September 23, 2014

The question has been raised about whether or not we should be using DSM 5. (See my blog from August 2013) In general psychiatry it is of little consequence but in the forensic area there are potential minefields. Recently a finding of the Victorian Medical Panels was challenged on the basis that the diagnosis made was a “somatisation disorder. On page 489 of DSM IV TR it states “by definition, all individuals with somatisation disorder have a history of pain symptoms, sexual symptoms and conversion or dissociative symptoms. Therefore if these symptoms occur exclusively during the course of somatisation disorder, this should not be an additional diagnosis of pain disorder et cetera.”

The diagnosis was challenged on the basis that it was a DSM IV TR diagnosis and should have been a DSM 5 diagnosis.

My own view is that the DSM 5 deals poorly with pain. It is interesting to note that the word “pain” does not appear in the index! Somatisation disorder, hypochondriasis, pain disorder and undifferentiated somatoform disorder had been removed from DSM 5. They are merged under the term “somatic symptom disorder. “Some individuals with chronic pain would be appropriately diagnosed as having somatic symptom disorder, with predominant pain.” (My emphasis).

I prefer the DSM IV TR term of Pain Disorder, and you will notice that it is actually in the index.

This is a significant issue for us and leaves us open to challenge, I can imagine the dialogue “so doctor did you use DSM IV TR or DSM 5 for your diagnosis. Could you explain why you chose to use DSM IV TR when it has been superseded by DSM 5? What would your response be?

I have commented on DSM 5 previously. The other areas where I believe the changes are significant include changing the term dysthymia to persistent depressive disorder that I think is a plus. I was once asked in court “Dr Epstein, you have diagnosis man with dysthymia that he would have to agree that there is no evidence that he has any problems with his thymus gland.”


Panic disorder has been separated from agoraphobia, this seems to be not a big issue. There have been changes to the qualifiers with regard to acute stress disorder that are now explicit as to whether the stressor  was expressed directly, witnessed or experienced indirectly. Criterion A2 has been eliminated (the one related to experiencing “fear, helplessness, or horror”.)

Adjustment disorders have been rejigged as stress response syndromes rather than a residual category for those who have clinically significant distress but whose symptoms do not meet the criteria for a more discreet disorder.

DSM 5 criteria for PTSD are said to differ significantly from the DSM IV TR criteria with criterion A being more explicit with regard to events that qualify as “traumatic” experiences”. I am pleased about that as too often I read that somebody has PTSD because they have had a negative assessment or because they have fallen over a chair or some other relatively minor trauma. You will note that criterion A2 had been eliminated as described above. There are now 4 symptom clusters clusters, re-experiencing, avoidance, persisted negative alterations in cognition and mood, alteration in arousal and reactivity including behavioural changes such as angry outbursts and reckless or self destructive behaviour. All these are of some value. I am not sure if any other changes are of great significance.

I would be interested if you can see any other DSM 5 diagnoses that are of value in terms of the work we do.

Nevertheless the initial point raised was whether or not we should be using DSM 5 or DSM IV TR and who decides. We have had no guidance from the College. DSM 5 does not make it explicit that it replaces DSM IV TR but by implication it must do so, the question is when does it do so, when it was published?

Which one do you prefer?


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