attorney
The Therapist
July/August 2010

In May, 2013, the American Psychiatric Association (APA) plans to release the latest version of the Diagnostic and Statistical Manual of Mental Disorders, (DSM) otherwise known as the DSM-5.1  This event is likely to have an impact on the lives of most clinicians. The current edition, known as the DSM-IV-TR, is widely used by psychotherapists of every discipline for purposes of assessment and treatment planning and to obtain reimbursement for treatment from insurance carriers and health plans. Health care providers and researchers in related fields also commonly utilize the DSM as an important reference for information regarding psychiatric disorders. 

Now in its fifth edition, the DSM has undergone a number of revisions since its initial publication as the DSM-I in 1952.2The process of revising this manual is no small undertaking:  Revision activities concerning the DSM have been ongoing for the past ten years.3 When it is finished, the DSM-5 will be the first complete revision of the DSM since 1994.45 DSM-5 Task Force members include the 13 chairs of each diagnostic work group as well as other experts in treatment, research, and epidemiology.6 DSM-5 Study Groups were created to address six broad topic areas: Diagnostic Spectra, Lifespan Developmental Approaches, Gender and Cross-Cultural Issues, Psychiatric/General Medical Interface, and Impairment Assessment and Diagnostic Assessment Instruments.7 DSM-5 Work Groups are comprised of approximately 120 experts in psychiatry and related fields, such as neuroscience, biology, genetics, statistics, epidemiology, and public health.8   Work groups are expected to analyze the DSM-IV in light of scientific advances regarding psychiatric disorders and to draft proposed, revised DSM-5 diagnostic criteria for each of the following categories: ADHD and Disruptive Behavior Disorders, Anxiety, Obsessive-Compulsive Spectrum, Post-traumatic and Dissociative Disorders, Childhood and Adolescent Disorders, Eating Disorders, Mood Disorders, Neurocognitive Disorders, Neurodevelopmental Disorders, Personality and Personality Disorders, Psychotic Disorders, Sexual and Gender Identity Disorders, Sleep-Wake Disorders, Somatic Symptom Disorders, and Substance-Related Disorders. 9

What Are the Possible Changes?There are numerous changes under consideration, all of which are available for review by visiting the APA DSM-5 website.10 According to the APA, the process of revising the DSM is subject to certain priorities, with the primary goal of producing a manual that has “clinical utility” for clinicians in their work with patients.11 For example, DSM-5 Work Groups have been asked to clarify the boundaries between diagnostic categories and to further delineate the differences between specific mental disorders and normal psychological functioning.12   There is also an effort to refine or replace the long-standing multi-axial classification system for diagnosis and to develop additional ways for a clinician to capture and describe the severity of symptoms by using “dimensional assessments.”13,14 The APA says that dimensional assessments would be intended to systematically describe a patient’s symptoms, such as his or her anxiety or depressed mood, or his or her substance abuse problems or difficulty with sleep, etc.15

The various DSM-5 Work Groups are recommending numerous changes in the formulation of diagnostic categories.  Samplings of some of the various changes that are under consideration include:

A DSM-5 subgroup has been charged with examining the utility of Axis III, (which is currently used in DSM-IV to document medical conditions related to the patient’s psychiatric diagnosis) recommends that DSM-5 combine Axes I, II, and III into one axis that contains all psychiatric and medical diagnoses, in order to bring DSM-5 into harmony with the single-axis approach used in the International Classification of Diseases (ICD).16 There is also some consideration for revising Axis IV in the DSM-IV, (where clinicians document psychosocial and environmental problems) so that it may more closely resemble the coding system found in the ICD.  As for Axis V in the DSM-IV, (which rates a patient’s overall level of functioning), the Impairment and Disability Study Group is discussing ways in which disability and distress can be better assessed and described in DSM-5.17

The proposed DSM-5 revisions include two new scales for assessing risk factors for committing suicide, one for adults and one for use with adolescents. The APA is also considering the inclusion of a new category in DSM-5 for Risk Syndromes, wherein symptoms are identified that place an individual at a higher risk for developing a mental disorder.18

The Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Work Group recommend that Adjustment Disorders be re-categorized within a grouping of Trauma and Stress-Related Disorders.19

The Personality and Personality Disorders Work Group proposes a significant reformulation in the assessment and diagnosis of personality disorders.  The revised system utilizes core impairments in personality functioning, pathological personality traits, and prominent pathological personality types.  In such a revised system, a Personality disorder is diagnosed when core impairments and pathological traits are severe or extreme and other diagnostic criteria are met.20

The Substance-Related Disorders Work Group argues for a change in the title of the category, Addiction and Related Disorders, and proposes, “Substance-Related Disorders,” which would include both substance use disorders and non-substance addictions. Gambling disorder has been moved into this category and other addiction-like behavioral disorders such as “Internet addiction” are under consideration as potential additions.  There is a general consensus in this workgroup that the word “dependence” as a label for compulsive, out-of-control drug use is problematic and confusing to many diagnosticians and has resulted in patients with normal tolerance and withdrawal from certain medications being labeled as “addicts.” This work group proposes that the word “dependence” be limited to physiological dependence: a normal response to repeated doses of various medications such as beta-blockers, antidepressants, opioids, anti-anxiety agents, and others.  Consequently, the presence of tolerance and withdrawal symptoms would not be considered as symptoms of a substance use disorder in the context of appropriate medical treatment with prescribed medications.21

The Eating Disorders Work Group proposes the recognition of “Binge eating disorder” as a new diagnosis in the DSM-5.22

The DSM-5 Neurodevelopmental Work Group proposes a number of new categories for learning disorders and a single diagnostic category entitled, “Autism spectrum disorders” that will incorporate the current diagnoses of Autistic disorder, Asperger’s disorder, Childhood disintegrative disorder, and Pervasive developmental disorder (not otherwise specified).23

The Mood Disorders Work Group proposes a new diagnostic category, Temper dysregulation with dysphoria (TDD), to be included within the Mood Disorders section of the manual.  This new category intends to differentiate children with TDD from those with Bipolar Disorder or Oppositional Defiant Disorder.24

The Current StatusThe diagnostic criteria proposed by the DSM-5 Work groups will continue to be reviewed and revised over the next two years.25 During that time, the APA intends to conduct three phases of field trials to test the proposed diagnostic criteria in real-world clinical settings. There are two standardized protocols for the DSM-5 field trials. One version is designed for academic or large clinical settings. The second version focuses on solo practitioners and smaller clinical practice settings.  The first field trial is anticipated to begin in summer, 2010.26 

Michael Griffin, JD, is a Staff Attorney at CAMFT. He is available to answer member questions regarding business, legal, and ethical issues.

1 American Psychiatric Association (APA),
2 Id.
 3 Id.
4 Id.
5 Id.
6 Id.
7 Id.
8 Id.
9 Id.
10 Id.
11 Id.
12 Id.
13 Id.
14 Id., See, “Guidelines for Making Changes to DSM-5” on the APA website
15 Id.
16 2010 ICD-9 CM For Physicians, Volumes 1&2, American Medical Association
17 American Psychiatric Association (APA), Id.
18 Id.
19 Id.
20 Id.
21 Id.
22 Id.
23 Id.
24 Id.
25 Id.
26 Id.