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The ''Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition'' (DSM-5), is the 2013 update to the '' Diagnostic and Statistical Manual of Mental Disorders'', the taxonomic and diagnostic tool published by the
American Psychiatric Association The American Psychiatric Association (APA) is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the largest psychiatric organization in the world. It has more than 37,000 members are invo ...
(APA). In the United States, the DSM serves as the principal authority for psychiatric diagnoses. Treatment recommendations, as well as payment by health care providers, are often determined by DSM classifications, so the appearance of a new version has practical importance. The DSM-5 is the only DSM to use an
Arabic numeral Arabic numerals are the ten numerical digits: , , , , , , , , and . They are the most commonly used symbols to write decimal numbers. They are also used for writing numbers in other systems such as octal, and for writing identifiers such as ...
instead of a Roman numeral in its title, as well as the only living document version of a DSM. The DSM-5 is not a major revision of the DSM-IV-TR but there are significant differences. Changes in the DSM-5 include the reconceptualization of Asperger syndrome from a distinct disorder to an autism spectrum disorder; the elimination of subtypes of
schizophrenia Schizophrenia is a mental disorder characterized by continuous or relapsing episodes of psychosis. Major symptoms include hallucinations (typically hearing voices), delusions, and disorganized thinking. Other symptoms include social w ...
; the deletion of the "bereavement exclusion" for depressive disorders; the renaming of ''gender identity disorder'' to '' gender dysphoria''; the inclusion of
binge eating disorder Binge eating disorder (BED) is an eating disorder characterized by frequent and recurrent binge eating episodes with associated negative psychological and social problems, but without the compensatory behaviors common to bulimia nervosa, OSFED, ...
as a discrete eating disorder; the renaming and reconceptualization of ''paraphilias'', now called ''paraphilic disorders''; the removal of the five-axis system; and the splitting of ''disorders not otherwise specified'' into ''other specified disorders'' and ''unspecified disorders''. Many authorities criticized the fifth edition both before and after it was published. Critics assert, for example, that many DSM-5 revisions or additions lack empirical support; inter-rater reliability is low for many disorders; several sections contain poorly written, confusing, or contradictory information; and the psychiatric drug industry may have unduly influenced the manual's content, given many DSM-5 workgroup participants had ties to pharmaceutical companies.


Changes from DSM-IV

The DSM-5 is divided into three sections, using
Roman numerals Roman numerals are a numeral system that originated in ancient Rome and remained the usual way of writing numbers throughout Europe well into the Late Middle Ages. Numbers are written with combinations of letters from the Latin alphabet, ...
to designate each section.


Section I

Section I describes DSM-5 chapter organization, its change from the multiaxial system, and Section III's dimensional assessments. The DSM-5 dissolved the chapter that includes "disorders usually first diagnosed in infancy, childhood, or adolescence" opting to list them in other chapters. A note under Anxiety Disorders says that the "sequential order" of at least some DSM-5 chapters has significance that reflects the relationships between diagnoses. The introductory section describes the process of DSM revision, including field trials, public and professional review, and expert review. It states its goal is to harmonize with the International Statistical Classification of Diseases and Related Health Problems (ICD) systems and share organizational structures as much as is feasible. Concern about the categorical system of diagnosis is expressed, but the conclusion is the reality that alternative definitions for most disorders are scientifically premature. DSM-5 replaces the
Not Otherwise Specified In medicine, Not Otherwise Specified (NOS) is a subcategory in systems of disease/disorder classification such as ICD-9, ICD-10, or DSM-IV. It is generally used to note the presence of an illness where the symptoms presented were sufficient to ...
(NOS) categories with two options: ''other specified disorder'' and ''unspecified disorder'' to increase the utility to the clinician. The first allows the clinician to specify the reason that the criteria for a specific disorder are not met; the second allows the clinician the option to forgo specification. DSM-5 has discarded the multiaxial system of diagnosis (formerly Axis I, Axis II, Axis III), listing all disorders in Section II. It has replaced Axis IV with significant psychosocial and contextual features and dropped Axis V (Global Assessment of Functioning, known as GAF). The World Health Organization's Disability Assessment Schedule is added to Section III (Emerging measures and models) under Assessment Measures, as a suggested, but not required, method to assess functioning.


Section II: diagnostic criteria and codes


Neurodevelopmental disorders

* "Mental retardation" was renamed " intellectual disability (intellectual developmental disorder)". * Speech or language disorders are now called communication disorders—which include language disorder (formerly expressive language disorder and mixed receptive-expressive language disorder), speech sound disorder (formerly phonological disorder), childhood-onset fluency disorder ( stuttering), and a new condition characterized by impaired social verbal and nonverbal communication called social (pragmatic) communication disorder. * Autism spectrum disorder incorporates
Asperger disorder Asperger syndrome (AS), also known as Asperger's, is a former neurodevelopmental disorder characterized by significant difficulties in social interaction and nonverbal communication, along with restricted and repetitive patterns of beha ...
, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (PDD-NOS)—see . * A new sub-category, motor disorders, encompasses developmental coordination disorder, stereotypic movement disorder, and the tic disorders including Tourette syndrome. *
Attention deficit hyperactivity disorder Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterised by excessive amounts of inattention, hyperactivity, and impulsivity that are pervasive, impairing in multiple contexts, and otherwise age-inap ...
(ADHD).


