UNIVERSITY OF NAIROBI
HUMANITIES AND SOCIAL SCIENCES
FACULTY OF ARTS
DEPARTMENT OF PSYCHOLOGY
ASSIGNMENT
DSM-5 HISTORY AND DEVELOPMENT
HANIEL GATUMU
WILFRED KERAMBO
C01/1018/2019
2OTH AUGUST 2020
INTRODUCTION
The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) marks the first
significant revision of the publication since the DSM-IV in 1994. Changes to the DSM were largely
informed by advancements in neuroscience, clinical and public health needs, and identified problems
with the classification system and criteria put forth in the DSM-IV. Much of the decision-making was also
driven by a desire to ensure better alignment with the International Classification of Diseases and its
upcoming 11th edition (ICD-11). In this paper, we describe select revisions in the DSM-5, with an
emphasis on changes projected to have the greatest clinical impact and those that demonstrate efforts
to enhance international compatibility, including integration of cultural context with diagnostic criteria
and changes that facilitate DSM-ICD harmonization. It is anticipated that this collaborative spirit between
the American Psychiatric Association (APA) and the World Health Organization (WHO) will continue as
the DSM-5 is updated further, bringing the field of psychiatry even closer to a singular, cohesive
nosology.
DEVELOPMENT OF DSM-5
DSM-5 was constructed with the goal of addressing limitations in the DSM-IV while integrating the latest
scientific and clinical evidence on the empirical basis of psychiatric disorders.The priority was to ensure
the best cure of patients possible and in the process,8mprove usability for clinicians and
researchers.Through the contribution of more than 400 experts from 13 countries, representative
disciplines of psychiatry, psychology, neurology, pediatrics, primary care, epidemiology, research
methodology and statistics,a series of 13 international research conferences were held (2003-2008),in
cooperation with the WHO Division of Mental Health and Substance Abuse with support from a 5-year
National Institutes of Health (NIH) cooperative agreement with the American Psychiatric Institute of
Research and Education,the research component of the APA(15).The resulting monographs were
produced to identify gaps in the current nosology and diagnostic criteria,providing a starting point from
where members of the DSM-5 Task Force and Work Groups would begin building their proposals for
DSM-5.
Membership in the DSM-5 Task Force and Work Groups was determined in part by the range of
knowledge needed and also by diversity of representation.Nearly every DSM-5 Work Group included at
least one international member.To ensure that cultural factors was included in early revision proposals a
DSM-5 Culture and Gender study Group was appointed to provide guidelines for the Work Group
literature reviews and data analyses 5hat served as the empirical rationale for draft
changes.Recommendations to the work groups included consideration of possible evidence of
racial,ethic or gender bias in diagnostic criteria;the emergence of new data about gender or cultural
difference like discrepancies in prevalence or symptom presentations;and the presence of gaps in the
literature signaling the need for field trial testing or secondary data analyses.
Although the subject of transcultural psychiatry has firmly established the relevance of culture and social
context to individual help seeking behaviours, clinical presentation and response to treatment,the DSM
leadership recognized that these issues would only increase in importance for both clinical care and
research applications. As a result in developing the chapter outline of text accompanying each diagnostic
criteria set,it was determined that culture,as well as age and gender; warranted separate discussion of
variance in symptom expression risk,course, prevalence and other aspects of diagnosis,where evidence
was available Although not included for every disorder,a substantial proportion of disorders included text
that references such findings.This is a notable improvement from the DSM-IV which more explicitly
recognises cultural context that the DSM-III(4),but regulates culture, gender and age to sporadic
discussion and collectively,rather than a separate topics. For instance the B criterion for social anxiety
disorder(criterion A in the DSM-IV) has been expanded beyond just fear of embarrassment or
humiliation of oneself to now include anxiety symptoms about offending others -a nod to the cultural
syndrome taijin kyofusho and an acknowledgement of the fact this presentation might be observed
more in individuals from non-western cultures (particularly Japan and Korea)
DSM-5 CLASSIFICATION
Despite the fact that the DSM is a US Classification system for the diagnosis of Mental disorders,in
conjunction with the use of official ICD statistical role code numbers International interest in the manual
has flourished since the DSM-III was published in 1980.The DSM-5 is based 9n explicit disorder
criteria,which taken together constitute a 'nomenclature' of mental disorders,along with an extensive
explanatory text that is fully referenced for the first time in the electronic version of this DSM. The
developers of DSM-5 sought to maintain and where possible enhance the consistency of DSM and ICD
revisions for clinical guidance-a challenging task given that revisions to each were not entirely concurrent
(the publication of the ICD-11 8s projected to 2015). However a DSM-ICD harmonization coordinating
group was organised early in the development process,under the direction of Steven Hyman,chair of the
WHO's International Advisory Group for the revision of ICD-10 Mental and Behaviour Disorders and a
DSM-5 Task Force member.
