DSM-5
Encyclopedia
The next edition of the American Psychiatric Association's
(APA) Diagnostic and Statistical Manual of Mental Disorders
(DSM), commonly called DSM-5 (previously known as DSM-V until the APA decided to abandon the Roman Numerals), is currently in consultation, planning and preparation. It is due for publication in May 2013 and will supersede the DSM-IV which was last revised in 2000. APA has an official development website for posting of draft versions of the DSM-5.
(NIMH), was held to set the research priorities. Research Planning Work Groups produced "white papers" on the research needed to inform and shape the DSM-V, and the resulting work and recommendations were reported in an APA monograph and peer-reviewed literature. There were six workgroups, each focusing on a broad topic: Nomenclature, Neuroscience and Genetics, Developmental Issues and Diagnosis, Personality and Relational Disorder
s, Mental Disorders and Disability, and Cross-Cultural Issues. Three additional white papers were also due by 2004 concerning gender issues, diagnostic issues in the geriatric population, and mental disorders in infants and young children. The white papers have been followed by a series of conferences to produce recommendations relating to specific disorders and issues, with attendance limited to 25 invited researchers.
On July 23, 2007, the APA announced the task force that will oversee the development of DSM-5. The DSM-5 Task Force consists of 27 members, including a chair and vice chair, who collectively represent research scientists from psychiatry and other disciplines, clinical care providers, and consumer and family advocates. Scientists working on the revision of the DSM have experience in research, clinical care, biology, genetics, statistics, epidemiology, public health, and consumer advocacy. They have interests ranging from cross-cultural medicine and genetics to geriatric issues, ethics and addiction. The APA Board of Trustees required that all task force nominees disclose any competing interests or potentially conflicting relationships with entities that have an interest in psychiatric diagnoses and treatments as a precondition to appointment to the task force. The APA made all task force members' disclosures available during the announcement of the task force. Several individuals were ruled ineligible for task force appointments due to their competing interests. Future announcements will include naming the workgroups on specific categories of disorders and their research-based recommendations on updating various disorders and definitions.
Owing to criticism over the perceived proliferation of diagnoses in the current edition of the DSM, David Kupfer, M.D., who is the DSM-5 Task Force chair and is shepherding the DSM's revision, said in an interview: "One of the raps against psychiatry is that you and I are the only two people in the U.S. without a psychiatric diagnosis."
Dimensional Assessments
In addition to proposed changes to specific diagnostic criteria, the APA is proposing that
“dimensional assessments” be added to diagnostic evaluations of mental disorders. These would
permit clinicians to evaluate the severity of symptoms, as well as take into account ”crosscutting” symptoms.
Careful Consideration of Gender, Race and Ethnicity
The process for developing the proposed diagnostic criteria for DSM-5 has included careful
consideration of how gender, race and ethnicity may affect the diagnosis of mental illness.
disorders (ASD). Under the proposed new classification, clinicians would rate the severity of clinical presentation of ASD as severe, moderate or mild. However, this proposal has inspired much controversy amongst Asperger's Syndrome specialists such as Tony Attwood
and Simon Baron-Cohen
and opposition groups, such as "Keep Asperger's Syndrome in the DSM-V."
There has been a proposal that for the Inattentive type and Hyperactive/Impulsive type, a minimum of only four symptoms need to be met if a person is 17 years of age or older. The current DSM-IV-TR criteria of meeting a minimum of six symptoms for the Inattentive type or Hyperactive/Impulsive Type would still apply for those 16 years of age or younger.
There have been proposals for more stringent criteria for the diagnosis of bipolar disorder in children
with a new diagnosis temper dysregulation disorder with dysphoria proposed.
, pornography use, cybersex
, etc.
The label “hypersexual disorder” was reportedly chosen because it did not imply any specific theory for what causes hypersexuality
, which remains unknown. A proposal to add sexual addiction
to the DSM system has been rejected by the APA, as not enough evidence suggested to them that the condition is analogous to substance addictions, as that name would imply.
The DSM-IV-TR includes "Sexual Disorder—Not Otherwise Specified" (Sexual Disorder NOS), which applies to, among other conditions, “distress about a pattern of repeated sexual relationships involving a succession of lovers who are experienced by the individual only as things to be used.”
It is proposed that a section be added to the diagnostic criteria for Oppositional Defiant Disorder stating that for children under 5 years of age, oppositional behavior "must occur on most days for a period of at least six months". For children 5 years or older, oppositional behavior "must occur at least once per week for at least six months". The current criteria states that four or more symptoms must be present for at least 6 months. The proposed change adds the criterion of frequency of symptoms and also delineates required frequency by the age of the child.