Schizophrenia spectrum and other psychotic disorders

* All subtypes of
schizophrenia Schizophrenia is a mental disorder characterized by continuous or relapsing episodes of psychosis. Major symptoms include hallucinations (typically hearing voices), delusions, and disorganized thinking. Other symptoms include social w ...
were removed from the DSM-5 (paranoid, disorganized, catatonic, undifferentiated, and residual) in favor of a severity-based rating approach. * A major mood episode is required for schizoaffective disorder (for a majority of the disorder's duration after criterion A elated to delusions, hallucinations, disorganized speech or behavior, and negative symptoms such as avolitionis met). * Criteria for delusional disorder changed, and it is no longer separate from
shared delusional disorder Shared may refer to: * Sharing * Shared ancestry or Common descent * Shared care * Shared-cost service * Shared decision-making in medicine * Shared delusion, various meanings * Shared government * Shared intelligence or collective intelligence ...
. * Catatonia in all contexts requires 3 of a total of 12 symptoms. Catatonia may be a specifier for depressive, bipolar, and psychotic disorders; part of another medical condition; or of another specified diagnosis.


Bipolar and related disorders

* New specifier "with mixed features" can be applied to bipolar I disorder,
bipolar II disorder Bipolar II disorder (BP-II) is a mood disorder on the bipolar spectrum, characterized by at least one episode of hypomania and at least one episode of major depression. Diagnosis for BP-II requires that the individual must never have experien ...
, bipolar disorder NED (not elsewhere defined, previously called "NOS", not otherwise specified) and MDD. * Allows other specified bipolar and related disorder for particular conditions. *
Anxiety Anxiety is an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events. Anxiety is different than fear in that the former is defined as the anticipation of a future threat wh ...
symptoms are a specifier (called "anxious distress") added to bipolar disorder and to depressive disorders (but are not part of the bipolar diagnostic criteria).


Depressive disorders

* The bereavement exclusion in DSM-IV was removed from depressive disorders in DSM-5. * New disruptive mood dysregulation disorder (DMDD) for children up to age 18 years. *
Premenstrual dysphoric disorder Premenstrual dysphoric disorder (PMDD) is a mood disorder characterized by emotional, cognitive, and physical symptoms that cause significant distress or impairment in menstruating women during the luteal phase of the menstrual cycle. The symptom ...
moved from an appendix for further study, and became a disorder. * Specifiers were added for mixed symptoms and for anxiety, along with guidance to physicians for suicidality. *The term
dysthymia Dysthymia ( ), also known as persistent depressive disorder (PDD), is a mental and behavioral disorder, specifically a disorder primarily of mood, consisting of similar cognitive and physical problems as major depressive disorder, but with l ...
now also would be called persistent depressive disorder.


Anxiety disorders

* For the various forms of phobias and
anxiety Anxiety is an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events. Anxiety is different than fear in that the former is defined as the anticipation of a future threat wh ...
disorders, DSM-5 removes the requirement that the subject (formerly, over 18 years old) "must recognize that their fear and anxiety are excessive or unreasonable". Also, the duration of at least 6 months now applies to everyone (not only to children). * Panic attack became a specifier for all DSM-5 disorders. * Panic disorder and agoraphobia became two separate disorders. * Specific types of phobias became specifiers but are otherwise unchanged. * The generalized specifier for social anxiety disorder (formerly, social phobia) changed in favor of a performance only (i.e., public speaking or performance) specifier. * Separation anxiety disorder and selective mutism are now classified as anxiety disorders (rather than disorders of early onset).


Obsessive-compulsive and related disorders

* A new chapter on obsessive-compulsive and related disorders includes four new disorders:
excoriation (skin-picking) disorder Excoriation disorder, more commonly known as dermatillomania, is a mental disorder on the obsessive–compulsive spectrum that is characterized by the repeated urge or impulse to pick at one's own skin, to the extent that either psychological or ...
,
hoarding disorder Hoarding is a behavior where people or animals accumulate food or other items. Animal behavior ''Hoarding'' and ''caching'' are common in many bird species as well as in rodents. Most animal caches are of food. However, some birds will ...
, substance-/medication-induced obsessive-compulsive and related disorder, and obsessive-compulsive and related disorder due to another medical condition. * Trichotillomania (hair-pulling disorder) moved from "impulse-control disorders not elsewhere classified" in DSM-IV, to an obsessive-compulsive disorder in DSM-5. * A specifier was expanded (and added to body dysmorphic disorder and hoarding disorder) to allow for good or fair insight, poor insight, and "absent insight/delusional" (i.e., complete conviction that obsessive-compulsive disorder beliefs are true). * Criteria were added to body dysmorphic disorder to describe repetitive behaviors or mental acts that may arise with perceived defects or flaws in physical appearance. * The DSM-IV specifier "with obsessive-compulsive symptoms" moved from anxiety disorders to this new category for obsessive-compulsive and related disorders. * There are two new diagnoses: other specified obsessive-compulsive and related disorder, which can include body-focused repetitive behavior disorder (behaviors like nail biting, lip biting, and cheek chewing, other than hair pulling and skin picking) or
obsessional jealousy Obsessional jealousy is jealousy that is characterized by intrusive and excessive thoughts, and may be accompanied by compulsive checking of the partner. It is not classified as a mental disorder in the psychiatric manuals DSM or ICD, but it is men ...
; and unspecified obsessive-compulsive and related disorder.


