The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, also known as DSM-V) is the most up-to-date classification of mental disorders established by the American Psychiatric Association in 2013, replacing the previous edition – DSM-IV.
Specialists divided the current DSM into several disorder groups to which individual diseases belong. For example, in the category of mood disorders, we will find not only various types of depressive disorders but also bipolar disorders or dysthymia.
Depending on the DSM-5, interviewing the Patient is the first diagnosing stage. The diagnostic criteria in the classification refer to specific diseases (e.g., depression or schizophrenia), so the first stage of diagnosis is to conduct a conversation with the Patient about the symptoms experienced. On this basis, the specialist determines whether the person has any mental disorders at all and, if so, what they may be.
The construction and description of mental conditions in current diagnosis methods (DSM-IV, DSM-5, ICD-10, ICD-11) vary extensively from standard pathological concepts. This is due to the demand for more specific ideas as part of the operationalization, the more prominent inclusion of current study outcomes, and the necessity of making compromises on a global level. The general purpose is to enhance the validity and dependability of psychiatric diagnostics.
DSM-5 is high quality because its development was thorough, regarding the most delinquent scientific conclusions and including input from many prominent specialists. It describes the present status of global consensual knowledge about mental disorders and is an essential reference citation. Notably, the word disorder has become increasingly favored over the phrase disease or illness in operationalized diagnostic systems in psychiatry, especially influenced by US publications.
This term conveys the idea that these phenomena mainly do not compare to those in medicine but to something not yet thoroughly evident from a medical viewpoint and can only be dealt with in detail. Due to length restrictions, it is not possible to demonstrate all the appropriate elements of the lengthy DSM-5. Therefore, this paper will discuss significant fundamental aspects and a few disorder-related factors.
Implementing DSM-5 in practical clinical work is in the most delinquent versions of psychiatric books. Contrary to the initial intentions, DSM-5 is not as creative as the creators had intended. For example, the originally favored conception of presenting a primarily syndromal/dimensional diagnostic system rather than the prior disease/disorder commodities was mostly abandoned for numerous scientific and practical reasons.
The preference to incorporate biomarkers for the diagnosing objectification in numerous diseases/disorders was likewise not recognized due to a deficiency of adequate stable neurobiological conclusions. Prevailing, the creators of DSM-5 did not manage to conceptualise mental illnesses/disorders as neurobiologically determined commodities, although it was the initial intent. The condition of empirical knowledge, even though it has been known for a long time, has dissatisfied specialists.
Due to diverse motivations, such as lack of validity and practicality, the initial strategy to merge schizophrenic psychoses with bipolar disorders into a comprehensive ‘psychotic spectrum' category didn't materialize. It has raised concerns among some experts, especially regarding the genetic similarities between these two disorder groups. As a result, in DSM-5, a primary section is still dedicated to schizophrenic disorders, titled ‘Schizophrenia spectrum and other psychotic disorders.'
The symptom-based description of schizophrenic psychoses
was further simplified compared to DSM-IV. Due to a lack of reliability and consistency, the first-rank symptoms and most traditional subtypes were not included. Only catatonia, out of the original subtypes, remains, but it is no longer classified as a subtype of schizophrenia. Instead, it is considered a cross-diagnosis specifier for catatonic manifestation, which may also be applied, among others, to affective conditions.
A notable aspect of DSM-5 is the inclusion of a separate chapter for bipolar disorders, labeled ‘Bipolar and related disorders.' This chapter encapsulates both mania (as before) and depression as integral parts of bipolar disorder. Notably, this is the first moment that these two primary phenomenological types of bipolar disorders – mania and depression – have been shown together in an autonomous chapter.
Experts in the field widely support the decision to focus on bipolar disorders, although some who specialize in affective disorders as a whole have raised concerns about the lack of association with unipolar depression. This new approach aims better to represent the monitored phenomenon in kids and adolescents. By introducing the ‘disruptive mood dysregulation disorder' category, the aim is to address the overdiagnosis of bipolar disorder in children in the USA.
The inclusion of a ‘mixed feature' specifier is intended to capture the combination of manic and depressive symptoms, providing a more nuanced representation of ‘mixed states.' Additionally, the category ‘Other specified bipolar and related disorder' expands the diagnostic options for subsyndromal bipolar manifestations. As a result, the depression chapter currently exclusively focuses on ‘major depressive disorder,' distinct from depression as a component of bipolar disorder.
The depression chapter in DSM-5 now contains major depression in its episodic and relapsing state, combining the previous ‘dysthymia' classification with chronic forms of depression under ‘persistent depressive disorder.' It also includes ‘premenstrual dysphoric disorder'. The DSM-5 gives attention to mild symptomatic signals for bipolarity and mixed states between depression and mania, using the specifier ‘with mixed features' to apprehend these subsyndromal changes. It also presents the specifier ‘with anxious distress' to address the transitional area between depression and anxiety.
The chapter focusing on anxiety disorders now only includes classical anxiety disorders, with the description of generalized anxiety disorder having been altered. Trauma- and stressor-related disorders have been moved to an independent chapter, which also contains posttraumatic stress disorder. Lastly, the somatic symptom and related disorders chapter contains some disorders previously included in DSM-IV and ICD-10, with altered definitions that emphasize the aspect of stress or anxiety alongside somatoform symptoms.
