The DSM multiaxial system was praised for its clinical utility because it provided a comprehensive and systematic evaluation of the patients’ presenting problems, integrating a bio-psycho-social approach. DSM-5 does not present an alternative conceptualization to the multiaxial approach to diagnosis.
Despite multiple proposed categorical or dimensional changes, only a few were adopted in the final version of DSM-5. One of the major proposals rejected was the revision of the hybrid categorical-dimensional model for personality disorders. Implementation of this proposed new model by October 2014 would probably have imposed significant burden on clinical practice and the research community and would have required a revision of academic curriculums for residency programs and clinical practice guidelines. Instead, this model was included in Section III for further research.
Changes in terminology included deletion of terms that have been a mainstay of mental health vocabulary for nearly a quarter century. Some terms were deleted as an attempt to reduce stigma (eg, mental retardation, developmental disorder, stuttering, reading disorder, and mathematics disorder), others because of lack of validity (eg, autism, Asperger syndrome, schizophrenia subtypes), and still others as an attempt to simplify the nomenclature and make a smoother transition toward the style used in ICD-10 coding (eg, hair pulling disorder, skin picking disorder).
There were few changes in diagnostic groupings. Mood disorders are streamlined into separate broad categories of bipolar and related disorders and depressive disorders. Obsessive-compulsive and related disorders are separated from anxiety disorders as a separate broad category. Similarly, PTSD is regrouped with trauma- and stress-related disorders and separated from anxiety disorders. Substance use disorders are restructured by combining both abuse and dependence diagnoses. For the first time, DSM includes a behavioral addiction disorder—gambling disorder—within the substance-related and addictive disorders group.
DSM-5 also introduced completely new categories based on the exten-sive research published over the past decade. Major and mild neurocognitive disorders have attracted much attention. Concerns were expressed about the potential for over-diagnosing mental illness. On the other hand, the inclusion of these categories was considered to be in alignment with current neurobiological models and also would allow for early intervention. Other noteworthy categories are agoraphobia—which can now be diagnosed without the presence of panic attacks—and disruptive mood dysregulation disorder. The latter raised criticism in the media, and opinions will likely continue to diverge. Advocates emphasized that this new category will reduce the overuse or misdiagnosis of bipolar disorder in children and adolescents, whereas its opponents fear that more children will gain a mental health diagnosis given the rather minimal and vague criteria required.
Several new disorders added in DSM-5 also caused controversy because of their potential impact on the prevalence of mental disorders: premenstrual dysphoric disorder, hoarding disorder, skin picking disorder, pain disorder, and binge eating disorder. It was agreed that identification of binge eating disorder would provide the possibility of early treatment and intervention to prevent further morbidity and progression to bulimia or anorexia.
Concerns were expressed about potential over-diagnosis and for increasing the rate of psychiatric diagnoses in the US. Similar concerns were voiced over making the age criterion less restrictive for certain disorders, thus allowing the expansion of the diagnosis to more patients (eg, autism spectrum disorder, ADHD, feeding and eating disorders).
Clinical practice and research criteria will be influenced by the revisions that occurred in the specific diagnostic criteria for schizophrenia, bipolar disorder, and PTSD. The removal of bereavement as an exclusion criterion for MDD when the duration of symptoms is less than 2 months after the death of a loved one will also impact clinical practice and research. Bipolar disorders now are in a category of their own, and mixed episode is eliminated. All major subtypes for schizophrenia are deleted: 2 symptoms are now required instead of 1 from the quad of delusions, hallucinations, and disturbed speech and behaviors. DSM-5 also eliminates the special attribution of bizarre delusions and first-rank auditory hallucinations in diagnosing schizophrenia. Similarly, the requirement of non-bizarre delusions is eliminated for delusional disorder, and shared delusional disorder is no longer a separate entity. For PTSD, the subjective experience criterion is removed and now there are 4 instead of 3 distinct clusters (re-experiencing, avoidance, negative cognition, and arousal).
Dr Salloum is Chief of the Division of Substance and Alcohol Abuse in the Department of Psychiatry and Behavioral Sciences at the University of Miami, Miller School of Medicine, Miami. Dr Vasiliu-Feltes is Chief of Clinical Compliance and Quality Assurance and Director of the Clinical Trials Program in the Department of Psychiatry and Behavioral Sciences at the University of Miami, Miller School of Medicine.
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