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AGuidetoDSM5
BretS.Stetka,MD,ChristophU.Correll,MD

May21,2013

DSM5Revisions
Indevelopmentformorethanadecade,thefiftheditionoftheDiagnosticandStatisticalManualofMental Disorders [1](DSM5)isnowareality.Themanual'sofficialreleasewasannouncedatanearlymorningpress conferenceonMay18,2013,attheAmericanPsychiatricAssociation'sAnnualMeetinginSanFrancisco, California. Revisingpsychiatry'sprimarydiagnosticresourcetakesworkyearsofplanning,conductingfieldtrials,revising, solicitingpublicfeedback,revisingagainandtheefforthasledtoarevampedguidetopsychiatricdiagnosis. Newdiagnoseshavebeenadded,othersamendedorcombined.Someoriginallyproposedcriteriadrewsomuch publicandprofessionalcontroversytheywereultimatelywithdrawnfromthefinaldraft.Butperhapsthemost significantchangestothemanualareconceptual:removingthemultiaxialsystem,addingadimensional diagnosticapproach,andrearrangingthechapterorderandgroupingofdisorders. Thecurrent5axialdiagnosticsystemhasbeenremovedfromDSM5infavorofnonaxialdocumentationof diagnosis.ThenewapproachwillcombinetheformeraxesI,II,andIIIwithseparatenotationsforpsychosocial andcontextualfactors(formerlyaxisIV)anddisability(formerlyaxisV).Inadditiontocategoricaldiagnoses,a dimensionalapproachallowsclinicianstoratedisordersalongacontinuumofseveritythatwilllargelyeliminate theneedfor"nototherwisespecified(NOS)"conditions,nowtermed"notelsewheredefined"(NED)"conditions. Thedimensionaldiagnosticsystemalsobettercorrelateswithtreatmentplanning. Furthermore,therevisedchapterorderisintendedtobetterreflectadvancesintheunderstandingofthe underlyingvulnerabilitiesofdisease,aswellassymptomcharacteristicsofmentalhealthdisorders.Finally, diagnosticcriteriaforsomedisordershavebeenaddedorrevisedandareincludedinSection2ofthemanual, whereasthoserequiringfurtherinvestigationareincludedinSection3(appendix). CriticsofDSM5haveraisedconcernthatitmaybetooearlytocreateanewclassificationofpsychiatric diseases.Themainquestioniswhethertherehavebeensufficientadvancesinthepathophysiologic, phenomenologic,andtherapeuticunderstandingofmentalillnesstowarrantarevisedDSM.Althoughtheultimate aimistobasediagnosesmostlyonobjectiveand,ideally,biologicallymeasurablecriteria,psychiatryis unfortunatelystillfarfromthisgoal. ThiscontroversyhasplayedoutininitialcommentsbythedirectoroftheNationalInstituteofMentalHealth (NIMH),ThomasInsel,whourgedforthedevelopmentofamorebiologicallybasednosologyofmentaldisorders. InablogpostpublishedontheNIMHWebsite,Dr.InselpointedtothenewNIMHResearchDomainCriteria (RDoC)projectasapossiblereplacementdiagnostictoolsometimeinthefuture,whichwillincorporategenetics, imaging,andotherdataintoanewclassificationsystemandas"afirststeptowardsprecisionmedicine."Ina laterjointstatementbyDr.InselandnewlyappointedAmericanPsychiatricAssociationpresidentJeffrey Lieberman,bothcommentedthatDSMandtheInternationalClassificationofDiseases(ICD)"remainthe contemporaryconsensusstandardtohowmentaldisordersarediagnosedandtreated,"andthat"whatmaybe realisticallyfeasibletodayforpractitionersisnolongersufficientforresearchers."However,bothalso acknowledgedthat"lookingforward,layingthegroundworkforafuturediagnosticsystemthatmoredirectly reflectsmodernbrainscience,willrequireopennesstorethinkingtraditionalcategories.Itisincreasinglyevident thatmentalillnesswillbebestunderstoodasdisordersofbrainstructureandfunctionthatimplicatespecific domainsofcognition,emotion,andbehavior,"whichisatthecoreoftheRDoCinitiative.Thesestatementsall convergedinthebeliefthat"DSM5andRDoCrepresentcomplementary,notcompeting,frameworksforthis goal." Inthiscontext,theDSM5committeemembershaveattemptedarationalreexaminationoftheDSMIVcriteria

onthebasisoflongitudinalresearch,incorporatingdataontheapparentrelatednessofcertaindiagnoseswith oneanother,includingsimilaritiesinunderlyingvulnerabilities,symptomcharacteristics,anddiseasetrajectories. Overall,mostofthediagnosesandrelevantcriteriaincludedinDSM5remainidentical,orsimilar,tothosein DSMIV.Howevertheupdatesaresignificantandrepresentanewdiagnosticerainpsychiatry. WhatfollowsisaguidehighlightingthemajoradditionsandrevisionsinthenewDSM5edition.

