The American Psychiatric Association’s (APA) publication, the Diagnostic and Statistical Manual of Mental Disorders (DSM), has been the industry standard for clinicians, researchers, pharmaceutical companies, insurance companies, and policymakers since the original draft was published in 1952.
The fifth revision of the Manual, known as DSM-5, was published on May 22, 2013. Although the manual remains the standard for the diagnosis of mental disorders, each revision has been met with criticism due to the changes in diagnostic categories and the removal or inclusion of specific disorders. In most respects, the DSM-5 is not greatly modified from the DSM-IV-TR; however, some significant differences exist between them. Notable changes in the DSM-5 include the reconceptualization of Asperger syndrome from a distinct disorder to an autism spectrum disorder; the elimination of subtypes of schizophrenia; the deletion of the “bereavement exclusion” for depressive disorders; the renaming of gender identity disorder to gender dysphoria, the inclusion of binge eating disorder as a discrete eating disorder; the renaming and reconceptualization of paraphilias, now called paraphilic disorders; the removal of the five-axis system; and the splitting of disorders not otherwise specified into other specified disorders and unspecified disorders. Concerns regarding proposed changes to specific disorders, along with the inclusion of those that many argue were not truly mental disorders, led to negative press and direct appeals to the APA to seriously consider the impact the revisions would have in the identification and diagnosis of mental disorders. Despite this, the DSM-5 continues to be the main guide for mental health clinicians across the United States.
Revisions to the DSM-5 began in 1999 and took over fourteen years to complete. Task forces and workgroups were charged with examining current trends in mental health and utilizing research findings to make the appropriate revisions to the diagnostic categories.
Throughout the process, the APA solicited feedback from experts in the field of mental health and ensured that each discipline and the diagnostic category was represented. Working criteria for diagnoses were established, and then field tests were conducted. Data were then used to modify, change, or create new diagnoses as warranted. During the revision process, there was much speculation about which disorders would be included in the new edition of the manual, and the availability of information spurred controversy as various groups and individuals began to weigh in on the potential changes. Speculation that the psychiatric drug industry unduly influenced the manual’s content sparked additional concern.
This course provides a comprehensive overview of the DSM-5, its history, and purpose, and the manual’s changes and transitions from the DSM-IV. In addition, information on diagnostic criteria needed to assess the presence of psychiatric disorders and examples are provided, along with a brief overview of newly classified disorders and those disorders that have been removed or reclassified. The developmental, life-course perspective is addressed as it pertains to specific disorders. The course seeks to provide social workers, psychologists, mental health counselors, marriage and family therapists, and other behavioral health providers with the information necessary to understand the purpose and challenges of using the DSM-5 in order to provide the most accurate diagnosis and treatment for clients.
American Psychiatric Association
In order to understand the importance of the DSM-5 in the mental health field, knowing the history of the American Psychiatric Association (APA) is also vital. The APA was founded in 1844 and serves as the world’s largest psychiatric organization. It seeks to promote the highest quality care for individuals with mental disorders, including intellectual disabilities and substance use disorders and their families, promote psychiatric education and research, advance and represent the profession of psychiatry, and serve the professional needs of its membership (American Psychiatric Association (APA). This organization provides education and training for its members as well as other mental health providers across various disciplines, is a leading publisher of mental health-related publications, and supports research agendas of its members.
An important aspect of the American Psychiatric Association is the numerous publications the organization produces each year. The APA is most known for the Diagnostic and Statistical Manual of Mental Disorders (DSM). In addition to the DSM, the APA is considered the world’s premier publisher of books, multimedia, and journals on psychiatry, mental health, and behavioral science. Utilizing the expertise of a broad network of mental health professionals, the APA produces a variety of publications that provide up-to-date information for mental health professionals through various formats, including journals and numerous papers relevant to psychiatric care.
APA is one of the leading psychiatric research organizations in the world. The goal of the research is to improve the quality of psychiatric care and expand the knowledge base of mental health professionals. Specific research programs include the Practice Research Network, clinical and health services research, producing evidence-based practice guidelines, and oversight of the development of the Diagnostic and Statistical Manual of Mental Disorders (DSM). Research is also used to develop educational programs that disseminate new and emerging research findings and help translate those findings into clinical practices. APA research seeks to bridge the gap between practice and research, improve the quality of psychiatric care, expand understanding of mental disorders across the lifespan, and inform health policy.
Purpose of the DSM
The Diagnostic and Statistical Manual of Mental Disorders sets out to be the authoritative guide used by healthcare professionals throughout the world as a guide for the recognition and diagnosis of mental disorders. It provides a comprehensive list of identified mental disorders by classification category and includes a description and symptoms, as well as clearly established criteria for the diagnosis of each disorder. The manual offers a common language for practitioners and a tool for researchers to help bridge the divide between practice and research. The DSM also provides a coding system that is used for statistics, insurance, and administrative processes. Each diagnosis has a numerical code to assist with effective medical record-keeping and diagnosis. The purpose of the DSM is to provide a helpful guide to clinical practice, facilitate research, and improve communication among clinicians and researchers, and to serve as an educational tool for teaching psychopathology. Practitioners use the manual to assess and diagnose mental disorders. Although it does not include guidelines for the treatment of identified disorders, the DSM is a valuable asset in the treatment of clients as it provides the first step of treatment: proper identification. By requiring the practitioner to carefully assess and determine the severity of a client’s symptoms, the DSM helps measure the effectiveness of treatment, and initial data gathering provides a baseline for changes in symptom severity over time in treatment. This baseline data is helpful in assessing treatment response since long term monitoring will include the evaluation of changes in symptom severity.
The DSM has gone through four major revisions and two minor revisions since it was first published, not including the initial publication of the manual. There have been seven separate editions of the manual published, though two of the editions were minor revisions and did not receive a new edition number. Instead, the APA added a qualifier to the primary edition. The first four editions utilized roman numerals to indicate the number of the edition (DSM-I, DSM-II, DSM-III, DSM-III-R, DSM-IV, and DSM-IV-TR) until the most recent edition, DSM-5 in which standard numbering was used instead. This will allow the APA to easily identify new versions of the current edition, as it enables the use of a decimal system. For example, a new version of the DSM-5 will be noted as DSM–5.2. The following is a brief history of each DSM edition.