Trauma- and stressor-related disorders

* Post traumatic stress disorder (PTSD) is now included in a new section titled "Trauma- and Stressor-Related Disorders." * The PTSD diagnostic clusters were reorganized and expanded from a total of three clusters to four based on the results of confirmatory factor analytic research conducted since the publication of DSM-IV. * Separate criteria were added for children six years old or younger. * For the diagnosis of acute stress disorder and PTSD, the stressor criteria (Criterion A1 in DSM-IV) was modified to some extent. The requirement for specific subjective emotional reactions (Criterion A2 in DSM-IV) was eliminated because it lacked empirical support for its utility and predictive validity. Previously certain groups, such as military personnel involved in combat, law enforcement officers and other first responders, did not meet criterion A2 in DSM-IV because their training prepared them to not react emotionally to traumatic events. * Two new disorders that were formerly subtypes were named: reactive attachment disorder and disinhibited social engagement disorder. * Adjustment disorders were moved to this new section and reconceptualized as stress-response syndromes. DSM-IV subtypes for depressed mood, anxious symptoms, and disturbed conduct are unchanged.


Dissociative disorders

* Depersonalization disorder is now called depersonalization/derealization disorder. * Dissociative fugue became a specifier for dissociative amnesia. * The criteria for dissociative identity disorder were expanded to include "possession-form phenomena and functional neurological symptoms". It is made clear that "transitions in identity may be observable by others or self-reported". Criterion B was also modified for people who experience gaps in recall of everyday events (not only trauma).


Somatic symptom and related disorders

* Somatoform disorders are now called somatic symptom and related disorders. * Patients that present with chronic pain can now be diagnosed with the mental illness somatic symptom disorder with predominant pain; or ''psychological factors that affect other medical conditions''; or with an ''adjustment disorder''. * Somatization disorder and undifferentiated somatoform disorder were combined to become somatic symptom disorder, a diagnosis which no longer requires a specific number of somatic symptoms. * Somatic symptom and related disorders are defined by positive symptoms, and the use of medically unexplained symptoms is minimized, except in the cases of conversion disorder and pseudocyesis (false pregnancy). * A new diagnosis is psychological factors affecting other medical conditions. This was formerly found in the DSM-IV chapter "Other Conditions That May Be a Focus of Clinical Attention". * Criteria for conversion disorder (functional neurological symptom disorder) were changed.


Feeding and eating disorders

* Criteria for pica and
rumination disorder Rumination syndrome, or merycism, is a chronic motility disorder characterized by effortless regurgitation of most meals following consumption, due to the involuntary contraction of the muscles around the abdomen. There is no retching, nausea, he ...
were changed and can now refer to people of any age. *
Binge eating disorder Binge eating disorder (BED) is an eating disorder characterized by frequent and recurrent binge eating episodes with associated negative psychological and social problems, but without the compensatory behaviors common to bulimia nervosa, OSFED, ...
graduated from DSM-IV's "Appendix B -- Criteria Sets and Axes Provided for Further Study" into a proper diagnosis. * Requirements for
bulimia nervosa Bulimia nervosa, also known as simply bulimia, is an eating disorder characterized by binge eating followed by purging or fasting, and excessive concern with body shape and weight. The aim of this activity is to expel the body of calories eaten ...
and binge eating disorder were changed from "at least twice weekly for 6 months" to "at least once weekly over the last 3 months". * The criteria for anorexia nervosa were changed; there is no longer a requirement of amenorrhea. * "Feeding disorder of infancy or early childhood", a rarely used diagnosis in DSM-IV, was renamed to
avoidant/restrictive food intake disorder Avoidant/restrictive food intake disorder (ARFID) is a type of eating disorder in which people eat only within an extremely narrow repertoire of foods. It is a serious mental health condition that causes the individual to restrict food intake by ...
, and criteria were expanded.


Elimination disorders

* No significant changes. * Disorders in this chapter were previously classified under disorders usually first diagnosed in infancy, childhood, or adolescence in DSM-IV. Now it is an independent classification in DSM 5.


Sleep–wake disorders

* "Sleep disorders related to another mental disorder, and sleep disorders related to a general medical condition" were deleted. * Primary insomnia became insomnia disorder, and narcolepsy is separate from other
hypersomnolence Hypersomnia is a neurological disorder of excessive time spent sleeping or Excessive daytime sleepiness, excessive sleepiness. It can have many possible causes (such as seasonal affective disorder) and can cause Distress (medicine), distress and ...
. * There are now three breathing-related sleep disorders: obstructive sleep apnea hypopnea,
central sleep apnea Central sleep apnea (CSA) or central sleep apnea syndrome (CSAS) is a sleep-related disorder in which the effort to breathe is diminished or absent, typically for 10 to 30 seconds either intermittently or in cycles, and is usually associated w ...
, and sleep-related
hypoventilation Hypoventilation (also known as respiratory depression) occurs when ventilation is inadequate (''hypo'' meaning "below") to perform needed respiratory gas exchange. By definition it causes an increased concentration of carbon dioxide (hypercapni ...
. * Circadian rhythm sleep–wake disorders were expanded to include advanced sleep phase syndrome, irregular sleep–wake type, and non-24-hour sleep–wake type.
Jet lag Jet lag is a physiological condition that results from alterations to the body's circadian rhythms caused by rapid long-distance trans-meridian (east–west or west–east) travel. For example, someone flying from New York to London, i.e. from ...
was removed. * Rapid eye movement sleep behavior disorder and
restless legs syndrome Restless legs syndrome (RLS), also known as Willis-Ekbom disease (WED), is generally a long-term disorder that causes a strong urge to move one's legs. There is often an unpleasant feeling in the legs that improves somewhat by moving them. This ...
are each a disorder, instead of both being listed under "dyssomnia not otherwise specified" in DSM-IV.