FieldTrialResults
AspartoftheDSM5fieldtrials,2246patientswithvariousdiagnosesanddegreesofcomorbiditywere interviewed(86%twice)onthebasisoftheDSM5criteria.Interviewswereconductedby279cliniciansin variousdisciplineswhoreceivedtrainingsimilartowhatwouldbeavailabletocliniciansafterpublicationofthe DSM5.[2,3] Thefieldtrialstestedthecriteriafor23disorders:15adultand8child/adolescentdiagnoses.Reliabilityasa measureofagreementbetween2independentclinicianswasmeasuredwithkappastatistics.Forexample,if2 cliniciansagreedonadiagnosis85%ofthetime,thekappavaluewas0.46asitwasforschizophreniaand conductdisorder.Overall,5diagnoseswereinthe"verygood"range(kappa=0.600.79),9wereinthe"good" range(kappa=0.400.59),6wereinthe"questionable"range(kappa=0.200.39),and3wereunacceptable (kappa<0.20)(Figures1and2).

Figure1. DSM5fieldtrials:diagnosticreliabilityinadults.ModifiedfromFreedmanR,etal.[2]

Figure2. DSM5fieldtrials:diagnosticreliabilityinchildrenandadolescentsaged617years.ModifiedfromFreedmanR, etal.[2] For8diagnoses,includingseveralpersonalitydisorders,samplesizeswereinsufficienttogenerateprecise kappaestimates.Amongthe14mostreliablediagnoseswereposttraumaticstressdisorder,bipolarIdisorder, borderlinepersonalitydisorder,schizoaffectivedisorder,schizophrenia,bipolarIIdisorder,andalcoholuse disorderinadults,aswellasautismspectrumdisorder(ASD),attentiondeficit/hyperactivitydisorder,bipolarI disorder,conductdisorder,andoppositionaldefiantdisorderinyouth. WhereasnewDSM5entries,suchasmajorneurocognitivedisorder,complexsomaticsymptomdisorder, hoardingdisorder,bingeeatingdisorder,andASDwereamongthemostreliablediagnoses,disruptivemood dysregulationdisorderwasinthe"questionable"reliabilityrange,asweretheunmodifiedmajordepressive disorder(MDD)andgeneralizedanxietydisorder(GAD)diagnoses.The2diagnosesthatfellintothe "unacceptable"reliabilitycategory,mixedanxietydepressivedisorderandnonsuicidalselfinjury,havebeen removedorincludedinSection3,respectively. CriticsofthefieldtrialresultshavefocusedonthefactthattheunchangeddisordersMDDandGADwereamong the6disorderswithquestionablereliability,andthatthekappathresholdsfor"good"bytheDSM5fieldtrials werelowerthantraditionalthresholds.Moreover,forconditionswhereseveraldifferentsitescontributeddata, therewereconsiderablevariationsinreliability.[3]

NeurodevelopmentalDisorders
TheChange

InDSM5,"mentalretardation"hasanewname:"intellectualdisability(intellectualdevelopmentaldisorder),"the firstsectionintheneurodevelopmentaldisorderschapter.Thechangeisduetoagradualcallfordestigmatization amongclinicians,thepublic,andadvocacygroups.Alsoincludedinthischapterarecommunicationdisorders formerlyphonologicaldisorderandstutteringwhichincludelanguagedisorder,speechsounddisorder, childhoodonsetfluencydisorder,andanewconditioncharacterizedbyimpairedsocialverbalandnonverbal communicationcalledsocial(pragmatic)communicationdisorder.Attentiondeficit/hyperactivitydisorder(ADHD), specificlearningdisorder,andmotordisorders(eg,Tourettedisorder)arealsoincluded,asisthenewDSM5

diagnosis,autismspectrumdisorder(seepage4).
TheImplications

Thiscategorygroupsconditionswithonsetinchildhoodandadolescencethatarethoughttobeduetoabnormal neuralcircuitdevelopment,causingvariousdysfunctionsincognition,learning,communication,andbehavior. Thegroupingoftheseconditionshopefullywillurgeclinicianstotrytodifferentiatethemfromeachotherand considerdifferentialdiagnosesandcomorbiditiesmorecarefully.

