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The new DSM-5: where have we been and where are we going?

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is celebrating its 60th birthday this year. Many generations of social work students have graduated since the inception of this diagnostic tool, which has become the encyclopedia for helping professionals across the country. As we anticipate the upcoming publication of the DSM-5 in May 2013, it is worth briefly reflecting on where we have come and where we are going in terms of the use of this manual within social work to guide our assessments and interventions with clients who live with mental and emotional challenges.

The DSM, though developed and published by the American Psychiatric Association (APA), has gained wide acceptance over the past several decades as the authoritative codebook for mental disorders. It is used not only by the medical profession, but also by the majority of mental health professionals, insurance companies, researchers, grant-funding agencies, and academicians in the United States for diagnostic, assessment, and educational purposes. Its development has consistently reflected the U.S. zeitgeist, including the relevant import of theory or research in guiding the conceptualization of mental illness, the definition of mental illness, and political and social developments within mainstream American culture.

Prior to the publication of the DSM-I in 1952, numerous classification systems were used to describe mental illness, leading to a confusing array of terms that often described the same phenomena and preventing a common language across mental health providers (Keely, Burgess, & Blashfield, 2008). One of the first classifications of mental illness was developed for the purpose of the census in the 1880s and consisted of seven categories: mania, melancholia, monomania, paresis, dementia, dipsomania, and epilepsy (Grob, 1991).

This nosology proved to be problematic, leading the Bureau of the Census to use the Statistical Manual for the Use of the Institutions for the Insane in 1917. This nranual was developed by committees of the American Medico-Psychological Association and the National Commission on Mental Hygiene. Mental disorders were divided into 22 categories in this initial volume, which was revised 10 times through 1942, and continued to be used as the official classification system for the purpose of the U.S. census (Keely et al., 2008). During this same period of time, psychoanalysis took a tirol hold in the United States and was considered the bedrock of psychiatric treatment.

When the DSM-I was published in the early 1950s, it contained 108 descriptions of mental disorders referred to as "reactions"--a term coined by Adolph Meyer (Keely et al., 2008). This was a vast improvement over the seven broad categories developed in the 19th century, as the DSM was based on lessons learned by psychiatrists during World War II and incorporated diagnoses intended for outpatient populations (Grob, 1991). The first DSM was constructed by a very small committee of APA members who prepared and circulated drafts of the materials to their membership and related organizations for feedback and suggestions (Keely et al., 2008).

Sixteen years later, in 1968, APA revised the DSM-II nosology to include 182 disorders and 10 classes of disorders described in less than 40 pages (Corcoran & Walsh, 2010; Keely et al., 2008). As with the DSM-I, a small comnfittee of APA members and a similar process was used to develop this manual, with particular attention to increasing its alignment with the International Classification of Diseases (ICD). Although the DSM-II retained many of the psychoanalytic underpinnings for describing symptom constellations, including retaining the word "neurosis" in some categories, the term "reaction" was eliminated. As with the earlier version, there was not a serious effort to justify the classification DSM-5tal disorders on the basis of scientific evidence. Of particular interest is the controversy that erupted over the inclusion of homosexuality in the DSM-II as a mental illness. The gay rights movement, which emerged in the early 1970s, directed protests toward APA for its perceived stigmatization of homosexuals. In 1974, the APA membership voted to remove homosexuality from the DSM-II; however, they retained a "sexual orientation disturbance" and "egodystonic homosexuality" for individuals uncomfortable with their homosexuality (Corcoran & Walsh, 2010).

In the 1980s, with the publication of the DSM-III, which had been expanded to 265 disorders and 17 categories, an attempt was made to empirically validate the classification of mental disorders (Keely et al., 2008). In fact, APA presented this new version as a scientific document, representing a major turning point in the field of psychiatry away from traditional theoretical diagnostic approaches (Corcoran & Walsh, 2010). For the first time, the development of this manual involved the input of several more participants and relied on literature reviews and field trials (Keely et al., 2008). It was widely accepted that interrater reliability among professionals using the DSM was imperative; however, diagnostic criteria for several disorders lacked adequate scientific support. Instead, evidence for diagnostic categories was largely limited to the frequency of their use and reported clinical relevance by professionals. Although the scientific base was lacking, social workers lauded the new multiaxial approach to diagnosis and the V-codes, as these changes supported the consideration of potential causes or consequences within relationships or the environment that may affect an individual (Corcoran & Walsh, 2010). The DSM-III was also the first version of the manual that provided a definition of a mental disorder.

