The video below is the section for DSM-5 from Part 6 of TSM’s lecture series on DSM-5 and the EPPP, followed by a transcript. This lecture series aims to equip those preparing for the EPPP with everything you need to know about the impact DSM-5 will be having on the EPPP. To watch all of Part 6, click HERE. To watch earlier lectures in this series, or register for our webinar series on DSM-5 and the EPPP, click HERE.
Transcript of DSM-5 EPPP Lecture Video: DSM-5
The Diagnostic and Statistical Manual of Mental Disorders is the standard classification of mental disorders used by mental health professionals. The current version is the fifth edition, referred to as the DSM-5, and published by the American Psychiatric Association in May 2013.
The DSM-5 is intended to be used by clinicians and researchers of many different orientations (e.g., biological, psychodynamic, cognitive-behavioral, family systems), applicable across different clinical settings (e.g., outpatient, in-patient, consultation-liaison, private practice, community clinics), and useful to a range of health and mental health professionals (e.g., psychiatrists and other physicians, psychologists, social workers, nurses, marriage and family therapists, occupational and rehabilitation therapists, and counselors).
Historically, each edition of the DSM was identified by Roman numerals corresponding to the number of that edition: DSM-I through DSM-IV.
In light of continued scientific advances, including findings from research in genetics and neuroimaging, the DSM-5 broke with this tradition in numeration, with the goal of facilitating revisions for timely integration of new relevant data. Updates will be identified with decimals, i.e., DSM-5.1, DSM-5.2, and so on, until a new edition is required.
The DSM-5 separates mental disorders into types or categories, based on symptom clusters and defining sets of criteria, much like other specialties in Medicine have traditionally classified illnesses. The DSM-5 also attempts to view mental disorders from a dimensional perspective, without assuming that there are necessarily clear demarcations between different mental disorders, and acknowledging a degree of continuity among the categories named and the underlying factors they may share.
A categorical approach to classification works best when there are distinct boundaries between groups, when there is homogeneity among group members, and when groups are mutually exclusive (an item can belong to only one group). But in reality, boundaries between mental disorders are unclear, there is heterogeneity among individuals within any diagnostic category, and categories often overlap (comorbidity).
In order to address the problems associated with a categorical system of classification, the DSM-5 includes polythetic criteria for making diagnoses; that is, an individual must display a certain number of (but not necessarily all) defining characteristics or symptoms of a disorder in order to receive that diagnosis. Thus, individuals with differing clinical presentations may be given the same diagnosis, and individuals with different diagnoses may share a number of symptoms.
Contrasting with categories, dimensions allow for better measurement of symptom severity, which in turn affects a person’s level of functioning. Individuals with the same diagnosis may present various symptoms with differing degrees of severity during distinct periods of the course of their illness. It has been consistently shown that level of functioning is a better predictor of prognosis than categorization. Thus, the DSM-5 categories invite or require assessment of severity of symptoms and descriptions of levels of functioning. Although not a perfect system, it can be considered a significant shift in our understanding and description of mental disorders, and a significant step in the development of assessment tools.
The chapters in the DSM-5 are organized to reflect a lifespan approach, beginning with diagnoses more likely to be found in children and progressing toward disorders more frequently diagnosed in older adults.
When research (e.g., in genetics, neurobiology) has indicated that different diagnostic categories share underlying factor(s), those disorders were linked into a spectrum, reminding us of their sometimes hidden connections. An example of this is the Autism Spectrum Disorder, which links pervasive developmental disorders into a wider continuum. Another example is the Schizophrenia Spectrum Disorder and its link to Schizotypal Personality Disorder.
For clinically significant symptoms that are characteristic of a group of disorders, but do not meet full criteria for any of the disorders of that class, the proper diagnosis is “Other Specified Disorder” (when the specific reason that the presentation does not meet criteria for any of the existing disorders is communicated) or “Unspecified Disorder” (when the reason that the diagnostic criteria were not fully met for a specific disorder is not communicated). An example found in the DSM-5 indicates that depressive symptoms causing impairment lasting more than 4 days but less than 13 days, in an individual whose clinical picture has never met criteria for any depressive, bipolar disorder, or psychotic disorder, would lead to a diagnosis of Other Specified Depressive Disorder: short duration depressive episode.
Each type or subtype of mental disorder is assigned a code, a number that identifies the diagnostic category. The DSM-5 includes two sets of codes for each diagnosis. The first code corresponds to the coding system of the International Classification of Diseases, 9th edition (ICD-9), which is currently used in the USA.
The second code, printed in parenthesis and in grey font, corresponds to the coding system of the International Classification of Diseases, 10th edition (ICD-10), currently being used internationally. The codes from the ICD-10 are not expected to be adopted in the USA prior to October 2015, according to information posted on the website of the Centers for Disease Control and Prevention (CDC, www.cdc.gov).
The DSM-5 recognizes that not all presenting problems, nor all conditions that are likely to benefit from clinical attention, constitute mental disorders. To allow identification and record of these conditions by clinicians, there is a chapter that lists “Other Conditions That May Be a Focus of Clinical Attention,” which include relational (e.g., parent-child relational problem, child maltreatment) and environmental conditions (e.g., inadequate housing, acculturation difficulty). The documentation of diagnoses pertinent to a person is done by listing the identified disorders and conditions in decreasing order of importance at the time of the assessment.
To clarify the clinical picture of a person’s diagnosis, or to describe the current episode of a person’s chronic mental disorder, the DSM-5 diagnostic categories are to be further described with specifiers (e.g., with manic features, in partial remission). The person being treated is also to be assessed for level of functioning, i.e., the degree of disability is to be measured and recorded. The WHO Disability Assessment Schedule (WHODAS) is included among other emerging measures and models in a separate chapter. The DSM-5 chapter that follows these assessment tools focuses on the importance of a cultural conceptualization of the person and his/her illness, and includes a newly developed Cultural Formulation Interview.
1. Categorical approach to classification attempts to view mental disorder from a dimensional perspective, without assuming necessarily clear demarcations between different mental disorder, while acknowledging degree of continuity among the categories and the underlying factors shared
2. Mental Disorders separated into types or categories, based on symptom clusters and defining sets of criteria
3. Polythetic criteria: individual must display a certain number of defining characteristics/symptoms to be diagnosed
4. Severity and Levels of Functioning: a better predictor of prognosis than categorization
5. DSM-5 chapters organized to reflect lifespan approach
6. Two sets of codes for each diagnosis:
A. ICD 9th Ediition (used in US)
B. ICD 10th Edition (used internationally)
7. WHO Disability Assessment Schedule (WHODAS): an emerging measure/model for assessing degree fo disability
Psychosocial and Contextual Factors used to be known as:
A. Axis III.
B. Axis V.
C. Axis I.
D. Axis IV.
The correct answer is D. The DSM-5 does not utilize a multiaxial diagnosis but instead it combines axes I, II, and III and carries a separate notion for significant psychosocial and contextual factors, which make A and C false. Axis five, which supplied the GAF but now known as disability, which makes answer B incorrect.