Yesterday, the board of trustees of the American Psychiatric Association (APA) approved a set of updates, revisions and changes to the reference manual used to diagnose mental disorders. The revision of the manual, called the Diagnostic and Statistical Manual of Mental Disorders and abbreviated as the DSM, is the first significant update in nearly two decades.
Disorders that will be in the new DSM-5 — but only in Section 3, a category of disorders needing further research — include: Attenuated psychosis syndrome, Internet use gaming disorder, Non-suicidal self-injury, and Suicidal behavioral disorder. Section 3 disorders generally won’t be reimbursed by insurance companies for treatment, since they are still undergoing research and revision to their criteria.
So here’s a list of the major updates…
Overall Changes to the DSM
According to the American Psychiatric Association’s statement, there are two major changes to the overall DSM — the dumping of the multiaxial system, and rearranging the chapter order of disorders. Most clinicians only paid attention to Axis I and II, so it’s no surprise the Axis system was never a big hit. The current chapter order has always been a bit of a mystery to most clinicians, so it’s good to know there’s some thought going into the new order of chapters.
Chapter order:
DSM-5’s 20 chapters will be restructured based on disorders’ apparent relatedness to one another, as reflected by similarities in disorders’ underlying vulnerabilities and symptom characteristics.
The changes will align DSM-5 with the World Health Organization’s (WHO) International Classification of Diseases, eleventh edition (ICD-11) and are expected to facilitate improved communication and common use of diagnoses across disorders within chapters.
Removal of multiaxial system:
DSM-5 will move to a nonaxial documentation of diagnosis, combining the former Axes I, II, and III, with separate notations for psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V).
Specific Disorders
Autistic disorders will undergo a reshuffling and renaming:
“[Autism] criteria will incorporate several diagnoses from DSM-IV including autistic disorder, Asperger’s disorder, childhood disintegrative disorder and pervasive developmental disorder (not otherwise specified) into the diagnosis of autism spectrum disorder for DSM-5 to help more accurately and consistently diagnose children with autism,” according to an APA statement Saturday.
The rest of this update comes from the APA’s news release on the changes:
Binge eating disorder will be moved from DSM-IV’s Appendix B: Criteria Sets and Axes Provided for Further Study to DSM-5 Section 2. The change is intended to better represent the symptoms and behaviors of people with this condition.
This means binge eating disorder is now a real, recognized mental disorder.
Disruptive mood dysregulation disorder will be included in DSM-5 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 intended to address concerns about potential over-diagnosis and overtreatment of bipolar disorder in children. Will children now stop being diagnosed with bipolar disorder, which has been a recurring concern among many clinicians and researchers? We will see.
Excoriation (skin-picking) disorder is new to DSM-5 and will be included in the Obsessive-Compulsive and Related Disorders chapter.
Hoarding disorder is new to DSM-5.
Its addition to DSM is supported by extensive scientific research on this disorder. This disorder will help characterize people with persistent difficulty discarding or parting with possessions, regardless of their actual value. The behavior usually has harmful effects — emotional, physical, social, financial and even legal — for a hoarder and family members.
Pedophilic disorder criteria will remain unchanged from DSM-IV, but the disorder name will be revised from pedophilia to pedophilic disorder.
Personality disorders:
DSM-5 will maintain the categorical model and criteria for the 10 personality disorders included in DSM-IV and will include the new trait-specific methodology in a separate area of Section 3 to encourage further study how this could be used to diagnose personality disorders in clinical practice.
Posttraumatic stress disorder (PTSD) will be included in a new chapter in DSM-5 on Trauma- and Stressor-Related Disorders.
DSM-5 pays more attention to the behavioral symptoms that accompany PTSD and proposes four distinct diagnostic clusters instead of three. PTSD will also be more developmentally sensitive for children and adolescents.
Removal of bereavement exclusion:
The exclusion criterion in DSM-IV applied to people experiencing depressive symptoms lasting less than two months following the death of a loved one has been removed and replaced by several notes within the text delineating the differences between grief and depression. This reflects the recognition that bereavement is a severe psychosocial stressor that can precipitate a major depressive episode beginning soon after the loss of a loved one.
Specific learning disorder broadens the DSM-IV criteria to represent distinct disorders which interfere with the acquisition and use of one or more of the following academic skills: oral language, reading, written language, or mathematics.
Substance use disorder will combine the DSM-IV categories of substance abuse and
substance dependence. In this one overarching disorder, the criteria have not only been combined, but strengthened. Previous substance abuse criteria required only one symptom while the DSM-5’s mild substance use disorder requires two to three symptoms.
