Print Page   |   Sign In   |   Register
DSM-5: Mastering the Changes
Share |


DSM-5: Mastering the Changes

Carlton E. Munson, PhD, LCSW-C


Dr. Munson is Professor of Social Work at the University of Maryland School of Social Work. He is author of the Mental Health Diagnostic Desk Reference that is a guide to using the DSM-IV, and he participated in the American Psychiatric Association field trials for the DSM-5. Dr. Munson is currently working on a new edition of his book for use with the DSM-5. If you wish to contact Dr. Munson about this article, he can be reached at
The opinions expressed in this article are not associated with the policies or positions of the American Psychiatric Association or the National Association of Social Workers
The latest edition of the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) was released during the American Psychiatric Association (APA) Annual Meeting in San Francisco, May 18, 2013. I wrote an article about the proposed changes to the DSM in the winter issue of The Maryland Social Worker. Most of the proposed changes I discussed in that article were implemented along with a number of changes that were not announced in advance of the release of the DSM-5. This article is the first of a series of articles about the DSM-5 and mastering the changes to the manual. In this article, I cover implementation of DSM-5 use, overview of reorganization of the manual, recording a diagnosis, explanation of coding changes, and recommended resources for mastering DSM-5.
No specific date for initiating use of DSM-5 has been announced by the APA. The APA has always been proprietary about the content of DSMs but has been cautious about mandating any directives regarding use of the DSMs. APA has indicated that many payers have reported their computer systems may not be completely converted to DSM-5 until December 2013. Currently, practitioners who assign DSM diagnoses should make clear in documentation whether DSM-IV or DSM-5 criteria were used in assigning a client’s diagnosis. For some disorders there were no criteria changes (for example, enuresis). Other diagnoses have major changes (for example, autism spectrum disorder) or minor alterations (for example, intermittent explosive disorder) that could have treatment consequences. The DSM-5 makes numerous references to the link between diagnosis and treatment (see, for example, DSM-5, p. 5). The linkage of diagnosis and treatment has been refined over the last three decades after the case of Osheroff v. Chestnut Lodge (1980) that was settled out of court, but had significant impact on the diagnosis and treatment planning connection (Knoll, 2013). Ethical practice and general practice standards require that practitioners make clear the source of diagnoses assigned to clients as well as the connection between the diagnosis and the treatment. Clinical social workers doing forensic work should be especially clear and precise about the source of their diagnoses because their diagnoses will be closely scrutinized by lawyers and judges during legal proceedings.
Overview of Reorganization
The DSM-5 is organized into three sections and an appendix that contains seven content areas. There is an updated Glossary of Technical Terms that is greatly improved over the DSM-IV version. There is an index of the disorders, but no comprehensive index of terms that, for example, would allow you to look up where terms such as principal and provisional diagnosis are explained and differentiated. “Section I” contains an introduction to the DSM-5 and information on how to use the updated manual. I urge practitioners to read the “Introduction” and “Use of the Manual” sections before attempting to use the DSM-5. Reading the two sections will aid users in orienting to the strategy that led to how the manual is now organized and how diagnosis is to be recorded. “Section II” lists categorical diagnoses using a significantly revised chapter organization with an increase from 16 to 20 categories of disorders. The infancy, childhood, and adolescent disorders section of DSM-IV has been eliminated, and the disorders dispersed into other categories. The mood disorders classification has been eliminated and depressive disorders and bipolar disorders have their own separate categories. Obsessive-compulsive disorders and trauma-related disorders have been moved out of the anxiety disorders classification and placed in their own separate categories. Adjustment disorders have been moved into the new trauma disorders category. The DSM-IV classification of Sexual and Gender Identity Disorders was divided into two new categories of Sexual Dysfunctions and Paraphilic Disorders. Other new classifications include Neurodevelopmental Disorders, Gender Dysphoria, and Neurocognitive Disorders. There are eight sections in the neurodevelopmental disorders category including intellectual disabilities, communication disorders, autism spectrum disorder, ADHD, specific learning disorder, motor disorders, tic disorders, and other neurodevelopmental disorders.
The Other Conditions that May Be a Focus of Clinical Attention related to child neglect, physical abuse, and sexual abuse have undergone significant change. I did not see any information about these changes we could comment on before release of DSM-5. The organization for reporting these conditions do not seem to me to be consistent with how we formulate information about victims and offenders in the United States. Approaches to diagnosis related to maltreatment of children vary greatly by country. The model used in DSM-5 seems to be more fitting to a European model. They did add mental injury to the array of maltreatment types, which is good news. I will report on this in a later article in detail. I would like to hear from practitioners in child welfare about their reaction to the DSM-5 criteria for abuse and neglect.