The DSM-I, approved in 1952, was the first version of the DSM and was based primarily on the Medical 203 classification system. The DSM-I was 145 pages long and included a total of 106 disorders. In the first DSM, all disorders were described in paragraph form, and it was expected that psychiatrists would use the descriptions to assess clients. During the development of the DSM-I, the APA distributed questionnaires to 10% of the membership, asking for feedback on the potential categories. As a result of the feedback, the final version of the manual assigned categories based on symptoms rather than disorder types.
The three main categories of psychopathology included:
- organic brain syndromes
- functional disorders
- mental deficiency
The DSM-I also included a category for somatization reactions. Within these categories were 106 diagnoses. In addition to the standard categories and descriptions, the DSM-I also provided nondiagnostic terms that could be used for coding test results and other significant observations. The DSM-I did not include a section for childhood disorders.
The DSM-II was published in 1968 and, while it followed the same basic format of the DSM-I, it included a number of significant changes. Rather than three categories, the DSM-II contained eleven major diagnostic categories, which included 182 specific diagnoses. The manual was 136 pages. The DSM-II also included a section focused on problems prevalent in children and adolescents. The section devoted to children and adolescents was called Behavior Disorders of Childhood-Adolescence such as Hyperkinetic Reaction, Overanxious Reaction, and Group Delinquent Reaction. This edition also included a section on sexual deviations and included specific disorders, such as Homosexuality, Fetishism, Pedophilia, Transvestism, Exhibitionism, Voyeurism, Sadism, and Machoism.
The DSM-III was published in 1980 and was considered a radical shift from previous versions of the manual. Unlike earlier versions, the DSM-III was quite large, included 265 diagnoses, and was over 494 pages in length. In addition, the DSM-III utilized a new classification system that was vastly different from that used in the DSM-I and the DSM-II. The DSM-III was published at a time when psychiatric medicine was advancing and gaining credibility as a true medical field. Individuals were taking mental disorders more seriously, and reliance on psychiatric care was increasing. Therefore, the DSM-III became widely recognized as the authoritative source on mental disorders and was used by professionals in the mental health field, including social workers, therapists, mental health counselors, psychologists, and psychiatrists. Psychiatric medicine was changing rapidly at this time in history, and the DSM mirrored this. The DSM-III included the multiaxial system of assessment to examine the client as an individual, as well as a family and community member. This altered the classification system and made the criteria for diagnosing a client more consistent and reliable, therefore increasing the credibility of the manual and establishing a defined system for the identification and diagnosis of mental disorders, as well as providing. The multiaxial system of evaluation and classification provided guidelines that ensured that every client was evaluated in a number of specific domains. The multiaxial system included the following domains:
Axis I: Clinical Disorders of Mental Illness
Axis II: Personality Disorders and Mental Retardation
Axis III: General Medical Conditions
Axis IV: Psychosocial and Problems (homelessness, legal issues, etc.)
Axis V: Global Assessment of Functioning: A single number from 0 to 100.
Shortly after the DSM-III was released in 1980, it became apparent that some changes would need to be made and that many practitioners found the wording of the criteria difficult to comprehend and inconsistent. In addition, the criteria for the diagnosis of mental disorders included an arbitrary number of symptoms and were not based on empirical evidence. This led to the overdiagnosis of disorders as individuals who presented with more than a minimal number of symptoms were automatically diagnosed with the associated disorder. A challenge that also arose was that individuals who presented with fewer than the required number of symptoms, even if that number was just one below the minimum, were not able to receive a diagnosis So, as the result of the emergence of research findings, the outcomes of field trials, and issues with the coding system, the APA published a modified version of the DSM-III in 1987, called the DSM-III-R. The DSM-III-R included significant changes to the criteria as well as the renaming and reorganization of categories. Six of the new categories were removed, and 22 others were added. The DSM -III-R also utilized data from field trials and diagnostic interviews in the revision process
In 1994, the DSM-IV was published in response to feedback received regarding the DSM-III and the DSM-III-R. To improve the reliability and credibility of the manual, a committee was convened to ensure that research and development included empirical evidence and data-based decisions. Using empirical evidence, the committee required every change to go through three specific phases: systematic literature review, secondary data reanalysis, and focused field trials. Changes were then critiqued by other workgroup members and a larger advisory group. The advisory group was charged with identifying inaccuracies, biases, and gaps in the proposed changes. To further reduce the chance of criticism, a four-volume companion to the DSM-IV was published, which outlined the rationale and empirical evidence used for each change. The DSM-IV was significantly different than previous versions of the DSM. Many of the categories were restructured, and more detailed information about each disorder was included. The manual grew to include 365 diagnoses and was over 886 pages long.
In 2000, the APA produced a text revision of the DSM-IV, and it was renamed the DSM-IV-TR to differentiate it from the original edition. The DSM-IV-TR was not significantly different from the DSM-IV, as it only contained minor changes. The committee focused on the four areas during the revision process:
- correcting minor errors found in the original DSM-IV edition
- making changes based on new research
- enhancing the educational value of the document by adding more text
- updating the coding scheme to match international standards
In 2013, the fifth edition of the DSM, known as the DSM-5, was released. It was based on fourteen years of work and is still in use today.
During the time that the DSM-5 was being developed, advances such as changes in medical technology, which allowed for advances in brain imaging techniques and improved methods for analyzing research results were made, all of which contributed to the changes in the manual. These new technologies have enabled practitioners to better understand and diagnose mental disorders. As a result, the classification system and the scientific basis for mental health diagnosis evolved in the new manual to reflect the emerging trends in mental health diagnosis and treatment. The multiaxial system utilized in earlier versions of the DSM was discontinued. This multiaxial system had been the framework used by practitioners to diagnose their clients.
Each version of the DSM differs from its predecessor. Using data analysis and feedback from professionals in the field, the APA makes revisions to the manual. In addition, each revision of the DSM is intended to outline the criteria for mental disorders in a way that is useful for those working in the mental health field. Therefore, the DSM-5, like previous versions, contains some significant changes from the previous versions of the manual. This section will provide a general overview of the changes.
Organization of the Manual
The structure of the DSM-5 changed from the DSM-IV. Although the current edition contains approximately the same number of disorders, the specific disorders changed. The DSM-5 is organized into the following three sections:
Section 1: Introduction to the Introduction to the DSM-5 and information on how to navigate the updated manual
Section II: Diagnoses and Disorders – This section provides a revised chapter organization and includes 20 disorders, which is an increase from the 16 included in the DSM-IV-TR.