, introversion, antagonism
, disinhibition
, compulsivity
, and schizotypy
). In addition, patients would be assessed on how much they match each of six prototypic personality disorder types: antisocial
/psychopathic
, avoidant
, borderline
, narcissistic
, obsessive-compulsive
, and schizotypal
with their criteria being derived directly from the dimensional personality trait domains. Some former personality disorders, like histrionic personality disorder
, will be submerged under facets of various personality type domains (in this case, the narcissism and histrionism facets of antagonism).
It is proposed that the wording of "non-food substances" be added alongside the current DSM-IV-TR wording of "non-nutritive substances". "Non-food" was added to further clarify that items consumed are not just merely lacking nutrients (diet soda, according to the DSM-V committee, is an example of a non-nutritive substance), but are actual non-foodstuffs.
These disorders have been proposed because the recognized somatoform disorders are either too restrictive or too broad. In a study of 119 primary care patients, the following prevalences were found:
, the head of the DSM-III task force, has publicly criticized the APA for mandating that DSM-5 task force members sign a nondisclosure agreement, effectively conducting the whole process in secret: “When I first heard about this agreement, I just went bonkers. Transparency is necessary if the document is to have credibility, and, in time, you’re going to have people complaining all over the place that they didn’t have the opportunity to challenge anything.” Allen Frances
expressed a similar concern.
Although the APA has since instituted a disclosure policy for DSM-5 task force members, many still believe the Association has not gone far enough in its efforts to be transparent and to protect against industry influence. In a recent Point/Counterpoint article, Lisa Cosgrove, PhD and Harold J. Bursztajn, MD noted that "the fact that 70% of the task force members have reported direct industry ties---an increase of almost 14% over the percentage of DSM-IV task force members who had industry ties---shows that disclosure policies alone, especially those that rely on an honor system, are not enough and that more specific safeguards are needed."
David Kupfer, MD, chair of the DSM-5 task force, and Darrel A. Regier, MD, MPH, Vice Chair of the task force, whose industry ties are disclosed with those of the task force, countered that "collaborative relationships among government, academia, and industry are vital to the current and future development of pharmacological treatments for mental disorders." They asserted that the development of DSM-5 is the "most inclusive and transparent developmental process in the 60-year history of DSM." The developments to this new version can be viewed on. Perhaps as an effort towards this transparency, public input is requested for the first time in the history of the manual. Until June 15, 2011, members of the general public can sign up at the DSM-V website and provide feedback on the various proposed changes.
In June 2009 Allen Frances, head of the DSM-IV task force, issued strongly worded criticisms of the processes leading to DSM-5 and the risk of "serious, subtle, (…) ubiquitous" and "dangerous" unintended consequences such as new "false 'epidemics'". He writes that "the work on DSM-V has displayed the most unhappy combination of soaring ambition and weak methodology" and is concerned about the task force's "inexplicably closed and secretive process.". His and Spitzer's concerns about the contract that the APA drew up for consultants to sign, agreeing not to discuss drafts of the fifth edition beyond the task force and committees, have also been aired and debated.
The appointment, in May 2008, of two of the taskforce members, Kenneth Zucker
and Ray Blanchard
, has led to an internet petition to remove them. According to MSNBC, "The petition accuses Zucker of having engaged in 'junk science' and promoting 'hurtful theories' during his career." According to The Gay City News, "Dr. Ray Blanchard, a psychiatry professor at the University of Toronto, is deemed offensive for his theories that some types of transsexuality are paraphilias, or sexual urges. In this model, transsexuality is not an essential aspect of the individual, but a misdirected sexual impulse." Blanchard responded, "Naturally, it's very disappointing to me there seems to be so much misinformation about me on the Internet. [They didn't distort] my views, they completely reversed my views." Zucker "rejects the junk-science charge, saying there 'has to be an empirical basis to modify anything' in the DSM. As for hurting people, 'in my own career, my primary motivation in working with children, adolescents and families is to help them with the distress and suffering they are experiencing, whatever the reasons they are having these struggles. I want to help people feel better about themselves, not hurt them.'"
in DSM-5. The paper How Advocacy is Bringing BPD into the Light reports that "the name BPD is confusing, imparts no relevant or descriptive information, and reinforces existing stigma
...". There is also discussion about changing Borderline Personality Disorder, an Axis II diagnosis (personality disorders and mental retardation), to an Axis I diagnosis (clinical disorders).
, might fruitfully be analysed as Kuhnian anomalies leading the DSM system to a scientific crisis. As a consequence, a radical rethinking of the concept of mental disorder was proposed, acknowledging for its constructive nature. Based on similar views, several revolutionary approaches were proposed, ranging from dimensional diagnosis to various forms of etiopathogenetic diagnosis.)
in the United Kingdom stated in its June 2011 response that it had "more concerns than plaudits". It criticized proposed diagnoses as "clearly based largely on social norms, with 'symptoms' that all rely on subjective judgements... not value-free, but rather reflect[ing] current normative social expectations", noting doubts over the reliability, validity, and value of existing criteria, that personality disorders were not normed on the general population, and that "not otherwise specified" categories covered a "huge" 30% of all personality disorders.