AutismSpectrumDisorders
TheChange

DSM5includesasingleASDcategorythatdoesnotdifferentiatebetweenthepreviouslyuseddiagnoses.The newcriteriagroupthefollowingformerlydistinctdiagnosesintoasingleASDdiagnosis:autisticdisorder, Aspergerdisorder,childhooddisintegrativedisorder,andpervasivedevelopmentaldisordernototherwise specified(PDDNOS).

TheImplications

AmongthemostcontroversialoftheDSM5revisions,thischangewasmadeowingtotheDSM5TaskForce's dimensionalapproachtocategorizingpsychopathology.Althoughtherewasconcernthatalargepercentageof personsformerlydiagnosedwithanASDwouldfalloutsideofthenewdiagnosticcriteria,andthusbeineligible forcertainservices,thisseemsunlikelyinmostsituations.Rather,patientswillbediagnosedmoreconsistently acrossasinglespectrum,withindicatorsofdifferentseverityofsymptoms. InacommentarypublishedonMedscapeinJune2012,DSM5TaskForceChair,Dr.DavidKupfer,commented, "AdvocatesforthosewhosufferfromAspergersyndromeandautismdisorderswanttoensurethatchildrenwith DSMIVdefinedconditionsarenotdeniedservicesunderDSM5.Ourfieldtrialdatadonotshowthatpeoplewith treatmentneedswillbenegativelyaffected,andallwillbehelpedbecauseclinicianswillbeguidedbymore explicitdefinitionsanddescriptionsofsymptomsandbehaviors." However,concernremainsthattherevisedcriteriacouldresultinaconfoundingofveryheterogeneousclinical presentations,withmildPDDNOSontheoneendandsevereautismontheother.Ontheotherhand,clinicians candiagnoseacrossameaningfullyrelatedspectrumofsymptomsandbehaviorsrecognizingoverlapping featuresofanddifferencesinindividualpresentationsandfocusingontheseverityofthesymptoms,whichwill helpguidetreatmentapproachesmoredirectly.Clinicianswillprobablyneedtotakesometimetodiscusswith parentsanychangesinthediagnosisoftheirchildrenbasedonDSM5criteria.

BingeEatingDisorder
TheChange

InDSM5,bingeeatingdisordergraduatedfromDSMIV'sAppendixBCriteriaSetsandAxesProvidedfor FurtherStudytoanofficialdiagnosisinthenewmanual'sSection2.
TheImplications

DSMIVrecognizedonly3eatingdisorderdiagnosticcategories:anorexianervosa,bulimianervosa,andeating disorderNOS.Theupdateallowsforadditionaldiagnosticnuance. BingeeatingdisorderseemstohaveadistinctclinicalprofilefromtheeatingdisordersincludedinDSMIV.Like bulimianervosa,theconditionischaracterizedbyrecurrentepisodesofbingeeating.However,unlikebulimia, patientsdonotexhibitinappropriatecompensatorybehaviors,suchaspurging,fasting,orexcessiveexercise. Criticshavenotedthat(1)abingeeatingdiagnosismayshareconsiderablesymptomoverlapwithnonpathologic problematiceating,and(2)bingeeatingcanbeamanifestationofotherillnesses,andthereforethenewmanual

failstoaddresscausation.Thiscontroversyhighlightsthecomplexitiesofabnormaleatingbehaviorsthat,again, areonacontinuumfromnormaltoproblematictoabecomingadisorder.Inclusionofbingeeatingdisorder withoutcompensatorybehaviorsalsoimpliestherecognitionofpsychiatricunderpinningsofcertaintypesof obesity.

DisruptiveMoodDysregulationDisorder(DMDD)
TheChange

Thisnewdiagnosticcategoryincludeschildrenexhibitingpersistentirritabilityandseverebehavioraloutbursts3 ormoretimesperweekformorethan1year.Themoodinbetweentemperoutburstsispersistentlynegative (irritable,angry,orsad),whichisobservablebyothers,andthetantrumsandnegativemoodarepresentinat least2settings.Tomeetcriteriaforthenewdiagnosis,onsetofillnesshastobebeforeage10yearsandina childwithachronologicalordevelopmentalageofatleast6years. DMDDisintendedtocapturechildrenwithfrequenttempertantrumsandirritability,inparttopreventthe overdiagnosisofbipolardisorderinyouthwithprepubertalonsetofthesesymptoms.Often,suchpresentations resultinadiagnosisofbipolardisorderoroppositionaldefiantdisorder.[4]