The DSM-III-R quickly followed the DSM-III due to APA's justification of a revision in light of the time between the DSM-III and the publication of the DSM-IV, and a need to integrate accumulated research into the document. Although all diagnoses were reviewed for consistency, clarity, and conceptual accuracy by DSM-III-R committees, reliability studies were not conducted to corroborate their existence (Corcoran & Walsh, 2010; Keely et al., 2008). Twenty-seven new disorders, hierarchal exclusionary rules, and specifiers of severity were added to the revised manual (Keely et al., 2008). Of particular controversy was the proposal to include paraphilic rape, premenstrual dysphoric disorder, and masochistic personality disorder (Corcoran & Walsh, 2010). Feminist groups and much of the general public voiced concern about these disorders, as behaviors typically viewed as normal or criminal within our society were being labeled as pathological in the DSM-III-R (Corcoran & Walsh, 2010; Lerman, 1996). Specifically, there was a concern that paraphilic rape would justify repeated rape by labeling it as a disorder and lessen the accountability for these offenders. The proposed masochistic personality disorder also generated controversy, as it described individuals with an ongoing need to experience interpersonal suffering and, consequently, there was concern that this label may stigmatize individuals (particularly women at this time) who were having difficulty separating from an abusive situation (Lerman, 1996). It is interesting that both paraphilic rape and premenstrual dysphoric disorder have been proposed in the current DSM-5 revision, although paraphilic rape, now called paraphilic coercive disorder, has been relegated to the DSM-5 Appendix.

Seven years later, in 1994, the DSM-IV was published. Unlike previous revisions, this effort was undertaken with a 16-member task force and 13 work groups, each consisting of 50 to 100 people with expertise in disparate content areas (Corcoran & Walsh, 2010). The DSM-IV contained 340 mental disorders, classified into 16 types, and its content was based on 150 reviews of the literature, reanalysis of 50 data sets already collected, and 12 issue-specific field trials (Frances, Widiger, & Pincus, 1989). The goal was to include diagnoses only if they had substantial research support and to simplify the wording of the diagnostic criteria to make them more practice friendly (Frances et al., 1989). This revision also emphasized a need for clinically significant distress or impairment in client functioning, in addition to meeting diagnostic criteria, to justify a diagnosis.

The DSM IV-TR was published in 2000 and was only a slight variation of the original DSM-IV (Keely et al., 2008). This revised version, like the DSM-III-R, was released to integrate more up-to-date research on mental disorders prior to a more extensive DSM-5 revision. There were not any changes to the number of disorders, the diagnostic criteria, or the organizational structure of the manual. Primary changes included updates to the coding to bring it into alignment with the current ICD, correction of errors or ambiguities, and further clarification on providing a more accurate, reliable Global Assessment of Functioning score.

The highly anticipated publication of the DSM-5 will occur in May 2013. The development of this revised manual has been no small effort, involving sponsorship from the National Institute of Mental Health and APA, 29 Task Force members, 13 DSM workgroups, six study groups to address cross-cutting issues relevant to all work groups, and strict criteria for membership, precluding remuneration for service and limitations on money or other forms of remuneration that can be accepted by "industry entities" such as pharmaceutical companies (APA, 2012a). Again, there has been a large emphasis on research evidence to guide revisions, although there are criticisms of the level of evidence that has been deemed acceptable for inclusion (Frances, 2012). Unlike prior revisions of the DSM, the DSM-5 Task Force has placed its proposed revisions on the web for public viewing at http://www.dsm5.org/Pages/Default.aspx. Many of the proposed revisions will likely affect how social workers conceptualize, diagnose, treat, and research mental disorders. We recognize that many new proposals and revisions continue to be made, so this editorial is based on revised changes available on the aforementioned website in March 2012. Additional changes may be made after further input for revisions is solicited in spring 2012.

Although previous versions of the DSM (for example, DSM-III and DSM-IV) categorized diagnoses according to specific criteria, the DSM-5 will have an organizational structure based on "clusters" of diagnoses that have been gleaned from the existing scientific evidence as being distinct from one another. Within each cluster of diagnoses, disorders that have similar characteristics will be listed and described in developmental order from childhood disorders to adult disorders, thereby eliminating the need for a separate section on Disorders Usually Found in Infancy and Childhood. For example, the Eating Disorders section of the DSM-5 will include pica and rumination disorder (two disorders previously listed in the childhood disorders section) as well as anorexia, bulimia, and the new diagnosis of binge eating disorder.

