Ch-ch-ch-ch-changes (to the DSM)
The DSM V IS OUT! Many of us in the Teen Skepchick backchannel are voraciously reading up on the changes in it, and I’ve gotten my hands on a copy as I work for a mental health organization. But we here at TS recognize that the DSM is expensive as all get out, and that many of our readers might be interested in the Cliff Notes version of what happened in version V. If that’s the case for you, you need look no further. The following is a summary of the major changes that were made in the DSM, with a few notes about the impacts of these changes.
ADHD: There are a few changes to the ADHD diagnosis, mostly to ensure that adults can be diagnosed and treated. More examples of how symptoms might present in various stages of life are included, and the age of first onset of symptoms has been changed from before 7 to before 12.
Autism Spectrum Disorders have gotten a fair amount of overhaul in this version of the DSM. In the last version of the DSM there were four different pervasive developmental disorders, and in this version they have all been consolidated to autism spectrum disorders. It has also made some strides towards diagnosing at a younger age, but still allows for a continuum of ages and severities.
Major Depressive Disorder: The only major change to the depression diagnosis is a fairly controversial one. This is the removal of the bereavement exclusion, or the bit that said you can’t be diagnosed with MDD within two months of a major loss. Many people are worried that this will lead to turning a normal process into a mental illness, however there a fair number of safeguards against this in the DSM: it specifically tells what differentiates grief from depression, and cautions therapists only to diagnose depression, not grief.
Conduct Disorder: There is only one change to this diagnosis, which is the addition of a new subtype of the disorder: prosocial. Typically, conduct disorder only involves unacceptable social behaviors, however the prosocial type manifests in strained interpersonal relationships, little to no empathy, and more severe forms of the disorder. This change can help with treatment options.
Disruptive Mood Dysregulation Disorder: This is an entirely new diagnosis for this edition of the DSM. Its main characteristics are extreme temper outbursts beyond what is reasonable for the stimuli, and a continuous angry or irritable mood through 2 domains of life, at least one of which is severely disrupted. It’s similar to ODD, however it’s considered more severe, and BD, although it is more continuous in the mood rather than episodic.
Eating Disorders: This is another category that had a fair amount of controversy surrounding the changes. Binge Eating Disorder was introduced as a new categorization, characterized by extreme intakes of food and calories, often as a way to deal with emotions. Many are worried that this will turn overeating into a mental illness, however the diagnosis was introduced to illustrate the differences between the two: binge eating disorder comes with feelings of shame, guilt, and embarrassment, and extreme emotional disruption. There has been a change in the criteria for anorexia, namely the deletion of amenorrhea. The bulimia criteria have been adjusted so that the frequency of binge/purge episodes is fewer. Overall the changes were instituted to lower the number of EDNOS diagnoses. With these changes, men are now as likely as women to get an eating disorder diagnosis.
Gender Dysphoria: This is a new diagnosis, a replacement for Gender Identity Disorder. This is when an individual is born as a gender they do not identify with. This definitely could be a dangerous diagnosis as some could view it as turning gender nonconformity into a disorder, however the most important characteristic of this disorder is that it causes extreme distress to the individual. The changing of the wording to dysphoria is definitely an improvement against stigma, and if this diagnosis is applied well, it could help a number of people gain access to services.
Intellectual Disability: This diagnosis is replacing mental retardation (to which I can only say YAY!), and is meant to move away from the multiaxial approach to diagnoses. The DSM V has only a single axis and all mental illness is weighted the same (also pretty happy with this change). Another great change here is that IQ tests are no longer used to determine a diagnosis or the severity, but functioning and clinical assessments are used.
Internet Gaming Disorder: I had NO IDEA this was in here. It’s not formally or fully accepted, but they’re in the process of researching it right now. There may be evidence that some extremely hardcore gamers show similar brain changes to those in an addict. Definitely something to keep your eyes open for, as I’m sure more research will be forthcoming.
Mild Neurocognitive Disorder: This is another new diagnosis, and another one that people are somewhat upset about. It is the precursor to dementia. Some think that it’s just normal aging. The diagnosis makes sure to specify that this is beyond the normal aging process, and is aging that requires the development of new skills to continue functioning. It was created to begin intervening earlier in cases of dementia.
Obsessive Compulsive and Related Disorders: This is a new chapter, and moves OCD out of the anxiety disorder category. Disorders that now reside in this chapter are obsessive-compulsive disorder, body dysmorphic disorder and trichotillomania (hair-pulling disorder) and two new disorders have been added: hoarding disorder and excoriation (skinpicking) disorder.
Paraphilic Disorders: The main changes to these disorders was to specify that atypical sexual behaviors are not disorders, but rather that something is only a disorder if it causes distress to the individual or if it causes physical or psychological harm to another human being. This seems to be moving in the right direction to me, however I worry that many people only feel distressed about their atypical sexual behaviors because those behaviors are stigmatized, and keeping them in a diagnosable category may continue that stigma.
Personality Disorders: The biggest change here is removing the “axis” style of diagnosing. Personality disorders are now on par with all other disorders. Again, I think this will go a ways towards reducing stigma, but it could also lead to more of people lumping all of mental illness together in one giant undifferentiated glob. There is also the addition of a diagnosis called Personality Disorder-Trait Specified, in which a personality disorder is deemed present, but it does not fit any of the specified disorders. To me this sounds a bit like EDNOS for personality disorders and I think it’s a great addition, as many people with some serious difficulties don’t quite fall into one or another category.
PTSD: PTSD is also being moved out of the anxiety disorders category and into its own chapter. There are also some updates to the criteria, including more specificity in what constitutes trauma. Finally, it looks at the behaviors of PTSD and identifies four types of behaviors: re-experiencing, avoidance, negative cognitions and mood, and arousal.
Schizophrenia: There are only two small changes to schizophrenia. In the DSM IV an individual only had to present one of the symptoms listed, now they must present two. In addition, subtypes have been deleted as unhelpful.
Sleep-Wake Disorders: There has been some shuffling of diagnoses in this category, with some being combined and others being separated, primarily with the intent of ensuring that those who need to see a sleep specialist will be referred, regardless of whether the cause of the disorder is physical or mental.
Social Anxiety Disorder: Social Phobia is now Social Anxiety Disorder, and with the name change come some other changes as well. In the DSM IV, a patient had to recognize that their discomfort was unreasonable, whereas in the DSM V the clinician can do this. It also adds more possible behaviors as manifestations in children.
Social Communication Disorder: This is another entirely new diagnosis. This is for those individuals who have extreme difficulty communicating, but whose difficulties cannot be explained by low cognitive ability. Symptoms include lack of acquisition of language, and difficulties with responding appropriately.
Somatic Symptom Disorder: This is a replacement for what was previously called Somatoform Disorders. Most of the disorders there are now SDD, and instead of requiring a list of criteria, simply focus on the distress the somatic symptoms cause to the patient. In addition, in this edition of the DSM the symptoms may have a medical cause.
Specific Learning Disorder: All learning disorders have been grouped under this diagnosis in the new DSM. These can then be further specified based on type. Therapists can diagnose based on whether an individual is below what is appropriate for age and intelligence.
Substance-Related and Addictive Disorders: All the substance related disorders (abuse and dependence) are now one diagnosis on a continuum, and it requires 2-3 symptoms rather than 1. Gambling Disorder and Gaming Disorder are now included in addictive disorders.
I relied heavily on the DSM V website for information about changes. If anyone has further changes that I missed, please let me know in comments.