Changes, Controversy, and Implications
for Psychiatric Nursing
Margaret Jordan Halter,
PhD, APRN;
Donna Rolin-Kenny,
PhD, APRN, PMHCNS-BC;
and Laura Cox Dzurec,
PhD, PMHCNS-BC
30
ABSTRACT
Scheduled for publication in May 2013, the Diagnostic and Statistical Manual of
Mental Disorders, fifth edition (DSM-5), will guide clinical diagnoses, treatment
plans, medication choices and protocols, insurance reimbursements, and research
agendas throughout the United States. It will also serve as a reference manual for
clinicians around the world. This primary diagnostic source used by psychiatric
and mental health providers is undergoing significant change in organization and
content relative to the previous edition. This article provides a general overview of
what to expect in the DSM-5, highlighting major aspects of the revision. Included is
a list of the proposed diagnostic categories and an overview of some of the debate
and discussion accompanying the changes. Implications for psychiatric nurses and
psychiatric nursing are presented.
Copyright © SLACK Incorporated
Earn
Contact
Hours
© 2013 Shutterstock.com/Boffi
chiatric and mental health providers,
the DSM-5 is undergoing significant
change in organization and content
relative to the previous edition.
This article provides a general
overview of what to expect in the
DSM-5. It collates information provided previously on the APA website, information available in recently
published multi-disciplinary literature
and discussion regarding the changes
to the new manual, and APA’s latest
announcements. A table of contents
included in a recent APA (2012a)
news release provides a summary of final decisions about the contents and
order of diagnostic categories included
in the DSM-5. In early 2013, the APA
launched a separate website devoted
to the DSM-5, which contains essential preview information regarding final changes (APA, 2013).
O
n December 1, 2012, the
American Psychiatric Association’s (APA) Board of
Trustees approved the fifth edition of
the Diagnostic and Statistical Manual of
Mental Disorders (DSM-5). The publication will debut at the APA’s annual
convention in May 2013. It will guide
clinical diagnoses, treatment plans,
medication choices and protocols, insurance reimbursements, and research
agendas throughout the United States
and will serve as a reference manual
for clinicians around the world. The
primary diagnostic source used by psy-
THE REVISED FORMAT OF THE DSM-5
The DSM-5 represents the first substantial revision to its clinical practice guidelines in more than 30 years.
Changes to this updated version were
structured in light of several overarching ideals. First, the manual was
planned to be a living document, amenable to updates as knowledge about
characteristics of psychiatric problems
and approaches to their management
improves. As a consequence, the bulky
Roman numeral format (e.g., DSM-I,
DSM-II, DSM-IV-Text Revision [TR])
that was previously used to indicate
manual updates will be abandoned in
favor of Arabic numerals (e.g., DSM5, DSM-5.1, DSM-5.2), which will
be easier to track over time. Ongoing
revisions to individual diagnoses and
diagnostic categories are planned to be
based on current evidence. If changes
are made electronically, as they are in
the Oxford English Dictionary and in
course catalogs in many universities,
regular and frequent updates will become more feasible and affordable.
Journal of Psychosocial Nursing • Vol. 51, No. 4, 2013
The 20 diagnostic categories in
the revised manual are purported to
be evidence-based (i.e., built on current best evidence informing decisions
about care for individual patients). Although research-based diagnosis is not
a new concept in the development of
diagnoses and criteria, the emphasis in
this manual was planned to be hardhitting. The leadership at APA sought
to provide diagnoses based on scientific evidence developed within the past
two decades (APA, 2012a).
Building on that evidence, the
DSM-5 aimed for increased crosscultural application. The DSM-IV-TR
(APA, 2000) included an abbreviated
list of “Culture-Bound Syndromes”
in the appendix. The current revision expands cultural considerations,
incorporating the Cultural Formulation Interview (CFI) (Bäärnhielm
& Scarpinati-Rosso, 2009), a standard
method for simple and efficient cultural
assessment, into criteria for diagnosis.