Beyond the reorganization of the manual, there are many proposed changes to extant diagnoses, several eliminated disorders, the addition of severity ratings and rating scales, and movement of various diagnoses to new diagnostic categories. In addition, there has been a move from categorical classification of mental illness to an integrated categorical--dimensional approach. As such, the DSM-5 will include cross-cutting dimensional assessment instruments, which have been designed to help increase diagnostic accuracy, assess severity, or track changes in severity during the treatment process (APA, 2012c). Like the third and fourth revisions of the manual, many of these changes have generated controversy and discourse concerning the impact of these changes for diagnostic and reimbursement purposes and clients with regard to services and stigma. However, much of this discourse has occurred within psychiatry, psychology, and counseling, with less discussion within social work. It is essential for social workers, who provide the majority of mental health services in the United States (Whitaker, 2009), to become familiar with these proposed changes and critically consider their impact on social work practice with vulnerable populations. Although the full composite of revisions is online for your review, we have synthesized this information to highlight some of the potential costs and benefits of the most controversial proposed changes.

Perhaps one of the most controversial changes is that Asperger's disorder and pervasive developmental disorder--not otherwise specified (PDD-NOS) is being subsumed under the umbrella of autism spectrum disorders (ASDs). In other words, instead of these disorders being conceptualized as separate disorders, they will be viewed along a spectrum of autism, from mild to severe. In addition, the DSM-5 conceptualizes two symptom dimensions--social communication and interaction and restrictive, repetitive behavior--instead of the three original DSM-IV-TR domains. The potential benefits of these changes include providing more accurate diagnosis, better treatment, and more consistent application of diagnostic criteria across various clinics or centers (APA, 2012b). One potential cost with the proposed DSM-5 criteria, as demonstrated in various research studies, is that many individuals diagnosed with PDD-NOS or Asperger's disorder will no longer qualify for a diagnosis of an ASD with the DSM-5 (Frazier et al., 2012; Mattila et al., 2011). A joint statement from the Autism Society and the Autistic Self Advocacy Network suggests that the DSM-5 criteria should ensure that those who have had a diagnosis under the DSM-IV would maintain access to an ASD diagnosis to support ongoing access to services and increased quality of life (keeping in mind that ASD treatment is not currently publicly funded) (see http://www.autism-society.org/news/in-the-news/the-joint-statement-of-the.html). These concerns are rooted in the possibility that families and various environmental systems may be less understanding of individuals with milder forms of autism and their associated symptoms because many will no longer meet the criteria for a diagnosable mental disorder. It is also conceivable that some individuals who have been diagnosed with Asperger's, or what many refer to as "high functioning autism," may be resistant to these changes, fearing that an autism label will come with greater stigma and discrimination. Researchers have examined the validity of these changes to PDD criteria and suggest that, although we are likely increasing our specificity in diagnosis, there may be a need for expansion of the current DSM-5 diagnostic criteria to include milder forms of autism (Frazier et al., 2012; Mattila et al., 2011).

Another controversial change that will likely affect many clients we work with is the elimination of the bereavement exclusion from the major depressive episode (MDE). Currently, a diagnosis of an MDE requires that symptoms be present for two weeks, but if the symptoms occur after the loss of a loved one, it is recommended that symptoms be present for at least two months or result in marked impairment in functioning that is uncharacteristic of a normal grief response before a diagnosis of a major depression is warranted. This exclusion was included in the DSM-IV to preclude pathologizing normal grief reactions and an over diagnosis of MDE. The proposed revision to remove this bereavement exclusion in the DSM-5 is based on a review of the literature by Zisook and Kendler (2007) referenced on the DSM-5 website that examines evidence for the validity for distinguishing bereavement-related depression (BRD) from standard depression (SMD). This review concludes:
   Overall, the prevailing evidence more strongly supports
   similarities than differences between BRD and SMD. Because so few
   studies focus on BRD occurring within the first 2 months of
   bereavement, the period identified by the DSM to exclude the
   diagnosis of MDE [major depressive episode], more research is
   needed specifically on this group to help us evaluate the validity
   of this important convention. (p. 779)


Despite this, and the many limitations noted by the authors of the studies included in this review, the DSM-5 is providing this literature review as the seminal piece of evidence to remove the bereavement exclusion (Zisook & Kendler, 2007). Similarly, the argument provided by the DSM-5 Mood Disorders Workgroup that there are systematic similarities in symptoms and risk factors between uncomplicated bereavement and MDE does not take into account the potential qualitative and contextual differences defining the onset of bereavement (even if encompassing more severe criteria for MDE) as different from an MDE associated with other psychosocial stressors. For example, from a cultural and societal perspective, it is not uncommon for the meaning and subsequent response to the death of a loved one to be more devastating when compared with other losses, such as divorce. Psychosocial distress associated with the death of a loved one within the first two weeks is typically expected to be more severe than other losses (although this varies by individual), and is likely to result in false positive diagnoses without a bereavement exclusion.