At the outset it was clear that one of the primary strategies would be to develop a joint approach to
organising the megastructure or organizational framework by which disorders are grouped into similar
clusters based on shared pathophysiology, genetic disease and other findings from neuroscience and
clinical experience. The DSM-IV's descriptive and phenomenological approach to classification was
outdated and in the framework of research from science that had emerged over the previous two
decades,also inaccurate.
As a result a DSM-5 initiative to develop a more valid basis for the organisation of a mental disorder
classification was rapidly converted into a joint effort of the DSM-5 Task Force and the ICD-10 revision
(ICD-11 development) Advisory Committee. Using an expanded set of validity criteria from those
originally proposed by Robins and Guze in 1976(26)a series of analyses and papers were developed that
were published in an international Psychiatric journal. It was rapidly recognised that the application of
such validators was much more meaningful for large groups or disorder spectra than for individual
categorical diagnoses.
Much of the research from genetics and psychiatry over the past 20 years points to an overlapping
genetic liability between psychotic and mood disorders, particularly bipolar disorders,that belie DSM-IV’s
separation of these as distributive. In the DSM-5 classification,the chapter on Schizophrenia and other
psychotic disorders is sequenced with that of bipolar and related disorders (which are now separated
from unipolar mood disorders),which is followed by the chapter on depressive disorders. This also is
consistent with recent findings from the largest genome-wide study of mental disorders to date,which
identified shared polymorphisms between select neurodevelopmental disorders (autism spectrum
disorder,ASD and attention-deficit/hyper-activity disorder,ADHD), Schizophrenia, bipolar and major
depressive disorders. Incidentally,these comprise the first four chapters of DSM-5.
A similar pattern-grouping based more so on neuroscience and less on symptoms expression-also occurs
within the diagnostic categories.As noted above ASD AND ADHD are now grouped together in
neurodevelopment disorders,with some of the former DSM-IV.In the obsessive-compulsive and related
disorders chapter are body dysmorphic disorder (previously classified in DSM-IV”somatoform
disorders”)and trichotillomania (hair pulling disorder),which belonged to DSM-IV’s chapter on impulse
control disorders not elsewhere classified.Like the pediatric disorders, DSM-IV anxiety disorders two are
distributed into separate chapters of fear circuitry based anxiety, disorders (phobias); anxiety disorders
related to obsession and compulsions (obsessive-compulsive disorder);those that arise from trauma or
extreme stress (post-traumatic stress disorder;Disorders.
