DSM Dilemma: Issue 2

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) marks the first significant revision of the publication since the DSM-IV in 1994. The manual was released in May 2013 amidst much controversies.

Cipla's DSM Dilemma endeavors to bring to light DSM-5's biggest changes and the possible impact they may have on mental health care.

The first issue of DSM dilemma reflected on the journey of the psychiatric manual from the conception of first DSM-I to DSM-5. The current issue of DSM Dilemma is a comprehensive guide of DSM-5 highlighting the major additions and revisions in the new DSM-5 edition.

The aim of the fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was to address limitations of DSM-IV while integrating the latest scientific and clinical evidence on the empirical basis of psychiatric disorders. With the help of 400 specialists of psychiatry, psychology, neurology, pediatrics, primary care, epidemiology, research methodology and statistics from 13 countries, a series of 13 international research conferences was held (2003-2008) to enhance the utility of the manual for clinicians and researchers. On the basis of the resultant monographs, the DSM-5 Task Force and Work Groups identified loopholes in current nosology and diagnostic criteria.¹

The committee members have attempted to incorporate information and statistics on the apparent relatedness of certain diagnoses with one another, including similarities in underlying vulnerabilities, symptom characteristics, and disease trajectories. Overall, most of the diagnoses and relevant criteria included in DSM-5 remain identical, or similar, to those in

DSM-IV. However the updates are significant and represent a new diagnostic era in psychiatry.² The current newsletter highlights some of the significant changes for specific disorders that will be found in the new DSM-5 manual.

The most publically discussed example of combining criteria from multiple disorders into a single diagnosis is autism spectrum disorder (ASD).¹ ASD now encompasses the previous DSM-IV autistic disorder (autism), Asperger's disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified.³ Somatic symptom disorder encompasses somatization disorder, hypochondriasis, pain disorder, and undifferentiated somatoform disorder. Substance use disorder is a combination of DSM-IV's substance abuse and substance dependence.¹

There are a few instances in DSM-5 where DSM-IV disorders have been divided into independent disorders. First, DSM-IV's reactive attachment disorder included the subtypes 'emotionally withdrawn/inhibited' and 'indiscriminately social/disinhibited'.¹ Although the two disorders have similar etiological pathway, they differ significantly. Owing to the diminished positive effect, reactive attachment disorder is essentially equivalent to a lack of or incompletely formed preferred attachments to caregiving adults. It resembles more closely to internalizing disorders. On the contrary, the latter more closely resembles ADHD; it may occur in children who do not necessarily lack attachments and may have established or even secure attachments.3 Secondly, the DSM-5 now lists the DSM-IV subtypes of breathing-related sleep disorder as independent disorders with separate criteria (i.e., obstructive sleep apnea hypopnea syndrome, central sleep apnea, and sleep related hypoventilation).¹

The numbers of specifiers and subtypes have been increased in the DSM-5 for giving a different aspect to the disorders. Within the depressive disorders and bipolar and related disorders, a new specifier, 'with mixed features', has been added that can be applied to 1) episodes of mania or hypomania when depressive features are present, and 2) episodes of depression in the context of major depressive disorder or bipolar disorder when features of mania/hypomania are present. A specifier of 'with limited prosocial emotions' is added to conduct disorder for children displaying extreme callousness, negative affectivity, and different severity (e.g., more frequent and severe patterns of aggression). People who meet criteria for the specifier tend to have a relatively more severe form of the disorder and a different treatment response. ^1,3

In DSM-IV, neurodegenerative disorders were classified as dementia due to another medical condition, such as HIV, head trauma, Parkinson's disease, Huntington's disease, Pick's disease, Creutzfeldt-Jakob disease. Individual criteria sets were designated for dementia of the Alzheimer's type, vascular dementia, and substance-induced dementia. The revisions in DSM-5 include preservation of major or mild vascular neurocognitive disorder (NCD) and major or mild NCD due to Alzheimer's disease and addition of separate criteria for major or mild NCD due to frontotemporal NCD, Lewy bodies, traumatic brain injury, Parkinson's disease, HIV infection, Huntington's disease, prion disease, another medical condition, and multiple etiologies. Substance / medication induced NCD and unspecified NCD are also included as diagnoses.³

New disorders (many of them elevated from DSM-IV's chapter on 'conditions for further study') included in DSM-5 were based on existing evidence from neuroscience, clinical need, and public health significance. The major inclusions include: Hoarding disorder: excessive collection of often useless items, including garbage, which frequently results in hazardous living conditions for patients and/or dependents and disruptive mood dysregulation disorder (DMDD): children with extreme behavioral dyscontrol but non-episodic irritability no longer qualify for a diagnosis of bipolar disorder in the DSM-5 and instead would be considered for DMDD.1 Other prominent new disorders include binge eating disorder, premenstrual dysphoric disorder, restless legs syndrome, and REM sleep behavior disorder, excoriation (skin-picking) disorder.^1,3

The change that has been considered as the most contentious change in DSM-5 was the elimination of the bereavement exclusion for

major depressive episodes. The workforce for DSM-5 has provided several rationales for the change: 1) to recognize that the duration of bereavement is more commonly 1-2 years and not only 2 months; 2) bereavement is recognized as a severe psychosocial stressor, which can lead to major depressive episode in a vulnerable individual, generally beginning soon after the loss 3) Bereavement-related major depression is genetically influenced and individuals with past personal and family histories of major depressive episodes are prone to experience the disease. 4) Finally, the depressive symptoms associated with bereavement-related depression respond to the same psychosocial and medication treatments as non-bereavement-related depression. Further, to facilitate the critical distinction between the symptoms characteristic of bereavement and those of a major depressive episode, the basic DSM-IV exclusion has been reinstated with an exhaustive footnote

DSM-5 has made some important changes in the naming conventions of disorders. The most notable and welcome change is the change in the term 'mental retardation', which underwent several draft changes before the name 'intellectual disability (intellectual developmental disorder)' was approved. The terms 'substance abuse and substance dependence' have been removed and are now replaced jointly by 'substance use disorder'. The name of the substance chapter itself ('substance-related and addictive disorders') was altered to include the term 'addictive'. Another change in naming conventions includes renaming the 'not otherwise specified' categories in the DSM-IV with 'other specified' and 'unspecified' categories in order to match the International Classification of Diseases (ICD) language.

Revising the DSM manual is an arduous task. It takes several years of planning and involves tasks such as conducting field trials, revising, soliciting public feedback, and revising again. The efforts of DSM-5's work group have culminated into a revamped guide to psychiatric diagnosis. New diagnoses have been added, others amended or combined. However, the latest edition of DSM has been widely criticized on two bases: an unhealthy influence of the pharmaceutical industry on the revision process and an increasing tendency to "medicalise" patterns of behaviour and mood that are not considered to be particularly extreme. However, the real debate is about the validity and utility of DSM; the debate has taken on an unprecedented dimension with the rejection of the DSM by the National Institutes of Mental Health. Nonetheless, there are defenders of the manual who claim that despite a flawed classification system in comparison with other existing manuals, DSM-5 is probably second to none. Only time will give the final verdict of DSM-5. The clinical utility of the manual will testify the failure or success of the manual.^1,4

The forthcoming issues of DSM Dilemma endeavors to discuss the controversies surrounding the manual in detail.