TheImplications

CriticsofthisupdatecitethemodestbodyofresearchintothevalidityofDMDDasaviablediagnosticentity,[5] aswellastheworrythatsuchadiagnosiscouldincreasethenumberofchildrendiagnosedwithmentalillness andsubsequentexposuretopsychotropicmedicationswithpotentiallongtermsideeffects. Furthermore,arecentstudybyAxelsonandcolleagues [6]concludedthat"Inthisclinicalsample,DMDDcould notbedelimitedfromoppositionaldefiantdisorderandconductdisorder,hadlimiteddiagnosticstability,andwas notassociatedwithcurrent,futureonset,orparentalhistoryofmoodoranxietydisorders.Thesefindingsraise concernsaboutthediagnosticutilityofDMDDinclinicalpopulations."Inafollowupeditorial,[7]Dr.Axelson wrote,"Onecanconcludethatatthistime,notenoughscientificdataaboutthesekidsareavailabletocreatea newdiagnosis.However,weshouldallagreeonthevitalimportanceofthisproblemandtheneedtoexpandour effortstobetterunderstandthecomplexconstructofirritabilitysothatwecanimprovetheassessment, diagnosis,andtreatmentofsomeofoursickestchildren." AlthoughthevalidityandspecificityofthenewDMDDdiagnosisremaininquestion,thehopeisthattherisein bipolardisorderdiagnosesfornonepisodicmooddysregulationandaggressionwithprepubertalonsetmay decrease.Whetherthisnewdiagnosiswillalsoleadtoamorejudicioususeofpsychotropicmedicationsand increasedutilizationofbehavioral,psychosocial,andfamilyinterventionsremainstobeseen,buttheadditionof DMDDinDSM5willhopefullyencouragesuchresearch.

Hoarding,SkinPicking,andRethinkingOCD
Newtothemanualisachaptergroupingobsessivecompulsivedisorder(OCD)withrelateddisorders,including bodydysmorphicdisorder,andconditionsformerlyfoundinthe"impulsecontroldisorder(ICD)notelsewhere classified"section,includingtrichotillomania(pullingoutone'shair).Twonewdiagnosesareincludedinthis chapter:excoriation(skinpicking)disorder,characterizedbyrepetitiveandcompulsivepickingofskinresultingin tissuedamageandhoardingdisorder,inwhichsufferershavepersistentdifficultydiscardingwithpossessions regardlessoftheirvalue.
TheImplications

DistinguishingbetweenOCDanddisordersthatwereformerlyincludedintheICDsectioncanbedifficult,owing tosymptomoverlap.Skinpickingandotherimpulsivebehaviorsaresometimesseenasmanifestationsor symptomsofunderlyingOCDoranxiety,andthereforeaddinganewexcoriationdisorderdiagnosisrisks stigmatizingpatientswith2psychiatricdiagnoses.However,alargebodyofresearchsuggeststhatICDsare distinctfromOCD,bothneurobiologicallyandclinically,[8,9]anddatadosupportthenewdiagnosticcriteria.[10]In

addition,treatmenteffectsalsotendtodiffer. TheadditionofthehoardingdisorderdiagnosistotheDSM5issupportedbyextensiveresearchsuggestingthat althoughOCDandhoardingcancooccur,theyarealsoneurobiologicallyandclinicallydistinctandmayrespond differentlytotherapy.[11]PatientswithOCDandcompulsivehoardinghaveadifferentpatternofcerebralglucose metabolismthanthatofnonhoardingpatientswithOCD.[12]Also,manypatientswhoexhibithoardingbehaviors donothaveothersymptomsofOCD.[11,12]

PersonalityDisorders
TheChange

Indevelopingdiagnosticcriteriaforpersonalitydisorders,theDSM5WorkGroupinitiallyproposedasomewhat dramaticnewapproach:Maintain6personalitydisorderdiagnosesfromtheprior10inDSMIV,andmovefroma categoricaltoatraitbased,dimensionalclassificationsystem.Perthecategoricalsystem,apatienteitherhasa diagnosisornot,whereasadimensionalsystembettercapturesthenuancesofhumanpersonalitybymeasuring avarietyoftraitsonacontinuum.Theproposalwasultimatelyvoteddownhowever,thealternativehybrid dimensionalcategoricalmodelisincludedinaseparatechapterinSection3ofDSM5tostimulatefurther researchonthismodifiedclassificationsystem. Ofnote,despitetherequiredenduringandimpairingnatureofpersonalitydisordersymptomsandtraits,inthe fieldtrials,onlyborderlinepersonalitydisorderhadgoodinterraterreliability.Incontrast,obsessivecompulsive personalitydisorderandantisocialpersonalitydisorderwereinthequestionablereliabilityrange,andtoofew patientswithotherpersonalitydisorderswereincludedtotesttheirreliability.Althoughalloriginal10personality disordersfromDSMIVwerefinallyretained,DSM5hasmovedfromthemultiaxialtoamonoaxialsystemthat removesthearbitraryboundariesbetweenpersonalitydisordersandothermentaldisorders.
TheImplications

