Key conceptual frameworks and approaches DSM 5

ICD-11/DSM-5 Harmonization and Implementation

  • DSM-5 diagnostic criteria were finalized just as ICD-11 working groups were beginning to develop ICD-11 clinical descriptions and diagnostic guidelines.
  • Some improvement in harmonization at the disorder level was achieved because many ICD-11 working group members had participated in the development of the DSM-5 diagnostic criteria. ICD-11 working groups were instructed to review the DSM-5 criteria sets and strive to make ICD-11 diagnostic guidelines as similar to DSM-5 as possible unless there was a considered reason for them to differ.
  • A review comparing DSM-5/ICD-11 differences with DSM-IV/ICD-10 differences found that ICD and DSM are now closer than at any time since DSM-II and ICD-8 and that current differences are based largely on differing priorities and uses of the two diagnostic systems and on differing interpretations of the evidence.
  • Although ICD-11 was officially endorsed for use by WHO member nations during the 72nd World Health Assembly in May 2019 and officially came into effect on January 1, 2022, each country chooses when to adopt ICD-11. There is currently no proposed timeline for implementation of ICD-11 in the United States. Consequently, for the foreseeable future the official coding system in the United States continues to be the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM).

Key Conceptual Frameworks and Approaches

Definition of a Mental Disorder

  • Each disorder identified in Section II of the manual must meet the definition of a mental disorder. Although no definition can capture all aspects of the range of disorders contained in DSM-5, the following elements are required:
  • A mental disorder is a syndrome characterized by clinically significant disturbance in an individual's cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning.
  • Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities.
  • An expectable or culturally approved response to a common stressor or loss, such as the death of a loved one, is not a mental disorder.
  • Socially deviant behavior (e.g., political, religious, or sexual) and conflicts that are primarily between the individual and society are not mental disorders unless the deviance or conflict results from a dysfunction in the individual, as described above.
  • The diagnosis of a mental disorder should have clinical utility: it should help clinicians to determine prognosis, treatment plans, and potential treatment outcomes for their patients. However, the diagnosis of a mental disorder is not equivalent to a need for treatment. Need for treatment is a complex clinical decision that takes into consideration symptom severity, symptom salience (e.g., the presence of suicidal thoughts), the individual's distress (mental pain) associated with the symptom(s), disability related to the individual's symptoms, risks and benefits of available treatments, and other factors (e.g., psychiatric symptoms complicating other illness).
  • Clinicians may thus encounter individuals whose symptoms do not meet full criteria for a mental disorder but who demonstrate a clear need for treatment or care. The fact that some individuals do not show all symptoms indicative of a diagnosis should not be used to justify limiting their access to appropriate care.
  • It should be noted that the definition of mental disorder was developed for clinical, public health, and research purposes. Additional information is usually required beyond that contained in the DSM-5 diagnostic criteria in order to make legal judgments on such issues as criminal responsibility, eligibility for disability compensation, and competency (see the cautionary statement for forensic use of DSM-5 at the conclusion of Section I).

Categorical and Dimensional Approaches to Diagnosis

  • Structural problems rooted in the categorical design of DSM have emerged in both clinical practice and research. Relevant evidence includes high rates of comorbidity among disorders, symptom heterogeneity within disorders, and substantial need for other specified and unspecified diagnoses to classify many clinical presentations that do not meet criteria for any of the specific DSM disorders.
  • Studies of genetic and environmental risk factors (twin designs, familial transmission, molecular analyses) have raised questions about whether a purely categorical approach is optimal.
  • There is broad recognition that a too-rigid categorical system does not capture clinical experience or important scientific observations. Boundaries between many disorder “categories” are more fluid over the life course than previously recognized, and many essential features of a disorder may occur at varying levels of severity in many other disorders.
  • A dimensional approach classifies clinical presentations based on quantification of attributes rather than assignment to categories and works best for phenomena distributed continuously without clear boundaries. Dimensional descriptions increase reliability and convey more clinical information (e.g., subthreshold features) but have serious limitations and thus far have been less useful than categorical systems in clinical practice.
  • Numerical dimensional descriptions are less familiar than category names, and there is no agreement on the optimal dimensions for classification. With growing research and clinically meaningful cut points, dimensional approaches may become more accepted for conveying clinical information and serving as research tools.
  • For clinical utility and compatibility with the categorical ICD classification required for coding, DSM-5 remains primarily categorical with dimensional elements. There is no assumption that each category is a completely discrete entity with absolute boundaries. Clinicians should recognize heterogeneity within a diagnosis and that boundary cases are often best approached probabilistically. This outlook allows greater flexibility and encourages attention to boundary cases and to information beyond diagnosis.