The 14-question CFI has the potential
to improve patient-centered care while
reducing racial and ethnic disparities
in treatment. Furthermore, it may help
providers screen and identify individuals
who would benefit from the presence of
language translators.
Most DSM-5 disorder categories will
incorporate dimensional assessments
that will support appraisal of symptom severity for each individual client. Rather
than a simple yes or no decision related
to a symptom’s existence, the clinician
can now identify the severity of symptoms on a scale of 3 or more ordinal-level
points, emphasizing patient self-assessment of symptom severity (Narrow &
Kuhl, 2011). Dimensional assessments
are drawn from tools already in use such
as scales from the Patient-Reported Outcomes Measurement Information System
(National Institutes of Health, n.d.). The
DSM-5 work groups also developed and
tested other measures that will be included in the manual.
31
TABLE
DIAGNOSTIC CATEGORIES IN THE DSM-5
1. Neurodevelopmental Disorders
11. Elimination Disorders
2. Schizophrenia Spectrum and Other
Psychotic Disorders
12. Sleep-Wake Disorders
3. Bipolar and Related Disorders
13. Sexual Dysfunctions
4. Depressive Disorders
14. Gender Dysphoria
5. Anxiety Disorders
15. Disruptive, Impulse Control, and
Conduct Disorders
6. Obsessive-Compulsive and Related
Disorders
16. Substance Related and Addictive
Disorders
7. Trauma and Stressor-Related
Disorders
17. Neurocognitive Disorders
8. Dissociative Disorders
18. Personality Disorders
9. Somatic Symptom and Related
Disorders
19. Paraphilic Disorders
10. Feeding and Eating Disorders
20. Other Disorders
Note. DSM = Diagnostic and Statistical Manual of Mental Disorders.
Adapted from American Psychiatric Association (2013).
Cross-cutting assessments are included as a psychiatric version of
general medicine’s “review of systems” and are meant to be conducted
without regard to a specific diagnosis
(Kuhl, Kupfer, & Regier, 2011). It is
well known that some symptoms (e.g.,
sleep deprivation) are present across
numerous disorders. Detailed, clinically significant assessments will prompt
more in-depth follow up of the initial
clinician- administered assessments.
Diagnostic categories and diagnoses
included in the DSM-5 incorporate objective measures based on knowledge
emerging from recent innovations and
advancements in neurodiagnostics, including measurements available through
genetic work-ups, neuroimaging, or
neurochemistry. Some sleep disorders
categorized in the DSM-5 will include a
requirement for polysomnography prior
to formal diagnosis (Gever, 2012). Narcolepsy/hypocretin deficiency (formerly
known as narcolepsy) will require measurement of hypocretin in the cerebrospinal fluid. Such techniques may represent
the dawn of a new era through which
32
objective measurements validate the existence of underlying causes, illuminating
previously unrecognized physical pathology. The potential for stigma reduction as
a consequence of more exacting diagnostic criteria is an exciting prospect emerging from the changes in the DSM-5.
Additionally, across diagnostic
groups, the use of functional impairment as a criterion for diagnosis has
been reduced, but not eliminated.
Diagnoses such as autism and other
disorders involving neuropsychiatric
deficits will retain functional diagnostic criteria, as functional impairment
is a cornerstone of these disorders
(Gever, 2012). For other conditions,
functionality may be included in the
dimensional assessments rather than
in diagnostic criteria.
In the previous edition of the DSM,
the not otherwise specified (NOS) diagnoses tended to be catchall categories.
For example, more than half of all eating
disorders were listed in the Eating Disorder NOS diagnostic classification (Gever,
2012). In the new manual, NOS will be
replaced with not elsewhere classified
(NEC). Although this sounds similar to
the previous system, the inclusion of a
requisite list of specifiers, each with a specific diagnostic code, refines and streamlines the process and conveys important,
distinct clinical information. For example, depressive disorder NEC may involve any one or any combination of five
specifiers, such as “short duration,” that
indicate the patient’s clinical condition
and provide rationale as to why the presenting condition does not meet criteria
for one of the main depressive syndromes.
