The Evolution of the Diagnostic & Statistical Manual of Mental Disorders (DSM)

1. The Evolution of the Diagnostic & Statistical Manual of Mental Disorders (DSM) Rebecca Rotondo, M. Ed. 2013

2. DSM-1 1950-American Psychiatric Association produced the first draft 1952-DSM-I was published marking the beginning of modern mental illness classification 106 diagnoses primarily characterized as reactions to psychological, social, and biological factors 130 pages

3. DSM-II • published in 1968 • listed 182 disorders • 134 pages long • quite similar to the DSM-I • The term "reaction" was dropped, but the term “neurosis" was retained

4. Seventh printing of the DSM-II • 1974 • no longer listed homosexuality as a category of disorder. The diagnosis was replaced with the category of "sexual orientation disturbance".

5. DSM-III • Published in1980 • The pychodynamicor physiological view was abandoned, in favor of a regulatory or legislative model. • A new "multiaxial" system attempted to yield a picture more open to a statistical population census, rather than just a simple diagnosis • 494 pages • listed 265 diagnostic categories

6. DSM-III-R • In 1987 the DSM-III-R was published as a revision of DSM-III • Categories were renamed, reorganized, and significant changes in criteria were made. • Six categories were deleted while others were added. Controversial diagnoses considered and discarded. • "Sexual orientation disturbance" was also removed and was largely included under "sexual disorder not otherwise specified" which can include "persistent and marked distress about one’s sexual orientation.“ • 292 diagnoses • 567 pages long

7. DSM-IV • Published in 1984 • 297 disorders • 886 pages • major change from previous versions was the inclusion of a clinical significance criterion to almost half of all the categories, which required symptoms cause "clinically significant distress or impairment in social, occupational, or other important areas of functioning“ • Some personality disorder diagnoses were deleted or moved to the appendix

8. DSM-IV-TR • Published in 2000 • "text revision" of the DSM-IV • diagnostic categories and the vast majority of the specific criteria for diagnosis were unchanged • text sections giving extra information on each diagnosis were updated, as were some of the diagnostic codes

9. Categorization • Qualifiers are sometimes used, for example mild, moderate or severe forms of a disorder • For nearly half the disorders, symptoms must be sufficient to cause "clinically significant distress or impairment in social, occupational, or other important areas of functioning • Each category of disorder has a numeric code taken from the ICD coding system, used for health service (including insurance) administrative purposes.

10. Multi-axial system • psychiatric diagnosis into five dimensions (axes) relating to different aspects of disorder or disability: • Axis I: All diagnostic categories except mental retardation and personality disorder • depression, anxiety disorders, bipolar disorder, ADHD, autism spectrum disorders, anorexia nervosa, bulimia nervosa, and schizophrenia • Axis II:Personality disorders and mental retardation (although developmental disorders, such as Autism, were coded on Axis II in the previous edition, these disorders are now included on Axis I) • include personality disorders: paranoid personality disorder, schizoid personality disorder, schizotypal personality disorder, borderline personality disorder, antisocial personality disorder, narcissistic personality disorder, histrionic personality disorder, avoidant personality disorder, dependent personality disorder, obsessive-compulsive personality disorder; and intellectual disabilities. • Axis III: General medical condition; acute medical conditions and physical disorders • brain injuries and other medical/physical disorders which may aggravate existing diseases or present symptoms similar to other disorders. • Axis IV: Psychosocial and environmental factors contributing to the disorder • Axis V:Global Assessment of Functioning or Children's Global Assessment Scale for children and teens under the age of 18

11. Criticism • Validity and reliability • Superficial symptoms • Dividing lines • Some argue rather a categorical approach, a fully dimensional, spectrum or complaint-oriented approach would better reflect the evidence • Cultural bias • Medicalization and financial conflicts of interest • Political controversies • “Labeling” individuals causing social stigmas or discrimination

12. DSM-V • Timeline • 1999-2007: Phase 1-Pre-Planning white papers (research on a number of topics) • 2004-2007: Phase 2-Refining the Research Agenda • 2006-2008: DSM-5 Work Group Chairs and Members are appointed and announced. • 2008-2010: Work Groups formulating their proposed draft criteria, including conducting extensive literature reviews, performing secondary data analyses, and soliciting feedback from colleagues and professionals. • April, 2010-February, 2012: Field Trials and Data Collection • March 2012-November 2012: Final Drafts of Texts • March-December 2012: Presentation of DSM-5 proposals to APA Board of Trustees; Feedback and final revisions; Final Approval by APA Board of Trustees; Submission to American Psychiatric Publishing, Inc. • May 18-22, 2013: it will be released

13. Proposed changes to DSM-IV Diagnoses • Asperger’s Syndrome • eliminated as a separate disorder, and merged under autism spectrum disorders (ASD). • Clinicians now will rate the severity of clinical presentation of ASD as severe, moderate or mild http://en.wikipedia.org/wiki/Diagnosis_of_Asperger_syndrome#Proposed_changes_to_DSM-5

