DSM-5

The current classification system of psychiatric illnesses is known as the The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), which was published by the American Psychiatric Association (APA) in 2022. Psychiatrists and other mental health specialists use the DSM-5-TR to understand the overall and specific nature of mental illnesses. The DSM-5-TR is the authoritative handbook for research and statistical (epidemiological/public health) analyses; in other words, it serves as a template to estimate the incidence (new cases) and prevalence (existing cases) of mental disorders in the general population. Most important, the DSM-5-TR provides common terminology and criteria to standardize the assessment and diagnosis of mental illnesses in a variety of clinical settings.

TYPE OF PSYCHOLOGY: Clinical; Abnormal; Counseling; Neuroscience

Introduction

Mental illnesses are purportedly the result of abnormalities in brain structure and functioning. People are predisposed to symptoms of mental illnesses by unknown combinations of genetic predispositions (nature) and environmental and life experiences (nurture) that trigger inherited or acquired vulnerabilities to express symptoms (self-reported distress) and signs (observable indicators) of these diseases. As reflected in the DSM-5-TR, psychiatric disorders can afflict children and the elderly, men and women, and people of all races, ethnicities, and nationalities.

Mental illnesses are disturbances that affect people's thoughts, feelings, and behaviors. According to the DSM-5-TR, the overarching definition of mental disorders consists of three elements: distress (the occurrence of emotional pain and suffering), impairment or dysfunction (the inability to perform in school and work and to engage in healthy social relationships and activities), and comportment (the failure to adhere to widely accepted [culturally normative] expectations of behaviors that are operative in a particular place and time). The third element recognizes that symptoms of mental illnesses can be experienced, interpreted, and expressed in culturally specific ways.

Diagnosis is the first step in treating any disease, illness, or infection. However, unlike other medical problems, mental illnesses can rarely be identified or ruled out with objective tests (e.g., blood tests, brain imaging, or biopsies). To determine the causes, onset, course, and prognosis of psychiatric disorders, mental health providers must rely on patients' self-reported psychiatric histories, mental status examinations (lengthy interviews), and observations of patients' behaviors that might indicate signs of mental illnesses. This evaluation process must be performed systematically to achieve consistent and accurate diagnoses. The DSM-5-TR affords clinicians the structure and guidelines needed to arrive at diagnoses that are widely accepted and understood by members of the profession and reimbursable through insurance coverage.

Precursors to the DSM

The origins of the DSM can be traced to the 1840s when the US Census Bureau attempted to count the number of patients in public psychiatric hospitals. The superintendent of one such hospital and a pioneer of modern psychiatry, Isaac Ray, spoke to fellow psychiatrists at a professional conference where he called for the formulation of a national system to measure mental illnesses (naming, classifying, and recording) thereby capturing the nature and extent of hospitalized patients' conditions. The first Statistical Manual for Psychiatric Diseases was compiled in 1933 by the Medico-Psychological Association (MPA) and was adopted by the American Neurological Association. This manual was revised several times from 1933 to 1952, the same year the APA published the first edition of the DSM.

DSM-I and DSM-II

The DSM-I was written by psychiatrists who were mostly followers of Sigmund Freud and who adopted the theories of psychoanalysis as a model to explain, describe, and treat mental illnesses. In the DSM-I, the causes of psychiatric disorders (called “reactions”) were attributed to internal conflicts that arose in childhood and were primarily of a sexually repressive nature. The DSM-I included 106 disorders and incorporated terminology and classification schemes from the nosology of the MPA and the general categories of mental disorders identified by the U.S. Army/Veterans Association. The psychoanalytic orientation continued to dominate the DSM-II, which was published in 1968. This second edition strived to achieve greater consistency with the World Health Organization's (WHO) International Classification of Diseases (ICD). The DSM-II included 182 disorders.

