DSM-5 —The Future Arrived

THE NEXT REVISION OF PSYCHIATRY’S DIAGNOSTIC AND Statistical Manual of Mental Disorders (DSM-5) will be published in May 2013 and is the first revision of this psychiatric nomenclature in almost 2 decades. DSM-5 involved an international, multidisciplinary team of more than 400 individuals who volunteered vast amounts of their time throughout this 6-year official process, as well as many contributions from numerous international conferences that were held during the last decade. Readers will recognize a few notable differences from DSMIV. One distinction is DSM-5’s emphasis on numerous issues important to diagnosis and clinical care, including the influence of development, gender, and culture on the presentation of disorders. This is present in select diagnostic criteria, in text, or in both, which include variations of symptom presentations, risk factors, course, comorbidities, or other clinically useful information that might vary depending on a patient’s gender, age, or cultural background. Another distinct feature is ensuring greater harmony between this North American classification system and the International Classification of Diseases (ICD) system. For example, the chapter structure of DSM now begins with those in which neurodevelopmental influences produce early-onset disorders in childhood. This restructuring brings greater alignment of DSM-5 to the structuring of disorders in the future ICD-11 but also reflects the manual’s developmental emphasis, rather than the previous edition’s sequestering of all childhood disorders to a separate chapter. A similar approach to harmonizing with the ICD was taken to promote a more conceptual relationship between DSM-5 and classifications in other areas of medicine, such as the classification of sleep disorders. Many of the revisions in DSM-5 will help psychiatry better resemble the rest of medicine, including the use of dimensional (eg, quantitative) approaches. Disorder boundaries are often unclear to even the most seasoned clinicians and underscore the proliferation of residual diagnoses (ie, “not otherwise specified” disorders) from DSM-IV. But a large proportion of DSM-5 users will not be psychiatrists; most patients, for instance, will first present to their primary care physician—not to a psychiatrist—when experiencing psychiatric symptoms. The use of definable thresholds that exist on a continuum of normality is already present throughout much of general medicine, such as in blood pressure and cholesterol measurement, and these thresholds aid physicians in more accurately detecting pathology and determining appropriate intervention. Thus DSM-5 provides a model that should be recognizable to nonpsychiatrists and should facilitate better diagnosis and follow-up care by such clinicians. In addition, the multiaxial system that characterized earlier editions of DSM—wherein clinicians recorded diagnoses, comorbid medical conditions, nondisorder reasons for clinical visit (eg, partner/relational problems), and ratings of disability and functioning on 5 separate axes— has been discontinued. This is largely due to its incompatibility with diagnostic systems in the rest of medicine, as well as the result of a decision to place personality disorders and intellectual disability at the same level as other mental disorders. The above major changes represent those throughout the entire volume. What follows is a sampling from a larger summary of select recommended changes for specific disorders that will be found in the new DSM-5 manual: • Autism spectrum disorder: The criteria from DSMIV ’s autistic disorder, Asperger disorder, childhood disintegrative disorder, and pervasive developmental disorder (not otherwise specified) have been combined into a single diagnosis of autism spectrum disorder. The aim is to more accurately characterize children with social communication and interaction deficits as well as restrictive, repetitive behaviors, activities, or interests. This revision is not expected to significantly alter prevalence rates. The criteria were developed with enough sensitivity and specificity such that most children (91%) previously diagnosed with a pervasive developmental disorder under DSM-IV would meet criteria for autism spectrum disorder, allowing them to retain a diagnosis and continue receiving treatment and educational services.