It also expressed a major concern that "clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences... which demand helping responses, but which do not reflect illnesses so much as normal individual variation".
The Society suggested as its primary specific recommendation, a change from using "diagnostic frameworks" to a description based on an individual's specific experienced problems, and that mental disorders are better explored as part of a spectrum shared with normality
:
American Psychiatric Association
The American Psychiatric Association is the main professional organization of psychiatrists and trainee psychiatrists in the United States, and the most influential worldwide. Its some 38,000 members are mainly American but some are international...
(APA) Diagnostic and Statistical Manual of Mental Disorders
Diagnostic and Statistical Manual of Mental Disorders
The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and provides a common language and standard criteria for the classification of mental disorders...
(DSM), commonly called DSM-5 (previously known as DSM-V until the APA decided to abandon the Roman Numerals), is currently in consultation, planning and preparation. It is due for publication in May 2013 and will supersede the DSM-IV which was last revised in 2000. APA has an official development website for posting of draft versions of the DSM-5.
Development of DSM-5
In 1999, a DSM–5 Research Planning Conference, sponsored jointly by APA and the National Institute of Mental HealthNational Institute of Mental Health
The National Institute of Mental Health is one of 27 institutes and centers that make up the National Institutes of Health...
(NIMH), was held to set the research priorities. Research Planning Work Groups produced "white papers" on the research needed to inform and shape the DSM-V, and the resulting work and recommendations were reported in an APA monograph and peer-reviewed literature. There were six workgroups, each focusing on a broad topic: Nomenclature, Neuroscience and Genetics, Developmental Issues and Diagnosis, Personality and Relational Disorder
Relational disorder
According to Michael First, MD, of the DSM-5 working committee the locus of a relational disorder, in contrast to other DSM-IV disorders, "is on the relationship rather than on any one individual in the relationship."...
s, Mental Disorders and Disability, and Cross-Cultural Issues. Three additional white papers were also due by 2004 concerning gender issues, diagnostic issues in the geriatric population, and mental disorders in infants and young children. The white papers have been followed by a series of conferences to produce recommendations relating to specific disorders and issues, with attendance limited to 25 invited researchers.
On July 23, 2007, the APA announced the task force that will oversee the development of DSM-5. The DSM-5 Task Force consists of 27 members, including a chair and vice chair, who collectively represent research scientists from psychiatry and other disciplines, clinical care providers, and consumer and family advocates. Scientists working on the revision of the DSM have experience in research, clinical care, biology, genetics, statistics, epidemiology, public health, and consumer advocacy. They have interests ranging from cross-cultural medicine and genetics to geriatric issues, ethics and addiction. The APA Board of Trustees required that all task force nominees disclose any competing interests or potentially conflicting relationships with entities that have an interest in psychiatric diagnoses and treatments as a precondition to appointment to the task force. The APA made all task force members' disclosures available during the announcement of the task force. Several individuals were ruled ineligible for task force appointments due to their competing interests. Future announcements will include naming the workgroups on specific categories of disorders and their research-based recommendations on updating various disorders and definitions.
Owing to criticism over the perceived proliferation of diagnoses in the current edition of the DSM, David Kupfer, M.D., who is the DSM-5 Task Force chair and is shepherding the DSM's revision, said in an interview: "One of the raps against psychiatry is that you and I are the only two people in the U.S. without a psychiatric diagnosis."
First draft diagnostic criteria for DSM-5
The first draft diagnostic criteria for DSM-5 has now been released. Revisions include the following:- The recommendation of new categories for learning disorders and a single diagnostic category, “autism spectrum disorders” that will incorporate the current diagnoses of autistic disorders, Asperger’s Syndrome, childhood disintegrative disorder and pervasive developmental disorder (not otherwise specified). Work group members have also recommended that the diagnostic term “mental retardation” be changed to “intellectual disability,” bringing the DSM criteria into alignment with terminology used by other disciplines.
- Eliminating the current categories substance abuse and dependence, replacing them with the new category “addiction and related disorders.” This will include substance use disorders, with each drug identified in its own category. Eliminating the category of dependence will better differentiate between the compulsive drug-seeking behavior of addiction and normal responses of tolerance and withdrawal that some patients experience when using prescribed medications that affect the central nervous system.
- Creating a new category of “behavioral addictions,” in which gambling will be the sole disorder. Internet addiction was considered for this category, but work group members decided there was insufficient research data to do so, so they recommended it be included in the manual’s appendix instead, with a goal of encouraging additional study.
