DSM-5 in Practice
The fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, otherwise known as the DSM-5, was released in May of this year. Its release was met with both approval and controversy within the mental health field. As the expected date of complete transition from DSM-IV to DSM-5 looms closer (the APA expects it to be January 1st, 2014), we thought it prudent to highlight general changes that all clinicians (and non-clinicians) should know as they are integrated into practice.
Multiaxial to Nonaxial System
The departure from the traditional 5-Axis assessment that almost all clinicians know and love has not been an easy concept for many to digest. The DSM-5 is implementing a nonaxial system of documenting diagnoses. A common issue for providers is the fear of not documenting significant medical and psychosocial factors that will affect an individual’s prognosis and treatment.
The removal of axial designations does not imply that these important assessment features should be left out of the diagnosis. DSM-5 has combined Axes I, II, and III. Pertinent medical conditions, in the context of a more thorough understanding and treatment of a person’s mental disorder, should continue to be listed.
DSM-5 recommends separate notations for significant psychosocial factors, formerly documented on Axis IV. Instead of developing its own classification of environmental issues, a selected set of the ICD-9-CM V codes (and eventually the new ICD-10-CM Z codes) should be used.
A separate notation is also recommended for the evaluation of an individual’s level of functioning/disability. The Global Assessment of Functioning (GAF) scale rating was formerly noted on Axis V. As most clinicians know, the GAF score is highly subjective and not strong in psychometric properties. Because of its limitations, the GAF score has been dropped by the DSM-5 task force.
The World Health Organization Disability Assessment Schedule (WHODAS) is included in Section III of the DSM-5 as a global measure of assessing disability. The WHODAS is self-administered, translated into 40 languages, and comes in 12-item and 36-item forms. Though not required, the WHODAS is a highly recommended clinical tool for assessment purposes.
Section II of the DSM-5 is dedicated to Diagnostic Criteria and Codes for mental health disorders. With 20 disorder chapters, the structure reflects an overlap between particular disorder groups based on the most recent neuroscientific findings. Certain groups seem to share significant features, such as heritability, genetics, and specific risk factors. The overlap between schizophrenia, bipolar disorder, and other psychotic disorders is an example.
Taking developmental and lifespan considerations…into consideration, the DSM-5 organizes the disorders beginning with diagnoses thought to develop early in life (e.g., neurodevelopmental and schizophrenia spectrum disorders), followed by diagnoses that usually occur in adolescence and young adulthood (e.g., bipolar, depressive, and anxiety disorders), and concludes with diagnoses that typically develop later in life (e.g., neurocognitive disorders).
The DSM-5 was largely guided by emerging scientific findings that altered the conceptualization of boundaries and grouping between and among certain disorders. Some of the major revisions include:
Autism Spectrum Disorder (ASD)
Autistic Disorder, Asperger’s Disorder, Childhood Disintegration Disorder, and Pervasive Developmental Disorder NOS are now combined under ASD. The rationale for the revision was the inconsistent and inaccurate application of DSM-IV-TR symptoms by clinicians, leading to poor support for their continued separation. Specifiers will be used to describe variations of ASD.
Substance Use Disorders (SUDs)
Substance “abuse” and “dependence” disorders have been combined under Substance Use Disorders. The term “dependence” is often interchanged with “addiction,” and has negative connotations. Many medications induce symptoms of physiological dependence that do not make an individual an addict. Levels of severity will be used as modifiers. Gambling Disorder is classified under Unspecified Other Substance-Related Disorder. This comes as a result of scientific findings that many “behavioral addictions,” such as gambling, operate on the same reward system of the brain as do substances.
Binge Eating Disorder (BED)
BED is listed in the DSM-IV-TR as a condition requiring further study. Individuals who met BED criteria were given the diagnosis of Eating Disorder NOS. The DSM-5 included BED as a diagnosable disorder under Feeding and Eating Disorders.
Mental retardation was replaced by intellectual disability, reflecting the wording that was adopted into U.S. law in 2010. Intellectual disability is no longer reliant solely on IQ scores, but also considers deficits in functioning as part of a more comprehensive assessment.
In Section III, the DSM-5 includes assessment measures that are optional based on requiring more data to define their clinical utility. A dimensional approach, which includes an individual’s self-report along with clinical interpretation, to diagnosing mental disorders is emerging as best practice while our understanding of disease states improves. Because more research is needed, using these measures in clinical practice is encouraged to facilitate critical feedback. Based on field trials, the provided measures are rated as having overall excellent reliability and as being useful in practice.
These measures can be administered at intake and over time to track an individual’s symptoms, severity of disorder, and response to treatment.
Cross-cutting symptom measures assess mental health domains that are significant across psychiatric diagnoses. Reviewing numerous mental functions fosters a more comprehensive assessment by pinpointing symptoms that might not fit into specific diagnostic criteria, but are still important to address in the individual’s overall care.
Cross-cutting measures include two levels.
Level 1: Brief survey (13 symptom domains for adults/12 for children and adolescents) to be rated by the individual which assesses domains across diagnoses.
Level 2: A more in-depth assessment of particular domains as determined by scores on Level 1 measures.
These measures are more specific to criteria that closely correspond to a disorder.
Conditions for Further Study
Section III of the DSM-5 also includes proposed criteria for conditions that warrant further research. Included are:
- Caffeine Use Disorder
- Internet Gaming Disorder
- Persistent Complex Bereavement Disorder
- Suicidal Behavior Disorder
- Nonsuicidal Self-Injury
If you have any questions about the DSM-5, updated coding guidelines, or issues with its integration into clinical practice, please visit the APA wesbite for more information.