Section III: This is a new section in the manual. It includes a number of conditions that cannot be classified as official disorders until they undergo further research and analysis. This section also includes cultural concepts of distress and the names of individuals who were involved in the development of the DSM-5.
Coding of Disorders
The coding system used in the DSM-5 is consistent with the International Classification of Diseases, ninth edition (ICD-9), and the ICD-10. The ICD-10 is the current manual used in the medical field to diagnosis physical and mental disorders and requires the use of a seven-digit code instead of the five-digit code used in the ICD-9.
Culture and DSM-5
The DSM-IV included a brief section on the role of culture in diagnosing mental illness. This section was part of the appendix and included a Glossary of Cultural Bound Syndromes and an Outline of Cultural Formulation. While the appendix provided a means for understanding cultural implications in mental disorders, it did not align well with many of the DSM disorders. In the DSM-5, Cultural Formulation is included in the section entitled Emerging Measures and Models and includes descriptive information as well as the Cultural Formulation Interview (CFI), which is a sixteen-question tool that is administered during a client’s initial visit.
The DSM-5 is organized differently from previous editions of the manual. While some of the sections have remained the same, new sections have been added, and some mental disorders have been moved to new sections. To best understand the DSM-5, one must understand the overall organization of the manual and the implications this has on the classification system and criteria used to identify and diagnose mental disorders.
The DSM-5 is divided into four distinct sections, each of which contains an abundance of information that can be used by mental health professionals to diagnose and, subsequently, treat individuals with mental disorders. The following is a list of the sections included in the DSM-5:
- Section I: DSM-5 Basics
- Section II: Diagnostic Criteria and Codes
- Section III: Emerging Measures and Models
Section I: DSM-5 Basics
The first section of the DSM-5 provides information on the basics of the manual and provides an introduction to the manual as well as for instructions for its use. A new section included by the APA is a cautionary statement for forensic use of the DSM-5, which was not included in previous editions of the manual.
The first part of section I is the introduction in which the APA provides an overview of the purpose of the manual as a tool for the identification, understanding, and diagnosis of mental disorders. It also provides an overview of the history of the DSM as well as an outline of the revision process. The final section of the introduction provides information on the organization of the manual, and includes information on the following components:
- Organizational Structure
- Harmonization with ICD-11
- Dimensional Approach to Diagnosis
- Developmental and Lifespan Considerations
- Cultural Issues
- Gender Differences
- Use of Other Specified and Unspecified Disorders
- The Multiaxial System
- Online Enhancements
Use of the Manual
The second part of section I provides an overview of how to use the manual in which the APA indicates that the primary purpose of the DSM-5 is to assist trained clinicians in the diagnosis of their clients’ mental disorders as part of a case formulation assessment that leads to a fully informed treatment plan for each individual. The APA also stresses that the symptoms included in the manual are not comprehensive definitions of underlying disorders, but rather they summarize characteristic signs and syndromes that indicate an underlying disorder section part of section I also includes:
- Approach to Clinical Case Formulation
- Definition of a Mental Disorder
- Criterion for Clinical Significance
- Elements of a Diagnosis
- Diagnostic Criteria and Descriptors
- Subtypes and Specifiers
- Medication Induced Movement Disorders and Other Conditions That May Be a Focus of Clinical Attention
- Principal Diagnosis
- Provisional Diagnosis
- Coding and Reporting Procedures
- Looking to the Future: Assessment and Monitoring Tools
Cautionary Statement for Forensic Use of DSM-5
The final section of section 1 provides information on how the manual can, and should, be used as part of forensics.
Section II: Diagnostic Criteria and Codes
Section II of the DSM-5 provides the descriptions and criteria for each of the diagnosable disorders as well as coding information. The diagnostic criteria and codes are broken into categories based on the type of disorder.
Diagnoses in DSM-5 are structured into the following categories and appear in the following order:
- neurodevelopmental disorders
- schizophrenia spectrum and other psychotic disorders
- bipolar and related disorders
- depressive disorders
- anxiety disorders
- obsessive-compulsive and related disorders
- trauma- and stressor-related disorders
- dissociative disorders
- somatic symptom and related disorders
- feeding and eating disorders
- elimination disorders
- sleep-wake disorders
- sexual dysfunctions
- gender dysphoria
- disruptive, impulse-control, and conduct disorders
- substance-related and addictive disorders
- neurocognitive disorders
- personality disorders
- paraphilic disorders
- other mental disorders
Each category includes a basic overview of the type of disorder and the common attributes for the category. This descriptive section provides information regarding how these disorders typically manifest and the impact they have on the individual. This general overview also includes information on the specific disorders that make up the category. After the general overview, each disorder specific to the category is listed with the diagnostic criteria and other factors associated with each disorder. For each disorder, the following information is provided:
- Diagnostic Criteria
- Diagnostic Features
- Associated Features Supporting Diagnosis
- Development and Course
- Risk and Prognostic Factors
- Culture Related Diagnostic Issues
- Gender-Related Diagnostic Issues
- Diagnostic Markers
- Differential Diagnosis
- Relationship to Other Classifications
While each disorder includes the same categories, the information included within these categories is unique to the specific disorder. Some disorders have different levels of severity, while others have different diagnostic categories within the general diagnosis. Therefore, the individual diagnostic section is tailored to the specific attributes of the disorder.
Section III: Emerging Measures and Models
This is a new section in the DSM-5. The APA uses this section to provide information on the types of assessments available, as well as potential future revisions and conditions for further study.