Some of the potential costs of eliminating the bereavement exclusion include labeling individuals experiencing a normal grief reaction with a mental illness, increased stigma associated with severe depressive symptoms following the loss of a loved one, decreased interest in accessing services, and even coverage and reimbursement issues with insurance companies given a prior diagnosis of MDE. In addition, Allen Frances (2010), chairman of the DSM-IV committee, suggested that
   medicalizing normal grief stigmatizes and reduces the normalcy and
   dignity of the pain, short circuits the expected existential
   processing of the loss, reduces reliance on the many well
   established cultural rituals for consoling grief, and would subject
   many people to unnecessary and potentially harmful medication
   treatment.


Despite these potential costs, a plausible benefit includes providing earlier treatment for those who experience MDE symptoms immediately after a loss, perhaps preventing a more chronic course of depression (Frances, 2010; Pies, 2010) or suicide (Pies, 2010). One possibility that is being recommended by those on both sides of the debate is an increase in duration for a diagnosis of MDE beyond two weeks or a reduction of the DSM-IV duration for bereavement of two months (Frances, 2010; Pies, 2010). As Kendler (2010), a member of the DSM-5 Mood Disorder Workgroup suggested, a diagnosis of MDE during early bereavement may lead to important "watchful waiting" to see if treatment is necessary.

Other newly added disorders of interest include attenuated psychosis syndrome (APS) and disruptive mood regulation disorder (DMRD), which were developed to account for expressions of mental disorders that may emerge in earlier stages of development (see http://www.dsm5.org/ Pages/Default.aspx). Attenuated psychosis syndrome is designed to identify "young people at risk for later manifestation of a psychotic disorder" and to determine if there are ways to prevent the progression of a psychotic disorder (see http://www.dsm5.org/proposedrevision/Pages/propose drevision.aspx?rid=412#). The potential danger, which is being considered by the workgroup, is whether the introduction of such a diagnosis will do harm by resulting in inaccurate diagnosis, and a greatly lacking literature base for interventions with proven efficacy and safety (see http://www.dsm5.org/proposedrevision/Pages/proposedrevision. aspx?rid=412#) (Frances, 2011). Similarly, DMRD was developed to account for the increase in diagnosis of childhood bipolar disorder and the different, yet severely impaired, presentation that many have--mainly nonepisodic irritability (APA, 2010). Potential benefits associated with a disparate label include the development and research of new treatment approaches associated with this unique symptom presentation and additional research on this presentation of symptoms and its longitudinal course (APA, 2010).

Another major revision to the DSM includes a completely revamped Personality Disorders section. Although a discussion of these changes would be too lengthy for this editorial, it will be very important for social workers to become familiar with the following four changes: (1) adoption of a hybrid dimensional--categorical model, (2) utilization of six personality types instead of 10, (3) use of rating scales for all levels of personality functioning, and (4) greatly revised diagnostic criteria. The new proposed section is far more complex than the DSM-IV-TR version, and it is yet to be seen whether this system will be truly feasible in real practice settings.

One final change worth noting is the removal of the abuse and dependency dichotomy in the DSM for alcohol or substance abuse disorders, and removal of the legal criterion and addition of a craving criterion. Although there is sufficient evidence for eliminating the abuse/dependence dichotomy, the new criteria yielded a 60 percent increase in the diagnosis of alcohol use disorders in a recent study compared with those diagnosed with the DSM-IV-TR (Teeson, Slade, & Mewton, 2011), suggesting a potential need to increase the threshold for diagnosis. One potential benefit is that the new alcohol or substance use disorder label may result in less stigma than that of "abuse" or "dependence."