Several studies showed that DSM-based language for diagnosing psychiatric illnesses produced unreliable clinical findings. When presented with the same case materials or videotaped reenactments of patient interviews, different psychiatrists arrived at different diagnoses based on the descriptions of mental illnesses in the DSM-I and the DSM-II. Researchers also began to question the usefulness and validity of diagnostic categories, as well as the reification of these illnesses. In other words, unlike other types of medical illnesses, psychiatric disorders were not amenable to objective confirmatory evidence to verify diagnoses (e.g., blood tests and MRI findings); nonetheless, they were and are considered “real” diseases with different causes and definitive treatments. Concerns about the reliability and validity of the DSM-II led to a sea change in the field of psychiatry—the eponymous neo-Kraepelinian revolution—that drove the next edition of the DSM.

Known as the father of “scientific” psychiatric diagnoses, Emil Kraepelin was a late nineteenth-, early twentieth-century physician who practiced in Germany. He argued that mental illnesses were genetically determined brain anomalies that should be treated with medical remedies. A keen observer and cataloger of symptom patterns, he studied and logged the apparent causes, onsets, courses, and prognoses of large numbers of patients under his care and supervision. Through these observations, he discovered commonalities in symptoms that he organized into discernible groupings of mental disorders. Kraepelin essentially created the first diagnostic nomenclature in the field of psychiatry. In particular, Kraepelin was noted for his differentiations among the three most serious psychiatric illnesses: schizophrenia (formerly known as dementia praecox), bipolar disorder (formerly known as manic depression), and major depression (formerly known as melancholia). These disorders are still considered major categories of serious mental illnesses.

DSM-III

Published in 1980, the DSM-III fundamentally changed the procedures for defining, categorizing, and diagnosing mental illnesses. Unlike its predecessors, the DSM-III eschewed the psychoanalytic orientation of earlier editions and replaced them with a more scientific methodology predicated on quantifiable symptoms and behaviors and specific diagnostic criteria. The DSM-III also introduced a multi-axial diagnostic system: Axis I (clinical disorders), Axis II (personality disorders and developmental disabilities), Axis III (medical conditions), Axis IV (psychosocial and environmental problems), and Axis V (Global Assessment of Functioning Scale). This edition of the DSM was heavily influenced by a group of psychiatrists at Washington University in St. Louis who established research diagnostic criteria, referred to as the Feighner Criteria, for 14 categories of mental illnesses, including schizophrenia, antisocial personality disorder, and anxiety disorder. The publication of these criteria became the basis for constructing the DSM-III and revising the ICD manual. The DSM-III included 265 disorders. All subsequent editions of the DSM have replicated the framework of the DSM-III.

DSM-IV

After the implementation of the DSM-III, inconsistencies were found in the descriptions of diagnostic categories and within those categories, and the diagnostic criteria were deemed unclear. To correct these problems, the APA convened a workgroup to revise the DSM-III. The outcome of this workgroup's activities included several modifications that were published as the DSM-III-R (revised) in 1987. In 1994, the DSM-IV was published following a six-year effort that involved more than 1,000 professionals from several organizations. These professionals reviewed scientific studies to create an empirical platform to modify and update the manual. The DSM-IV-TR (text revision), published in 2000, included new diagnostic categories and recodified diagnostic criteria sets and 297 disorders.

DSM-5

After more than six years of expert meetings and field tests, the DSM-5 was released in 2013. The switch from Roman to Arabic numerals facilitated the labeling of subsequent editions (DSM-5.1, 5.2) and reflected the organic and dynamic nature of the manual. Heralded as a paradigm shift in psychiatric diagnoses, the newest edition promised major, but produced mostly moderate, changes to the previous volume. Mimicking its two immediate predecessors, modifications were instituted as the result of a consultative process that involved discussions of diagnostic experts, public debates and presentations, professional and academic journal articles, and national field tests of new diagnostic categories and criteria. Specifically, the DSM-5 revision process involved a task force and six study groups that addressed a number of essential diagnostic issues (e.g., gender and culture differences that affect psychiatric evaluations). In addition, 13 workgroups were formed to study disorders through literature reviews and submit proposals for new or reconstituted diagnostic criteria.

