DSM-5 finally debuts, markedly changed from earlier editions

There were 13,000 responses to online drafts of the revised psychiatric manual, but there is uncertainty about how it should be used in primary care.

By — Posted June 3, 2013

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Nearly two decades after work began on the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, the manual is ready for use by physicians.

The long-awaited print version was released May 17 during the American Psychiatric Assn's. annual meeting in San Francisco. DSM-5 will be available online later this year.

The manual's publication follows an unprecedented call for public comment on drafts of the guidebook posted online, drawing more than 13,000 responses from health professionals, patients, professional societies and researchers.

The feedback was reviewed and led to some modifications in the final version, including changing the name of “intellectual developmental disorder” to “intellectual disability,” said psychiatrist David J. Kupfer, MD, chair of the DSM-5 Task Force.

“We were all impressed with the quantity and quality of feedback we received,” he said.

This marks the first time since 1994 that classifications and criteria of mental disorders have been revised, the APA said.

Fundamental changes from DSM-IV include revised chapter organization that signals how disorders might relate to one another based on underlying vulnerabilities or symptom characteristics. Several new disorders were added to DSM-5, including binge eating disorder and hoarding disorder, and a third section was added. The new section introduces conditions, such as suicidal behavior disorder, that warrant more research before they might be considered formal disorders.

Members of the DSM-5 Task Force have stressed the guidebook's importance across all medical specialties but particularly in primary care, as mental health conditions increasingly are being diagnosed in that setting. There is some uncertainty, however, in the medical community about how primary care doctors should use the revised manual. At the same time, some health professionals and the public are concerned about its contents.

At issue, critics say, is the creation of new diagnoses, such as disruptive mood dysregulation disorder, that could lead millions of healthy people to be medicated wrongly.

Just as concerning, some say, is the grouping of four autism-related classification from DSM-IV into one diagnosis — autism spectrum disorder. That change could cause children to lose access to essential services, including those that help improve educational performance, language skills and socialization.

Among the most vocal DSM-5 critics is psychiatrist Allen Frances, MD, who chaired the DSM-IV Task Force.

“The DSM-5 will magnify what already is a serious problem” of healthy people wrongly taking medications for conditions such as attention-deficit/hyperactivity disorder and depression, he said. For that reason, he urges physicians to use the revised manual “cautiously, if at all.”

Manual's place in primary care

Amid the controversy, primary care physicians largely have remained quiet. Perry A. Pugno, MD, MPH, vice president for education for the American Academy of Family Physicians, is not surprised he hasn't heard concerns about DSM-5 from the organization's members.

“From a pragmatic perspective, we don't use [the manual] very much,” he said. “Most of the things we see we already know the diagnostic criteria for them.”

As a family physician, Dr. Pugno said he is most likely to reference the guidebook when he's uncertain whether a patient has a particular condition. He also uses the manual when he is trying to get an individual into a support program that requires the doctor to report on specific signs and symptoms of a mental health condition.

In those instances, the DSM-5 probably will help physicians more precisely identify mental disorders and offer better care for their patients, the DSM-5 Task Force said.

“The manual is written in a way to be more user-friendly to medical specialties beyond psychiatry,” Dr. Kupfer said.

He encourages primary care physicians to read section I, which provides a thorough overview and introduction of the manual. That section also contains information on some of the most commonly treated mental health conditions in primary care, including anxiety and major depressive disorder, Dr. Kupfer said.

The APA plans to make the future DSM revision process more responsive to breakthroughs in research and probably will issue incremental updates on individual conditions until a new edition is required. The organization is determining whether a version of DSM-5 tailored to primary care physicians is needed, Dr. Kupfer said.

“The aim was to, wherever possible, make appropriate changes to the diagnostic criteria so they more accurately describe the behaviors and symptoms of patients seeking help,” he said. DSM-5 “will provide clinicians with a more precise guidebook to use when making a diagnosis.”

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What's new in DSM-5

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders features some fundamental differences from DSM-IV:

  • The development process included requests for public comment on drafts of the manual that were posted online.
  • Chapters are organized in a way that indicates how disorders might relate to one another based on underlying vulnerabilities or symptom characteristics.
  • Section III was created to introduce several conditions that warrant more research before they might be considered formal disorders.
  • Disorders are organized along a developmental life span within each chapter, meaning that conditions typically diagnosed in childhood come first, followed by those in adolescence, adulthood and later life.
  • Several new categories were added, including binge eating disorder, disruptive mood dysregulation disorder and hoarding disorder.
  • Certain conditions were combined because the relationships among categories placed them along a single continuum, as was the case with autism spectrum disorder.

Source: American Psychiatric Assn. on DSM-5 implementation and support (link)

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External links

American Psychiatric Assn. on DSM-5 implementation and support (link)

Ordering information on DSM-5, APA (link)

“The New Crisis in Confidence in Psychiatric Diagnosis,” Annals of Internal Medicine, May 17 (link)

“Why All of Medicine Should Care About DSM-5,” The Journal of the American Medical Association, May 19, 2010 (link)

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