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DSM-5: What It Will Mean to Your Practice

DSM-5: What It Will Mean to Your Practice

Table 1: Changes from DSM-IV-TR to DSM-5Table 1
Table 2: New disorders and their codes in DSM-5Table 2
Table 3: DSM-IV-TR disorders combined in DSM-5Table 3
Table 4: Nomenclature changes in DSM-5Table 4

Despite the numerous changes, clinicians will not find DSM-5 to be unfamiliar because the new manual is another revision of recent DSMs. While some contributors suggested a “paradigm shift” during the development of DSM-5, by the time of its completion on December 2, 2012, the final product retained the style of the last 3 DSMs.

Many of the changes in DSM-5 are summarized in the Tables. Table 1 lists some of the changes from DSM-IV-TR to DSM-5, Table 2 lists the new disorders, Table 3 lists the DSM-IV-TR disorders that have been combined in DSM-5, and Table 4 lists nomenclature changes. In addition, there are about 464 differences between DSMIV and DSM-5 criteria-sets; the vast majority are very minor (eg, the word “individual” has been substituted for “person”). The title and criteria set are completely unchanged in only 10 DSM-IV-TR disorders: conduct disorder, kleptomania, pyromania, and 7 personality disorders—antisocial, avoidant, borderline, dependent, histrionic, narcissistic, and obsessive-compulsive. The changes we believe to be most relevant are reviewed in this article.

New disorders

Psychiatric Times readers have been thoroughly informed by the series of blogs by Allen Frances, MD, concerning the potential dangers that some of the new disorders introduced in DSM-5 may pose. With the release of DSM-5 in May, we should begin to find out whether the dire predictions about those disorders are correct.

Most of the new disorders are not controversial: DSM-IV-TR not otherwise specified entities have been replaced with the less confusing “other disorder” and “unspecified disorder” entities. “Other disorder” is used for syndromes that are not included in DSM-5 (eg, passive-aggressive personality disorder, zoophilia). Section III also includes conditions in need of further research, such as “Internet gaming disorder.” Unlike “other disorder,” “unspecified disorder” is used in cases that do not meet any specific syndrome.

Another group of new disorders, also not controversial, are the 10 “mild” forms of each of the “neurocognitive disorders” (the new term for what was previously dementia). These changes should help focus psychiatry on prevention by providing a name and a code that clinicians can use in the early stages of a neurocognitive disorder.

Combining disorders

There was a concerted effort to simplify DSM by combining disorders when nothing was clinically lost by such a combination. Changing to the combined diagnosis should go smoothly and be easy to explain to patients; however, if problems occur, the clinician may continue using DSM-IV-TR terminology and code. Removing a disorder in DSM does not remove it from the rest of medicine. For example, if a patient with a diagnosis of Asperger’s prefers that label, it and its name and codes (299.8 [ICD-9-CM] and F84.5 [ICD-10-CM]) can still be used.

Coding. What new codes does DSM-5 bring to clinical practice? None. What about ICD-10-CM coding, which is to begin October 1, 2014? Fortunately, DSM-5 provides the ICD-10-CM codes for all of the DSM-5 disorders. All DSM-5 coding is within the ICD-9-CM system that the rest of medicine uses. All of the disorders listed in Tables 2, 3, and 4 have ICD-9-CM codes. All new entities share codes already existing within the ICD-9-CM system (eg, excoriation disorder shares code 698.4 with dermatitis factitia; caf-feine withdrawal and cannabis withdrawal share code 292.0 with 8 other disorders, and so forth).

The reason for the use of identical numbers for multiple entities is that DSM-5 must use only those codes already listed in ICD 9-CM and could not add new numbers. As a result, for example, 292.89 is the number used to code for 31 different DSM-5 substance-related disorders.

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