Cross-Cutting Symptom Measures

  • Given that psychiatric pathologies are not reliably discrete with sharp boundaries, clinicians are encouraged to assess beyond prototypical presentations that neatly fit DSM categories.
  • Section III, Emering Measures and Models, provides the DSM-5 Level 1 Cross-Cutting Symptom Measure, developed to help clinicians assess all major areas of psychiatric functioning (e.g., mood, psychosis, cognition, personality, sleep) and to uncover latent disorders, atypical presentations, subsyndromal conditions, and coexistent pathologies.
  • Just as the review of systems in general medicine acts as an inventory to call attention to overlooked symptoms, the DSM-5 Level 1 Cross-Cutting Symptom Measure acts as a review of mental systems to aid in identifying latent disorders and symptoms in need of more detailed assessment (and potentially treatment).
  • The DSM-5 Level 1 Cross-Cutting Symptom Measure is recommended as an important component of psychiatric evaluation; endorsed by The American Psychiatric Association Practice Guidelines for the Psychiatric Evaluation of Adults as a first step in addressing heterogeneity across diagnostic categories.
  • Self-, parent/guardian-, and child (age 11–17) versions of the Level 1 measure are available online without charge for clinical use at www.psychiatry.org/dsm5.

Removal of the DSM-IV Multiaxial System

  • DSM-IV offered a multiaxial system of recording diagnoses across several axes. DSM-5 moved to nonaxial documentation of diagnosis, listing disorders and conditions formerly on Axis I (clinical disorders), Axis II (personality disorders and intellectual developmental disorders), and Axis III (other medical conditions) together without formal differentiation, typically in order of clinical importance.
  • Psychosocial and contextual factors (formerly Axis IV) are listed with diagnoses using Z codes in the chapter "Other Conditions That May Be a Focus of Clinical Attention."
  • DSM-IV Axis V consisted of the Global Assessment of Functioning (GAF) scale, representing clinicians' judgment of overall functioning on a hypothetical mental health-illness continuum. This scale has been replaced by the WHODAS (World Health Organization Disability Assessment Schedule), which is included in Section III of DSM-5 (see the chapter "Assessment Measures"). The WHODAS is based on the International Classification of Functioning, Disability and Health (ICF) for use across all of medicine and health care.

Cultural and Social Structural Issues

  • Mental disorders are defined and recognized by clinicians and others in the context of local sociocultural and community norms and values. Cultural contexts shape the experience and expression of symptoms, signs, behaviors, and thresholds of severity that constitute criteria for diagnosis. Sociocultural contexts also shape aspects of identity (such as ethnicity or race) that confer specific social positions and differentially expose individuals to social determinants of health, including mental health. These cultural elements are transmitted, revised, and recreated within families, communities, and other social systems and institutions and change over time.
  • Diagnostic assessment should include how an individual's experiences, symptoms, and behaviors differ from relevant sociocultural norms and lead to difficulties in adaptation in his or her current life context.
  • Clinicians should also take into account how individuals' clinical presentations are influenced by their position within social structures and hierarchies that shape exposure to adversity and access to resources. Key aspects of sociocultural context relevant to diagnostic classification and assessment have been carefully considered in the development of DSM-5-TR.