- New suicide scales for adults and adolescents to help clinicians identify those individuals most at risk, with a goal of enhancing interventions across a broad range of mental disorders; the scales include research-based criteria such as impulsive behavior and heavy drinking in teens.
- Consideration of a new “risk syndromes” category, with information to help clinicians identify earlier stages of some serious mental disorders, such as neurocognitive disorder (dementia) and psychosis.
- A proposed new diagnostic category, temper dysregulation with dysphoria (TDD), within the Mood Disorders section of the manual. The new criteria are based on a decade of research on severe mood dysregulation, and may help clinicians better differentiate children with these symptoms from those with bipolar disorderBipolar disorderBipolar disorder or bipolar affective disorder, historically known as manic–depressive disorder, is a psychiatric diagnosis that describes a category of mood disorders defined by the presence of one or more episodes of abnormally elevated energy levels, cognition, and mood with or without one or...
or oppositional defiant disorderOppositional defiant disorderOppositional defiant disorder is a diagnosis described by the Diagnostic and Statistical Manual of Mental Disorders as an ongoing pattern of disobedient, hostile and defiant behavior toward authority figures which goes beyond the bounds of normal childhood behavior...
. - New recognition of binge eating disorder and improved criteria for anorexia nervosa and bulimia nervosa, as well as recommended changes in the definitions of some eating disorders now described as beginning in infancy and childhood to emphasize that they may also develop in older individuals.
Dimensional Assessments
In addition to proposed changes to specific diagnostic criteria, the APA is proposing that
“dimensional assessments” be added to diagnostic evaluations of mental disorders. These would
permit clinicians to evaluate the severity of symptoms, as well as take into account ”crosscutting” symptoms.
Careful Consideration of Gender, Race and Ethnicity
The process for developing the proposed diagnostic criteria for DSM-5 has included careful
consideration of how gender, race and ethnicity may affect the diagnosis of mental illness.
Asperger syndrome
There have been proposals to eliminate Asperger's syndrome as a separate disorder, and instead merge it under autism spectrumAutism spectrum
The term "autism spectrum" is often used to describe disorders that are currently classified as pervasive developmental disorders. Pervasive developmental disorders include autism, Asperger syndrome, Childhood disintegrative disorder, Rett syndrome and Pervasive Developmental Disorder Not Otherwise...
disorders (ASD). Under the proposed new classification, clinicians would rate the severity of clinical presentation of ASD as severe, moderate or mild. However, this proposal has inspired much controversy amongst Asperger's Syndrome specialists such as Tony Attwood
Tony Attwood
Tony Attwood is an English psychologist who lives in Queensland, Australia and is an author of several books on Asperger's Syndrome....
and Simon Baron-Cohen
Simon Baron-Cohen
Simon Baron-Cohen FBA is professor of Developmental Psychopathology in the Departments of Psychiatry and Experimental Psychology at the University of Cambridge in the United Kingdom. He is the Director of the University's Autism Research Centre, and a Fellow of Trinity College...
and opposition groups, such as "Keep Asperger's Syndrome in the DSM-V."
Attention Deficit Hyperactivity Disorder
There has been a proposal to increase the diagnostic criteria for the age when symptoms became present. The proposal would change the diagnostic criteria from symptoms being present before seven years of age to symptoms being present before twelve years of age. The new diagnostic criteria would read: "B. Several noticeable inattentive or hyperactive-impulsive symptoms were present by age 12."There has been a proposal that for the Inattentive type and Hyperactive/Impulsive type, a minimum of only four symptoms need to be met if a person is 17 years of age or older. The current DSM-IV-TR criteria of meeting a minimum of six symptoms for the Inattentive type or Hyperactive/Impulsive Type would still apply for those 16 years of age or younger.
Bipolar disorder
There have been proposals to include further and more accurate sub-typing for bipolar disorder (Akiskal and Ghaemi, 2006).There have been proposals for more stringent criteria for the diagnosis of bipolar disorder in children
Bipolar disorder in children
Bipolar Disorder , formerly known as "Manic Depression", is characterized by extreme changes in mood that range from depressive "lows" to manic "highs"...
with a new diagnosis temper dysregulation disorder with dysphoria proposed.