The APA board of trustees also outright rejected some new disorder ideas. The following disorders won’t appear anywhere in the new DSM-5:
- Anxious depression
- Hypersexual disorder
- Parental alienation syndrome
- Sensory processing disorder
Although clinicians are “treating” these concerns, the board of trustees felt like there wasn’t even enough research to consider putting them in Section 3 of the new DSM (disorders needing further research).
So there you have it. What do you think about these final decisions for the DSM-5?
Read the full list of changes from the APA: American Psychiatric Association Board of Trustees Approves DSM-5 (PDF)
Read the full article: Psychiatric association approves changes to diagnostic manual
34 comments
Great summary John!
I am surprised and a little disturbed that parental alienation syndrome did not make it in at all, given the amount of good research out there and growing acknowledgement in legal citations. Here’s hoping for more sense in VTR.
Thanks for the great summary. I know we all will have to go to trainings to learn about the updates.
Too bad there is not a hypersexual disorder. Seems to be something that I see all of the time in my practice these days.
Is Excoriation the same as Dermatillomania?
Yes it is
Dermatillomania (also known as neurotic excoriation, pathologic skin picking (PSP), compulsive skin picking (CSP) or psychogenic excoriation) is an impulse control disorder characterized by the repeated urge to pick at one’s own skin, often to the extent that damage is caused.
How many of the people who played a role in the product will either be retiring within 3-5 years, and how many are already not practicing primary psychiatric care now? And how many pharmaceutical companies will be going to more PCP offices to sell their products to treat patients who never see a mental health care provider first?
Between the new CPT coding and DSM 5, mental health is in serious trouble. And like lemmings, no one is even looking forward and seeing the oncoming cliff. Wow, so sad patients are being marginalized and minimized by the very people who are supposed to be advocates and supporters.
Oh well.
All these school & mass shooting & a few ppl that make this decision don’t believe that SPD or ODD could possibly be responsible for adolescents that r not treated for these personality traits bc insurance & the general public think the r brats or have had bad parenting. Obviously quite obviously, NO ONE ON THIS COMMITTEE IS A PARENT OR RELATIVE OF A SPD OR ODD toddler or child. I’m beyond being upset, I’m physically ill to think that this is the best way to try to treat this LARGE POPULATION OF CHILDREN that parents see from babies to toddlers to preteens to young ppl r not able to function like some of their relatives or peers. Families r being ripped apart, divorce is caused more often & downright child abuse is being done bc these Children cannot get the proper therapies needed & maybe not require meds later on in life, bc they feel more research is needed. Well with out insurance to cover some of these therapies how & why should parents even bother‼ï¸
Dr. John,
So with the new tantrum disorder and the reasoning for such, does this suggest that we have children being treated for a disorder (bi-polar) that actually does not exists?
And if so, for how long has this being going on do you suppose?
How can those who write the rules make amends for the misuse of psychotropic drugs on the children and the possible or probable damage these drugs have done?
I am not a clinician but a patient with several DSM-4 recognized disorders. I find it very troubling that Non-suicidal self-injury and Suicidal behavioral disorder have been reclassified under Section 3, as disorders needing more research (and not reimbursable). These are extremely serious disorders that can cause dysfunction and even death. Many of us experience them as separate and self-perpetuating disorders that don’t respond to current treatment even when provided. (It’s often not.) They are perhaps better thought of as a form of OCD (my personal opinion) but in any case they are clearly psychiatric in nature and potentially disabling and even fatal.
I just wonder if BPD or Borderline Personality Disorder is still included as a disease or if it is one requiring further investigation. Also, has it received a new name yet?
“The section on personality disorders was the main casualty. The [APA] board backed a recommendation to exclude it from the main text and instead publish it in a section describing diagnoses requiring further study.”
~Newscientist, Dec. 3, 2012
Unfortunately, I think you misunderstood what Newscientist was referring to — specifically, just the 5-trait system for diagnosing personality disorders was put into Section 3 — not all the personality disorders themselves.
Here’s the news release section on personality disorders:
What’s being included in Section 3 (the area where conditions are listed needing further research) is the trait-specific methodology — not the personality disorders themselves.
The 10 personality disorders remain in the DSM 5 unchanged. The working group wanted to completely revamp how personality disorders were conceptualized and diagnosed. That revamping is to undergo further research.
What about Borderline disorder?
My heart is broken that Sensory Prossessing Disorder did not make the list. We live with knowing this exists in my 4 1/2 year old boy every day. I’ll keep fighting the fight to educate people on this disorder. It’s real and it really exists in our children.