Finally, one of most notable changes in the forthcoming DSM-5 pertains
to the axis system. Beginning in 1980,
the DSM-III (APA, 1980) adopted the
following categories, or axes, to organize diagnostic conceptualization:
l Axis I: Major mental disorders.
l Axis II: Personality disorders and
intellectual disabilities.
l Axis III: Acute medical conditions.
l Axis IV: Environmental factors
contributing to the disorder.
l Axis V: Global Assessment of
Functioning Scale (GAF).
DSM-5 authors concluded that
there was no scientific basis for these
categories; thus, the new version will
retire the five axes. The categories in
the DSM-5 are at once simpler and
more complex. Specifically, Axes I, II,
and III will be collapsed into a single
axis that contains all of the psychiatric
and medical diagnoses. This approach
is congruent with the system used by
the International Classification of Diseases (ICD) (World Health Organization [WHO], 2010b). Additionally,
the DSM-5 will likely incorporate clinician use of a 15-page ICD checklist
(WHO, 2010b) for assessment of psychosocial and contextual factors previously assessed on Axis IV.
The traditional Axis V GAF score
has been criticized for mixing symptom severity with functional severity.
It may be replaced by the WHO Disability Assessment Schedule (WHODAS) (WHO, 2010a). WHODAS is
a 36-item measure that addresses six
domains—cognition, mobility, selfCopyright © SLACK Incorporated
care, getting along with others, life
activities, and participation. Selfadministration takes 5 to 10 minutes,
and clinician administration takes 20
minutes.
These conceptual changes to the
manual’s organization and method of
content delivery provide the context
for changes to specific diagnoses and
diagnostic categories. The discussion
that follows addresses each of the diagnostic categories in the DSM-5 individually.
DIAGNOSTIC CATEGORIES AND
THEIR SEQUENCING
The DSM-5 lists approximately the
same number of disorders as the DSM-IVTR, roughly 300 across 20 diagnostic categories. The sequencing of the diagnostic
categories specified in the new manual
generally follows a neurodevelopmental
life span approach, as do the disorders
identified within category listings. In
other words, categories generally follow a
sequence from problems that typically are
diagnosed in childhood through those
typical of adolescents, adults, and finally,
older adults.
The DSM-5 authors also sought to arrange disorders by relatedness, taking into
account similar vulnerabilities and characteristic symptoms for disorders listed
within individual categories. For example, schizophrenia and bipolar disorder
are listed in succession, as individuals affected by one of these two disorders may
share common genetic variations and
overlapping manifestations (Craddock,
O’Donovan, & Owen, 2005). Likewise,
depression is listed immediately before
anxiety, reflecting the long-recognized
interrelationship of these two disorders.
Finalized categories in the DSM-5 are
summarized in the Table (APA, 2013).
The care and forethought characterizing
development of the 20 diagnostic categories and the diagnoses within them
does not imply that they have been met
with universal agreement in the mental
health community. The following discussion highlights some of the controversies
accompanying the diagnostic changes in
the DSM-5, in addition to summarizing
the diagnoses slated for inclusion within
each diagnostic category.
Neurodevelopmental Disorders
As noted, diagnostic categories in
the DSM-5 are arranged across the life
span, beginning with infancy. The Neurodevelopmental Disorders category was
formerly identified as Disorders Usually
First Evident in Infancy, Childhood, and
Adolescence.
In the DSM-IV-TR, intellectual developmental disorder was called mental retardation. The revised name aligns the DSM-5
with federal legislative language (Moran,
2013b). Impairment in adaptive functioning will be coupled with intelligence quotient to serve as the dual bases for diagnosis (Sederer, 2011). Severity measures
for mild, moderate, severe, and profound
intellectual disability will be included.
Specific learning disorders, formerly learning disorders, will group the
neurodevelopmental disorders that
previously stood alone—dyslexia,
dyscalculia, and disorder of written
expression—into a single problem.
