PART V Psychiatric Diagnoses and Conditions 17 The DSM-5: A System for Psychiatric Diagnosis Anna M. Georgiopoulos, MD, and Abigail L. Donovan, MD KEY POINTS disseminated internationally. The World Health Organiza- tion’s (WHO) International Statistical Classification of Diseases 6 Background and Related Health Problems, Tenth Revision (ICD-10) is also in wide use internationally. The ICD is used in the United States • A useful psychiatric diagnostic system allows clinical for coding purposes within medical billing systems, with a and research endeavors to flourish. switch from the previous version, the International Classifica- • The DSM-5, the most common diagnostic system tion of Diseases, Ninth Revision, Clinical Modification (ICD- used in the United States, encourages evaluation and 9-CM)7 to the ICD-10 planned for 2014, and subsequently description of multiple kinds of information: delayed to October 2015.8 psychiatric, medical, and psychosocial. The DSM-5, released in 2013, represents the latest in an • Careful use of the DSM-5 can promote rigorous ongoing process of change in our psychiatric diagnostic system.9 While the original Diagnostic and Statistical Manual: conceptualization of psychiatric issues and enhance 10 clinical communication. Mental Disorders was published in 1952, the transition from the second edition (DSM-II)11 to the third edition (DSM-III)12 History represented a major shift in the approach to psychiatric diag- • DSM-5, released in May 2013, is the most recent nosis. Psychodynamic formulations were no longer intrinsic revision to our psychiatric diagnostic system. to diagnostic categorization, and the DSM-III was considered • Several new disorders were added to DSM-5, while to be atheoretical and descriptive in orientation, using a diagnostic criteria for others were revised. multi-axial diagnostic system. As subsequent revisions were made,5,13,14 there were increasing efforts to ensure diagnostic Clinical and Research Challenges reliability and validity, to incorporate research findings, and • As part of an evolving diagnostic system, the DSM-5 to gather new information via field trials.3,15–18 remains subject to future revision based on new Prior to the advent of DSM-5, the DSM-IV, and its subse- research findings and changing diagnostic quently updated text revision (DSM-IV-TR)8 continued to use frameworks. the multi-axial diagnostic system. Axis I contained all psychi- Practical Pointers atric disorders except for the personality disorders and mental • Diagnostic formulation using the DSM-5 is an retardation, which were recorded on Axis II. Axis III listed non-psychiatric medical illnesses. Psychosocial and environ- ongoing process that requires clinical judgment and 19 skill. mental problems were listed on Axis IV. The Global Assess- ment of Functioning (GAF), a numerical value summarizing thes patient’ current degree of psychosocial, occupational, and educational impairment, was recorded on Axis V.20 For some applications, the DSM-5 is being gradually phased in to full DSM-5 IN CONTEXT: AN EVOLVING use. For example, the DSM-IV-TR criteria will continue to be DIAGNOSTIC SYSTEM used for psychiatric board certification examinations until 2017.21 , Therefore although the multi-axial system has been Psychiatric diagnostic classification serves a variety of pur- eliminated in DSM-5, familiarity with DSM-IV-TR constructs poses. Diagnosis marks the borders between mental disorders may continue to be relevant for some time in clinical and and non-disorders (such as normal personality variations) research contexts. and between one type of disorder and another.1 Diagnostic schemata have practical implications for helping clinicians to The Process of Change for DSM-5 conceptualize psychiatric issues, to communicate with patients and other clinicians, and, ideally, to make prognostic predic- Even as DSM-IV-TR was being published, efforts had begun to tions and to plan effective treatments.2,3 A useful diagnostic consider improvements for DSM-5. DSM-IV-TR’s Appendix system also enables psychiatric research to flourish. It permits contained diagnostic criteria sets for potential inclusion in valid and reliable classification of diseases that may benefit future editions. Additional suggestions for change reflected from basic research. Efforts to document, describe, and classify advances in psychiatric research, or appeals based on clinical mental illness go back thousands of years; they include utility.2 The American Psychiatric Association (APA), the attempts to group diseases by cross-sectional phenomenology, WHO, the World Psychiatric Organization, the National Insti- by theories of causation, and, later, by clinical course.4 tutes of Mental Health, and the National Institute on Alcohol- In the United States, the diagnostic system in widest use ism and Alcohol Abuse5,9 were all active in the preparation is the Diagnostic and Statistical Manual of Mental Disorders, phase for DSM-5. Work groups in the APA’s DSM-5 Task Force Fifth Edition (DSM-5).5 The DSM has been increasingly made proposals for revisions, field trials were conducted,22 165 Downloaded for Rohul Amin ([email protected]) at Uniformed Services Univ of the Health Sciences from ClinicalKey.com by Elsevier on September 29, 2018. For personal use only. No other uses without permission. Copyright ©2018. Elsevier Inc. All rights reserved. 