I agree with you WillsMom. I am sure you have heard of orphan drugs; Sensory Processing Disorder is a diagnosis that is stuck in the birth canal. I had hoped it would be seen as a psychiatric diagnosis; it appears to be recognized as an Occupational Therapy diagnosis. I remember early research in the 1960s that showed that children with autism had significant problems with cross-modal integration, a sign of sensory problems. I have tried to look to see if children with sensory problems might have autism, but that does not always comply. Unfortunately, the public, particularly insurance companies and government organizations, view the APA as the ultimate authority on mental health and the APA is reluctant to grant too much credence or credit to any other health professionals. They are “doctors” after all. But, I have usually found there is some room within categories to fit the problems that would otherwise fall between the cracks.
yeah, I think in the future they may enlarge the autism spectrum to include spd, or another new one is “highly sensitive” which is noted as more of a personality type but the symptoms overlap.
I am happy they got rid of the other 3, however. Hypersexuality seems like an extreme on a biological range like skin color or sexual orientation to me and compulsive *anything* is an addiction, “anxious depression” is simply an amalgam of 2 disorders (“comorbidity”) and wth is parental alienation syndrome” anyway? sounds like more of an event to me.
Very disappointed that Sensory Processing Disorder (SPD) was not included. My wife noticed something wrong with our daughter since about age 2. Diagnosed and started therapy at 4 years old. Now 5 years old and having issues in school because the teacher doesn’t know how to deal with her and the school district won’t help with special accommodations because its not a diagnoses in the DSM. The teacher attributes her difficulties to behavioral problems. These doctors that decides what goes in the DSM needs to take a closer look at SPD.
I am psychotherapist in the North Alabama area and I m interested in workshops in the area with training on the new DSM 5. When will it be ready to purchase?
I personally think that the rejection of hypersexual disorder, aka sex addiction, is an ethical, scientifically-based decision. The belief in sex addiction, by both addicts and the sex addiction treatment industry, is more akin to a fath, than a scientific practice. This decision is merely the latest in many that show that there is poor science behind this pop-psychology concept. I hope that this decision leads to more people considering the questions of why there is such a discrepancy, between the believers and the skeptical scientific community. The sex addiction label obscures the high rates of comorbidity, moral issues, relationship issues, and socio-sexual values conflicts that are truly behind this alleged disorder. Rather than mere strengthening of resolve to “keep fighting” for sex addiction, I hope that this might spur greater open, non-defensive dialogue about what is actually going on here, and how people can be helped.
I disagree with the rejection of hypersexual disorder. I also am of the firm thinking that pornography addiction exists. I wonder if those deciding diagnoses have personal reasons for rejection and acceptance.
All you need is taking an antidepressant SSRI and I assure you that your sexual life will stop bothering you.
That’s why this class of antidepressants is helping treating paraphilias.
Search for PSSD and you’ll see how SSRIs works for these cases.
Just like the DSM-IV, the DSM-V will be abused to prescribe medication: synthesized substances, foreign to the body, with often frightening results, like suicide, homicide and self mutilation.
So instead of concentrating on all the newly described and often ludicrous sounding disorders in the DSM-V, I plead for looking at the causes of symptoms and behaviour in people.
True health, physical and emotional, never is a question enough of medication or enough vaccines…
True health and wellbeing are created and maintained by a safe and effective nutritious diet (the correct balance in vitamins, minerals, fatty acids, trace elements), a safe, loving and nurturing environment…
And all of it starts before conception!
It is a complete travesty that Parental Alienation Syndrome will not be part of the DSM V. It is also surprising that the board of trustees state that more research is needed, especially since there is so much out there already. Nonetheless, this should not discourage all of us to expand our efforts and give them more than enough research, so that when the next release is due, their excuse will not be valid.
I agree with you on parental alienation. I am an alienated grandparent. I cannot tell you the amount of suffering and depression I have been thru because of this alienation. Go to the website Alienated grandparents anonymous-Florida. You can read a letter to healthcare providers about grandparent alienation and the toll it takes on our physical and emotional wellbeing. This sight also recognizes parental alienation. As a therapist I work with children who are victims of parental alienation. Unless a person has suffered from this they cannot understand it. PAS and GPA is at an epidemic level in this county. I have been diagnosed with PTSD because no other diagnosis exists.
So there is new section on Trauma?
What about the proposed Developmental Trauma Disorder, authored by Bessel van der Kolk and colleagues?
DTD essentially acknowledges that trauma can occur from “non-life-threatening”stressors (such as physical and emotional abuse and neglect) that are experienced over a prolonged period of time.
In my opinion and experience, the result of such stressors is every bit as debilitating and dangerous as any other mental illness, and should therefore be accounted for in the DSM, which seems to serve as the gateway to obtaining financial and psychological support in order to recover.
An excellent description of DTD is at:
http://www.attachmentdisordermaryland.com/traumadisorders.htm
I am a patient. I have been diagnosed in the past with BPD, GAD and Bipolar II. Non of these fit as well as DTD for me. I have had a lifetime of suicidal ideation and attempts and social anxiety attacks. Essentially, it seems that because I am able to articulate what is going on so clearly, I am not mentally ill, and have no disability.
