The DSM-V (DSM-5)

The newest diagnostic manual, DSM-5 (APA, 2013), was under development from 1999 to 2013 (Smith, 2012) and was first published in May of 2013. The DSM-5 includes a sleeker, more computer-friendly name, which replaces the Roman numeral tradition of the DSM. Subsequent editions, like computer software, will follow with editions 5.1, 5.2, 5.3, and so on. In addition to the print version of DSM-5, an online component (www.psychiatry.org/dsm5) is now available for supplemental materials such as assessment measures, but it also includes related news articles, fact sheets, and audiovisual materials. Another important change that has been made to the DSM-5 is an effort to align it with the ICD-9, and later, the ICD-10 (release date: October 1, 2014). This serves to unify the diagnostic and billing process between psychological and medical professions. Thus the DSM-5 gives both the ICD-9 and ICD-10 codes, and when making a diagnosis, one may want to list the ICD-9 code first and place the ICD-10 code in parenthesis. Clearly, it is important to know which version of the ICD is being used when making your diagnosis.

Single-Axis vs. Multiaxial Diagnosis

Perhaps the most significant change in the DSM-5 was the return to a single-axis diagnosis (APA, 2013; Wakefield, 2013). This was done for a number of reasons. First, the separation of personality disorders to Axis II under DSM-IV gave these disorders undeserved status and the misguided belief that they were largely untreatable (Good, 2012; Krueger & Eaton, 2010). Clients who met the criteria for an Axis II diagnosis may now find it easier to navigate mental health treatment as they will no longer be seen as having a diagnosis that is more difficult to treat than a host of other disorders. In DSM-5, medical conditions are no longer listed on a separate axis (Axis III in DSM-IV). Thus, they will likely take a more significant role in mental health diagnosis as they can be listed side-by-side with the mental disorder (Wakefield, 2013). Also, psychosocial and environmental stressors, previously listed on Axis IV of DSM-IV, will be listed alongside mental disorders and physical health issues. In fact, DSM-5 has increased the number of “V codes” (Z codes in ICD-10), which are considered nondisordered conditions that sometimes are the focus of treatment and often are reflective of a host of psychosocial and environmental issues (e.g., homelessness, divorce, etc.). As for the GAF score, previously on Axis V of DSM-IV, the APA intended to replace this historically unreliable tool with a different scaling assessment altogether. One assessment instrument, now being researched, is the World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0). This 36-item, self-administered questionnaire assesses a client’s functioning in six domains: understanding and communicating, getting around, self-care, getting along with people, life activities, and participation in society (APA, 2013). Disorders and other assessments that are under review for further research can be found in Section III of the DSM-5.

Specific Diagnostic Categories

Section II of DSM-5 offers an in-depth discussion of 22 broad diagnostic categories and their subtypes as well as descriptions of medication-induced disorders and what is called “other conditions that may be a focus of clinical attention.” The following offers a brief description of these disorders and is summarized from DSM-5 (APA, 2013). Please refer to the DSM-5 for an in-depth review of each disorder. When you finish reviewing these diagnoses, the class may want to do Exercise 3.1.

• Neurodevelopmental Disorders. This group of disorders typically refers to those that manifest during early development, although diagnoses are sometimes not assigned until adulthood. Examples of neurodevelopmental disorders include intellectual disabilities, communication disorders, autism spectrum disorders (incorporating the former categories of autistic disorder, Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder), ADHD, specific learning disorders, motor disorders, and other neurodevelopmental disorders. 

• Schizophrenia Spectrum and Other Psychotic Disorders. The disorders that belong to this section all have one feature in common: psychotic symptoms, that is, delusions, hallucinations, grossly disorganized or abnormal motor behavior, and/or negative symptoms. The disorders include schizotypal personality disorder (which is listed again, and explained more comprehensively, in the category of Personality Disorders in the DSM-5), delusional disorder, brief psychotic disorder, schizophreniform disorder, schizophrenia, schizoaffective disorder, substance/medication-induced psychotic disorders, psychotic disorders due to another medical condition, and catatonic disorders.

• Bipolar and Related Disorders. The disorders in this category refer to disturbances in mood in which the client cycles through stages of mania or mania and depression. Both children and adults can be diagnosed with bipolar disorder, and the clinician can work to identify the pattern of mood presentation, such as rapid-cycling, which is more often observed in children. These disorders include bipolar I, bipolar II, cyclothymic disorder, substance/medication-induced, bipolar and related disorder due to another medical condition, and other specified or unspecified bipolar and related disorders.