Section III includes the following:
- Cross-Cutting Symptom Measures
- DSM-5 Self Rated Level 1 Cross-Cutting Symptom Measures
- Clinician Rated Dimensions of Psychosis Symptom Severity
- World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0)
- Cultural Formulation Interview (CFI)
- Cultural Formulation Interview (CFI) – Informant Version
Alternative DSM-5 Model for Personality Disorders
Conditions for Further Study
- Attenuated Psychosis Syndrome
- Depressive Episodes with Short Duration Hypomania
- Persistent Complex Bereavement Disorder
- Caffeine Use Disorder
- Internet Gaming Disorder
- Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure
- Suicidal Behavior Disorder
- Non-suicidal Self Injury
The first part of section III focuses on assessment and includes Cross-Cutting Symptom Measures, Clinician Rated Dimensions of Psychosis Symptom Severity, and the WHODAS 2.0. Cross-cutting assessments, psychiatry’s version of general medicine’s “review of systems” focus on areas of functioning likely to “cut across” diagnostic boundaries (e.g., mood, anxiety, cognitive status, sleep, psychotic symptoms, suicidal ideation) and may be of clinical relevance. All of these assessments are intended to provide a more dimensional approach to the diagnosis of mental disorders that allows for combinations with the DSM-5 categorical diagnoses. The assessment measures enable practitioners to better identify and diagnose different mental disorders, including the level of severity, symptom intensity, and type and duration of the symptoms.
Cross-Cutting symptom measures provide two levels for diagnosis: Level I and Level II. The first level provides a general assessment and includes 13 symptom domains for adult clients and 12 domains for children. The second level is a more in-depth assessment of the domains. The Cross-Cutting symptom measures are intended for use during an initial screening as well as throughout the duration of treatment.
The Clinician Rated Dimensions of Psychosis Symptom Severity is intended for use when diagnosing individuals with psychotic disorders. According to the DSM-5, the Clinician Rated Dimensions of Psychosis Severity provides scales for the dimensional assessment of the primary symptoms of psychosis, including hallucinations, delusions, disorganized speech, abnormal psychomotor behavior, and negative symptoms. This assessment evaluates the severity of symptoms in individuals with psychotic disorders to ensure proper diagnosis and assist with the development of an appropriate treatment plan. The assessment tool is used during the initial consult and throughout the duration of treatment to monitor progress and identify any changes in the client’s status.
The World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) is a 36-item measure that assesses disabilities in adults. The scale, which is completed by the client or caregiver, corresponds to concepts contained in the WHO International Classification of Functioning, Disability, and Health. It uses six domains to determine the type and level of disability. The six domains are:
- Understanding and communicating
- Getting around
- Getting along with people
- Life activities (e.g., household, work, school)
- Participation in society
The WHODAS is administered during an initial consultation with the client and can subsequently be used to monitor changes in status.
The DSM-5 website provides electronic links to all of the assessment forms that are used during client diagnosis and treatment and can be found in the reference section of this course.
The addition of this section to the DSM-5 is an important revision that will enable practitioners to better assess and address cultural issues related to client diagnosis and care. It is part of Section III in the DSM-5. Earlier editions of the DSM did not take cultural issues into account. In the DSM-5, Cultural Formulation is included in the section entitled Emerging Measures and Models and includes descriptive information as well as the Cultural Formulation Interview (CFI), which is a sixteen-question tool that is administered during a client’s initial visit.
It is imperative to understand the cultural impact and context of mental disorders in the diagnosis and treatment process. Therefore, practitioners are encouraged to use this section of the manual, as well as the Cultural Formulation Interview, to better understand the cultural implications of mental disorders. In this section, the APA provides a definition for culture to establish a context from which to work. According to the APA, the definition of culture is as follows:
“Belief systems and value orientations that influence customs, norms, practices, and social institutions, including psychological processes (language, care-taking practices, media, educational systems) and organizations (media, educational systems). Culture has been described as the embodiment of a worldview through learned and transmitted beliefs, values, and practices, including religious and spiritual traditions. It also encompasses a way of living informed by the historical, economic, ecological, and political forces on a group” (APA, 2017, 165).
This definition provides a foundation for understanding the role culture plays in an individual’s experience with a mental disorder and can be used to better understand the effect on diagnosis and treatment. Once a definition for culture has been established, the APA provides an explanation of race and ethnicity and how the two fit in with culture to influence the client’s experience, especially in the areas of economic inequalities, racism, and discrimination, which result in health disparities.
Cultural Formulation Interview
The Cultural Formulation Interview is a sixteen-question tool that can be used by practitioners to gather cultural information about a client during an initial assessment. The CFI is intended to assess the effects of culture on key aspects of an individuals’ mental disorder and subsequent treatment. The CFI is administered by the practitioner and focuses on the client’s individual experiences and views. The CFI is client-centered and relies on the client’s individual perspective to assess the cultural factors that influence participation in care. While the CFI is primarily intended to be used during an initial assessment, it can also be helpful in later stages of care when the client is showing resistance to treatment or changes in the care plan. In the DSM-5, the CFI is presented as two columns with the left side is intended to be used as a guide for the interviewer and includes notes regarding how to frame specific questions, the things the interviewer should focus on, and other appropriate factors. The right side of the form provides specific questions to ask to identify issues and concerns within four domains.
The CFI directs the interviewer to tell the client that there are “no right or wrong answers” and assesses the client across the following four domains:
- Cultural Definition of the Problem
This section solicits the client’s perspective on his or her problems in her own words; asks how they explain the problems to their friends, family, and loved ones; and, identifies the aspects of the problems that matter most to the client. The following questions are suggested in the right column of the tool:
- What brings you here today?
- How would you describe your problem?
- How would you describe your problems to your friends, family, or members of your community?
- What troubles you most about your problem?
- Cultural Perceptions of Cause, Context, and Support
This section explores the meaning of the problem to the client and to his or her community. The community meaning may differ from the individual client’s meaning, and both meanings may be clinically relevant. Interviewers are also directed to gather information on the client’s life context in terms of resources, resilience, stressors, and the role of their cultural identity. Suggested questions in this section include:
- What do you think is the cause of your problem?
- Why do you think this is happening?
- What do your family members or other important community members think is causing your problem?
- Are there any kinds of support that make your problem better?
- Are there things that make your problem worse?
- What are the most salient aspects of your cultural identity, and do they make a difference with respect to your problem?
- Cultural Factors Affecting Self-Coping and Past Help-Seeking
This section’s questions include elicits the client’s perspective on various sources of help (including self-copying) and previous experiences seeking help. Suggested questions include:
- What have you done on your own to cope with your problem?
- In the past, what kinds of treatment, help, advice, or healing have you sought for this problem?
- What was most helpful?
- What was unhelpful?
- Has anything prevented you from getting the help you need?
- Cultural Factors Affecting Current Help-Seeking
This section guides the interviewer to focus on the client’s current perceptions about the problem and his or her expectations about getting help. Questions to gather this information include:
- What types of help do you think would be most useful to you at this time?