Dissociative identity disorder
Proposed changes to the controversial dissociative identity disorder diagnosis include adding a new diagnostic criterion: "C. Causes clinically significant distress or impairment in social, occupational, or other important areas of functioning." This phrase, which occurs in several other diagnostic criteria, is proposed for inclusion in 300.14 as part of a proposed merger of dissociative trance disorder with DID. Criterion C would be included to "help differentiate normative cultural experiences from psychopathology". For example, professionals would be able to take shamanism, which involves voluntary possession trance states, into consideration, rather than diagnosing those who report it as having a mental disorder.Hypersexual disorder
Hypersexual Disorder is proposed as a new category to be added. The diagnosis would apply when a person experiences several of the indicated symptoms (extreme amounts of time spent in the sexual activity, using the sexual activity in response to low mood or stress, failed attempts to reduce the behaviors, etc.). Moreover, it would apply only when the problem lasted six months or more, when person experienced significant distress or impairment in major life areas because of it, and when the problem was not directly caused by a medication or drugs, as well as other criteria. Under the proposal, an official diagnosis would also specify which behavior(s) are problematic in the case: masturbationMasturbation
Masturbation refers to sexual stimulation of a person's own genitals, usually to the point of orgasm. The stimulation can be performed manually, by use of objects or tools, or by some combination of these methods. Masturbation is a common form of autoeroticism...
, pornography use, cybersex
Cybersex
Cybersex, also called computer sex, Internet sex, netsex, mudsex, TinySex and, colloquially, cybering, is a virtual sex encounter in which two or more persons connected remotely via computer network send each other sexually explicit messages describing a sexual experience...
, etc.
The label “hypersexual disorder” was reportedly chosen because it did not imply any specific theory for what causes hypersexuality
Hypersexuality
Hypersexuality is extremely frequent or suddenly increased sexual urges or sexual activity. Hypersexuality is typically associated with lowered sexual inhibitions. Although hypersexuality can be caused by some medical conditions or medications, in most cases the cause is unknown...
, which remains unknown. A proposal to add sexual addiction
Sexual addiction
Sexual addiction is a popular model to explain hypersexuality—sexual urges, behaviors, or thoughts that appear extreme in frequency or feel out of one's control...
to the DSM system has been rejected by the APA, as not enough evidence suggested to them that the condition is analogous to substance addictions, as that name would imply.
The DSM-IV-TR includes "Sexual Disorder—Not Otherwise Specified" (Sexual Disorder NOS), which applies to, among other conditions, “distress about a pattern of repeated sexual relationships involving a succession of lovers who are experienced by the individual only as things to be used.”
Oppositional Defiant Disorder
It is proposed that the eight symptoms of Oppositional Defiant Disorder should be divided into the following categories: Angry/Irritable Mood; Defiant/Headstrong Behavior; and Vindictiveness. However, just as in the DSM-IV-TR, four of these symptoms need to be present to meet diagnostic criteria. The minimum four symptoms can come from all (or even just one or two) of the three categories.It is proposed that a section be added to the diagnostic criteria for Oppositional Defiant Disorder stating that for children under 5 years of age, oppositional behavior "must occur on most days for a period of at least six months". For children 5 years or older, oppositional behavior "must occur at least once per week for at least six months". The current criteria states that four or more symptoms must be present for at least 6 months. The proposed change adds the criterion of frequency of symptoms and also delineates required frequency by the age of the child.
Personality disorders
Major changes have been proposed in the assessment and diagnosis of personality disorders. These include a revamped definition of personality disorder and a dimensional rather than a categorical approach based on the severity of dysfunctional personality trait domains (negative emotionalityNeuroticism
Neuroticism is a fundamental personality trait in the study of psychology. It is an enduring tendency to experience negative emotional states. Individuals who score high on neuroticism are more likely than the average to experience such feelings as anxiety, anger, guilt, and depressed mood...
, introversion, antagonism
Antagonism
Antagonism is hostility that results in active resistance, opposition, or contentiousness.Additionally, it may refer to:*Antagonism , where the involvement of multiple agents reduces their overall effect...
, disinhibition
Disinhibition
Disinhibition is a term in psychology used to describe a lack of restraint manifested in several ways, including disregard for social conventions, impulsivity, and poor risk assessment. Disinhibition affects motor, instinctual, emotional, cognitive and perceptual aspects with signs and symptoms...
, compulsivity
Conscientiousness
Conscientiousness is the trait of being painstaking and careful, or the quality of acting according to the dictates of one's conscience. It includes such elements as self-discipline, carefulness, thoroughness, organization, deliberation , and need for achievement. It is an aspect of what has...
, and schizotypy
Schizotypy
Schizotypy is a psychological concept which describes a continuum of personality characteristics and experiences ranging from normal dissociative, imaginative states to more extreme states related to psychosis and in particular, schizophrenia...
). In addition, patients would be assessed on how much they match each of six prototypic personality disorder types: antisocial
Antisocial personality disorder
Antisocial personality disorder is described by the American Psychiatric Association's Diagnostic and Statistical Manual, fourth edition , as an Axis II personality disorder characterized by "...a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood...
