DSM 5 – Is it as bad as has been described?

July 13, 2013

DSM 5 was published in May 2013. We all need to be aware of those areas that have been changed and those that remain the same as in DSM IV TR. There is a detailed analysis of DSM5 on the website.  But also see Nick Haslam’s article).

The general changes are that the multi axial system has been dropped, I believe this is a recognition that it was not useful and that it was rarely used in clinical practice although the concept it conveyed of looking at the mental disorder, personality issues, other medical issues, psychosocial issues remains a part of most clinicians’ diagnostic formulation.

The Global Assessment of Function scale has been dropped. It is interesting that the authors of AMA 6 chose to include the GAF and now that it has been removed it has even less credibility as does chapter 14 in AMA 6.

The chapter on Schizophrenia Spectrum and Other Psychotic Disorders has some minor changes with the addition that at least one of the Criterion A symptoms must be delusions, hallucinations, or disorganised speech. That DSM IV TR subtypes were eliminated. There have been changes to the conceptualisation of Bipolar 1 Disorder and Bipolar 2 Disorder as they now include both changes in mood and changes in activity or energy. The major change with regard to depressive disorders, apart from some new minor diagnoses, is the name change from dysthymia to persistent depressive disorder. There have been changes in relating bereavement and major depressive episodes.

Anxiety disorders include significant changes including separate chapters for Obsessive-Compulsive and Related Disorders and Trauma and Stressor Related Disorders. Panic disorder and agoraphobia are now regarded as discrete entities and if they occur together both diagnoses need to be made.

A number of comparatively rare new disorders have been encompassed under the concept of Obsessive-Compulsive and Related Disorders. The specifier has been modified to allow for a range between those who have good insight and those who have no insight into their behaviour.


Trauma and Stressor Related Disorders including Acute Stress Disorder and Post Traumatic Stress Disorder has had significant changes, the Criterion A requirement involving a person’s response to the trauma has been eliminated and the notion of repeated or extreme exposure to trauma such as that expressed by first responders is acknowledged. The only other major change has been to recognise negative mood and irritable behaviour and angry outbursts. Adjustment disorders have been appropriately bought into the category of stress-related disorders. The authors of DSM 5 claim that these disorders have been “reconceptualised as a mixed array of stress-response syndromes that occur after exposure to a distressing event rather than as a residual category for individuals who exhibit clinically significant distress but whose symptoms do not met the criteria for or more discrete disorder (in other words a wastebasket diagnosis). However the diagnostic criteria are identical so no real change there.

The authors have recognised that although the concept of Pain Disorder as in DSM IV TR was conceptually neat it was not based on any scientific evidence. The authors state that pain is almost always associated with psychological factors and recognise that some individuals with chronic pain have somatic symptom disorder, with predominant pain. For others an appropriate diagnosis may be psychological factors affecting other medical conditions or an ad­justment disorder.

I was impressed with the DSM 5 and thought that a lot of the criticism was a great deal of nonsense. Critics appear to have picked on rare diagnoses to beat the authors with implying they are trying to medicalise normal behaviour. As a consultant psychiatrist the changes relevant to my areas seem sensible and understandable.


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