Sexual dysfunctions

* DSM-5 has sex-specific sexual dysfunctions. * For females, sexual desire and arousal disorders are combined into female sexual interest/arousal disorder. * Sexual dysfunctions (except substance-/medication-induced sexual dysfunction) now require a duration of approximately 6 months and more exact severity criteria. * A new diagnosis is genito-pelvic pain/penetration disorder which combines
vaginismus Vaginismus is a condition in which involuntary muscle spasm interferes with vaginal intercourse or other penetration of the vagina. This often results in pain with attempts at sex. Often, it begins when vaginal intercourse is first attempted. ...
and
dyspareunia Dyspareunia ( ) is painful sexual intercourse due to medical or psychological causes. The term ''dyspareunia'' covers both female dyspareunia and male dyspareunia, but many discussions that use the term without further specification concern the ...
from DSM-IV. * Sexual aversion disorder was deleted. * Subtypes for all disorders include only "lifelong versus acquired" and "generalized versus situational" (one subtype was deleted from DSM-IV). * Two subtypes were deleted: "sexual dysfunction due to a general medical condition" and "due to psychological versus combined factors".


Gender dysphoria

* DSM-IV's gender identity disorder is similar to, but not the same as, gender dysphoria in DSM-5. Separate criteria for children, adolescents and adults that are appropriate for varying developmental states are added. * Subtypes of gender identity disorder based on sexual orientation were deleted. * Among other wording changes, criterion A and criterion B (cross-gender identification, and aversion toward one's gender) were combined. Along with these changes comes the creation of a separate gender dysphoria in children as well as one for adults and adolescents. The grouping has been moved out of the sexual disorders category and into its own. The name change was made in part due to stigmatization of the term "disorder" and the relatively common use of "gender dysphoria" in the GID literature and among specialists in the area. The creation of a specific diagnosis for children reflects the lesser ability of children to have insight into what they are experiencing and ability to express it in the event that they have insight.


Disruptive, impulse-control, and conduct disorders

Some of these disorders were formerly part of the chapter on early diagnosis, oppositional defiant disorder;
conduct disorder Conduct disorder (CD) is a mental disorder diagnosed in childhood or adolescence that presents itself through a repetitive and persistent pattern of behavior that includes theft, lies, physical violence that may lead to destruction, and reckles ...
; and disruptive behavior disorder not otherwise specified became other specified and unspecified disruptive disorder,
impulse-control disorder Impulse-control disorder (ICD) is a class of psychiatric disorders characterized by impulsivity – failure to resist a temptation, an urge, or an impulse; or having the inability to not speak on a thought. Many psychiatric disorders feature impu ...
, and
conduct disorder Conduct disorder (CD) is a mental disorder diagnosed in childhood or adolescence that presents itself through a repetitive and persistent pattern of behavior that includes theft, lies, physical violence that may lead to destruction, and reckles ...
s. Intermittent explosive disorder,
pyromania Pyromania is an impulse control disorder in which individuals repeatedly fail to resist impulses to deliberately start fires, to relieve some tension or for instant gratification. The term ''pyromania'' comes from the Greek word (''pyr'', 'fi ...
, and
kleptomania Kleptomania is the inability to resist the urge to steal items, usually for reasons other than personal use or financial gain. First described in 1816, kleptomania is classified in psychiatry as an impulse control disorder. Some of the main cha ...
moved to this chapter from the DSM-IV chapter "Impulse-Control Disorders Not Otherwise Specified". *
Antisocial personality disorder Antisocial personality disorder (ASPD or infrequently APD) is a personality disorder characterized by a long-term pattern of disregard of, or violation of, the rights of others as well as a difficulty sustaining long-term relationships. Lack ...
is listed here ''and'' in the chapter on personality disorders (but
ADHD Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterised by excessive amounts of inattention, hyperactivity, and impulsivity that are pervasive, impairing in multiple contexts, and otherwise age-inap ...
is listed under neurodevelopmental disorders). * Symptoms for oppositional defiant disorder are of three types: angry/irritable mood, argumentative/defiant behavior, and vindictiveness. The conduct disorder exclusion is deleted. The criteria were also changed with a note on frequency requirements and a measure of severity. * Criteria for conduct disorder are unchanged for the most part from DSM-IV. A specifier was added for people with limited "prosocial emotion", showing callous and unemotional traits. * People over the disorder's minimum age of 6 may be diagnosed with intermittent explosive disorder without outbursts of physical aggression. Criteria were added for frequency and to specify "impulsive and/or anger based in nature, and must cause marked distress, cause impairment in occupational or interpersonal functioning, or be associated with negative financial or legal consequences".