• Depressive Disorders. Previously grouped into the broader category of “mood disorders” in the DSM-IV-TR, these disorders describe conditions where depressed mood is the overarching concern. They include disruptive mood dysregulation disorder, major depressive disorder, persistent depressive disorder (also known as dysthymia), and premenstrual dysphoric disorder. 

• Anxiety Disorders. There are a wide range of anxiety disorders, which can be diagnosed by identifying a general or specific cause of unease or fear. This anxiety or fear is considered clinically significant when it is excessive and persistent over time. Examples of anxiety disorders that typically manifest earlier in development include separation anxiety and selective mutism. Other examples of anxiety disorders are specific phobia, social anxiety disorder (also known as social phobia), panic disorder, and generalized anxiety disorder.

• Obsessive-Compulsive and Related Disorders. Disorders in this category all involve obsessive thoughts and compulsive behaviors that are uncontrollable and the client feels compelled to perform them. Diagnoses in this category include obsessive-compulsive disorder, body dysmorphic disorder, hoarding disorder, trichotillomania (or hair-pulling disorder), and excoriation (or skin-picking) disorder.

• Trauma- and Stressor-Related Disorders. A new category for DSM-5, trauma and stress disorders emphasize the pervasive impact that life events can have on an individual’s emotional and physical well-being. Diagnoses include reactive attachment disorder, disinhibited social engagement disorder, posttraumatic stress disorder, acute stress disorder, and adjustment disorders.

• Dissociative Disorders. These disorders indicate a temporary or prolonged disruption to consciousness that can cause an individual to misinterpret identity, surroundings, and memories. Diagnoses include dissociative identity disorder (formerly known as multiple personality disorder), dissociative amnesia, depersonalization/derealization disorder, and other specified and unspecified dissociative disorders.

• Somatic Symptom and Related Disorders. Somatic symptom disorders were previously referred to as “somatoform disorders” and are characterized by the experiencing of a physical symptom without evidence of a physical cause, thus suggesting a psychological cause. Somatic symptom disorders include somatic symptom disorder, illness anxiety disorder (formerly hypochondriasis), conversion (or functional neurological symptom) disorder, psychological factors affecting other medical conditions, and factitious disorder.

• Feeding and Eating Disorders. This group of disorders describes clients who have severe concerns about the amount or type of food they eat to the point that serious health problems, or even death, can result from their eating behaviors. Examples include avoidant/restrictive food intake disorder, anorexia nervosa, bulimia nervosa, binge eating disorder, pica, and rumination disorder. 

• Elimination Disorders. These disorders can manifest at any point in a person’s life, although they are typically diagnosed in early childhood or adolescence. They include enuresis, which is the inappropriate elimination of urine, and encopresis, which is the inappropriate elimination of feces. These behaviors may or may not be intentional.

• Sleep-Wake Disorders. This category refers to disorders where one’s sleep patterns are severely impacted, and they often co-occur with other disorders (e.g., depression or anxiety). Some examples include insomnia disorder, hypersomnolence disorder, restless legs syndrome, narcolepsy, and nightmare Disorder. A number of sleep-wake disorders involve variations in breathing, such as sleep-related hypoventilation, obstructive sleep apnea hypopnea, or central sleep apnea. See the DSM-5 for the full listing and descriptions of these disorders.

• Sexual Dysfunctions. These disorders are related to problems that disrupt sexual functioning or one’s ability to experience sexual pleasure. They occur across sexes and include delayed ejaculation, erectile disorder, female orgasmic disorder, and premature (or early) ejaculation disorder, among others.

• Gender Dysphoria. Formerly termed, “gender identity disorder,” this category includes those individuals who experience significant distress with the sex they were born and with associated gender roles. This diagnosis has been separated from the category of sexual disorders, as it is now accepted that gender dysphoria does not relate to a person’s sexual attractions.

• Disruptive, Impulse Control, and Conduct Disorders. These disorders are characterized by socially unacceptable or otherwise disruptive and harmful behaviors that are outside of the individual’s control. Generally, more common in males than in females, and often first seen in childhood, they include oppositional defiant disorder, conduct disorder, intermittent explosive disorder, antisocial personality disorder (which is also coded in the category of personality disorders), kleptomania, and pyromania.