Section III of DSM-5 covers four areas: Assessment Measures, Cultural Formulation, Alternative DSM-5 Model for Personality Disorders, and Conditions for Further Study that require further research before they can be considered as formal disorders. The assessment measures include a number of scales that can be used to survey symptoms for crosscutting measures and a complex scale to assess psychosis severity. It will be interesting to see if busy clinicians will take the time to use these scales which take time to administer, and have detailed instructions on how to score the scales. The section on cultural formulation contains a structured clinical interview that is cumbersome. Section III also has eight disorders that are reserved for further study, but none of the eight disorders reserved for further study in DSM-5 can be diagnosed in daily clinical practice (see DSM-5, p. 783). The utility of Section III is in doubt because, unlike DSM-IV procedures that allowed use of the NOS category as part of clinical diagnosis, no such utilization is permitted as part of DSM-5 for the disorders reserved for further study. Also, of interest is that in DSM-IV there were 23 disorders and three scales that were to be assessed for inclusion in the revised DSM. None of the scales made it into DSM-5, and only premenstrual dysphoric disorder and binge-eating disorder were elevated to full disorders in DSM-5. I saw no systematic literature reviews justifying exclusion of the 21 disorders in DSM-IV that were to be researched for inclusion in DSM-5.
Diagnostic Recording
The DSM-IV multiaxial system has been changed in DSM-5 to a “nonaxial” format that contains several elements. The former Axes I, II and III have been combined to form a core “narrative” diagnosis. There can be separate “notations” for “psychosocial and contextual factors (formerly Axis IV).” The DSM-IV psychosocial factors have been merged with the Other Conditions that May Be a Focus of Clinical Attention, which are included at the end of the DSM-5“Section II” that contains all disorders and their criteria. For a history of the psychosocial and environment stressors see my article in the winter issue of The Maryland Social Worker. Although Axis III has been merged with Axis I and Axis II in DSM-5, APA provides the directive that, “clinicians should continue to list medical conditions that are important to the understanding or management of an individual’s mental disorder” (DSM-5, p. 16) as part of the diagnostic formulation. Axis V has been deleted and a description of severity of the client’s level of “disability” is now part of the narrative diagnosis. Many disorders now have recording requirements of expanded severity specifiers that are listed with each disorder as part of the criteria sets. For example, persistent depressive disorder that replaces Dysthymic Disorder has five levels of severity that must be specified as part of the diagnosis. The five specifiers that must be part of the diagnostic formulation are: associated features, remission status, illness onset, episode type, and current severity of mild, moderate, severe (DSM-5, p. 169).
Also, eliminated was the Not Otherwise Specified (NOS) category that accompanied most diagnoses. NOS was used when an individual did not meet the full criteria for a specific diagnosis (for example children who did not meet the full criteria for a PTSD diagnosis would be assigned “Anxiety Disorder, NOS”). The NOS diagnosis has been replaced with two separate diagnostic categories for most disorders. For example, in the Depressive Disorders the two options are: other specified depressive disorder and unspecified depressive disorder. Details of these categories will be explained in a subsequent article.
Coding Changes
The coding changes are more complex and more fluid than past DSM changes. In order to understand coding in the DSM system, it is important to understand the history of DSM coding. It is my experience that many clinicians who use the diagnostic codes in their daily practice do not know the origins of the code systems. Therefore, before explaining the changes, I will provide a brief history of the coding systems that may help clarify the situation in the DSM-5.
There are two recognized systems for coding mental disorders–the International Classification of Diseases (ICD) and the APA diagnostic and statistical manual (DSM). The ICD system was first published in 1900 and is supposed to be revised every 10 years, hence the designation "ICD-1, ICD-2,” etc.)The ICD coding system is sponsored by the World Health Organization (WHO) and the United Nations (UN). By international treaty, the ICD system provides codes for all known medical and mental conditions. The DSM system was first published in 1952, but has a much longer tradition in other forms going back to about 1900. The APA DSM system only classifies mental disorders and has always used a similar, but somewhat different numbering system from that of the much broader ICD system. Also, there are mental disorders in the ICD system that are not in the APA system, and the reverse is also true. There has been an effort for decades to make the two systems of mental disorders compatible, but there has not been complete success in this endeavor.
 In the 1990s all nations except the United States moved to using the ICD-10 system for coding of medical conditions and mental disorders. Because of complex logistic processing issues, the United States continued to use the codes in the ICD-9-CM manual, which was first published in 1973. The CM stands for clinical modification, which covers changes in coding during the 10-year period between the issuance of the ICD manual editions.