/psychopathic
Psychopathy
Psychopathy is a mental disorder characterized primarily by a lack of empathy and remorse, shallow emotions, egocentricity, and deceptiveness. Psychopaths are highly prone to antisocial behavior and abusive treatment of others, and are very disproportionately responsible for violent crime...
, avoidant
Avoidant personality disorder
Avoidant personality disorder is a personality disorder recognized in the Diagnostic and Statistical Manual of Mental Disorders handbook in a person characterized by a pervasive pattern of social inhibition, feelings of inadequacy, extreme sensitivity to negative evaluation, and avoidance of...
, borderline
Borderline personality disorder
Borderline personality disorder is a personality disorder described as a prolonged disturbance of personality function in a person , characterized by depth and variability of moods.The disorder typically involves unusual levels of instability in mood; black and white thinking, or splitting; the...
, narcissistic
Narcissistic personality disorder
Narcissistic personality disorder is a personality disorder in which the individual is described as being excessively preoccupied with issues of personal adequacy, power, prestige and vanity...
, obsessive-compulsive
Obsessive-compulsive personality disorder
Obsessive–compulsive personality disorder is a personality disorder characterized by a pervasive pattern of preoccupation with orderliness, perfectionism, and mental and interpersonal control at the expense of flexibility, openness, and efficiency.- Signs and symptoms :The primary symptoms of OCPD...
, and schizotypal
Schizotypal personality disorder
Schizotypal personality disorder, or simply schizotypal disorder, is a personality disorder that is characterized by a need for social isolation, anxiety in social situations, odd behavior and thinking, and often unconventional beliefs.-Genetic:...
with their criteria being derived directly from the dimensional personality trait domains. Some former personality disorders, like histrionic personality disorder
Histrionic personality disorder
Histrionic personality disorder is defined by the American Psychiatric Association as a personality disorder characterized by a pattern of excessive emotionality and attention-seeking, including an excessive need for approval and inappropriately seductive behavior, usually beginning in early...
, will be submerged under facets of various personality type domains (in this case, the narcissism and histrionism facets of antagonism).
Pica
It is proposed that Pica is reclassified from the "Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence" classification to the "Eating Disorders" classification.It is proposed that the wording of "non-food substances" be added alongside the current DSM-IV-TR wording of "non-nutritive substances". "Non-food" was added to further clarify that items consumed are not just merely lacking nutrients (diet soda, according to the DSM-V committee, is an example of a non-nutritive substance), but are actual non-foodstuffs.
Posttraumatic stress disorder
Various criteria changes are proposed.Schizophrenia
The following disorders are proposed for deletion from DSM-5:- 295.30 Schizophrenia - Paranoid Type
- 295.10 Schizophrenia - Disorganized Type
- 295.20 Schizophrenia - Catatonic Type
- 295.90 Schizophrenia - Undifferentiated Type
- 295.60 Schizophrenia - Residual Type
- 297.3 Shared Psychotic Disorder
Somatoform disorder
Additional proposed somatoform disorders are:- Abridged somatization disorder - at least 4 unexplained somatic complaints in men and 6 in women
- Multisomatoform disorder - at least 3 unexplained somatic complaints from the PRIME-MD scale for at least 2 years of active symptoms
These disorders have been proposed because the recognized somatoform disorders are either too restrictive or too broad. In a study of 119 primary care patients, the following prevalences were found:
- Somatization disorderSomatization disorderSomatization disorder is a psychiatric diagnosis applied to patients who persistently complain of varied physical symptoms that have no identifiable physical origin...
- 1% - Abridged somatization disorder - 6%
- Multisomatoform disorder - 24%
- Undifferentiated somatoform disorder - 79%
Proposed DSM-5 new diagnoses
The proposed DSM-5 new diagnoses include the following:- Absexual
- Complex post-traumatic stress disorderComplex post-traumatic stress disorderComplex post-traumatic stress disorder is a psychological injury that results from protracted exposure to prolonged social and/or interpersonal trauma with lack or loss of control, disempowerment, and in the context of either captivity or entrapment, i.e. the lack of a viable escape route for the...
- Depressive personality disorderDepressive personality disorderDepressive Personality Disorder is a controversial psychiatric diagnosis that denotes a personality disorder with depressive features....
- Negativistic (passive-aggressive) personality disorder
- Relational disorderRelational disorderAccording to Michael First, MD, of the DSM-5 working committee the locus of a relational disorder, in contrast to other DSM-IV disorders, "is on the relationship rather than on any one individual in the relationship."...
- Sluggish cognitive tempoSluggish cognitive tempoSluggish Cognitive Tempo is an unformalized descriptive term which is used to better identify what appears to be a homogeneous sub-subgroup within the formal subgroup "ADHD predominantly inattentive"...