Substance-related and addictive disorders

* Gambling disorder and tobacco use disorder are new. *
Substance abuse Substance abuse, also known as drug abuse, is the use of a drug in amounts or by methods which are harmful to the individual or others. It is a form of substance-related disorder. Differing definitions of drug abuse are used in public health, ...
and
substance dependence Substance dependence, also known as drug dependence, is a biopsychological situation whereby an individual's functionality is dependent on the necessitated re-consumption of a psychoactive substance because of an adaptive state that has develope ...
from DSM-IV-TR have been combined into single substance use disorders specific to each substance of abuse within a new "addictions and related disorders" category. "Recurrent legal problems" was deleted and "craving or a strong desire or urge to use a substance" was added to the criteria. The threshold of the number of criteria that must be met was changed and severity from mild to severe is based on the number of criteria endorsed. Criteria for
cannabis ''Cannabis'' () is a genus of flowering plants in the family Cannabaceae. The number of species within the genus is disputed. Three species may be recognized: '' Cannabis sativa'', '' C. indica'', and '' C. ruderalis''. Alternative ...
and
caffeine Caffeine is a central nervous system (CNS) stimulant of the methylxanthine chemical classification, class. It is mainly recreational drug use, used recreationally as a Nootropic, cognitive enhancer, increasing alertness and attentional perfor ...
withdrawal were added. New specifiers were added for early and sustained
remission Remission often refers to: *Forgiveness Remission may also refer to: Healthcare and science *Remission (medicine), the state of absence of disease activity in patients with a chronic illness, with the possibility of return of disease activity *R ...
along with new specifiers for "in a controlled environment" and "on maintenance therapy". There are no more polysubstance diagnoses in DSM-5; the substance(s) must be specified.


Neurocognitive disorders

*
Dementia Dementia is a disorder which manifests as a set of related symptoms, which usually surfaces when the brain is damaged by injury or disease. The symptoms involve progressive impairments in memory, thinking, and behavior, which negatively affe ...
and amnestic disorder became major or mild neurocognitive disorder (major NCD, or mild NCD). DSM-5 has a new list of neurocognitive domains. "New separate criteria are now presented" for major or mild NCD due to various conditions. Substance/medication-induced NCD and unspecified NCD are new diagnoses.


Personality disorders

*
Personality disorder Personality disorders (PD) are a class of mental disorders characterized by enduring maladaptive patterns of behavior, cognition, and inner experience, exhibited across many contexts and deviating from those accepted by the individual's cultu ...
(PD) previously belonged to a different axis than almost all other disorders, but is now in one axis with all mental and other medical diagnoses. However, the same ten types of personality disorder are retained. * There is a call for the DSM-5 to provide relevant clinical information that is empirically based to conceptualize personality as well as psychopathology in personalities. The issue(s) of heterogeneity of a PD is problematic as well. For example, when determining the criteria for a PD it is possible for two individuals with the same diagnosis to have completely different symptoms that would not necessarily overlap. There is also concern as to which model is better for the DSM - the diagnostic model favored by psychiatrists or the dimensional model that is favored by psychologists. The diagnostic approach/model is one that follows the diagnostic approach of traditional medicine, is more convenient to use in clinical settings, however, it does not capture the intricacies of normal or abnormal personality. The dimensional approach/model is better at showing varied degrees of personality; it places emphasis on the continuum between normal and abnormal, and abnormal as something beyond a threshold whether in unipolar or bipolar cases.


Paraphilic disorders

* New specifiers "in a controlled environment" and "in remission" were added to criteria for all paraphilic disorders. * A distinction is made between paraphilic behaviors, or
paraphilia Paraphilia (previously known as sexual perversion and sexual deviation) is the experience of intense sexual arousal to atypical objects, situations, fantasies, behaviors, or individuals. It has also been defined as sexual interest in anything ot ...
s, and paraphilic disorders. All criteria sets were changed to add the word disorder to all of the paraphilias, for example,
pedophilic disorder Pedophilia ( alternatively spelt paedophilia) is a psychiatric disorder in which an adult or older adolescent experiences a primary or exclusive sexual attraction to prepubescent children. Although girls typically begin the process of puberty a ...
is listed instead of
pedophilia Pedophilia ( alternatively spelt paedophilia) is a psychiatric disorder in which an adult or older adolescent experiences a primary or exclusive sexual attraction to prepubescent children. Although girls typically begin the process of puberty ...
. There is no change in the basic diagnostic structure since DSM-III-R; however, people now must meet both qualitative (criterion A) and negative consequences (criterion B) criteria to be diagnosed with a paraphilic disorder. Otherwise they have a paraphilia (and no diagnosis).


Section III: emerging measures and models

It includes dimensional measures for the assessment of symptoms, criteria for the cultural formulation of disorders and an alternative proposal for the conceptualization of personality disorders, as well as a description of the currently studied clinical conditions. It presents selected tools and research techniques focused on diagnosis, taking into account the sociocultural context, and also presents a hybrid-dimensional-categorical model of personality disorders. Specific personalities (antisocial, borderline, avoidant, narcissistic, obsessive-compulsive, schizotypal) and non-specific disorders were distinguished.


