DSM-5 —The Future Arrived FREE

The next revision of psychiatry's Diagnostic and Statistical Manual of Mental Disorders (DSM-5)¹ will be published in May 2013 and is the first revision of this psychiatric nomenclature in almost 2 decades. DSM-5 involved an international, multidisciplinary team of more than 400 individuals who volunteered vast amounts of their time throughout this 6-year official process, as well as many contributions from numerous international conferences that were held during the last decade.

Readers will recognize a few notable differences from DSM-IV. One distinction is DSM-5 's emphasis on numerous issues important to diagnosis and clinical care, including the influence of development, gender, and culture on the presentation of disorders.² This is present in select diagnostic criteria, in text, or in both, which include variations of symptom presentations, risk factors, course, comorbidities, or other clinically useful information that might vary depending on a patient's gender, age, or cultural background. Another distinct feature is ensuring greater harmony between this North American classification system and the International Classification of Diseases (ICD) system. For example, the chapter structure of DSM now begins with those in which neurodevelopmental influences produce early-onset disorders in childhood. This restructuring brings greater alignment of DSM-5 to the structuring of disorders in the future ICD-11 but also reflects the manual's developmental emphasis, rather than the previous edition's sequestering of all childhood disorders to a separate chapter. A similar approach to harmonizing with the ICD was taken to promote a more conceptual relationship between DSM-5 and classifications in other areas of medicine, such as the classification of sleep disorders.

Many of the revisions in DSM-5 will help psychiatry better resemble the rest of medicine, including the use of dimensional (eg, quantitative) approaches. Disorder boundaries are often unclear to even the most seasoned clinicians and underscore the proliferation of residual diagnoses (ie, “not otherwise specified” disorders) from DSM-IV. But a large proportion of DSM-5 users will not be psychiatrists; most patients, for instance, will first present to their primary care physician—not to a psychiatrist—when experiencing psychiatric symptoms. The use of definable thresholds that exist on a continuum of normality is already present throughout much of general medicine, such as in blood pressure and cholesterol measurement, and these thresholds aid physicians in more accurately detecting pathology and determining appropriate intervention.³ Thus DSM-5 provides a model that should be recognizable to nonpsychiatrists and should facilitate better diagnosis and follow-up care by such clinicians. In addition, the multiaxial system that characterized earlier editions of DSM—wherein clinicians recorded diagnoses, comorbid medical conditions, nondisorder reasons for clinical visit (eg, partner/relational problems), and ratings of disability and functioning on 5 separate axes—has been discontinued. This is largely due to its incompatibility with diagnostic systems in the rest of medicine, as well as the result of a decision to place personality disorders and intellectual disability at the same level as other mental disorders.

The above major changes represent those throughout the entire volume. What follows is a sampling from a larger summary of select recommended changes for specific disorders that will be found in the new DSM-5 manual⁴:

The classification system should be able to incorporate future advances in the neuroscience and genetics of psychiatric illness.⁸DSM-5 is intended to be readily updatable as relevant knowledge is accumulated in neuroscience, cognitive science, genetics, and in clinical practice. DSM-5 also will include a third major section following the introductory materials and the descriptions of the fully validated categorical disorders. This third section is intended to provide future directions for DSM-5 that will lead to its subsequent editions. Section III will guide clinicians and researchers in examining measures and criteria sets that emerged during the process of developing the manual but were deemed in need of further study before official inclusion in the nomenclature. This section will include criteria sets for potential new disorders, including a new approach to the assessment of personality disorders, a listing of the dimensional assessments that were included in the DSM-5 field trials, and assessments related to culture-specific formulations of the DSM disorders.

The most important next challenge is identification of DSM-5 criteria of particular relevance to specialties outside of psychiatry. Even though the criteria for the most common DSM disorders were written with the general medical practitioner in mind, the American Psychiatric Association is developing a collaborative approach to identifying the disorders most frequently seen in primary medical care settings and the particular way in which those disorders are likely to present in such settings—an emphasis to make the DSM-5 of greater value to all of medicine.⁹