The American Psychiatric Association has finalized its restructuring of the Diagnostic and Statistical Manual of Mental Disorders, clearing the way for publication of the fifth edition of the DSM in May 2013 and cementing some controversial changes.
On Dec. 1, the APA’s Board of Trustees approved the final diagnostic criteria, which had been developed by a task force of clinicians and researchers over the last 6 years. The document now will undergo final editing before being published by American Psychiatric Publishing.
"We have sought to be very conservative in our approach to revising DSM-5," Dr. David J. Kupfer, chair of the DSM-5 Task Force, said in a statement. "Our work has been aimed at more accurately defining mental disorders that have a real impact on people’s lives, not expanding the scope of psychiatry."
Along with a restructuring of how the diagnostic chapters are organized and the removal of the multiaxial system, the board of trustees also approved several controversial changes to common psychiatric disorders.
The DSM-5 will include a section on autism spectrum disorder that includes Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder (not otherwise specified). Previously, these had all been separate diagnoses. Critics have voiced concerns that this will lead to lower rates of diagnosis and a possible disruption in school services.
But the work group members that recommended the change said it would lead to move accurate diagnosis by recognizing differences from person to person.
The final DSM-5 also will include a new diagnosis of disruptive mood dysregulation disorder, which will be used to diagnose children who exhibit persistent irritability and frequent episodes of behavior outbursts three or more times a week for more than a year. The diagnosis is meant to help address the possible overdiagnosis of bipolar disorder in children, according to the APA. But Dr. Allen J. Frances, a psychiatrist who chaired the DSM task force that developed the DSM-IV, said this is an example of pathologizing normal behavior by turning "temper tantrums" into a psychiatric diagnosis.
Another change that drew the ire of critics is the removal of the bereavement exclusion. Under the DSM-IV, the exclusion was used to describe people who experienced depressive symptoms lasting less than 2 months after the death of a loved one. Instead, the text of the DSM-5 will include notes clarifying the differences between grief and depression. The APA said the change is intended to reflect the recognition that bereavement is a significant psychological stressor that can precipitate a major depressive episode after the death of a loved one.
But during the drafting of the DSM-5, the proposal was ridiculed by some opponents who said that removing the exclusion could lead clinicians to diagnose major depressive disorder in people experiencing brief periods of normal grief.
The DSM-5 also will include some new disorders, including excoriation (skin picking) disorder and hoarding disorder. Binge eating disorder will be moved out of the DSM-IV’s Appendix B, used for diagnoses requiring further study, and into the main manual. Posttraumatic stress disorder (PTSD) will be made part of a new chapter on Trauma- and Stressor-Related Disorders in the DSM-5. There will be a greater focus on the behavioral symptoms associated with PTSD, according to the APA.
The DSM-5 also combines the substance abuse and substance dependence categories into a single new category called substance use disorder. Instead of requiring only one symptom for diagnosis, the DSM-5 will require two to three symptoms for a diagnosis of mild substance abuse.
Many areas will remain relatively unchanged. For instance, the pedophilia criteria are the same as in the DSM-IV, but will undergo a name change in DSM-5, becoming pedophilic disorder.
The categorical model and criteria for the 10 personality disorders in the DSM-IV will remain the same in the new manual. However, to encourage further study on how personality disorders can be diagnosed, the DSM-5 will include a separate section with new trait-specific methodology.