INTEGRATION AND DIMENSIONS
Despite the statement in the DSM-IV that there is no assumption that each category of mental disorders
is a completely discrete entity with absolute boundaries dividing it from other mental disorders,the use
of strict categorical boundaries has given the impression of psychiatric disorders as unitary, discrete
phenomena.Throughout general medicine, conditions are frequently conceptualised on a continuum
from normal to pathological, without relying on a singular threshold to distinguish the presence or
absence of disease,as in serum cholesterol and glycated hemoglobin.Specifiers and subtypes delineate
phenomenological variants of a disorder indicative of specific subgroupings, which impact, among other
outcomes, on treatment planning and treatment developments. The numbers of specifiers and subtypes
in the DSM-5 has been expanded to account for efforts to dimensionalize disorders more so than in the
DSM-IV. Within the depressive disorders and bipolar and related disorders, a specifier of “with mixed
features” replaces the diagnosis of bipolar I, mixed episode in the DSM-IV, given that subthreshold mixed
states of major depressive and manic episodes are much more common and may have specific treatment
implications 42,43 but would be excluded from diagnosis by continuing DSM-IV's requirement that full
criteria are met for both syndromes. The “with mixed features” specifier, therefore, now applies to
unipolar as well as bipolar conditions. A specifier of “with limited prosocial emotions” is added to
conduct disorder for children displaying extreme callousness and negative affectivity, different severity
(e.g., more frequent and severe patterns of aggression), and poorer treatment response than children
who do not qualify for the specifier 44. Specific treatment interventions have been developed that are
more successful with this subgroup.
Combining and splitting DSM-IV disorders
Some disorders were revised by combining criteria from multiple disorders into a single diagnosis, as in
instances where there was a lack of data to support their continued separation. The most publicly
discussed example of this is ASD. As noted previously, the addition of behavioral specifiers indicates
variants of ASD that account for the DSM-IV disorders it subsumed. Somatic symptom disorder largely
takes the place of somatization disorder, hypochondriasis, pain disorder, and undifferentiated
somatoform disorder, although many individuals previously diagnosed with hypochondriasis will now
meet criteria for illness anxiety disorder (new to DSM-5). Substance use disorder is a combination of
DSM-IV substance abuse and substance dependence, the latter of which was deemed inappropriate due
to the pejorative nature of the term dependence used to describe normal physiological responses of
withdrawal from certain substances and medications. Further, the addition of severity ratings for
substance use disorder enables a diagnosis of mild substance use disorder, that will be coded separately
(with the ICD code for substance abuse in DSM-IV) from moderate-to-severe levels (coded with the ICD
codes previously used for substance dependence).
Specifiers and subtypes
Specifiers and subtypes delineate phenomenological variants of a disorder indicative of specific
subgroupings, which impact, among other outcomes, on treatment planning and treatment
developments. The numbers of specifiers and subtypes in the DSM-5 has been expanded to account for
efforts to dimensionalize disorders more so than in the DSM-IV. Within the depressive disorders and
bipolar and related disorders, a specifier of “with mixed features” replaces the diagnosis of bipolar I,
mixed episode in the DSM-IV, given that subthreshold mixed states of major depressive and manic
episodes are much more common and may have specific treatment implications 42,43 but would be
excluded from diagnosis by continuing DSM-IV's requirement that full criteria are met for both
syndromes. The “with mixed features” specifier, therefore, now applies to unipolar as well as bipolar
conditions. A specifier of “with limited prosocial emotions” is added to conduct disorder for children
displaying extreme callousness and negative affectivity, different severity (e.g., more frequent and severe
patterns of aggression), and poorer treatment response than children who do not qualify for the
specifier 44. Specific treatment interventions have been developed that are more successful with this
subgroup.
New disorders
A rigorous review process was established for assessing all proposed revisions to the DSM-5, and those
suggesting inclusion of new disorders were among the most stringently assessed. Based on a review of
existing evidence from neuroscience, clinical need, and public health significance, a handful of new
disorders are included, many of which were elevated from DSM-IV's chapter on “conditions for further
study”. Hoarding disorder addresses the excessive collection of often useless items, including garbage,
which frequently results in hazardous living conditions for patients and/or dependents. Disruptive mood
dysregulation disorder (DMDD) was proposed in response to a decade-long debate about whether or not
chronic irritability in children is a hallmark symptom of pediatric bipolar disorder. With the prevalence of
childhood bipolar disorders growing at an alarming rate, the DSM-5 Childhood and Adolescent Disorders
Work Group compared evidence from natural history and treatment studies of classic bipolar disorder
versus bipolar disorder diagnosed using non-episodic irritability as a criterion, and determined that
separate disorders based on episodic versus persistent irritability were justified 45. Therefore, children
with extreme behavioral dyscontrol but non-episodic irritability no longer qualify for a diagnosis of
bipolar disorder in the DSM-5 and instead would be considered for DMDD. Other notable new disorders
(which were elevated from DSM-IV's appendix) include binge eating disorder, premenstrual dysphoric
disorder, restless legs syndrome, and REM sleep behavior disorder.