The DSM-5 is organized into three major sections. The first section, DSM Basics contains an overview of the manual and instructions on its use. The second section, Diagnostic Criteria and Codes, describes the diagnostic categories and enumerates diagnostic codes for medical and insurance records, criteria, subtypes when applicable (e.g., brief psychotic disorder, social anxiety disorder), and disease specifiers (e.g., early onset, chronic). The third section, Emerging Measures and Models, suggests areas for further research and discussion, contains a glossary of terms, and posits an alternative model to diagnose and classify personality disorders, which are enduring patterns of emotional experiences and expressions that adversely affect interpersonal relationships and undermine other areas of functioning. Compared to other types of psychiatric illnesses, personality disorders can be considered as “who patients are” rather than “what patients have.” Therefore, these conditions can be quite difficult to treat.

Section 2 is the heart of the manual; it outlines the more than 300 psychiatric illnesses contained in the DSM-5 and stipulates guidelines for rendering a diagnosis for each. In order to arrive at a more precise diagnosis, this section also differentiates each diagnosis from cognate conditions and rules out other psychiatric illnesses or medical causes that could account for symptoms. The chapters are roughly organized from disorders most likely to be diagnosed in childhood to those most likely to be diagnosed in later stages of life. As with the DSM-III and the DSM-IV, each diagnosis is accompanied by a set of diagnostic criteria.

A certain number of these criteria must be met for a diagnosis to be selected. Furthermore, most diagnoses provide clinicians with specifiers that guide a more nuanced and detailed assessment of patients who meet the requisite number of diagnostic criteria. Finally, clinicians can rate the gravity of symptoms on a scale from mild to severe. The complete listing of the DSM-5 chapters is as follows:

• 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 Use and Addictive Disorders
• Neurocognitive Disorders
• Personality Disorders
• Paraphilic Disorders
• Other Disorders

As an example, major depressive disorder consists of nine diagnostic criteria such as depressed mood, loss of pleasure in previously enjoyable activities or experiences, problems with appetite or sleep, and diminished energy. To receive a diagnosis of major depressive disorder, an individual must present with either depressed mood or loss of pleasure as well as four or more of the other diagnostic criteria. In addition, these symptoms must persist for a period of 2 weeks and be unexplained by the effects of substances or other medical conditions. As with other disorders in the DSM-5, the symptoms of depression can be mild, moderate, or severe. Symptoms can also be accompanied by psychotic features (i.e., hallucinations [false perceptions] and delusions [false beliefs]) or melancholic features (e.g., significant loss of appetite and weight loss and excessive and inappropriate guilt)

Differences between DSM-IV-TR and DSM-5

The DSM-5 differs from the DSM-IV-TR in several ways. For example, the chapter in the DSM-IV-TR that focused on “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence” was deleted, allowing the DSM-5 to recognize that such problems can appear throughout the life course. Additionally, the multi-axial diagnostic system was removed. The diagnoses subsumed under Axis II became separate diagnostic entities (e.g., personality disorders). Axis III and Axis IV were replaced by embedding medical, psychosocial, and contextual features within the diagnostic categories. Axis V was supplanted by the recommended use of the WHO Disability Assessment Schedule, which is included with other recommended but not prescribed assessment measures in Section 3 of the manual.

Other changes focused on specific diagnoses. For example, the subtypes of schizophrenia were eliminated because of acknowledged shortcomings in their validity and reliability. The diagnosis of “mental retardation” was changed to “intellectual developmental disorder” and its severity is now evaluated largely on the basis of adaptive functioning. The diagnosis of autism was also changed to autism spectrum disorder to acknowledge the multifariousness of the condition (i.e., not a single disorder) and variations in symptom severity. Asperger syndrome was eliminated as a stand-alone diagnosis and is now considered a manifestation of autism spectrum disorder. The diagnosis of hypochondriasis was renamed illness anxiety disorder and amended to consider the presence of somatic symptoms among those afflicted.