Impact of Cultural Norms and Practices

  • The boundaries between normality and pathology vary across cultural contexts for specific types of behaviors. Thresholds of tolerance for specific symptoms or behaviors differ across cultural contexts, social settings, and families. Hence, the level at which an experience becomes problematic or is perceived as pathological will differ.
  • Clinicians should routinely consider the impact of cultural meanings, identities, and practices on the causes and course of illness, for example, through factors such as levels of vulnerability and mechanisms that amplify fears (e.g., panic disorder or health anxiety); social stigma and support generated by family and community responses to mental illness; coping strategies that enhance resilience; help-seeking pathways to access health care of various types; acceptance or rejection of a diagnosis and adherence to treatments; and the effect of these factors on the course of illness and recovery.
  • Cultural contexts also affect the conduct of the clinical encounter, including the diagnostic interview, and have implications for the accuracy and acceptance of diagnosis, as well as treatment decisions, prognosis, and clinical outcomes.

Cultural Concepts of Distress

  • Since DSM-5, three culturally informed concepts offer greater clinical utility than the former culture-bound syndromes:
    1) Cultural idiom of distress: a behavior or linguistic term, phrase, or way of talking about symptoms, problems, or suffering among individuals with similar cultural backgrounds to express or communicate essential features of distress. An idiom of distress need not be tied to specific symptoms or etiologies and may convey a wide range of discomfort, including subclinical conditions or suffering due to social circumstances. Example: expressing low mood with phrases like "I feel so depressed."
    2) Cultural explanation or perceived cause: a label or explanatory model that provides a culturally coherent etiology (e.g., attributing symptoms to "stress," spirits, or failure to follow culturally prescribed practices).
    3) Cultural syndrome: a cluster of co-occurring, distinctive symptoms found in specific cultural groups or contexts (e.g., ataque de nervios). A cultural syndrome may or may not be recognized as an illness in the local context, but such patterns of distress can be recognizable to outsiders.
  • These concepts guide culturally informed understanding and description of distress and influence symptomatology, help-seeking, presentation, expectations of treatment, illness adaptation, and treatment response. The same cultural term can serve multiple functions and can change over time.

Impact of Racism and Discrimination on Psychiatric Diagnosis

  • Clinical work and research in psychiatry are deeply affected by social and cultural constructions of race and ethnicity. Race is a social, not a biological, construct, used to categorize people by superficial traits. Although there is no biological basis for race, discriminatory practices based on race have profound effects on health.
  • Racialization is the social process by which racial identities are constructed; racialized identities are linked to discrimination, marginalization, and social exclusion. Other identities (ethnicity, gender, language, religion, sexual orientation) may also be focal points for bias that affects diagnostic assessment.
  • Racism exists at multiple levels: personal, interpersonal, systemic/institutional, and social structural. Personal racism includes internalized stereotypes and experiences of threat or injustice; interpersonal racism includes microaggressions; systemic racism is embedded in institutions and practices, potentially via implicit biases and routines; social structural racism highlights inequities in resources, power, and opportunity that shape health outcomes.
  • Racism is an important social determinant of health that contributes to adverse outcomes (e.g., hypertension, suicidal behavior, PTSD) and can predispose to substance use, mood disorders, and psychosis. Negative stereotypes and attitudes affect psychological development and well-being of racialized groups. Discrimination also leads to unequal access to care, clinician bias in diagnosis and treatment, coercive pathways to care, shorter outpatient treatment durations, and more frequent use of restraints and suboptimal treatments.
  • Clinicians should actively recognize and address all forms of racism, bias, and stereotyping in clinical assessment, diagnosis, and treatment.