Removal from DSM-IV
One of the most controversial proposals for the DSM-5 concerned the removal of the bereavement
exclusion for major depressive episodes. Under the DSM-IV, individuals exhibiting symptoms of major
depressive disorder were excluded from diagnosis if also bereaved within the past 2 months. The
intention was to prevent individuals experiencing normal grief reactions to loss of a loved one from
being labeled as having a mental disorder. Unfortunately, this also prevented bereaved individuals who
were experiencing a major depressive episode from being appropriately diagnosed and treated. It also
implied an arbitrary time course to bereavement and failed to recognize that experiences of major loss –
including losses other than the death of a loved one, like job loss – can lead to depressive symptoms that
needed to be distinguished from those associated with a major depressive disorder. Although symptoms
of grief or other losses can mimic those of depression and do not necessarily suggest a mental disorder,
for the subset of individuals whose loss does lead to a depressive disorder (or for whom a depressive
disorder was already present), appropriate diagnosis and treatment may facilitate recovery. As a result,
the bereavement exclusion was lifted and replaced with much more descriptive guidance on the
distinction between symptoms characteristic of normal grief and those that are indicative of a clinical
disorder
Changes in naming conventions
Revisions in commonly used terminology required an evaluation of the most appropriate terms for
describing some mental disorders – an issue of particular concern for consumer-advocate organizations.
The term “mental retardation” underwent several draft changes before the name “intellectual disability
(intellectual developmental disorder)” was approved. The joint naming convention reflects use of the
term “intellectual disability” in US law 47, in professional journals, and by some advocacy organizations,
while the parenthetical term maintains language proposed for ICD-11 (48). As described previously, the
terms “substance abuse and substance dependence” have been removed and are now replaced jointly
by “substance use disorder”. The name of the substance chapter itself (“substance-related and addictive
disorders”) was altered to include the term “addictive”, matching a proposed ICD-11 naming convention,
which refers to inclusion of gambling disorder as a behavioral syndrome with symptoms and
pathophysiology (e.g., reward system activation) largely mirroring those in substance-related disorders.
Also in keeping with ICD language, the “not otherwise specified” categories in the DSM-IV have been
renamed and reconceptualized as “other specified” and “unspecified” categories in the DSM-5.
CONCLUSIONS
Final determination of DSM-5's impact must admit judgement until after the manual has been in use for
some time.Epidemiological studies will aid in detecting changes in prevalence and cornorbidaties from
the DSM IV, including implementation of cross-national surveys of disorders with high public health
relevance worldwide,such as Schizophrenia, major depressive disorder and, substance use disorders.The
more immediate next steps for the DSM-5 include the development of materials that may assist in its use
in primary care settings, adaptation of assessment instruments to DSM-5 and documenting the evidence
base for revision decisions in the DSM-5 electronic archives. There will also be further testing and
development of the dimensional assessments in the manual including that of a pediatric version of the
internationally used WHO Disability Assessment Schedule 2.0.By continuing collaboration with the WHO
in future editions of the DSM,we can assure a more comparable international statistical classification of
mental disorders and more close to a truly unified nosology and approach to diagnosis.Such a
collaborative effort should assist the 200,000 psychiatrists worldwide to better care for individuals with
these life-altering and potentially destructive conditions,and advance a more synergistic and cumulative
international research agenda to find the cause and cures of these disorders.
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