- Are there other kinds of help that your friends, family, or other community members have suggested might be helpful?
- Do you have any concerns about the kind of help you might receive?
In many instances, the client is unable to participate in the interview process. This can occur for a variety of reasons, including but not limited to, the client’s age, ability to speak, mental capacity, and other factors that may limit communication abilities. In those instances, an informant is used to gather information about the client. The informant is typically a family member or other person who is very familiar with the client. To ensure that cultural information is still gathered and assessed, the APA provides a separate CFI intended for the informant. When an informant is used the CFI guides the interviewer to clarify the informant’s relationship with the client and the client’s family (e.g., how would you describe your relationship with the client or his or her family? how often do you see the client? how long have you known the client?). When using the CFI with an informant, the same four domains are assessed but from the informant’s perspective. In other words, the interviewer is solicitous of the informant’s way of understanding the problem (e.g., what troubles you the most about the client’s problem? For you, what are the most important aspects of the individual’s background or identity?). Similarly, the interviewer is guided to seek the informant’s perspective on what the provider can do to give the client the help or n.
In addition to the CFI forms included above, the APA also provides supplemental modules for the CFI.
Cultural Concepts of Distress
The final component of the Cultural Formulation section focuses on cultural concepts of distress. Cultural concepts of distress refers to ways that cultural groups experience, understand, and communicate suffering, behavioral problems, or troubling thoughts and emotions. There are three main types of cultural concepts:
- Cultural syndromes
- Cultural idioms of distress
- Cultural explanations or perceived causes
The DSM-5 provides the following list of the reasons that cultural concepts are important to psychiatric diagnosis:
- To avoid misdiagnosis
- To obtain useful clinical information
- To improve clinical rapport and engagement
- To improve therapeutic efficacy
- To guide clinical research
- To clarify the cultural epidemiology
Mental health professionals must take an inclusive approach to practice in order to fully understand and effectively work with individuals from diverse backgrounds. By learning how to use the cultural formulation interview guidelines, a practitioner will be more likely to develop culturally-competent and culturally humble methods of intervention. Practitioners who recognize that behaviors are learned and displayed in particular cultural contexts will be able to conduct a more thorough assessment to ascertain whether an individual has a mental disorder or not.
Alternative DSM-5 Model for Personality Disorders
Section II of the DSM-5 provides information on the current criteria for the diagnosis of personality disorders. However, during the revision process, an alternative model was developed. While this model was not officially adopted and included in section II, the APA chose to include it in section III.
The alternative model that is included in section III provides a different model for diagnosing personality disorders. Under this model, personality disorders are characterized by impairments in personality functioning and pathological personality traits. According to the APA, this model is especially useful in diagnosing the following personality disorders:
- Schizotypal personality disorder
General Personality Disorder
The section on the alternative model for diagnosis then provides the general criteria for personality disorder, which originally appears in section II. After providing the general criteria, the section continues with the criteria for diagnosis under the alternative model. With this model, clients are diagnosed and described using criteria sets. The following is a list of the criteria sets that are used in this model:
- Criterion A: Level of Personality Functioning
- Criterion B: Pathological Personality Traits
- Criteria C and D: Pervasiveness and Stability
- Criteria E, F, and G: Alternative Explanations for Personality Pathology (Differential Diagnosis)
Specific Personality Disorder
In addition to providing criteria for the diagnosis of general personality disorder, the section also provides criteria for diagnosing the personality disorders listed above. The criteria for each disorder are included, and an explanation of how the client presents symptoms is provided. The description of each disorder includes information on different levels of severity, as well as specific symptoms and criteria for each disorder.
This section also includes information on the following components of the alternative model for diagnosing personality disorder:
- Personality Disorder Scoring Algorithms
- Personality Disorder Diagnosis
- Level of Personality Functioning
- Self and Interpersonal Functioning: Dimensional Definition
- Rating Level of Personality Functioning
- Personality Traits
- Definition and Description
- The dimensionality of personality traits
- The hierarchical structure of personality
- The Personality Trait Model
- Distinguishing Traits, Symptoms, and Specific Behaviors
- Assessment of the DSM-5 Section III Personality Trait Model
- Clinical Utility of the Multidimensional Personality Functioning and
Included in this section is the Level of Personality Functioning Scale, which examines the level of impairment based on the following four categories:
The categories listed above are broken down by the following two categories:
Conditions for Further Study
The final component of section III provides information on conditions for further study. In this section, the APA provides information about disorders that have not been researched or developed enough to include in section III, but that warrant further study. These conditions are currently being studied and will, most likely, be included in future editions of the manual. There are eight conditions included in this section, and the APA cautions that the criteria sets provided are not intended to be used as a diagnostic tool. At this point, these conditions cannot be diagnosed, as they are not officially recognized as mental disorders (APA, 2013d). They are not intended to be used for clinical purposes.
The eight conditions included in the conditions for the further study section are:
- Attenuated Psychosis Syndrome
- Depressive Episodes with Short Duration Hypomania
- Persistent Complex Bereavement Disorder
- Caffeine Use Disorder
- Internet Gaming Disorder
- Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure
- Suicidal Behavior Disorder
- Non-suicidal Self Injury
The appendix is the final section of the DSM-5 and includes important information for the reader. The appendix is broken down into the following sections:
- Highlights of Changes from DSM-IV to DSM-5
- Glossary of Technical Terms
- Glossary of Cultural Concepts of Distress
- Alphabetical Listing of DSM Diagnoses and Codes (ICD-9-CM and ICD-10-CM)
- Numerical Listing of DSM-5 Diagnoses and Codes (ICD-9-CM)
- Numerical Listing of DSM-5 Diagnoses and Codes (ICD-10-CM)
- DSM-5 Advisors and Other Contributors
Prior to the publication of the DSM-5, the DSM Multiaxial system used five axes to categorize and diagnose mental disorders. Practitioners use the multiaxial system to assess, identify, and diagnose mental disorders based on specific criteria. This is the system that was used in the DSM-IV-TR and consisted of the following:
- Axis I Clinical Syndromes. Conditions not attributable to a medical disorder
- Axis II Personality Disorders. Specific Developmental Disorders
- Axis III Physical Disorders
- Axis IV Psychosocial Stressors
- Axis V Global Functioning
An example of a multiaxial diagnosis is:
Axis I: Major Depressive Disorder, Single Episode, Severe Without Psychotic Features
Axis II: Borderline Personality Disorder
Axis III: Diabetes
Axis IV: Threat of job loss
Axis V: GAF = 45 (last year)
The revised recording system that is used in the DSM-5 is a “nonaxial,” or single-axis system. This is a major change from the multiaxial recording system that was used in previous versions of the DSM. In the new nonaxial system, Axes I, II, and III have been combined to create one broad diagnostic group that includes all of the disorders that had previously been listed separately. Instead of using Axes IV and V to indicate any relevant psychosocial and contextual factors (Axis IV) and disability status (Axis V), the nonaxial system utilizes separate notations for these factors.