Attention to Culture, Racism, and Discrimination in DSM-5-TR

  • During the DSM-5-TR review process, steps were taken to address the impact of culture, racism, and discrimination on psychiatric diagnosis in the disorder chapters.
  • A Cross-Cutting Review Committee on Cultural Issues (19 U.S.-based and international experts) reviewed texts for cultural influences on disorder characteristics and incorporated relevant information in culture-related diagnostic issues.
  • A separate Ethnoracial Equity and Inclusion Work Group (10 practitioners from diverse backgrounds) reviewed references to race, ethnicity, and related concepts to avoid perpetuating stereotypes or including discriminatory clinical information.
  • DSM-5-TR commits to language that challenges the view of races as discrete and natural entities. Terms used:
    • racialized instead of racial to emphasize social construction of race
    • ethnoracial to denote U.S. Census categories that combine ethnic and racial identifiers
    • Latinx preferred over Latino/a to promote gender-inclusive language
    • Caucasian avoided due to outdated views on origin; minority and non-White avoided to prevent reinforcing hierarchies
  • When necessary for clarity in reporting epidemiological data, group labels from the relevant studies are used; culture is used to refer to heterogeneity within societies rather than a fixed group.
  • Prevalence sections were reviewed to present findings with geographic or social group references (e.g., in the U.S. general population) to avoid overgeneralization. Prevalence data for ethnoracial groups were included when studies provided reliable estimates from representative samples; data from nonrepresentative samples may be misleading. There is limited data for some groups, notably Native Americans; there is an urgent need for further research. Readers are encouraged to read culture-related diagnostic issues to contextualize prevalence data.

Sex and Gender Differences

  • Sex refers to factors attributable to reproductive organs and XX/XY chromosomal patterns; gender refers to reproductive biology plus self-representation and the psychological, behavioral, and social consequences of perceived gender.
  • Much information on expression of psychiatric illness is based on self-identified gender; otherwise terms like sex differences are used when information pertains to sex (e.g., sex differences in metabolism, pregnancy, menopause).
  • Sex and gender can influence illness in multiple ways:
    • Sex may determine at-risk status for a disorder (e.g., premenstrual dysphoric disorder).
    • Sex/gender may moderate overall risk for development of a disorder, evidenced by prevalence and incidence differences between men and women.
    • Sex/gender may influence which symptoms are experienced (e.g., ADHD manifesting differently in boys vs. girls).
    • May affect help-seeking and service provision (e.g., women may endorse more symptoms or be more likely to seek care).
  • Reproductive life cycle events (menstrual cycle hormonal changes, pregnancy, menopause) contribute to sex differences in risk and symptom expression; the specifier “with peripartum onset” can apply to brief psychotic disorder or to a manic, hypomanic, or major depressive episode, marking a period of increased risk around childbirth. Postpartum hormonal changes can affect diagnostic reliability for sleep and energy disturbances.
  • The DSM-5-TR is configured to include sex and gender information at multiple levels. Where gender-specific symptoms exist, they are added to diagnostic criteria. A sex-related specifier (e.g., "with peripartum onset") provides additional information about sex and diagnosis. Prevalence estimates by sex/gender are included in the Prevalence section of each disorder, and other sex/gender-related diagnostic issues are discussed in the related section for the disorder.

Association With Suicidal Thoughts or Behavior

  • The DSM-5-TR includes considerations of the association with suicidal thoughts or behavior as part of clinical assessment and risk evaluation (details are provided in the corresponding sections).

Forensic and Legal Considerations

  • A cautionary statement for forensic use of DSM-5 is included in Section I, highlighting that the diagnosis should not be applied to legal judgments without careful, context-appropriate interpretation and information beyond DSM criteria.

Coding and International Classification Context

  • ICD-11 harmonization efforts aim to align DSM-5 and ICD-11 criteria where possible to improve consistency across systems used by clinicians worldwide.
  • The U.S. continues to rely on ICD-10-CM for coding in the foreseeable future, pending future policy decisions and timelines.