The distinction between substance abuse and dependence was also replaced by a single diagnostic category, substance-related disorders, with combined criteria and severity specifiers that more closely match the clinical presentations of these problems. The bereavement exclusion was removed from the diagnosis of major depression to acknowledge that these experiences are difficult to disentangle and that bereavement can trigger major depression among the bereft. The following enumerate the 17 disorders that were added to the DSM-5:

• Social (pragmatic) communication disorder
• Disruptive mood dysregulation disorder
• Premenstrual dysphoric disorder
• Hoarding disorder
• Caffeine withdrawal
• Cannabis withdrawal
• Excoriation (skin-picking) disorder
• Binge eating disorder
• Rapid eye movement sleep behavior disorder
• Restless legs syndrome
• Major neurocognitive disorder with Lewy body disease
• Mild neurocognitive disorder
• Disinhibited Social Engagement Disorder
• Central sleep apnea
• Sleep-related hypoventilation
• Gender dysphoria
• Gambling disorders

These 17 disorders were predicated on consensus panel debates, literature reviews, and field testing. Other conditions were discussed and relegated to the DSM-5 appendix because current evidence warranted that they be subjected to continued discussion and research. These conditions lacked the level of clinical or research support needed to reach the threshold of a bona fide diagnostic entity (e.g., attenuated psychosis disorder, Internet use gaming disorder, and non-suicidal self-injury). Still other conditions were rejected for inclusion with no further considerations recommended (e.g., anxious depression, hypersexual disorder, and sensory processing disorder).

DSM-5-TR

The American Psychiatric Association published the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) in 2022. A group of over two hundred experts reviewed the DSM-5, as did specific review groups for culture, sex and gender, suicide, forensics, and ethnoracial equity and inclusion. DSM editors updated text, references, diagnostic criteria, and medical claim-reporting codes. They added a new diagnostic entity, prolonged grief disorder (PGD), to the trauma- and stressor-related disorders chapter. PGD is defined as “intense yearning or longing for the deceased (often with intense sorrow and emotional pain), and preoccupation with thoughts or memories of the deceased.” They also restored the diagnostic entity for unspecified mood disorder, which had previously been dropped from the DSM-5. These are included in the APA’s list of diagnostic entries added to or revised for the DSM-5-TR:

• Attenuated Psychosis Syndrome
• Autism Spectrum Disorder
• Avoidant Restrictive Food Intake Disorder
• Bipolar and Related Disorders Due to Another Medical Condition
• Bipolar I and Bipolar II Disorders
• Delirium
• Depressive Disorder Due to Another Medical Condition
• Functional Neurological Symptom Disorder
• Gender Dysphoria
• Intellectual Disability
• Major Depressive Disorder
• Narcolepsy
• Olfactory Reference Disorder
• Other Specified Bipolar and Related Disorder
• Other Specified Delirium Disorder
• Other Specified Depressive Disorder
• Other Specified Feeding Disorder
• Other Specified Schizophrenia
• Persistent Depressive Disorder
• Prolonged Grief Disorder
• PTSD
• Social Anxiety Disorder
• Substance Medication Induced Bipolar Disorder
• Suicidal Behavior and Nonsuicidal Self Injury
• Unspecified Mood Disorder

Bibliography

Barnhill, J. W. (Ed.). DSM-5: Clinical Cases. American Psychiatric Publishing, 2013.

Diagnostic and Statistical Manual of Mental Disorders: DSM-5-TR. American Psychiatric Publishing, 2022.

"DSM-5-TR Fact Sheets." American Psychiatric Association, www.psychiatry.org/psychiatrists/practice/dsm/educational-resources/dsm-5-tr-fact-sheets. Accessed 16 July 2024.

First, M. B. Handbook of Differential Diagnoses. Arlington, VA: American Psychiatric Publishing, 2013.

Morrison, J. DSM-5 Made Easy: The Clinicians Guide to Diagnosis. Guilford Press, 2013.

Sadock, B.J., Sadock, V. A., & Ruiz, P. Synopsis Of Psychiatry, 11th ed. Wolters Kluwer, 2014.

Sperry, L., & Sperry, J. J. Cognitive Behavior Therapy of DSM 5 Personality Disorders: Assessment, Case Conceptualization, and Treatment. Routledge, Taylor & Francis, 2016.