The nonaxial system allows for a dimensional approach to diagnosis that expands the categorical approach used previously. The new system provides an opportunity for clinicians to rate disorders along a continuum of severity, rather than just as part of individual categories. This will eliminate commonly used “not otherwise specified (NOS)” conditions often reported by clinicians. The new system also allows for better treatment development and management.
OVERVIEW OF DSM-5 PSYCHIATRIC DIAGNOSES
Psychiatric diagnosis includes cognitive, emotional, or behavioral dysfunction(s) that cause distress and/or impairment, and has potential detrimental outcomes for an individual. Individuals experience distress stemming from the underlying dysfunction in the psychological, biological, or neurodevelopmental processes in which symptoms arise, causing difficulty in the interpersonal, occupational, or other areas of functioning. When conducting an assessment, practitioners must rule out any medical conditions that may be contributing to or causing symptoms that mimic a psychiatric disorder to ensure an accurate diagnosis. Psychiatric and mental health practitioners are assigned with the immense responsibility of deciding when a person is experiencing a “normal” human experience or emotional response such as sadness to an event versus the experience of psychiatric symptoms such as depression. This is a challenging task and a great source of debate within the mental health community. Knowing which psychiatric diagnosis to accurately give to a client takes years of study, experience, and practitioner skill with clients. The following section provides a brief overview of the overarching categories found in the DSM-5 and pertinent changes for which a practitioner should be made aware. Changes to the diagnoses will be provided, though providing individual criteria for each diagnosis is beyond the scope of this course. A list of renamed, removed disorders, and new disorders can be found in the tables below.
Renamed Disorders in the DSM-5
|Old DSM-IV Name||New DSM-5 Name|
|Mental retardation||Intellectual disability|
|Phonological disorder||Speech sound disorder|
|Stuttering||Childhood-onset fluency disorder|
|Substance abuse||Substance use disorder|
|Substance dependence||Substance use disorder|
|Reading disorder||Specific learning disorder|
|Mathematics disorder||Specific learning disorder|
|Disorder of written expression||Specific learning disorder|
|Dysthymia||Persistent depressive disorder|
|Conversion disorder||Functional neurological symptom disorder|
|Gender identity disorder||Gender dysphoria|
|Primary insomnia||Insomnia disorder|
|Circadian rhythm sleep disorders||Circadian rhythm sleep-wake disorders|
- Sexual aversion disorder
- Somatization disorder
- Pain Disorder
- Asperger’s disorder
- Dissociative fugue
List Of New Disorders in the DSM 5:
|Autism spectrum disorder||Neurodevelopmental disorders|
|Disruptive mood dysregulation disorder||Depressive disorders|
|Binge eating disorder||Feeding and eating disorders|
|Premenstrual dysphoric disorder||Depressive disorders|
|Hoarding disorder||Obsessive-compulsive and related disorders|
|Excoriation (skin-picking) disorder||Obsessive-compulsive and related disorders|
|Disinhibited social engagement disorder||Trauma-and stressor-related disorder|
|Tobacco use disorder||Substance-related and addictive disorders|
|Gambling disorder||Substance-related and addictive disorders|
|Illness anxiety disorder||Somatic symptoms and related disorder|
|Rapid eye movement sleep behavior disorder||Sleep-wake disorders|
|Restless legs syndrome||Sleep-wake disorders|
|Mild neurocognitive disorder||Neurocognitive disorders|
|Neuroleptic-induced movement disorders||Medication-in|
Disorders Listed In The DSM 5
Intellectual Disability (Intellectual Developmental Disorder)
Global Developmental Delay
Unspecified Intellectual Disability (Intellectual Developmental Disorder)
Speech Sound Disorder (previously Phonological Disorder)
Childhood-Onset Fluency Disorder (Stuttering)
Social (Pragmatic) Communication Disorder
Unspecified Communication Disorder
Autism Spectrum Disorder
Autism Spectrum Disorder
Other Specified Attention-Deficit/Hyperactivity Disorder
Unspecified Attention-Deficit/Hyperactivity Disorder
Specific Learning Disorder
Specific Learning Disorder
Developmental Coordination Disorder
Stereotypic Movement Disorder
Persistent (Chronic) Motor or Vocal Tic Disorder
Provisional Tic Disorder
Other Specified Tic Disorder
Unspecified Tic Disorder
Other Neurodevelopmental Disorders
Other Specified Neurodevelopmental Disorder
Unspecified Neurodevelopmental Disorder
Schizophrenia Spectrum and Other Psychotic Disorders
Schizotypal (Personality) Disorder
Brief Psychotic Disorder
Substance/Medication-Induced Psychotic Disorder
Psychotic Disorder Due to Another Medical Condition
Catatonia Associated With Another Mental Disorder (Catatonia Specifier)
Catatonic Disorder Due to Another Medical Condition
Other Specified Schizophrenia Spectrum and Other Psychotic Disorder
Unspecified Schizophrenia Spectrum and Other Psychotic Disorder
Bipolar and Related Disorders
Bipolar I Disorder
Bipolar II Disorder
Substance/Medication-Induced Bipolar and Related Disorder
Bipolar and Related Disorder Due to Another Medical Condition
Other Specified Bipolar and Related Disorder
Unspecified Bipolar and Related Disorder
Disruptive Mood Dysregulation Disorder
Major Depressive Disorder, Single and Recurrent Episodes
Persistent Depressive Disorder (Dysthymia)
Premenstrual Dysphoric Disorder
Substance/Medication-Induced Depressive Disorder
Depressive Disorder Due to Another Medical Condition
Other Specified Depressive Disorder
Unspecified Depressive Disorder
Separation Anxiety Disorder
Social Anxiety Disorder (Social Phobia)
Panic Attack (Specifier)
Generalized Anxiety Disorder
DSM-5 Table of Contents • 3
Substance/Medication-Induced Anxiety Disorder
Anxiety Disorder Due to Another Medical Condition
Other Specified Anxiety Disorder
Unspecified Anxiety Disorder
Obsessive-Compulsive and Related Disorders
Body Dysmorphic Disorder
Trichotillomania (Hair-Pulling Disorder)
Excoriation (Skin-Picking) Disorder
Substance/Medication-Induced Obsessive-Compulsive and Related Disorder