Conditions for further study

These conditions and criteria are set forth to encourage future research and are not meant for clinical use. * Attenuated psychosis syndrome * Depressive episodes with short-duration hypomania * Persistent complex bereavement disorder * Caffeine use disorder *
Internet gaming disorder Video game addiction (VGA), also known as gaming disorder or internet gaming disorder, is generally defined as the problematic, compulsive use of video games that results in significant impairment to an individual's ability to function in vario ...
* Neurobehavioral disorder associated with prenatal alcohol exposure * Suicidal behavior disorder *
Non-suicidal self-injury Self-harm is intentional behavior that is considered harmful to oneself. This is most commonly regarded as direct injury of one's own skin tissues usually without a suicidal intention. Other terms such as cutting, self-injury and self-mutilatio ...


Development

In 1999, a DSM-5 Research Planning Conference, sponsored jointly by APA and the
National Institute of Mental Health The National Institute of Mental Health (NIMH) is one of 27 institutes and centers that make up the National Institutes of Health (NIH). The NIH, in turn, is an agency of the United States Department of Health and Human Services and is the prima ...
(NIMH), was held to set the research priorities. Research Planning Work Groups produced "white papers" on the research needed to inform and shape the DSM-5 and the resulting work and recommendations were reported in an APA monograph and peer-reviewed literature. There were six workgroups, each focusing on a broad topic: Nomenclature, Neuroscience and Genetics, Developmental Issues and Diagnosis, Personality and Relational Disorders, Mental Disorders and Disability, and Cross-Cultural Issues. Three additional white papers were also due by 2004 concerning gender issues, diagnostic issues in the geriatric population, and mental disorders in infants and young children. The white papers have been followed by a series of conferences to produce recommendations relating to specific disorders and issues, with attendance limited to 25 invited researchers. On July 23, 2007, the APA announced the task force that would oversee the development of DSM-5. The DSM-5 Task Force consisted of 27 members, including a chair and vice chair, who collectively represent research scientists from psychiatry and other disciplines, clinical care providers, and consumer and family advocates. Scientists working on the revision of the DSM had a broad range of experience and interests. The APA Board of Trustees required that all task force nominees disclose any competing interests or potentially conflicting relationships with entities that have an interest in psychiatric diagnoses and treatments as a precondition to appointment to the task force. The APA made all task force members' disclosures available during the announcement of the task force. Several individuals were ruled ineligible for task force appointments due to their competing interests. The DSM-5 field trials included test-retest reliability which involved different clinicians doing independent evaluations of the same patient—a common approach to the study of diagnostic reliability. About 68% of DSM-5 task-force members and 56% of panel members reported having ties to the
pharmaceutical industry The pharmaceutical industry discovers, develops, produces, and markets drugs or pharmaceutical drugs for use as medications to be administered to patients (or self-administered), with the aim to cure them, vaccinate them, or alleviate symptoms. ...
, such as holding stock in pharmaceutical companies, serving as consultants to industry, or serving on company boards.


Revisions and updates

Beginning with the fifth edition, it is intended that diagnostic guideline revisions will be added incrementally. The DSM-5 is identified with
Arabic Arabic (, ' ; , ' or ) is a Semitic language spoken primarily across the Arab world.Semitic languages: an international handbook / edited by Stefan Weninger; in collaboration with Geoffrey Khan, Michael P. Streck, Janet C. E.Watson; Walter ...
rather than
Roman numerals Roman numerals are a numeral system that originated in ancient Rome and remained the usual way of writing numbers throughout Europe well into the Late Middle Ages. Numbers are written with combinations of letters from the Latin alphabet, ...
, marking a change in how future updates will be created. Incremental updates will be identified with decimals (DSM-5.1, DSM-5.2, etc.), until a new edition is written. The change reflects the intent of the APA to respond more quickly when a preponderance of research supports a specific change in the manual. The research base of mental disorders is evolving at different rates for different disorders.