14. Current Diagnoses (DSM-IV) • Pervasive Developmental Disorders include: • Autistic Disorder • Asperger’s Disorder • Pervasive Developmental Disorder, NOS • Rett’s Disorder • Childhood Disintegrative Disorder

15. Prevalence • Approximately 1 in 88 children will be diagnosed with an ASD (CDC, 2008) • Pervasive Developmental Disorders are more common in males • 3 – 4 times more common in males • Pervasive Developmental Disorders are the fastest growing developmental disabilities (CDC, 2007)

16. DSM–V Workgroup

17. DSM–V Workgroup

18. DSM–V Workgroup

19. Proposed Criteria A. Persistent deficits in social communication and social interaction across contexts, not accounted for by general developmental delays, and manifest by all 3 of the following: 1. Deficits in social-emotional reciprocity 2. Deficits in nonverbal communicative behaviors used for social interaction 3. Deficits in developing and maintaining relationships, appropriate to developmental level (beyond those with caregivers)

20. Proposed Criteria B. Restricted, repetitive patterns of behavior, interests, or activities as manifested by at least two of the following: 1. Stereotyped or repetitive speech, motor movements, or use of objects 2. Excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change 3. Highly restricted, fixated interests that are abnormal in intensity or focus 4. Hyper-or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment

21. Proposed Criteria C. Symptoms must be present in early childhood (but may not become fully manifest until social demands exceed limited capacities) D. Symptoms together limit and impair everyday functioning.

22. Key points in domain changes • Several social/communication criteria were merged • Increases clarity and specificity of diagnosis • Improves stability of ASD diagnosis over time • Encompasses various language levels • Premise that deficits in communication and social behaviors are inseparable and can be more accurately considered as a single set of symptoms

23. Lord & Jones, 2012

24. Attention deficit hyperactivity disorder • change the diagnostic criteria from symptoms being present before seven years of age to symptoms being present before twelve years of age. • Inattentive type and Hyperactive/Impulsive type, a minimum of only four symptoms need to be met if a person is 17 years of age or older. The current criteria of meeting a minimum of six symptoms for the would still apply for those 16 years of age or younger.

25. Bipolar disorder • include further and more accurate sub-typing for bipolar disorder. • more stringent criteria for the diagnosis of bipolar disorder in children with a new diagnosis temper dysregulation disorder with dysphoriaproposed • Depression • currently grief is only considered a sign of depression if two months have elapsed since the death of a loved one, the new version would allow for diagnosis within the first few weeks

26. Considerations • Research suggests that if implemented, up to 40% of those with autism as defined by the current criteria would be excluded from such a diagnosis • Study by McPartland et al. (2012) • Other researchers and experts in field disagree with findings Cathy Lord (ADOS)

27. Oppositional defiant disorder • the eight symptoms will be divided into the following categories: • Angry/Irritable Mood; • Defiant/Headstrong Behavior • Vindictiveness. • (four of these symptoms need to be present to meet diagnostic criteria. The minimum four symptoms can come from all (or even just one or two) of the three categories) • children under 5 years of age, oppositional behavior "must occur on most days for a period of at least six months". • For children 5 years or older, oppositional behavior "must occur at least once per week for at least six months". The current criteria states that four or more symptoms must be present for at least 6 months. • Personality disorders • revamped definition of personality disorder and a dimensional rather than a categorical approach based on the severity of dysfunctional personality trait domains (negative emotionality, introversion, antagonism, disinhibition, compulsivity, and schizotypy). In addition, patients would be assessed on how much they match each of six prototypic personality disorder types: antisocial/psychopathic, avoidant, borderline, narcissistic, obsessive-compulsive, and schizotypal with their criteria being derived directly from the dimensional personality trait domains.

28. Posttraumatic stress disorder • Various changes • http://en.wikipedia.org/wiki/Posttraumatic_stress_disorder#DSM-5_proposed_diagnostic_criteria_changes

29. Proposed new diagnoses • Complex post-traumatic stress disorder • Depressive personality disorder • Compulsive hoarding • Olfactory Reference Syndrome • Negativistic (passive-aggressive) personality disorder • Relational disorder • Skin Picking Disorder • Sluggish cognitive tempo • Binge Eating

30. Conditions proposed by outside sources • Apathy Syndrome • Body Integrity Identity Disorder • Complicated Grief Disorder • Developmental Trauma Disorder • Disorders of Extreme Stress Not Otherwise Specified • Fetal Alcohol Syndrome • Internet Addiction Disorder • Male-to-Eunuch Gender Identity Disorder • Melancholia • Parental Alienation Syndrome • Seasonal Affective Disorder • Sensory Processing Disorder

31. Additional References for DSM-V • http://www.goodtherapy.org/blog/dsm-v-5-criteria-aspergers-autism-spectrum-1203128 • http://www.dsm5.org/Pages/Default.aspx

32. 50 Year Change

33. Sources • Dsm-5 development. In (2013). American Psychiatric Association. Retrieved from http://www.dsm5.org/Pages/Default.aspx • (2011, November 1). Wikipedia. Retrieved fromhttp://en.wikipedia.org/wiki/Diagnostic_and_Statistical_Manual_of_Mental_Disorders