Problems will be grouped in diagnostic
statements descriptive of the patient’s
presenting symptoms (i.e., a specific
learning disorder with dyslexia). Opponents of this new system fear individuals with dyslexia, in particular, will be disadvantaged due to the
absence of a freestanding diagnostic
label. They believe that this change
may limit treatment options, as well
as restrict educational supports, legal
rights, and continued insurance coverage (Burgess, 2012).
Autism spectrum disorders now combines the subcategories of autistic disorder, Asperger’s disorder, childhood
disintegrative disorder, and pervasive
developmental disorder NOS, into one
broad label. These changes are based
on evidence from clinical field trials
that suggest clinicians make diagnoses
based on similar presenting problems
quite differently (Moran, 2013b). The
Neurodevelopmental Disorders Work
Group concluded that distinctions
Journal of Psychosocial Nursing • Vol. 51, No. 4, 2013
between the disorders tend to be in
terms of overall severity rather than in
terms of symptoms. Another change is
removing the requirement of symptom
onset before age 3; the new criterion
is expanded to early childhood. Also,
the DSM-IV-TR (APA, 2000) criteria
included three separate behavioral dimensions—social reciprocity, deficits
in communication, and restricted, repetitive behaviors and interests. The
DSM-5 collapses the three behavioral
dimensions into two domains by combining communication and social interaction into a single domain of social
communication or social reciprocity.
The second is restrictive or repetitive
behaviors that may be current or historical.
A significant controversy regarding
autism spectrum disorders is that people
with a previous diagnosis of Asperger’s disorder may be stigmatized with an autism
diagnosis, which might likely be termed
mild autism. Opponents of the change
suggest that this higher functioning subset could lose funding for services due to
tighter diagnostic criteria (Willingham,
2012). There are disparities in services offered to affected individuals by diagnosis;
a diagnosis of autism is eligible for speech,
occupational, physical, and behavioral
therapies, whereas funding for other diagnoses within the Neurodevelopmental
Disorders category is significantly less.
In the DSM-IV-TR, attention-deficit/
hyperactivity disorder symptoms were
only significant if they occurred before
age 7. Opponents of this criterion suggest
that this age for symptom manifestation
was arbitrary and not based on evidence.
Many reports have shown symptom onset among children older than 7 (APA,
2010). DSM-5 criteria thus extend diagnostic inclusion criteria to age 12.
Allen Frances (2012), chair of the
DSM-IV Task Force, reinforced an argument posed by those in opposition to the
new learning disorders characterizations.
He suggests that changes to the DSM
would result in inflation of children diagnosed with attention-deficit disorder. He
contends that the altered age criterion
33
would result in an easier-to-gain adult
diagnosis and increase the potential for
psychostimulant drug abuse.
Schizophrenia Spectrum and Other
Psychotic Disorders
Previously listed under the category of schizophrenia, disorders sharing
schizophrenia-like symptoms and underlying causes are listed in the DSM-5 as
schizophrenia spectrum disorders, roughly
arranged from least to most severe. This
change is one of the least controversial
in the new manual. Also, catatonic, disorganized, paranoid, residual, and undifferentiated have been removed as subtypes
of schizophrenia; however, catatonia will
be retained as a specifier throughout the
DSM-5 diagnostic categories.
Dimensional ratings for schizophrenia that would allow clinicians to rate
symptoms in terms of severity on a 0 to
5 scale were developed. However, they
were ultimately rejected as potentially
burdensome and not adequately tested
(Moran, 2013a). They will reside in
Section 3, an area in the appendix reserved for diagnoses requiring further
research (APA, 2012b) and may be
used in clinical settings.
One disorder that was proposed,
but not accepted, was attenuated psychosis syndrome. Individuals who develop attenuated psychotic symptoms
accompanied by dysfunction at school
and at home are thought to be more
likely than individuals in the general
population to develop schizophrenia
or other psychotic disorders within 2
years of symptom onset (Carpenter &
van Os, 2011). Proponents of making attenuated psychosis syndrome
a specific disorder believe that early
detection of symptoms and follow-up
treatment are neuroprotective and
helpful in reducing severity, neurobiological decompensation, and subsequent long-term disability. Opponents
of the diagnosis noted that although
35% of individuals with prodromal
psychotic states convert to psychosis
within 2 years, 65% do not (Cannon
et al., 2008). This proposed diagnosis
could result in too many false posi34
tives that could broaden stigma. Early
pharmacological treatment is argued
by opponents to expose people to unnecessary and potentially damaging
antipsychotic therapy. Consequently,
the diagnosis was moved to Section 3
of the DSM-5.