Theintegrationofpersonalitydisorderswithotherpsychiatricdiagnosesthatwerepreviouslyseparatedand classifiedonadifferentaxisreturnstoamoreunifiedanddimensionalviewofpersonality,character, temperament,andmentalillness.Ontheotherhand,retentionofpersonalitydisorderswithquestionableor untestedreliabilitycanleadtotheperpetuationofstigmatizingdiagnosesthatmaylackvalidityandforwhich treatmentapproachesarealsooftenunclear.Moreover,toofewpatientsinthefieldtrialswereavailabletotest7 ofthe10personalitydisorders,suggestingthatfuturefieldtrialsshouldurgentlyincludecommunitymentalhealth centersandcliniciansworkinginnonacademicprivatesettings,wherethesepatientsaremorelikelytobefound andtreatedoftenwithpsychotherapy. However,thefactthatborderlinepersonalitydisorderhadsuchgoodinterraterreliability,whereastheother personalitydisordersdidnot,maysupportpreviouslyendorsedviewsthatitcouldbelonginthebipolardisorder spectrumratherthanbeingclassifiedasapersonalitydisorder.Futureresearchwillhopefullyhelpclarifythis further.

PosttraumaticStressDisorder
TheChange

Formerlyinthe"AnxietyDisorders"chapter,inDSM5posttraumaticstressdisorder(PTSD)isnowincludedina newchaptertitled"TraumaandStressorRelatedDisorders."Furthermore,afourthdiagnosticcluster(inaddition toCriteriaB,C,andD)capturingbehavioralsymptomshasbeenadded.The6diagnosticcriteriaincludedin DSMIVweremaintained,withminorrevisions,and2additionalcriteriahavebeenadded:(1)negativealterations incognitionandmoodassociatedwiththetraumaticevent,beginningorworseningaftertheevent,and(2)the disturbanceisnotattributedtothedirectphysiologiceffectsofasubstanceoranothermedicalcondition. Inaddition,anewdiagnosticsubtypehasbeencreatedtoincludepreschoolagedchildrenwithPTSDsymptoms. Finally,DSM5furtherdefinestraumaticevents,criteriaaremoreculturallyapplicable,andthepriordistinction

betweenacuteandchronicPTSDhasbeenremoved.
TheImplications

ThecreationofaseparatechapterontraumaandstressorrelateddisorderswillgivePTSDtheappropriate attentionthatitdeservesasaconditionwithassociated,traceablecausalfactorsthatshouldbeaddressed.The highlightingofbehavioralaspectsofPTSDbythecreationofafourthdimensionwillalsoprobablyhelpfocus clinicians'attentiononthisimportantcomponentofthedisease.Thenewcriteriawillalsobettercharacterize PTSDinpediatricpopulations,whounfortunatelyarealltoooftenvictimsofPTSD.

RemovaloftheBereavementExclusionFromMDD
TheChange

ThebereavementexclusioninDSMIV,whichhasbeenremovedinDSM5,wasintendedtoexcludeindividuals experiencingdepressivesymptomslastinglessthan2monthsafterthedeathofalovedonefromadiagnosisof MDD.Theneweditioncharacterizesbereavementasaseverepsychologicalstressorthatcaninciteamajor depressiveepisodeevenshortlyafterthelossofalovedone.

TheImplications

Asdetractorshavepointedout,thiscontentiousrevisionriskspathologizinganormalhumanprocess,grief. Individualsmaybediagnosedwithdepressionevenintheabsenceofseveredepressionsymptoms(ie,suicidal ideation)andeventhoughtheirsymptomsmaybetransient.Furthermore,inarecentarticleinWorldPsychiatry, [13]Drs.JeromeWakefieldandMichaelFirstcallintoquestionthevalidityofresearchsupportingremovingthe exclusion,concluding,"...thereisnoscientificbasisforremovingthebereavementexclusionfromtheDSM5." Proponentsofeliminatingtheexclusionarguethatgriefdoesnotprecludethedevelopmentoffullblown depression,andfurtherthatgriefpredisposestoMDD.AcategoricalexclusionofMDDfor2monthsafterthe deathofalovedonewronglypresumesthatnobodycanbecomeseriouslydepressedwhilealsogrieving.Dr. RonaldPies,MedscapecolumnistandProfessorofPsychiatryatSUNYUpstateMedicalUniversitycommented inarecentcolumn,"Thereare...substantialdifferencesbetweengriefandMDD,andexperiencedclinicianswill beabletotellthedifference."Thus,itwillbeimportantforclinicianstocontinuetoassessthequality,reactivity, andextentofthedepressivesymptomsandtodiligentlydifferentiatebereavementfromMDDinclinicalpractice. Ifindoubt,pharmacologictreatmentmayneedtobedelayedtoassessthetrajectoryofthesymptoms,unless theyaresevereordangerous.