The DSM-5 is helpful for clinical work because it helps with making a differential diagnosis. It includes additional elements such as associated features, specifiers, and ratings, which enable a more thorough assessment of symptoms and their impact on a person's life beyond just diagnosing a disorder.
This detailed approach allows a patient's circumstances to be represented more comprehensively. However, it is unclear whether clinicians will have the time to utilize these additional options in their daily practice due to time constraints and staff shortages. Despite these limitations, dedicated clinicians can benefit from the various options in the DSM-5, particularly in tailoring psychotherapy and medication treatments for patients.
While many disorder entities in the DSM-5 are similar to those in the DSM-IV, some are new or defined differently. Additionally, there are changes in how disorders are grouped and named. In general, the DSM-5 reflects the growing empirical understanding, and most modifications are based on proof or other conceptual contemplations.
Specialists also use the ICD classification, or the International Statistical Classification of Diseases and Health Problems, in their work. The main difference is that the ICD refers to all kinds of diseases, while the DSM is a classification of problems directly related to the psyche and behavior.
Minor differences exist between the ICD and DSM classifications, but they are becoming increasingly blurred. The new eleventh edition of the ICD will soon come into effect.
It is worth knowing what the diagnosis of mental health disorders is like. It is also worth remembering, however, that making a genuine diagnosis for yourself is impossible. If you are worried that something is wrong with your mental health, it is best to make an appointment with a psychotherapist or psychiatrist and talk about your suspicions.
The DSM-5 is based on the latest scientific knowledge about mental disorders. However, other approaches could also be used. The ICD-11 will incorporate some, but not all, of the changes in DSM-5. The ICD-11 will be the required diagnostic system in all countries except the USA and remain separate from DSM-5. The work done for DSM-5 is significant for the development of ICD-11.
Unfortunately, DSM-5 did not meet all of its original goals and expectations. Even though it includes a lot of scientific knowledge, it did not confirm many diseases as biologically defined or at least confirmed by biomarkers. It was not the fault of the DSM-5 experts but was due to the lack of sufficient evidence. Although biomarkers have been described for individual disorders, they have not been well enough confirmed or shown enough power to distinguish between various disorders. It is unclear how the Research Domain Criteria (RDoC), a different concept not associated with DSM-5, will impact this issue.
The Research Domain Criteria (RDoC) does not refer to traditional clinical diagnoses. As a result, it is irrelevant for making diagnoses in a routine clinical approach and is seen as a tool for examination. The initially intended change to using a syndromal/dimensional diagnostic procedure that would especially abandon classic ‘disease entities’ was not executed. It became evident during discussions that the ‘disorder entities' supply practical further details, specifically in clinical care, and that this knowledge would be misplaced in a purely syndromal/dimensional approach.
Practical considerations about clinical practice, such as the indications for psychopharmaceuticals and billing to health insurance companies, also played a role in this decision. Finally, the decision was made to maintain the traditional approach due to pragmatic reasons.
The idea of combining schizophrenic and bipolar disorders into a psychosis spectrum has been extensively discussed for over two decades, mainly based on genetic findings. Nevertheless, this idea has not been fully executed, partly due to theoretical and practical reasons. The syndromal/dimensional approach was only added for additional information, serving as a secondary level of categorization, such as with transdiagnostic specifiers like the mixed features specifier. It highlights the concept that not all mental illnesses can be neatly classified as separate disease entities or disorder entities.
There are significant overlaps between different conditions, such as between major depression and anxiety disorders, as well as between unipolar and bipolar disorders. For instance, manic symptoms frequently occur in unipolar depression, and conversely, depressive symptoms are often present in mania, with mixed states representing the extreme. To address these overlaps, DSM-5 introduced relevant specifiers to capture the varying degrees of overlap. One such overlap is schizoaffective psychosis, which bridges affective disorders and schizophrenic psychoses.
Interestingly, DSM-5 maintains the traditional concept of schizoaffective psychosis as a distinct disease rather than adopting a specifier approach. This decision seems to be based on the relatively good interrater reliability scores achieved with the traditional concept.
Given the priority given to ICD-10 and future ICD-11 in countries outside the USA, DSM-5 may primarily be used in universities and research projects outside the USA. However, it lays the groundwork for the solutions offered in ICD-11, which is expected to share some similarities with DSM-5 while also introducing its solutions.
Experiences in clinical practice will demonstrate the capacity to which the changes in DSM-5 are useful.
Table of Contents
Bipolar disorder is a mental disorder characterized by the alternation of extremely different mental states – depression and mania. What… read more »
Dissociative identity disorder Ii is characterized by the presence of at least two independent and different personalities in one person.… read more »
Do you know why Asperger's Syndrome is no longer diagnosed? The diagnostic criteria for many mental disorders were updated. Learn… read more »
Post-traumatic stress disorder is a specific psychological reaction to a highly stressful event. How does it manifest itself? What is… read more »
Bulimia is an eating disorder characterized by binge eating followed by compensatory behaviors. What are its causes? How to treat… read more »
Antisocial personality disorders are mental dysfunctions that result in abnormal behavior of the individual. What are the typical behaviors? read more »
Depression is a mental disorder which usually is manifested by abnormal mood regulation. What are the signs of depression? Which… read more »
Tourette syndrome is characterized by tics. What are its causes? What to do if we observe disturbing symptoms? read more »
Dysmorphia is a mental disorder associated with a negative body image. It is a common problem these days. Learn how… read more »