Bipolar and Related Disorders
Previously listed under mood disorders
along with major depressive disorder, the
bipolar and related disorders now emphasize
core symptoms of increased energy/activ-
A significant
controversy regarding
autism spectrum
disorders is that
people with a previous
diagnosis of Asperger’s
disorder may be
stigmatized with an
autism diagnosis,
which might likely be
termed mild autism.
ity for both hypomanic and manic episodes. The diagnosis will be made on the
basis of a set of criteria that is consistent
across the life span, despite arguments
that the criteria are too stringent for children and adolescents (Kaplan, 2012).
Specifiers have been added to bipolar disorder. One is anxious distress
(Moran, 2013a). The rationale for this
addition is that anxiety is a serious
complication of bipolar disorder and
must be addressed. Also, a mixed state
specifier replaces the fully mixed type
of bipolar disorder, which was rarely
seen. The mixed state specifier will
apply to individuals who have major
depression along with three manic
symptoms, and to individuals who
have mania along with three depressive symptoms.
Depressive Disorders
As noted above, depressive disorders were previously listed under the
mood disorders. Disruptive mood dysregulation disorder is a new diagnosis
within this revised category. Disruptive mood dysregulation is characterized by qualities similar to, but more
severe than, those of oppositional defiant disorder. The diagnosis applies to
6- to 18-year-olds who have outbursts
up to four times per week that are out
of proportion to what is happening in
the environment. Previously, persistent foul temper punctuated by bursts
of rage was considered diagnostic of
bipolar disorder (onset before age 10).
Disruptive mood dysregulation is a
response to criticism that bipolar disorder diagnoses were being made too
frequently among children. The new
diagnosis is viewed as an alternative to
assigning a lifelong diagnosis of bipolar disorder, which often is accompanied by early and powerful drug treatment (Margulies, Weintraub, Basile,
Grover, & Carlson, 2012).
Psychiatric care providers and the
public alike have criticized the disruptive mood dysregulation disorder for
its medicalization of temper tantrums
(Frances, 2012). The new diagnoses
may result in attributing psychiatric
pathology where it is not appropriate.
Another controversial change is
the removal of the bereavement exclusion for major depression. This exclusion previously prevented individuals
with depressive symptoms from being diagnosed with major depression
if their symptoms occurred within 2
months of losing a loved one. Criteria for major depressive disorder in the
new manual support its diagnosis after
Copyright © SLACK Incorporated
2 weeks of sadness and loss of interest in life events—along with reduced
appetite, sleep, and energy—following
the loss of a loved one. The DSM5 Task Force cites a lack of evidence
to differentiate grief-related depressive episodes from major depression.
They argue that treatment delay for
severe grief increases the risk of suffering and impairment. Opponents of
the change contend that medicalizing
grief impairs the normal, dignified process of grief and may discourage the
appropriate use of cultural rituals, religion, and the comfort of family and
friends (Kleinman, 2012). A view that
minimizes normal grief may result in a
mental disorder label, stigma, and unnecessary treatment.
Formerly housed in the appendix, premenstrual dysphoric disorder
(PMDD) is now a bona fide diagnosis.
Its symptoms, including mood disturbance, are more severe than those
identified in the previous manual and
related role dysfunction is more pronounced, especially in the area of personal and family relationships. Controversy about this diagnosis 20 years
ago was heated. Opponents suggested
women’s hormones were being blamed
for mental illness and that the social
implications were dangerous (Tavris,
1993). For this revision, controversy
has been nearly absent. In fact, since
the last manual was published, the
U.S. Food and Drug Administration
has approved drugs for the treatment
of premenstrual dysphoria—Prozac®
(fluoxetine) was repackaged by Eli
Lilly as Sarafem®, and Yaz® (drospirenone and ethinyl estradiol) was introduced for those taking birth control
medication.