Trauma survivors get left in the dust until we get desperate enough to act out. This must be changed.
I was in a workshop yesterday and it was stated that the PD section was being deleted. Is that true?
I am quite glad that the DSM-V has finally been accomplished. Of course, as a work, it will be updated, again, to comply with ongoing research. It is not perfect, of course. It is meant to be a guideline for professionals, who can elicit more details from their clients, in order to provide a more exact diagnosis of their problems. While inconsistencies still exist,such as duplication of symptoms, or overlapping criteria,it is better that the old DSM-IV has been updated,into the new DSM-V version, rather than utilizing criteria which no longer has any evidentiary validity, nor reliability. The DSM-V is merely a guideline–not the final word–but it is in the most current form that the APA could muster. While some diagnoses, and criteria, have been eliminated, others have been added and updated. It is up to the professional to determine what applies to the client, as always, and, while some criteria may no longer apply, professionals need to recognize the changes, and the research, and alter their services to insure that their clients will receive the best treatment that their client can receive. After all, a psychologist should be able to roll with the changes, right? Trying new things should not be met with resistance, especially by the professional community. If your client no longer falls within the criteria guidelines, perhaps your client is misdiagnosed, and you should rethink the details you have been provided to give a more accurate diagnosis.
I welcome the changes, and the new DSM-V.
My question is about studies done using DSMIV criteria. For example, autism twin studies: Would there be some kind of conversion factor for studies using the CAST (childhood asperger syndrome test) as the selection factor?
How will future studies be able to be related to past studies? This is an important issue, since it can direct researchers in the most effective direction to study causes (i.e., genetic vs. environmental risk factors), of autism.
It’s funny that people are so concerned that these labels are not being included at DSM-5.
Go to the psychiatrist!
I’m sure that you’ll not leave the office without psychiatric help.
I assure you that you’ll be prescribed.
DSM is the Bible but the followers are always glad to give one, two, three… a cocktail of drugs to any person who seeks psychiatric help.
In case someone wants to remain at the loony we all know how easy it is to be admitted.
David Rosenham taught us all.
The problem sometimes is to get out of the mental institution. Alison Hymes is trying.
But you all sounds so eager to be treated by psychiatrists that once there I’m sure you’ll not want to leave,
Have a great stay!
I’m inclined to agree with you. The DSM in general is a highly contested catalogue since they have only a small percentage (I’d say less than 30%) of any data to support any of their categories, and most of their diagnostic criteria stems from observation over empirical research. As they say “comorbity is the rule, not the exception.” So, the genetic mutations (comorbities) that seem to be so prevalent have nearly obsoleted their catalogue of criteria unless they reconstruct it based on more research.
I believe that clinical psychology has become nothing but a business since pharmapsychology become the standardized practice. Honestly, the rigid and archaic members of the APA board are truly to blame for clinical psychology backsliding so far from the essential nature of their field: the scientific method coupled with empirical evidence.
Sensory Processing Disorder is omitted from the list. It is not a real disorder… until you have an advanced degree and can’t hold a job because of its symptoms …
Understanding is the key. People must show more of it to those in need. Hoarding disorder is not a disease, it is a condition caused by most commonly bad life experience and can be treated. More info on the same subject: http://blogs.nejm.org/now/index.php/hoarding-disorder/2014/05/23/comment-page-1/#comment-224654
They add disorders as soon as they know they can profit from them. If they can’t profit they will not add it. As soon as money is to be made, they’ll widen the umbrella, they’ll insist on “early detection, “awareness,” “mandatory screening,” and alas, demand that if we don’t comply, we’ll be rounded up, taken away on stretchers and forced into a lifetime of “disability” from the treatments they do to us. The Diagnostics and Statistical Manual is not a scientific book. It is causing fear in our society, a dichotomy between the “ill” and those that are not “ill,” and the ultimate goal of genocide of millions of people.
The logic that there is not enough evidence for parental alienation makes me wonder about the competence of the board or their ideologue mentality. Every good therapist or psychologist know that parental alienation is as real as autism and bipolar disorder. 22 million parents are effected in US alone and both moms and dads do it equally (Harman et al). Alienation can be quantified (Bernet et al). The long term effects are devestating including depression, drug abuse, suicidal ideation (Baker et al) and in some cases leading to murder. Not enough science? here is a list of publications on parental alienation:
http://parentalalienationresearch.com/scientific-evidence/
It is a shame that the board of directors didn’t bother to do a pub MED search – there is plenty of science and DSM board of directors needs to do there job to save children from this form of psychological child abuse.