SubstanceUseDisorder
TheChange

InDSM5,theDSMIVcriteriasubstanceabuseandsubstancedependencehavebeencombinedintosingle substanceusedisordersspecifictoeachsubstanceofabusewithinanew"addictionsandrelateddisorders" category.Eachsubstanceusedisorderisdividedintomild,moderate,andseveresubtypes.WhereasDSMIV substanceabusediagnosticcriteriarequiredonly1symptom,aDSM5diagnosisevenforjustmildsubstance usedisordernowrequiresatleast2.

TheImplications

TheDSM5revisionsareintendedto(1)strengthenthereliabilityofsubstanceusediagnosesbyincreasingthe numberofrequiredsymptomsand(2)clarifythedefinitionof"dependence,"whichisoftenmisinterpretedas implyingaddictionandhasatitscorecompulsivedrugseekingbehaviors.Incontrast,featuresofphysical dependence,suchastoleranceandwithdrawal,canbenormalresponsestoprescribedmedicationsthataffect thecentralnervoussystemandthatneedtobedifferentiatedfromaddiction.Moreover,althoughmarijuanaabuse canbefunctionallyveryimpairing,physicaldependenceisnotpartoftheclinicalpicture,eveninseverecases. Inthissense,thenewDSM5criteriarecognizethatmentalandbehavioralaspectsofsubstanceusedisorders aremorespecifictosubstanceusedisordersthanthephysicaldomainsoftoleranceandwithdrawal,whichare

notuniquetoaddiction. Althoughthenewcriteriarequireanincreasednumberofsymptomstoqualifyforasubstancerelateddiagnosis, criticsoftherevisionarguethatchancesofmeetingthenewcriteriaarenowmuchgreater.Theyfurtherworry thatmanyindividualswhoqualifyforasubstanceusedisorderdiagnosisperthenewcriteriahaveonlyminor symptoms,makingitmoredifficultforthosewithmoreseveresymptomsanddistresstoaccessalreadyscarce treatmentresources.

MixedMoodSpecifier
TheChange

InDSM5,thenewspecifier"withmixedfeatures"canbeappliedtobipolarIdisorder,bipolarIIdisorder,bipolar disorderNED(previouslycalled"NOS")andMDD.Thechangewasmadetoreflecttheclinicalphenomenonof "mixed"moodstatesthatdonotmeetfullcriteriaforamixedepisodeofbipolarIdisorder,reflectedbyco occurrenceoffullmaniaandMDD.Thus,thepredominantmoodcaneitherbedepression,mania,orhypomania. Thesecondarymoodcanbe"subclinical,"inthatsomeaspectsofthesecondarymooddiagnosiswouldbe presentbutnotsufficientlysotomakeaformaldiagnosis. Patientswhomeetthefullcriteriaforbothdepressionandmaniatogetherwillbelabeledashavingamanic episodewithmixedfeaturesowingtotheclinicalseverityofmania.Tobediagnosedwiththe"withmixed features"specifier,apersonhastomeetthefullcriteriaforonemood(depression,maniaorhypomania)and have3ormoresymptomsoftheothermoodpole.Symptomsthatarecommontobothmoodpoles (mania/hypomaniaanddepression)arenotincludedinthepossiblecriteriaforamixedmood.Theseinclude distractibility,irritability,insomnia,andindecisiveness. Forsomeonewithpredominantmaniaorhypomania,atleast4ofthefollowingdepressivesymptomsmustbe presentnearlyeverydayduringthemostrecentweekofamanicepisodeorduringthemostrecent4daysof ahypomanicepisode:depressedmood,diminishedinterestorpleasure,slowedphysicalandemotionalreaction, fatigueorlossofenergy,andrecurrentthoughtsofdeath.Forsomeonewithpredominantdepression,atleast3 ofthefollowingsymptomsmustbepresentnearlyeverydayduringthemostrecent2weeksofthemajor depressiveepisode:elevatedmood,inflatedselfesteem,decreasedneedforsleep,andanincreaseinenergyor goaldirectedactivity.
TheImplications