- Binge EatingBinge eatingBinge eating is a pattern of disordered eating which consists of episodes of uncontrollable eating. It is sometimes as a symptom of binge eating disorder. During such binges, a person rapidly consumes an excessive amount of food...
Conditions Proposed by Outside Sources
The following conditions have been proposed by outside sources for inclusion in the DSM-5:- Apathy Syndrome
- Body Integrity Identity DisorderBody integrity identity disorderBody Integrity Identity Disorder , formerly known as Amputee Identity Disorder, is a psychological disorder wherein sufferers feel they would be happier living as an amputee...
- Complicated Grief Disorder
- Developmental Trauma Disorder
- Disorders of Extreme Stress Not Otherwise Specified
- Fetal Alcohol SyndromeFetal alcohol syndromeFetal alcohol syndrome is a pattern of mental and physical defects that can develop in a fetus in association with high levels of alcohol consumption during pregnancy. Current research also implicates other lifestyle choices made by the prospective mother...
- Internet Addiction DisorderInternet addiction disorderInternet addiction disorder , or, more broadly, Internet overuse, problematic computer use or pathological computer use, is excessive computer use that interferes with daily life...
- Male-to-Eunuch Gender Identity Disorder
- MelancholiaMelancholiaMelancholia , also lugubriousness, from the Latin lugere, to mourn; moroseness, from the Latin morosus, self-willed, fastidious habit; wistfulness, from old English wist: intent, or saturnine, , in contemporary usage, is a mood disorder of non-specific depression,...
- Parental Alienation SyndromeParental alienation syndromeParental alienation syndrome is term coined by Richard A. Gardner in the early 1980s to refer to what he describes as a disorder in which a child, on an ongoing basis, belittles and insults one parent without justification, due to a combination of factors, including indoctrination by the other...
- Seasonal Affective DisorderSeasonal affective disorderSeasonal affective disorder , also known as winter depression, winter blues, summer depression, summer blues, or seasonal depression, is a mood disorder in which people who have normal mental health throughout most of the year experience depressive symptoms in the winter or summer, spring or autumn...
- Sensory Processing DisorderSensory processing disorderSensory processing disorder or SPD is a neurological disorder causing difficulties with taking in, processing and responding to sensory information about the environment and from within the own body .For those with SPD, sensory information may be sensed and perceived in a way that is different from...
Criticism of DSM-4
Robert SpitzerRobert Spitzer (psychiatrist)
Robert L. Spitzer was a major architect of the modern classification of mental disorders. He is a retired professor of psychiatry at Columbia University in New York City, United States and was on the research faculty of the Columbia University Center for Psychoanalytic Training and Research. He...
, the head of the DSM-III task force, has publicly criticized the APA for mandating that DSM-5 task force members sign a nondisclosure agreement, effectively conducting the whole process in secret: “When I first heard about this agreement, I just went bonkers. Transparency is necessary if the document is to have credibility, and, in time, you’re going to have people complaining all over the place that they didn’t have the opportunity to challenge anything.” Allen Frances
Allen Frances
Allen J. "Al" Frances is an American psychiatrist. He was chair of the DSM-IV Task Force. He also served as Chair of the department of psychiatry at Duke University School of Medicine...
expressed a similar concern.
Although the APA has since instituted a disclosure policy for DSM-5 task force members, many still believe the Association has not gone far enough in its efforts to be transparent and to protect against industry influence. In a recent Point/Counterpoint article, Lisa Cosgrove, PhD and Harold J. Bursztajn, MD noted that "the fact that 70% of the task force members have reported direct industry ties---an increase of almost 14% over the percentage of DSM-IV task force members who had industry ties---shows that disclosure policies alone, especially those that rely on an honor system, are not enough and that more specific safeguards are needed."
David Kupfer, MD, chair of the DSM-5 task force, and Darrel A. Regier, MD, MPH, Vice Chair of the task force, whose industry ties are disclosed with those of the task force, countered that "collaborative relationships among government, academia, and industry are vital to the current and future development of pharmacological treatments for mental disorders." They asserted that the development of DSM-5 is the "most inclusive and transparent developmental process in the 60-year history of DSM." The developments to this new version can be viewed on. Perhaps as an effort towards this transparency, public input is requested for the first time in the history of the manual. Until June 15, 2011, members of the general public can sign up at the DSM-V website and provide feedback on the various proposed changes.
In June 2009 Allen Frances, head of the DSM-IV task force, issued strongly worded criticisms of the processes leading to DSM-5 and the risk of "serious, subtle, (…) ubiquitous" and "dangerous" unintended consequences such as new "false 'epidemics'". He writes that "the work on DSM-V has displayed the most unhappy combination of soaring ambition and weak methodology" and is concerned about the task force's "inexplicably closed and secretive process.". His and Spitzer's concerns about the contract that the APA drew up for consultants to sign, agreeing not to discuss drafts of the fifth edition beyond the task force and committees, have also been aired and debated.