Obsessive-Compulsive and Related Disorder Due to Another Medical Condition
Other Specified Obsessive-Compulsive and Related Disorder
Unspecified Obsessive-Compulsive and Related Disorder
Trauma- and Stressor-Related Disorders
Reactive Attachment Disorder
Disinhibited Social Engagement Disorder
Posttraumatic Stress Disorder
Acute Stress Disorder
Other Specified Trauma- and Stressor-Related Disorder
Unspecified Trauma- and Stressor-Related Disorder
Dissociative Identity Disorder
Other Specified Dissociative Disorder
Unspecified Dissociative Disorder
Somatic Symptom and Related Disorders
Somatic Symptom Disorder
Illness Anxiety Disorder
Conversion Disorder (Functional Neurological Symptom Disorder)
Psychological Factors Affecting Other Medical Conditions
Other Specified Somatic Symptom and Related Disorder
Unspecified Somatic Symptom and Related Disorder
Feeding and Eating Disorders
Avoidant/Restrictive Food Intake Disorder
Other Specified Feeding or Eating Disorder
Unspecified Feeding or Eating Disorder
Other Specified Elimination Disorder
Unspecified Elimination Disorder
Breathing-Related Sleep Disorders
Obstructive Sleep Apnea-Hypopnea
Central Sleep Apnea
Circadian Rhythm Sleep-Wake Disorders
Non–Rapid Eye Movement Sleep Arousal Disorders
Rapid Eye Movement Sleep Behavior Disorder
Restless Legs Syndrome
Substance/Medication-Induced Sleep Disorder
Other Specified Insomnia Disorder
Unspecified Insomnia Disorder
Other Specified Hypersomnolence Disorder
Unspecified Hypersomnolence Disorder
Other Specified Sleep-Wake Disorder
Unspecified Sleep-Wake Disorder
Female Orgasmic Disorder
Female Sexual Interest/Arousal Disorder
Genito-Pelvic Pain/Penetration Disorder
Male Hypoactive Sexual Desire Disorder
Premature (Early) Ejaculation
Substance/Medication-Induced Sexual Dysfunction
Other Specified Sexual Dysfunction
Unspecified Sexual Dysfunction
Other Specified Gender Dysphoria
Unspecified Gender Dysphoria
Disruptive, Impulse-Control, and Conduct Disorders
Oppositional Defiant Disorder
Intermittent Explosive Disorder
Antisocial Personality Disorder
Other Specified Disruptive, Impulse-Control, and Conduct Disorder
Unspecified Disruptive, Impulse-Control, and Conduct Disorder
Substance-Related and Addictive Disorders
Substance Use Disorders
Substance Intoxication and Withdrawal
Substance/Medication-Induced Mental Disorders
Alcohol Use Disorder
Other Alcohol-Induced Disorders
Unspecified Alcohol-Related Disorder
Other Caffeine-Induced Disorders
Unspecified Caffeine-Related Disorder
Cannabis Use Disorder
Other Cannabis-Induced Disorders
Unspecified Cannabis-Related Disorder
Phencyclidine Use Disorder
Other Hallucinogen Use Disorder
Other Hallucinogen Intoxication
Hallucinogen Persisting Perception Disorder
Other Phencyclidine-Induced Disorders
Other Hallucinogen-Induced Disorders
Unspecified Phencyclidine-Related Disorder
Unspecified Hallucinogen-Related Disorder
Inhalant Use Disorder
Other Inhalant-Induced Disorders
Unspecified Inhalant-Related Disorder
Opioid Use Disorder
Other Opioid-Induced Disorders
Unspecified Opioid-Related Disorder
Sedative-, Hypnotic-, or Anxiolytic-Related Disorders
Sedative, Hypnotic, or Anxiolytic Use Disorder
Sedative, Hypnotic, or Anxiolytic Intoxication
Sedative, Hypnotic, or Anxiolytic Withdrawal
Other Sedative-, Hypnotic-, or Anxiolytic-Induced Disorders
Unspecified Sedative-, Hypnotic-, or Anxiolytic-Related Disorder
Stimulant Use Disorder
Other Stimulant-Induced Disorders
Unspecified Stimulant-Related Disorder
Tobacco Use Disorder
Other Tobacco-Induced Disorders
Unspecified Tobacco-Related Disorder
Other (or Unknown) Substance-Related Disorders
Other (or Unknown) Substance Use Disorder
Other (or Unknown) Substance Intoxication
Other (or Unknown) Substance Withdrawal
Other (or Unknown) Substance-Induced Disorders
Unspecified Other (or Unknown) Substance-Related Disorder
Other Specified Delirium
Major and Mild Neurocognitive Disorders
Major Neurocognitive Disorder
Mild Neurocognitive Disorder
Major or Mild Neurocognitive Disorder Due to Alzheimer’s Disease
Major or Mild Frontotemporal Neurocognitive Disorder
Major or Mild Neurocognitive Disorder With Lewy Bodies
Major or Mild Vascular Neurocognitive Disorder
Major or Mild Neurocognitive Disorder Due to Traumatic Brain Injury
Substance/Medication-Induced Major or Mild Neurocognitive Disorder
Major or Mild Neurocognitive Disorder Due to HIV Infection
Major or Mild Neurocognitive Disorder Due to Prion Disease
Major or Mild Neurocognitive Disorder Due to Parkinson’s Disease
Major or Mild Neurocognitive Disorder Due to Huntington’s Disease
Major or Mild Neurocognitive Disorder Due to Another Medical Condition
Major or Mild Neurocognitive Disorder Due to Multiple Etiologies
Unspecified Neurocognitive Disorder
General Personality Disorder
Cluster A Personality Disorders
Paranoid Personality Disorder
Schizoid Personality Disorder
Schizotypal Personality Disorder
Cluster B Personality Disorders
Antisocial Personality Disorder
Borderline Personality Disorder
Histrionic Personality Disorder
Narcissistic Personality Disorder
Cluster C Personality Disorders
Avoidant Personality Disorder
Dependent Personality Disorder
Obsessive-Compulsive Personality Disorder
Other Personality Disorders
Personality Change Due to Another Medical Condition
Other Specified Personality Disorder
Unspecified Personality Disorder
Sexual Masochism Disorder
Sexual Sadism Disorder
Other Specified Paraphilic Disorder
Unspecified Paraphilic Disorder
Other Mental Disorders
Other Specified Mental Disorder Due to Another Medical Condition
Unspecified Mental Disorder Due to Another Medical Condition
Other Specified Mental Disorder
Unspecified Mental Disorder
Medication-Induced Movement Disorders and Other Adverse Effects of Medication
In the months before the DSM-5 was approved at the APA annual meeting, there was a great deal of controversy surrounding its release. Various mental health organizations, scholars, and practitioners, as well as individual practitioners and those living with mental disorders, found fault in the proposed revisions. Before the manual was even released, many had already denounced it based on speculation regarding the changes that were being made to the manual and the potential impact these changes would have on the mental health community (Jones, 2012).