• Substance-Related and Addictive Disorders. Substance use disorders include disruptions in functioning as the result of a craving or strong urge. Often caused by prescribed and illicit drugs or the exposure to toxins, with these disorders the brain’s reward system pathways are activated when the substance is taken (or in the case of gambling disorder, when the behavior is being performed). Some common substances include alcohol, caffeine, nicotine, cannabis, opioids, inhalants, amphetamine, phencyclidine (PCP), sedatives, hypnotics or anxiolytics. Substance use disorders are further designated with the following terms: intoxication, withdrawal, induced, or unspecified.

• Neurocognitive Disorders. These disorders are diagnosed when one’s decline in cognitive functioning is significantly different from the past and is usually the result of a medical condition (e.g., Parkinson’s or Alzheimer’s disease), the use of a substance/medication, or traumatic brain injury, among other phenomena. Examples of neurocognitive disorders (NCD) include delirium, and several types of major and mild NCDs such as frontotemporal NCD, NCD due to Parkinson’s disease, NCD due to HIV infection, NCD due to Alzheimer’s disease, substance- or medication-induced NCD, and vascular NCD, among others.

• Personality Disorders. The 10 personality disorders in DSM-5 all involve a pattern of experiences and behaviors that are persistent, inflexible, and deviate from one’s cultural expectations. Usually, this pattern emerges in adolescence or early adulthood and causes severe distress in one’s interpersonal relationships. The personality disorders are grouped into three following clusters based on similar behaviors:

• Cluster A: Paranoid, schizoid, and schizotypal. These individuals seem bizarre or unusual in their behaviors and interpersonal relations. 

• Cluster B: Antisocial, borderline, histrionic, and narcissistic. These individuals seem overly emotional, are melodramatic, or unpredictable in their behaviors and interpersonal relations. 

• Cluster C: Avoidant, dependent, and obsessive-compulsive (not to be confused with obsessive-compulsive disorder). These individuals tend to appear anxious, worried, or fretful in their behaviors.

In addition to these clusters, one can be diagnosed with other specified or unspecified personality disorder, as well as a personality change due to another medical condition, such as a head injury.

• Paraphilic Disorders. These disorders are diagnosed when the client is sexual aroused to circumstances that deviate from traditional sexual stimuli and when such behaviors result in harm or significant emotional distress. The disorders include exhibitionistic disorder, voyeuristic disorder, frotteurisitc disorder, sexual sadism and sexual masochism disorders, fetishistic disorder, transvestic disorder, pedophilic disorder, and other specified and unspecified paraphilic disorders. 

• Other Mental Disorders. This diagnostic category includes mental disorders that did not fall within one of the previously mentioned groups and do not have unifying characteristics. Examples include other specified mental disorder due to another medical condition, unspecified mental disorders due to another medical condition, other specified mental disorder, and unspecified mental disorder. 

• Medication-Induced Movement Disorders and Other Adverse Effects of Medications. These disorders are the result of adverse and severe side effects to medications, although a causal link cannot always be shown. Some of these disorders include neuroleptic-induced parkinsonism, neuroleptic malignant syndrome, medication-induced dystonia, medication-induced acute akathisia, tardive dyskinesia, tardive akathisia, medication-induced postural tremor, other medication-induced movement disorder, antidepressant discontiunation syndrome, and other adverse effect of medication.

• Other Conditions That May Be a Focus of Clinical Assessment. Reminiscent of Axis IV of the previous edition of the DSM, this last part of Section II ends with a description of concerns that could be clinically significant, such as abuse/neglect, relational problems, psychosocial, personal, and environmental concerns, educational/occupational problems, housing and economic problems, and problems related to the legal system. These conditions, which are not consider mental disorders, are generally lised as V codes, which correspond to ICD-9, or Z codes, which correspond to ICD-10.

Sometimes, mental health conditions can co-occur or be “comorbid.” For example, suppose a client presents with an anxiety disorder but also abuses alcohol. In this situation, it would be appropriate to denote both disorders when making a diagnosis (e.g., generalized anxiety disorder and alcohol abuse). Sometimes disorders can even exacerbate each other. An example of this could be someone who meets the criteria for depression, but his or her symptoms only present while withdrawing from cocaine use. Rather than diagnosing this as a major depressive episode, it is more appropriate that he or she be diagnosed with a substance-induced mood disorder (see Exercise 3.1).