An Update on changes in the DSM-5 (aka DSM-V)

Nothing has been set in stone yet, however in February, 2010 the American Psychiatric Association released draft proposals for the next edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The DSM lists the criteria for recognized diagnoses in American psychiatry. The official publication of the next edition was delayed one year and is now scheduled for May, 2013. There has not been a substantial update of the actual diagnostic criteria since DSM-IV was published in 1994. There will still be additional research and committee meetings to determine the exact appearance of DSM-5, however some things have been made fairly clear via the website at DSM5.org

Would Aspergers disorder by any other name smell as sweet? Perhaps not if that name is “Autism.” Many families and patients who sometimes refer to themselves as “Aspies” may prefer to see the differences in what they typically view as Autism, however the DSM-5 is focusing on the dimensional similarities and may cluster these disorders together. Aspergers Disorder, which was first introduced in to the DSM in 1994, will likely be shown the door in DSM-V, or possibly become a sub-type. So too will many of the other pervasive developmental disorder categories such as pervasive developmental disorder NOS and another one no one has heard of (Childhood Disintegrative Disorder). They will likely be folded together with Autism in to a broader “Autistic Spectrum Disorder” dimension. Rett’s disorder has simply been proposed to be removed.

In order to resolve confusion in making differential diagnoses in children between pediatric bipolar disorder, oppositional defiant disorder (ODD), conduct disorder, Attention Deficit/Hyperactivity Disorder (ADHD), and disruptive behavior disorder NOS, why not add one more diagnosis to the mix? Given the plethora of kids being diagnosed with Bipolar Disorder NOS with the prominent symptoms noted in the proposed Temper Dysregulation Disorder with Dysphoria, it may not be as crazy as it sounds. If you’ve ever met them you would know, however, that these are a group of children with severe problems however, and it should in no way be comically reduced to kids who “just have a temper.” A callous and unemotional specifier has also been proposed for conduct disorder, so that it may be easier to point out the children with a tendency toward psychopathy.

You’ve probably heard all about “cutting” behavior, and it along with other self-injurious acts have been given their very own diagnosis: Non-suicidal Self Injury.

Cognitive Disorder NOS, Amnestic Disorder and Dementia have been proposed to simply become Minor Neurocognitive Disorder and Major Neurocognitive Disorder. An alzheimers subtype of the neurocognitive disorders is also proposed.

Under DSM-IV, there is a distinction made between abuse and dependence and these are noted to be separate diagnostic categories. The abuse and dependence diagnoses will simply be coded together as a substance “use” disorder. In addition, behavioral addictions will be added such as pathological gambling (once an impulse control disorder). You may also look for internet addiction to possibly appear in the appendix for further research. While a sexual addiction was proposed, the DSM-5 task force has added instead a proposed “Hypersexual Disorder” which reflects repeated, intense fantasies, urges and behaviors. Paraphilic Coercive Disorder is another new, proposed diagnosis which involves fantasies of sexual coercion, forcing sex on others.

A “psychosis risk syndrome,” or prodromal schizophrenia, may be included for further research and is designed to identify young people at risk for the development of schizophrenia. Catatonia may be added as a specifier for many disorders. The subtypes of Schizophrenia (Catatonic, Residual, Undifferentiated, Disorganized and Paranoid) may be removed from the DSM, leaving us with simply “Schizophrenia.”

Ever hear of Chronic Depressive Disorder? That’s right chronic depression under the DSM just became more simple and with fewer arbitrary criteria, or at least, it’s different. The proposal is to rename Dysthymic Disorder to Chronic Depressive Disorder while also dropping some exclusion criteria such as not having a major depressive episode in the first two years. In addition, the chronic specifier for major depressive disorder will also be dropped in favor of Chronic Depressive Disorder. Given that there are two distinctly different criteria sets for the former dysthymia and chronic major depressive disorder, its not fully clear how this will be resolved dimensionally at this point. However, what is clear is that chronic depression tends to be similar across these diagnoses and attempting to include them together simply makes sense.

The DSM-IV included “Mixed Anxiety-Depressive Disorder” in the appendix for further research. The current taskforce has proposed that “Mixed Anxiety Depression.” The proposals suggests that The patient has three or four of the symptoms of major depression (which must include depressed mood and/or anhedonia), and they are accompanied by anxious distress. The symptoms must have lasted at least 2 weeks, and no other DSM diagnosis of anxiety or depression must be present, and they are both occurring at the same time. Anxious distress is defined as having two or more of the following symptoms: irrational worry, preoccupation with unpleasant worries, having trouble relaxing, motor tension, fear that something awful may happen.” This criteria reflects revisions from the proposal in DSM-IV.

The specifier of “mixed episode” for mood disorders is being looked at and may be replaced with a “mixed features” approach. In addition, Bipolar disorder with most recent episode mixed may be dropped.

Depressive Disorder NOS (Not otherwise specified) may be renamed to “Depressive Conditions Not Elsewhere Classified” or Depressive CNEC. This may depend on the overall structure of the DSM and decisions related to making it more consistent with the ICD. There are separate categories of Depressive CNEC suggested such as “Depressive CNEC with insufficient information to make a diagnosis,” “Subsyndromal Depressive CNEC,” and “other Depressive CNEC.” This can assist in clarifying why an NOS / NEC diagnosis was made. The subsyndromal or subthreshold depression specifier includes examples of prodromal depression in individuals with a past history of major depressive episodes and depression which does not quite meet the criteria for another diagnosis. Similarly, Anxiety Disorder NOS may become Anxiety Disorder NEC (which is more consistent with the ICD terminology). There are additional recommendations that will “be forthcoming” to the dsm5.org website as noted under the Anxiety Disorder NOS section. With the exception of Depressive Disorder NOS, it would appear most NOS categories have been proposed to be changed to NEC similar to the ICD.