Criticism


General

Robert Spitzer, the head of the DSM-III task force, publicly criticized the APA for mandating that DSM-5 task force members sign a
nondisclosure agreement A non-disclosure agreement (NDA) is a legal contract or part of a contract between at least two parties that outlines confidential material, knowledge, or information that the parties wish to share with one another for certain purposes, but wi ...
, effectively conducting the whole process in secret: "When I first heard about this agreement, I just went bonkers. Transparency is necessary if the document is to have credibility, and, in time, you're going to have people complaining all over the place that they didn't have the opportunity to challenge anything." Allen Frances, chair of the DSM-IV task force, expressed a similar concern.Psychiatrists Propose Revisions to Diagnosis Manual.
via
PBS Newshour ''PBS NewsHour'' is an American evening television news program broadcast on over 350 PBS member stations. It airs seven nights a week, and is known for its in-depth coverage of issues and current events. Anchored by Judy Woodruff, the pro ...
, February 10, 2010 (interviews Frances and
Alan Schatzberg Alan F. Schatzberg is an American psychiatrist. He was the 136th president of the American Psychiatric Association (2009–2010). Since 1991, he has been the Kenneth T. Norris Jr . Professor of Psychiatry and Behavioral Sciences at Stanford Universi ...
on some of the main changes proposed to the DSM-5)
Although the APA has since instituted a disclosure policy for DSM-5 task force members, many still believe the association has not gone far enough in its efforts to be transparent and to protect against industry influence. In a 2009 Point/Counterpoint article, Lisa Cosgrove, PhD and Harold J. Bursztajn, MD noted that "the fact that 70% of the task force members have reported direct industry ties—an increase of almost 14% over the percentage of DSM-IV task force members who had industry ties—shows that disclosure policies alone, especially those that rely on an honor system, are not enough and that more specific safeguards are needed". David Kupfer, chair of the DSM-5 task force, and Darrel A. Regier, MD, MPH, vice chair of the task force, whose industry ties are disclosed with those of the task force, countered that "collaborative relationships among government, academia, and industry are vital to the current and future development of pharmacological treatments for mental disorders". They asserted that the development of DSM-5 is the "most inclusive and transparent developmental process in the 60-year history of DSM". The developments to this new version can be viewed on the APA website. During periods of public comment, members of the public could sign up at the DSM-5 website and provide feedback on the various proposed changes. In June 2009, Allen Frances issued strongly worded criticisms of the processes leading to DSM-5 and the risk of "serious, subtle, ..ubiquitous" and "dangerous" unintended consequences such as new "false 'epidemics'". He writes that "the work on DSM-V has displayed the most unhappy combination of soaring ambition and weak methodology" and is concerned about the task force's "inexplicably closed and secretive process". His and Spitzer's concerns about the contract that the APA drew up for consultants to sign, agreeing not to discuss drafts of the fifth edition beyond the task force and committees, have also been aired and debated. The appointment, in May 2008, of two of the taskforce members, Kenneth Zucker and
Ray Blanchard Ray Milton Blanchard ( ; born October 9, 1945) is an American-Canadian sexologist, best known for his research studies on transsexualism, pedophilia and sexual orientation. He found that men with more older brothers are more likely to be gay th ...
, led to an internet petition to remove them. According to MSNBC, "The petition accuses Zucker of having engaged in 'junk science' and promoting 'hurtful theories' during his career, especially advocating the idea that children who are unambiguously male or female anatomically, but seem confused about their
gender identity Gender identity is the personal sense of one's own gender. Gender identity can correlate with a person's assigned sex or can differ from it. In most individuals, the various biological determinants of sex are congruent, and consistent with the ...
, can be treated by encouraging gender expression in line with their anatomy." According to ''The Gay City News'', Blanchard responded, "Naturally, it's very disappointing to me there seems to be so much misinformation about me on the Internet.
hey didn't distort Hey or Hey! may refer to: Music * Hey (band), a Polish rock band Albums * ''Hey'' (Andreas Bourani album) or the title song (see below), 2014 * ''Hey!'' (Julio Iglesias album) or the title song, 1980 * ''Hey!'' (Jullie album) or the title ...
my views, they completely reversed my views." Zucker "rejects the junk-science charge, saying there 'has to be an empirical basis to modify anything' in the DSM. As for hurting people, 'in my own career, my primary motivation in working with children, adolescents and families is to help them with the distress and suffering they are experiencing, whatever the reasons they are having these struggles. I want to help people feel better about themselves, not hurt them.'" In 2011, psychologist
Brent Robbins Brent Dean Robbins is associate professor of psychology at Point Park University in Pittsburgh, Pennsylvania. His areas of research include grief, humor, self-consciousness, spirituality/religion, death anxiety, and the medicalization of the body ...
co-authored a national letter for the Society for Humanistic Psychology that brought thousands into the public debate about the DSM. Approximately 13,000 individuals and
mental health Mental health encompasses emotional, psychological, and social well-being, influencing cognition, perception, and behavior. It likewise determines how an individual handles Stress (biology), stress, interpersonal relationships, and decision-maki ...
professionals signed a petition in support of the letter. Thirteen other
American Psychological Association The American Psychological Association (APA) is the largest scientific and professional organization of psychologists in the United States, with over 133,000 members, including scientists, educators, clinicians, consultants, and students. It ha ...
divisions endorsed the petition. In a November 2011 article about the debate in the ''
San Francisco Chronicle The ''San Francisco Chronicle'' is a newspaper serving primarily the San Francisco Bay Area of Northern California. It was founded in 1865 as ''The Daily Dramatic Chronicle'' by teenage brothers Charles de Young and Michael H. de Young. The pa ...
'', Robbins notes that under the new guidelines, certain responses to grief could be labeled as pathological disorders, instead of being recognized as being normal human experiences. In 2012, a footnote was added to the draft text which explains the distinction between grief and depression. The DSM-5 has been criticized for purportedly saying nothing about the biological underpinnings of mental disorders. A book-long appraisal of the DSM-5, with contributions from philosophers, historians and anthropologists, was published in 2015. The financial association of DSM-5 panel members with industry continues to be a concern for financial conflict of interest. Of the DSM-5 task force members, 69% report having ties to the pharmaceutical industry, an increase from the 57% of DSM-IV task force members. A 2015 essay from an Australian university criticized the DSM-5 for having poor cultural diversity, stating that recent work done in cognitive sciences and cognitive anthropology is still only accepting western psychology as the norm. DSM-5 includes a section on how to conduct a "cultural formulation interview", which gives information about how a person's
cultural Culture () is an umbrella term which encompasses the social behavior, institutions, and norms found in human societies, as well as the knowledge, beliefs, arts, laws, customs, capabilities, and habits of the individuals in these groups.T ...
identity may be affecting expression of
signs and symptoms Signs and symptoms are the observed or detectable signs, and experienced symptoms of an illness, injury, or condition. A sign for example may be a higher or lower temperature than normal, raised or lowered blood pressure or an abnormality showi ...
. The goal is to make more reliable and valid diagnoses for disorders subject to significant cultural variation.