The ICD-9-CM codes will continue to be used in DSM-5 until October 1, 2014. The intent in planning the DSM-5 was to make it compatible with the updated ICD-10-CM codes that were to be released January 1, 2013, but the release was delayed until October 1, 2014. The solution was to print in the DSM-5 the ICD-9-CM code for each disorder along with the current ICD-10-CM code for the disorder. In the DSM-5 the ICD-9-CM code is printed as it was in DSM-IV and is in black lettering. Next to the ICD-9-CM code is printed the ICD-10-CM code in parentheses using shaded gray lettering. On October 1, 2014, clinicians in the United States will stop using the ICD-9-CM codes and will use the ICD-10-CMcodes (see DSM-5, p.23). All other countries have already adopted the ICD-10-CM codes and they are no longer using the ICD-9-CM codes.
Also, there are printing errors in the DSM-5, which include diagnostic code errors. APA has released a four-page set of corrections for the errors that can be viewed at the APA main website.
Further changes in the DSM-5 coding system will likely occur in 2015 when the ICD-11 release is scheduled. Indications are there will be a major change in the coding because of the vast increase in the number of medical conditions that are now known. This most likely means that the DSM-5 will have to be upgraded to DSM-5.1 in two years. In addition, NIMH is now developing a third system of diagnosis through an initiative referred to as Research Domain Criteria (RDoC). This research approach to mental disorder classification incorporates multiple dimensions that include behavior, thought patterns, neurobiological measures, and genetics. The immediate aim of RDoC is to provide a framework for research with the eventual goal of developing a new classification system for mental disorders. This system may replace the DSM system or we may have three mental disorder coding systems.
The APA has created a number of resources for the DSM-5 that have been released or are scheduled to be released between September and December 2013.The Desk Reference to the Diagnostic Criteria from DSM-5 is a concise companion to the DSM-5 that is currently available. It includes the revised diagnostic classification, as well as all the diagnostic criteria from DSM-5. The book is good for looking up criteria and codes, but it is not recommended for learning the DSM-5 because it does not have the detailed descriptive text to use in mastering the changes in the disorders. Also, an online version of the DSM-5 is now available. I have purchased the online version, but have not been able to review it before submitting this article. There is a mobile application (AKA “app”) available for cell phones and tablet devices that contains the diagnostic criteria sets for all DSM-5 disorders, but does not contain any disorder descriptive text or Section III DSM-5 content. I purchased this app, and it has flaws that need correction. For example, the videos that accompany the app have no audio. If you decide to buy the application, make sure this problem has been corrected before making your purchase.
Later this year APA plans to publish the following books that may be of interest to practitioners who want to learn more in depth about the DSM-5 and doing diagnosis: DSM-5 Clinical Cases edited by John W. Barnhill; and Study Guide to DSM-5 by Laura Weiss Roberts and Alan Lourie. This book is designed to help educators and students understand and apply diagnostic criteria and key clinical concepts through a variety of learning tools. APA reports this book can also serve as a training supplement to DSM-5 or used as a companion learning tool with the book, DSM-5 Clinical Cases. The DSM-5 Guidebook by Donald Black and Jon Grant is described by APA as a user-friendly, supplementary guide for mental health practitioners who need to know how DSM-5 differs from DSM-IV in organizational structure, diagnostic categories, and the diagnostic criteria. The book reportedly focuses on how to use the revised diagnostic criteria by providing a practical context for its clinical use. The DSM-5 Handbook of Differential Diagnosis by Michael First is a guide to differential diagnosis for both clinicians and students learning to perform diagnosis. APA describes this book as using the perspective that psychological distress cannot be reduced to a rubric, and clinicians must have empathy, listening skills, ability to identify symptoms, and familiarity with the body of knowledge represented by DSM-5 to do effective diagnosis and intervention.
Other helpful resource books are Joel Paris and James Phillips, Making the DSM-5: Concepts and Controversies (published by Springer), and Joel Paris, The Intelligent Clinician's Guide to the DSM-5 (published by Oxford University Press). Paris’s books are nice narrative approaches to DSM-5 diagnosis with an emphasis on diagnostic conservatism that highlights issues of clinical utility, clinical relevance, clinical significance, and clinical judgment. I will cover these topics in the next issue of this series. I enjoyed reading both of Paris’s books.
What’s Next?
In the next issue, I will cover examples of my model of a diagnostic formulation based on the brief description of diagnostic formulation in the DSM-5 along with the concepts mentioned above of clinical utility, clinical relevance, clinical significance, and clinical judgment.
Knoll, J. (2013). The Humanities and Psychiatry: The Rebirth of Mind. Psychiatric Times, March 15, pp.2-5.


Membership Management Software Powered by®  ::  Legal