Anxiety Disorders
There are two changes in the Anxiety Disorders category. The first is that
separation anxiety disorder now includes
adults. Adults may actually be at greater
risk than children for the disorder, with
a lifetime prevalence estimate of 6.6%
compared to 4.1% for children (Shear,
Jin, Ruscio, Walters, & Kessler, 2006).
The second change in this category is
that agoraphobia is now a freestanding
disorder and not necessarily a subset of
panic disorder.
Changes to generalized anxiety disorder garnered the most interest within this
category. The draft form of the DSM-5
included a reduction of symptom duration from 6 to 3 months, and a reduction
of the number of symptoms from three to
one. Opponents to this change include
Aaron Beck, the father of cognitive-behavioral therapy, who asserts that reducing the symptom threshold for anxiety
will result in false positives (Starcevic,
Portman, & Beck, 2012). Furthermore,
increased diagnoses might encourage
overuse of addictive anti-anxiety medications. It is possible that changes to this
disorder will be discarded in the final version of the manual.
A disorder that was proposed and
quickly rejected was mixed anxiety
depression. Early in the development
of the DSM-5, authors hoped to create a new diagnosis that included both
anxiety and depression where neither
clearly predominated, similar to the
diagnosis included in the ICD-10
(WHO, 2010a). This combined diagnosis did not test well in clinical field
trials and the disorder was abandoned.
Obsessive-Compulsive and Related
Disorders
Disorders within the ObsessiveCompulsive and Related Disorders
category previously were listed across
several other diagnostic groups. Obsessive-compulsive disorder was formerly
included in anxiety disorders; body dysmorphic disorder was a somatoform disorder, and hair pulling disorder (trichotillomania) was listed under Impulse
Control Disorders. All disorders in
this category have the core symptom
of abnormal and obsessive fixations.
Two new disorders have been added
to the DSM-5 in this category. The
first is excoriation disorder (skin picking), which results in noticeable physical damage, emotional distress, and
attempts to conceal the behavior (Odlaug & Grant, 2010). Second, hoard-
Journal of Psychosocial Nursing • Vol. 51, No. 4, 2013
ing disorder makes its debut in the new
manual. This devastating problem has
been showcased on prime-time television and become part of common language. People who amass huge quantities of belongings and have extreme
problems in parting with or discarding
them may receive this diagnosis. Typically, the individual and the family
suffer from chronic emotional, social,
physical, financial, and even legal
problems as a result of the hoarding
(APA, 2012b).
Trauma and Stressor-Related Disorders
This category is new and all disorders
share abnormal responses to external
trauma and stress (Friedman et al., 2011).
Four clusters of symptoms will define
posttraumatic stress disorder (PTSD)—intrusion, persistent avoidance, arousal/
reactivity, and negative mood and cognitions—rather than the three required
in the last edition of the manual. Direct
exposure or exposure of a close friend or
relative to a traumatic event, or repeated
exposure to the aversive details of trauma, such as that experienced by disaster
workers or first responders, will meet the
criteria for a PTSD diagnosis.
Friedman et al. (2011) noted that
all 17 of the DSM-IV criteria for PTSD
are slated for retention in the new version along with three new symptoms—
specious (misleading or nearly believable) self- or other-blame in regard to
the trauma, negative mood states, and
reckless or maladaptive behavior. A
subtype of PTSD was added to address
the needs of children younger than 6
who have been subjected to traumatic
events (Jagodzinski, 2011).
A new diagnosis for children is
disinhibited social engagement disorder.
These children demonstrate no normal fear of strangers, seem unfazed in
response to separation from a primary
caregiver, and are unusually willing to
go off with people who are unknown
to them.
Dissociative Disorders
Dissociative Disorders are purposefully listed immediately after Trauma
35
and Stressor-Related Disorders due to
the link with trauma and disorganized
attachment (Boysen, 2011). There
is some debate over whether the two
categories should be combined; the
outline of the manual (APA, 2013)
maintains them as separate categories.