There are many additional proposed revisions to the DSM-5. We encourage our colleagues to become more familiar with the current online proposal, critically consider its impact on social work practice, and provide input before its publication in May 2013. How will these changes affect the vulnerable populations we serve? What are the implications for social work practitioners? Will these changes in diagnoses alter the interventions we use? How can we best advocate for revisions that are both scientifically valid and culturally sensitive? Will there be a charge to use the cross-cutting dimensional assessment instruments associated with the DSM-5 diagnosis? We call on all social workers to study the proposed changes and to consider documenting the outcomes of the revisions as they are implemented. APA states that the DSM-5 will be a "living document," indicating that additional changes will be made as new evidence becomes available. Thus, social workers will have the opportunity and responsibility to provide input into the strengths and limitations of these changes and how they affect the clients we serve. As the largest group of mental health providers in the country, it is important for us to be present "at the table" for the discussions that will inevitably ensue as this new page in the evolution of mental health unfolds.

doi: 10.1093/sw/sws027

REFERENCES

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American Psychiatric Association. (2012a). American Psychiatric Association DSM-5 development. About DSM-5. Retrieved from http://www.dsm5.org/about/Pages/ BoardofTrusteePrinciples.aspx

American Psychiatric Association. (2012b). Nays release: DSM-5 proposed criteria for autism spectrum disorder designed to provide more accurate diagnosis and treatment (Release No. 12-03). Retrieved from http:// www.dsm5.org/Documents/12-03%20Autism% 20Spectmm%20Disorders%20-%20DSM5.pdf

American Psychiatric Association. (2012c). American Psychiatric Association DSM-5 development. Cross-cutting dimensional assessment. Retrieved from http://www.dsm5.org/proposedrevisions/pages/cross cuttingdimensionalassessmentinDSM-5.aspx

Corcoran, J., & Walsh, J. (2010). Social work and the DSM: Person-in-environment versus the medical model. In Clinical assessment and diagnosis in social work practice (2nd ed., pp. 11-33). New York: Oxford University Press.

Frances, A. (2010). DSM5 and the medicalization of grief: Two perspectives. Psychiatric Times, 27(5). Retrieved from http://www.psychiatrictimes.com/DSM-5/content/article/10168/1568760

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Frazier, T. W., Youngstrom, E. A., Speer, L., Embacher, R., Law, P., Constantino, J., et al. (2012). Validation of the proposed DSM-5 criteria for autism spectrum disorder. Jourual of the American Academy of Child & Adolescent Psychiatry, 51, 28-40.

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Keely, J. W., Burgess, D. R., & Blashfield, R. K. (2008). Diagnostic and statistical manual of mental disorders (DSM). In S. F. Davis & W. Buskist (Eds.), 21st Century psychology: A reference handbook (pp. 253-261). Thousand Oaks, CA: Sage Publications.

Kendler, K. S. (2010). A Statement from Kenneth S. Kendler, MD, on the proposal to eliminate the grief exclusion criterion from major depression. Retrieved from http://www.dsm5.org/about/ Documents/grief%20exclusion_Kendler.pdf

Lerman, H. (1996). Pigeonholing women's misery: A history and critical analysis of the psychodiagnosis of women in the twentieth century. New York: Basic Books.

Mattila, M., Kielinen, M., Linna, S, Jussila, K., Ebeling, H., Bloigu, R., et al. (2011). Autism spectrum disorders according to "DSM-IV-TR" and comparison with "DSM-5" draft criteria: An epidemiological study. Journal of the American Academy of Child & Adolescent Psychiatry, 50, 583-592.

Pies, R. (2010). The flip-side of good grief may be missed depression. Psychiatric Times. Retrieved from http://veww.psychiatrictimes.com/dsm-5/content/article/ 10168/1647390

Teeson, M., Slade, T., & Mewton, L. (2011). DSM-5: Evidence translating to change is impressive. Addiction, 106, 877-878.

Whitaker, T. (2009). Workforce trends affecting the profession 2009. Washington, DC: National Association of Social Workers.

Zisook, S., & Kendler, K. S. (2007). Is bereavement-related depression different than non-bereavement-related depression? Psychological Medicine, 37, 779-794.

Elizabeth C. Pomeroy, PhD, LCSW, is professor and codirector, Institute of Grief, Loss, and Family Survival, School of Social Work, University of Texas at Austin. Danielle E. Parrish, PhD, is assistant professor, Graduate College of Social Work, University of Houston, Houston, TX. Address correspondence to Elizabeth C. Pomeroy, School of Social Work, University of Texas at Austin, I University Station D3500, Austin, TX 78712; e-mail: bpomeroy@mail.utexas.edu. Advance Access Publication August 28, 2012
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Title Annotation:Diagnostic and Statistical Manual of Mental Disorders
Author:Pomeroy, Elizabeth C.; Parrish, Danielle E.
Publication:Social Work
Article Type:Critical essay
Geographic Code:1USA
Date:Jul 1, 2012
Words:4074
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