Initial criticism focused on the review and revision process. Of particular concern were the perceived lack of scientific rigor in the review process and the exclusion of key individuals in the mental health field. While members from the various mental health organizations, such as the American Psychological Association, American Counseling Association, American Mental Health Counselors Association, and others, provided initial suggestions and feedback on the proposed changes, there was little representation from social workers. This was considered problematic, as clinical social workers are responsible for providing a significant portion of the mental health services in the United States.
Much of the controversy surrounding the release of the DSM-5 centered around changes to specific disorders. The removal of Asperger’s from the manual as an individual condition was especially controversial (Giles, 2013). Revisions to other disorders have also caused a great deal of controversy, especially the changes made to schizophrenia, bipolar disorder, dissociative identity disorder, and depressive disorder (Halter, Rolin-Kenny, & Dzurec, 2013). The criteria for the diagnosis of these disorders were changed in the DSM-5, which affects how clients are identified and diagnosed. For example, as mentioned above, in previous versions of the manual, there was a bereavement exclusion in the major depressive disorder category that eliminated grief that occurred as the result of the death of a loved one as a diagnostic category. However, in the DSM-5, the new criteria indicate that an individual who suffers from grief as the result of the death of a loved one can be classified as depressed, as long as that grief lasts for longer than two weeks (Friedman, 2012). This has caused a great deal of controversy, as many mental health professionals do not consider grief from bereavement to be a mental disorder.
The bereavement issue was indicative of a greater issue with the manual. There were many disorders listed in the text that mental health practitioners do not consider diagnosable disorders (Frances, 2010). Common complaints against the manual have focused on the broad range of criteria and the ease with which some individuals can be diagnosed with a disorder. For example, previous behaviors, which were considered general behavior problems such as temper tantrums in children and general forgetfulness, are now considered diagnosable conditions with names like “disruptive mood dysregulation disorder” and “neurocognitive disorder.” The criticism against this was that not every behavior problem is a diagnosable mental disorder, and by establishing criteria in the DSM-5, the APA was going to increase the number of relatively “normal” individuals who are diagnosed with a mental disorder.
Other critics have expressed the opposite view of the criteria, complaining that they were too narrow to adequately diagnose those who actually have a mental disorder. For example, disruptive mood dysregulation disorder requires a number of qualifiers for a child to be diagnosed, and some critics argue that the strict criteria exclude a number of children who actually have disruptive mood dysregulation disorder. Other critics expressed similar sentiments regarding other disorders in the manual.
Another criticism against the DSM-5 was the change from a multiaxial coding system to a nonaxial coding system. The APA promotes the new coding system as making the diagnostic process more streamlined and comprehensive. Critics of the new coding system argued that it did not allow for the identification of individual disorders and symptoms as it removes the separate axes and combines them into one broad category. Critics also argued that the removal of axes IV and V eliminates the opportunity to specify relevant psychosocial and contextual factors (Axis IV) and disability status (Axis V) within the diagnosis. Meanwhile, supporters of the new nonaxial coding system argued that the removal of individual axes allows for clients to be diagnosed on a broad spectrum that focuses more on severity level than individual symptoms.
The controversy surrounding the release of the DSM-5 caused problems between the APA and other mental health organizations, including the National Institute of Mental Health and the American Psychological Association. These other groups expressed concerns similar to those listed above and have criticized the APA for expanding the breadth of the manual to the point that it would result in the overdiagnosis of numerous individuals who do not actually have a mental disorder. These organizations were hopeful that the new DSM would utilize scientific information and data to better outline the mental disorders plaguing individuals in society. However, according to them, the manual is not based on substantial scientific evidence and is detrimental to the mental health community as a whole. They are concerned that the manual lacks validity.
The DSM-5 revision process lasted fourteen years and culminated with the release of a comprehensive manual that is intended to be used to properly identify and diagnose mental disorders. The American Psychiatric Association utilized task forces and workgroups comprised of experts in the field throughout the process and relied on current scientific knowledge and recent research findings to develop the diagnostic criteria for mental disorders. The result is a manual that is comprised of numerous newly classified mental disorders, as well as many others that have been changed drastically. In addition, the manual features an expanded section focused on cultural awareness and assessment, as well as information regarding disorders still undergoing research.
The intent is for the DSM-5 to serve as the standard guidebook for mental health professionals to use in the identification and diagnosis of mental disorders. However, the revision process and the changes that have been made to the manual have received criticism from professionals in the field and from individuals and their families affected by mental health.
The DSM has served as the standard guide for mental health diagnosis since the DSM-III was published. However, there is less support for the manual. Many critics have determined that they will no longer rely on the DSM as a guide in the diagnostic process. In fact, the National Institute on Mental Health has publicly stated that they will begin developing a new standard for the diagnosis of mental disorders rather than rely on the DSM-5. Therefore, the future of the DSM is shaky at best and will continue to be highly debated among mental health professionals.