Untilnow,mixedmood,whichiscommonlyseeninclinicalpractice,couldonlybediagnosedinbipolarIdisorder, indicatingthecooccurrenceoffullcriteriaformaniaandMDD.TheadditionofamixedmoodspecifiertobipolarI disorder,bipolarIIdisorder,bipolardisorderNED,andMDDfollowsthedimensionalapproachofDSM5and allowsclinicianstoformallydiagnoseandtreatsubthresholdexpressionsoftheadmixtureofdepressive symptomstomaniaorhypomaniaaswellasofsubthresholdmanialikesymptomstodepression. Thisisclinicallyrelevant,becausetheavailabilityofthisspecifierwillsharpenclinicians'viewonthedimensional overlapofsuchsymptomadmixtures,whichhaveclearrelevanceforpatients'functioningandclinicians' treatmentselection.However,criticshaveraisedtheconcernthatclassifyingMDDwith3relevantmanialike symptomsasadepressivedisorderratherthanabipolarspectrumdisordermaybemisleadingandthatitis unclearwhatexacttreatmentrecommendationsaretobemadeforpatientswithMDDandmixedmanicor hypomanicfeaturesorforpatientswithbipolarIorIIdisorderandmixeddepressivesymptoms.

NeurocognitiveDisorder
TheChange

AttheDSM5pressconference,Dr.DilipJesteatthatpointstillAPApresidentreferredtothemovement amongsomepsychiatriststoretiretheterm"dementia"forstigmaticreasons,theliteralLatintranslationbeing "withoutmind."Jestepointedoutthatnotonlydoesthetermholdnegativeconnotations,butitisalsosimply

inaccuratemanypatientswithdiagnosed"dementia"maintainfaculties,awareness,andhaven'tactually"lost" theirmind.However,becauseoftheterm'slongmedicalhistoryanditsfamiliarityamongcliniciansandpatients, thenewDSMrecognizes"dementia"asanacceptablealternativeforthenewlypreferredandmorescientificterm "neurocognitivedisorder." ThisnewdiagnosisincludesboththedementiaandamnesticdisorderdiagnosesfromDSMIV.Furthermore, DSM5recognizesspecificetiologicsubtypesofneurocognitivedysfunction,suchasAlzheimerdisease, Parkinsondisease,HIVinfection,Lewybodydisease,andvasculardisease.Eachsubgroupcanbefurther dividedintomildormajordegreesofcognitiveimpairmentonthebasisofcognitivedecline,especiallythe inabilitytoperformfunctionsofdailylivingindependently.Inaddition,asubspecifier"with"or"withoutbehavioral disturbances"isavailable.
TheImplications

Thenosologicdistinctionsbetweenvaryingdementiaetiologiesshouldprovehelpfulindeterminingprognosisand therapeuticcourse.Moreover,clinicianswillbeabletomoreclearlydeterminewhetherthecognitivedeclinealone shouldbethefocusofconcernandintervention,orwhetherbehavioraldisturbancesshouldalsobeconsidered andaddressed. Theadditionofamilddegreeofcognitiveimpairmentisconsistentwithrecentresearchsuggestingthat treatmentsfordecliningcognitionmaybephasespecific,withcertainmedicationsandapproachespossiblyonly workingearlyinthediseasecourse.Althoughdistinguishingmildfrommajorimpairmentmay,insomecases, relyonclinicianjudgement,DSM5doesattemptanobjectivedistinction.Mildneurocognitivedisorderrequires "modest"cognitivedeclinewhichdoesnotinterferewith"capacityforindependenceineverydayactivities"like payingbillsortakingmedicationscorrectly.Cognitivedeclinemeetsthe"major"criteriawhen"significant" impairmentisevidentorreportedandwhenitdoesinterferewithapatient'sindependencetothepointthat assistanceisrequired.Inotherwords,thediagnosticdistinctionreliesheavilyonobservablebehaviors. Hopefully,thisnewclassificationsystemwillstimulateresearchintheareaofpreventionandearlyinterventionof neurocognitivedisorders.

ParaphiliasandParaphilicDisorders
TheChange

AdditionalchangesinDSM5includearethinkingofparaphilicdisorders.Whiletheirdiagnosticcriteriaremain unchangedfromDSMIV,theupdatedmanualdistinguishesbetweenparaphilicbehaviors,orparaphilias,and paraphilicdisorders.Aparaphilicdisorderisa"paraphiliathatiscurrentlycausingdistressorimpairmenttothe individualoraparaphiliawhosesatisfactionhasentailedpersonalharm,orriskofharm,toothers."