The with and without agoraphobia specifiers fpr panic disorder may be dropped, and agoraphobia included as a separate diagnosis regardless of panic disorder. In addition, anxiety disorders including hoarding disorder, skin picking disorder, and “olfactory reference syndrome” have been proposed. Body Dysmorphic Disorder and Trichotillomania (Hair-pulling disorder) may be reclassified as an Anxiety and Obsessive Compulsive Spectrum Disorder.

Developmental manifestations, or separate age-specific expressions of diagnostic criteria, may be included in DSM-5 for some disorders such as PTSD. There may be separate criteria for a preschool PTSD and “developmental trauma disorder” may also receive consideration.

Adjustment disorders may also cease to be its own category and join Trauma and Stress Related Disorders.

Factitious Disorder and Somatoform disorders like Somatization Disorder, Undifferentiated Somatoform Disorder, Pain Disorder and Hypochondriasis have been proposed to be lumped together as Complex Somatic Symptom Disorder. There will be optional specifiers to help resolve the different presentations.

Some minor changes to the dissociative disorder criteria have been proposed, including moving dissociative fugure in to a subtype of dissociative amnesia and revising some of the criteria of dissociative identity disorder (formerly multiple personality disorder).

A Binge eating disorder has been proposed with recurrent episodes of binge eating.

A number of sleep disorders have been proposed for inclusion in to the DSM-5, including a Disorder of Arousal (includes the former sleepwalking and sleep terror disorders) and Restless Leg Syndrome.

Are personality disorders dying? Perhaps one of the biggest proposed changes and signaling a trend in moving towards a more dimensional view of disorders (as opposed to disorders as separate and distinct categories that are not related), is the The DSM-5 Personality Disorders and personality traits proposed under DSM-5. All DSM-IV personality disorders have been “recommended for reformulation.” The proposed “personality disorders” section under DSM-5 may be seen as a test case in moving other diagnoses to more dimensional criteria. The current proposals may also be seen as a temporary compromise between researchers who feel the personality disorders (and in particular the “clusters” noted in DSM-IV) lack scientific merit and are removed from more “normal” personality disorder research and theory. Some suggest that the concept of a personality disorder may need to be removed entirely and replaced with a representation of different degrees of personality traits which may impact an individual’s presentation. How these will be specifically coded remains to be seen.

The current proposal includes (at this time) 5 personality disorder “types.” These are the “Antisocial/Psychopathic type,” the “Avoidant type,” the “Borderline type,” the “Obsessive-Compulsive type,” and “Schizotypal type.” There will be “type ratings” in which the clinician proposes the extent to which a person fits the type, however at this time there appears to be few guidelines or specific anchors that would allow this to be done in a standardized fashion.

Do you like to diagnose Personality Disorder NOS? Unfortunately all Personality Disorders may be Personality Disorder NOS, and from DSM-5 on no personality disorder will likely be diagnosed “Personality Disorder NOS” (or even NEC). Instead of Personality Disorder NOS, the specific personality traits and facets (much like a specific “sub-trait” or component of a trait) will be described. Every patient with a personality disorder may receive a “specific trait profile,” recognizing that their be many variations and combinations of personality traits and facets under the sun. The 5 suggested personality disorder “types” that include the old names of former personality disorders can be viewed as simply one suggested profile of a personality disorder. There could be and are many others. For example, under the depressive personality disorder category the task force recommends a profile of the prominent traits/facets of “Pessimism, Anxiousness, Depressivity, Low Self-esteem, Guilt/Shame, Anhedonia.” The extent to which future “personality types” (ex: “depressive type,” “histrionic type,” “Negativistic type,” etc.) will be developed, standardized and included to be coded as short-handed remains to be seen. There is a number of research studies comparing personality disorders with their results on the NEO-PI-R, however its not entirely clear at this point the full relevance of the traits and facets of the NEO-PI-R to the traits and facets proposed for DSM-5. The NEO-PI-R is based in part on the FFM.

The structure of the personality “disorder” section has been modified from the Five-Factor Model of Personality. The 6 proposed broad personality traits are taken from 4 out of the 5 domains of the Five-Factor model (FFM), however these traits have different names and facets that the FFM and may reflect more of a maladaptive expression of the FFM domains rather than a full range of normal personality (ex: one trait is Negative Emotionality which may be somewhat similar to the FFM’s Neuroticism, though the noted facets or component/sub-traits also have different names and the trait Introversion- similar to the FFM’s Extraversion but also with more maladaptively phrased facets). Openness to Experience was not included as it is not viewed as strongly related to personality disorder. As the FFM traits did not cover obsessive compulsive personality disorder (OCPD) or schizotypal personality disorder well, the compulsivity and schizotypy trait domains were added.

The 6 personality traits proposed, each with multiple components or “facets,” are Negative Emotionality, Introversion (technically shyness could be “diagnosed” now), Antagonism, Disinhibition, Compulsivity, Schizotypy. Get more details and definitions of the traits and facets proposed via dsm5.org

Learn more about Personality Disorders and the Five Factor Model of Personality:

Personality Disorders and the Five-Factor Model of Personality

Check back with WorldWideMentalHealth.com often, both the website and the blog, as we will be reviewing the criteria as well as associated research and creating a developing resource over time to help you understand the changes taking place in DSM-5. This article, located at http://www.dsm-5diagnosis.com will also be periodically updated.

You can see the DSM-5 proposals for yourself at DSM5.org

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