166 PART V Psychiatric Diagnoses and Conditions and public and professional commentary was elicited. A Sci- entific Review Committee provided peer review,23 and a Clini- BOX 17-1 “Other Specified” and “Unspecified” cal and Public Health Committee, as well as forensic and Diagnoses: Case Examples statistical consultants weighed in regarding proposed changes.5 In addition, efforts were made to coordinate the format of EXAMPLE 1: OTHER SPECIFIED DIAGNOSIS DSM-5 with the anticipated updating of the ICD-10 to ICD-11, A 20-year-old man is seen for an intake appointment at an resulting in structural changes to the groupings of disorders in outpatient clinic. He reports significant distress about his the DSM.24 prominent acne scars. He spends at least 4 hours every day examining his skin in the mirror, and picking at the skin around his scars. He has been unable to attend college or keep a job The Three-Section Structure of DSM-5 for the past 3 years due to this behavior and his appearance Section I concerns. He is diagnosed with “other specified obsessive- compulsive and related disorder: body dysmorphic-like disorder DSM-5 is divided into three sections. Section I provides a with actual flaws.” history of the DSM and guidance for its use. Of note, DSM-5 diagnostic criteria are not meant to be rigidly applied to EXAMPLE 2: UNSPECIFIED DIAGNOSIS mandate or exclude individuals from treatment when clinical A 25-year-old female is brought into the emergency room by an circumstances dictate otherwise. In addition, given that DSM-5 ambulance after some passers-by called 911. She had been has been created primarily for use in health care and research, running through the streets, dressed in only a nightgown, yelling it is not intended to be sufficient for making legal determina- that “Judgment Day is coming.” On exam, she was noted to be tions. In all settings, clinical judgment must be applied in extremely distractible and she had rambling and voluminous gathering and interpreting diagnostic information, ensuring speech. Her mood was irritable, and her affect was labile. She the presence of distress or functional impairment, and incor- reported hearing the voice of God telling her that Judgment Day porating all available data into a clinical formulation. was near. She also reported delusions that her neighbors were demons sent by Satan to monitor her whereabouts until the Section II Time of Judgment. The patient was unable to report any prior psychiatric or medical history, the time course of her current Section II lists DSM-5 diagnoses and codes, separated into symptoms, or any recent alcohol or substance abuse. categories of related disorders. Disorders are described begin- In the ER, she was given working diagnoses of: Unspecified ning with those which have a neurodevelopmental origin bipolar and related disorder; Unspecified schizophrenia early in the life span, and ending with diseases that most often spectrum and other psychotic disorder. appear late in life. Within the developmental framework, dis- The patient is admitted to the hospital’s inpatient psychiatric orders have also been grouped according to current neuro- unit. Her laboratory results are within normal limits, and her scientific understanding that links disorders based on shared toxicology screens are negative. All subsequent medical genetic findings (i.e., between bipolar and psychotic disor- work-up is negative. The patient’s parents, with whom she was 24 ders), clinical courses, and patterns of co-morbidity. Variabil- close, provided the following collateral information: For the past ity and changes in presentation that occur through the 2 weeks, the patient had been acting strangely. She slept only a life span—such as the age-dependent change in hyperactive few hours a night, and then stopped sleeping altogether. She symptoms that typically occurs in attention-deficit/hyperactiv- was very irritable, and quick to anger. She complained that her ity disorder (ADHD)—are also included for individual disor- thoughts were racing, and she was much more talkative than ders under the subheading of “Development and Course.” usual. She was also highly distractible. The day prior to her ER Gender-related factors that may have an impact on risk, pres- visit, she told them she was hearing God speak to her. She had entation, or clinical course are incorporated throughout one prior episode of depression in adolescence, and had never Section II as “Gender-related Diagnostic Issues.” These two heard voices or been paranoid before. She had normal function new sub-sections were added to highlight the importance of until 2 weeks prior to admission. At the time of discharge, her 25 development and gender in psychiatric diagnosis.