TheImplications

Thenewapproachtoparaphiliasdemedicalizesanddestigmatizesunusualsexualpreferencesandbehaviors, providedtheyarenotdistressingordetrimentaltoone'sselforothers.Cliniciansaretaskedwithdetermining whetherabehaviorqualifiesasadisorder,basedonathoroughhistoryprovidedbyboththepatientandqualified informants.

Section3Disorders
Section3ofDSM5includesselfassessmenttoolsintendedtobetterincorporatepatientperspective,aswellas culturaldifferences,intoclinicalassessmentandcare.Alsoincludedareanumberofconditionsrequiringfurther researchbeforeconsiderationasofficialdiagnoses.Asmentionedpreviously,thealternative,traitbased personalitydisorderclassificationsystemwasultimatelymovedtoSection3(seepage8). Becauseofthefrequentcooccurrenceofdepressiveandanxietydisorders,aswellasthepotentialfor concurrenttreatmentresponseofbothconditions,thisdiagnostichybridhadbeenconsideredforthemaintextof

DSM5,butitperformedpoorlyinthefieldtrials(seepage2). AnothernewdiagnosisthatultimatelywasincludedinSection3,"attenuatedpsychoticsymptomssyndrome," hadthesamereliabilityasschizophreniaintheDSM5fieldtrials.However,therewassignificantconcerninthe psychiatriccommunitythatincludingtheconditioninSection2wouldriskovermedicalizingoftennonspecific phenomenathattransitiontopsychosisinonly20%30%ofindividualsoveraperiodof13years.Moreover,in thefieldtrials,theattenuatedpsychoticsymptomssyndromewasassessedonlyinacademiccenters,someof whichhadbeeninvolvedinresearchonthistopic,andinterviewswereprobablyconductedwithmoretimethanis usuallyavailableinbusyclinicalsettings.Still,consideringattenuatedpsychoticsymptomssyndromeasanew conditionthatwarrantsstudyasapotentiallyimportantdiagnosticentitywillhopefullycontributetoenabling targetedpreventioninthefuture. WhereasinDSMIVnonsuicidalselfinjury(NSSI)wasconsideredasymptomofborderlinepersonalitydisorder (BPD),intherevisedmanualitisrecognizedasadistinctcondition.ResearchsuggeststhatNSSIcanoccur independentofBPD,suchasinpatientswithdepressionoreveninthosewithnootherdiagnosable psychopathology.CriteriaforNSSIrequire5ormoredaysofintentionalselfinflicteddamagetothesurfaceof thebodywithoutsuicidalintentwithinthepastyear.Patientsalsomustengageintheselfinjuriousbehaviorwith atleast1ofthefollowingexpectations:toseekrelieffromanegativefeelingorcognitivestate,toresolvean interpersonaldifficulty,ortoinduceapositivestate.Thebehaviormustalsobeassociatedwith1ofthefollowing criteria:interpersonaldifficultyornegativefeelingsandthoughtseg,depression,anxiety),premeditation,and ruminatingon(nonsuicidal)selfinjury.Sociallysanctionedbehaviors,likebodypiercingandtattooing,donot qualifyforthediagnosis,nordoscabpickingornailbiting.Importanttonoteisthatpatientswhoexpresssuicidal behaviorwithinthepast24months,butwhodon'tqualifyforanotherpsychiatricdisorder,nowfallunderthenew "suicidalbehavior"diagnosiscategory. Finally,InternetgamingdisorderisalsoincludedinSection3.ItisdistinctfromInternetgamblingdisorder,which iscategorizedastheonlynonsubstancerelatedaddictivedisorder.ToqualifyforInternetgamingdisorder, patientsmustmeetatleast5ofthe9followingcriteriawithinthepastyear:(1)preoccupationwithgames(2) psychologicalwithdrawalsymptoms(eg,anxiety,irritability)(3)tolerance(theneedtospendanincreasing amountoftimeplayinggames)(4)unsuccessfulattemptstocontrolorlimitgameparticipation(5)lossof interestinprevioushobbies(6)continuedusedespiteknowledgeofproblem(7)deceivingfamilymembers and/ortherapists(8)useofInternetgamestoescapeanegativemoodand(9)hasjeopardizedorlosta relationship,job,oreducationalopportunity.Despiteitsname,thenewdiagnosiscanapplytononWebbased gamesaswell. Timeandresearchwilltellwhetherthisconditionhassufficientneuropathologicandclinicalsimilaritiestoother addictivedisorderstobeincludedintheSubstanceRelatedandAddictiveDisorderchapterinSection2,asthe secondnonsubstancerelateddisorder.
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Citethisarticle:BretS.Stetka,ChristophU.Correll.AGuidetoDSM5.Medscape.May21,2013.