Borderline personality disorder controversy

In 2003, the Treatment and Research Advancements National Association for Personality Disorders (TARA-APD) campaigned to change the name and designation of
borderline personality disorder Borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD), is a personality disorder characterized by a long-term pattern of unstable interpersonal relationships, distorted sense of self, and strong ...
in DSM-5. The paper ''How Advocacy is Bringing BPD into the Light'' reported that "the name BPD is confusing, imparts no relevant or descriptive information, and reinforces existing stigma." Instead, it proposed the name "emotional regulation disorder" or "emotional dysregulation disorder." There was also discussion about changing borderline personality disorder, an Axis II diagnosis (personality disorders and mental retardation), to an Axis I diagnosis (clinical disorders). The TARA-APD recommendations do not appear to have affected the American Psychiatric Association, the publisher of the DSM. As noted above, the DSM-5 does not employ a multi-axial diagnostic scheme, therefore the distinction between Axis I and II disorders no longer exists in the DSM
nosology Nosology () is the branch of medical science that deals with the classification of diseases. Fully classifying a medical condition requires knowing its cause (and that there is only one cause), the effects it has on the body, the symptoms that ...
. The name, the diagnostic criteria for, and description of, borderline personality disorder remain largely unchanged from
DSM-IV-TR The ''Diagnostic and Statistical Manual of Mental Disorders'' (DSM; latest edition: DSM-5-TR, published in March 2022) is a publication by the American Psychiatric Association (APA) for the classification of mental disorders using a common langua ...
.


British Psychological Society response

The
British Psychological Society The British Psychological Society (BPS) is a representative body for psychologists and psychology in the United Kingdom. History It was founded on 24 October 1901 at University College London (UCL) as ''The Psychological Society'', the org ...
stated in its June 2011 response to DSM-5 draft versions, that it had "more concerns than plaudits". It criticized proposed diagnoses as "clearly based largely on social norms, with 'symptoms' that all rely on subjective judgements... not value-free, but rather reflect ngcurrent normative social expectations", noting doubts over the reliability, validity, and value of existing criteria, that personality disorders were not normed on the general population, and that "not otherwise specified" categories covered a "huge" 30% of all personality disorders. It also expressed a major concern that "clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences... which demand helping responses, but which do not reflect illnesses so much as normal individual variation". The Society suggested as its primary specific recommendation, a change from using "diagnostic frameworks" to a description based on an individual's specific experienced problems, and that mental disorders are better explored as part of a spectrum shared with normality: Many of the same criticisms also led to the development of the Hierarchical Taxonomy of Psychopathology, an alternative, dimensional framework for classifying mental disorders.


National Institute of Mental Health

National Institute of Mental Health The National Institute of Mental Health (NIMH) is one of 27 institutes and centers that make up the National Institutes of Health (NIH). The NIH, in turn, is an agency of the United States Department of Health and Human Services and is the prima ...
director Thomas R. Insel, MD, wrote in an April 29, 2013 blog post about the DSM-5: Insel also discussed an NIMH effort to develop a new classification system,
Research Domain Criteria The Research Domain Criteria (RDoC) project is an initiative of personalized medicine in psychiatry developed by US National Institute of Mental Health (NIMH). In contrast to the Diagnostic and Statistical Manual of Mental Disorders (DSM) maintai ...
(RDoC), currently for research purposes only. Insel's post sparked a flurry of reaction, some of which might be termed
sensationalistic In journalism and mass media, sensationalism is a type of editorial tactic. Events and topics in news stories are selected and worded to excite the greatest number of readers and viewers. This style of news reporting encourages Media bias, biased ...
, with headlines such as "Goodbye to the DSM-V", "Federal institute for mental health abandons controversial 'bible' of psychiatry", "National Institute of Mental Health abandoning the DSM", and "Psychiatry divided as mental health 'bible' denounced". Other responses provided a more nuanced analysis of the NIMH Director's post. In May 2013, Insel, on behalf of NIMH, issued a joint statement with Jeffrey A. Lieberman, MD, president of the American Psychiatric Association, that emphasized that DSM-5 "... represents the best information currently available for clinical diagnosis of mental disorders. Patients, families, and insurers can be confident that effective treatments are available and that the DSM is the key resource for delivering the best available care. The National Institute of Mental Health (NIMH) has not changed its position on DSM-5." Insel and Lieberman say that DSM-5 and RDoC "represent complementary, not competing, frameworks" for characterizing diseases and disorders. However, epistemologists of psychiatry tend to see the RDoC project as a putative revolutionary system that in the long run will try to replace the DSM, its expected early effect being a liberalization of the research criteria, with an increasing number of research centers adopting the RDoC definitions.Aragona M. (2014
Epistemological reflections about the crisis of the DSM-5 and the revolutionary potential of the RDoC project
Dialogues in Philosophy, Mental and Neuro Sciences 7: 11-20


See also

*
ICD-11 The ICD-11 is the eleventh revision of the International Classification of Diseases (ICD). It replaces the ICD-10 as the global standard for recording health information and causes of death. The ICD is developed and annually updated by the World H ...


References


External links

* * {{DEFAULTSORT:Diagnostic And Statistical Manual Of Mental Disorders Diagnostic and Statistical Manual of Mental Disorders it:Manuale diagnostico e statistico dei disturbi mentali#DSM-5