The appointment, in May 2008, of two of the taskforce members, Kenneth Zucker
Kenneth Zucker
Kenneth J. Zucker is a Jewish American-Canadian psychologist and sexologist, and head of the child and adolescent gender identity clinic at Toronto's Centre for Addiction and Mental Health. Based on his collaboration with Susan Bradley, Zucker is considered an international authority in the field...
and Ray Blanchard
Ray Blanchard
Ray Milton Blanchard is an American-Canadian sexologist, best known for his research studies on pedophilia, gender dysphoria, and sexual orientation. He has also published research studies on phallometry and several paraphilias, including transvestism and autoerotic asphyxia.-Education and...
, has led to an internet petition to remove them. According to MSNBC, "The petition accuses Zucker of having engaged in 'junk science' and promoting 'hurtful theories' during his career." According to The Gay City News, "Dr. Ray Blanchard, a psychiatry professor at the University of Toronto, is deemed offensive for his theories that some types of transsexuality are paraphilias, or sexual urges. In this model, transsexuality is not an essential aspect of the individual, but a misdirected sexual impulse." Blanchard responded, "Naturally, it's very disappointing to me there seems to be so much misinformation about me on the Internet. [They didn't distort] my views, they completely reversed my views." Zucker "rejects the junk-science charge, saying there 'has to be an empirical basis to modify anything' in the DSM. As for hurting people, 'in my own career, my primary motivation in working with children, adolescents and families is to help them with the distress and suffering they are experiencing, whatever the reasons they are having these struggles. I want to help people feel better about themselves, not hurt them.'"
Borderline personality disorder controversy
The Treatment and Research Advancements National Association for Personality Disorders (TARA-APD) campaigns to change the name and designation of borderline personality disorderBorderline personality disorder
Borderline personality disorder is a personality disorder described as a prolonged disturbance of personality function in a person , characterized by depth and variability of moods.The disorder typically involves unusual levels of instability in mood; black and white thinking, or splitting; the...
in DSM-5. The paper How Advocacy is Bringing BPD into the Light reports that "the name BPD is confusing, imparts no relevant or descriptive information, and reinforces existing stigma
Social stigma
Social stigma is the severe disapproval of or discontent with a person on the grounds of characteristics that distinguish them from other members of a society.Almost all stigma is based on a person differing from social or cultural norms...
...". There is also discussion about changing Borderline Personality Disorder, an Axis II diagnosis (personality disorders and mental retardation), to an Axis I diagnosis (clinical disorders).
More radical criticisms
Some authors believe that the problem is not simply of a few criteria to be deleted or modified. For example, a Kuhnian reformulation of the diagnostic debate suggested that apparently trivial problems of the DSM, like the extremely high rates of comorbidityComorbidity
In medicine, comorbidity is either the presence of one or more disorders in addition to a primary disease or disorder, or the effect of such additional disorders or diseases.- In medicine :...
, might fruitfully be analysed as Kuhnian anomalies leading the DSM system to a scientific crisis. As a consequence, a radical rethinking of the concept of mental disorder was proposed, acknowledging for its constructive nature. Based on similar views, several revolutionary approaches were proposed, ranging from dimensional diagnosis to various forms of etiopathogenetic diagnosis.)
The British Psychological Society Response
The British Psychological SocietyBritish Psychological Society
The British Psychological Society is a representative body for psychologists and psychology in the United Kingdom. The BPS is also a Registered Charity and, along with advantages, this also imposes certain constraints on what the society can and cannot do...
in the United Kingdom stated in its June 2011 response that it had "more concerns than plaudits". It criticized proposed diagnoses as "clearly based largely on social norms, with 'symptoms' that all rely on subjective judgements... not value-free, but rather reflect[ing] current normative social expectations", noting doubts over the reliability, validity, and value of existing criteria, that personality disorders were not normed on the general population, and that "not otherwise specified" categories covered a "huge" 30% of all personality disorders.
It also expressed a major concern that "clients and the general public are negatively affected by the continued and continuous medicalisation of their natural and normal responses to their experiences... which demand helping responses, but which do not reflect illnesses so much as normal individual variation".
The Society suggested as its primary specific recommendation, a change from using "diagnostic frameworks" to a description based on an individual's specific experienced problems, and that mental disorders are better explored as part of a spectrum shared with normality
Normality (behavior)
In behavior, normal refers to a lack of significant deviation from the average. The phrase "not normal" is often applied in a negative sense Abnormality varies greatly in how pleasant or unpleasant this is for other people.The Oxford English Dictionary defines "normal" as "conforming to a standard"...
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