Research indicates that patients
with dissociative disorders do not respond well to standard exposure-based
treatments designed for PTSD and
that they leave treatment prematurely
(Bland, Lanius, Vermetten, Lowenstein, & Spiegel, 2012). Experts in
this field are optimistic that the DSM5 will stimulate future studies in the
area of dissociative disorders.
Somatic Symptom and Related Disorders
This group was formerly known as
Somatoform Disorders. The diagnosis
of somatic symptom disorder subsumes
the former diagnoses of somatization
disorder, hypochondriasis, undifferentiated somatoform disorder, and pain disorder.
In the DSM-IV-TR (APA, 2000),
somatization disorder required eight
or more medically unexplained symptoms from four specified symptom
groups. Criteria in the new manual
include one of the following distressing reactions for a period of at
least 6 months: (a) disproportionate thoughts about the seriousness of
their symptom(s); (b) a high level of
anxiety about their health; or (c) devoting excessive time and energy to
symptoms or health concerns. Chapman (2012) stated that there is no
research to support this change, opining that the change opens the gates
to widespread diagnosis and treatment of people who would have been
previously considered “worrywarts.”
Furthermore, individuals with established medical illness, such as cancer
or heart disease, could be diagnosed
with a mental illness.
Feeding and Eating Disorders
The category called Feeding and Eating Disorders was formerly known as
36
Eating Disorders. It includes several
problems originally listed in Disorders of Infancy, Childhood, or Adolescence. These include pica, rumination disorder, and avoidant/restrictive
food intake disorder.
Symptoms of anorexia nervosa traditionally have included amenorrhea
and a fear of gaining weight. New
criteria include menstruating women
along with individuals who are not
fixated on weight gain. The twiceweekly binge and purge criterion
previously required for a diagnosis of
bulimia nervosa has been reduced to
once per week.
Binge-eating disorder is the newcomer to this category; it has been
moved from the appendix to inclusion as an actual disorder. One binge
per week for 3 months, feeling out of
control, and being distressed by the
behavior characterizes this disorder.
Affected individuals report that they
eat too rapidly, feel too full, and eat
when they are not hungry. Eating
alone is common due to embarrassment. Opponents of the inclusion of
this disorder note that while overeating is not healthy or good behavior, it
should not be used to label a common
eating behavior.
Elimination Disorders
The elimination disorders have not
changed and include enuresis and encopresis.
Sleep-Wake Disorders
This category, formerly known
as Sleep Disorders, has had a nearly
complete overhaul in the DSM-5.
The Sleep Disorders Work Group
recommends that the term primary be
dropped, with the currently named
primary insomnia disorder listed simply as insomnia disorder (Reynolds,
2011). Dimensional measures will
gauge severity and identify other contributing factors. Biological measures
mentioned above (e.g., measuring
hypocretin for narcolepsy) are also
recommended.
Sexual Dysfunctions
Sexual Dysfunctions were formerly
classified along with Sexual and Gender Identity Disorders. One disorder
that was proposed but not accepted
was hypersexual disorder. This disorder was to be characterized by intense,
recurrent, and distressing sexual urges,
fantasies, and behaviors lasting at least
6 months (Kafka, 2009). Hypersexual
disorder is associated with personal
distress and adverse consequences
(sexually transmitted diseases, pregnancy, disturbed relationships, financial problems, and role impairment).
Supporters of the diagnosis believed
that its inclusion in the DSM-5 could
lead to effective treatment. Alternatively, detractors believed that there
was not enough evidence to define
this as a distinct disorder; studies have
only included people seeking help for
conditions other than those related to
sexual dysfunction. Further research is
necessary to define this problem and
its criteria (Rettner, 2012).
Gender Dysphoria
This category was formerly listed
under the category of Sexual and Gender Identity Disorders. For years, advocates lobbied the APA to redefine
or remove gender identity disorder as a
psychiatric diagnosis. Their work has
been rewarded. To receive the new diagnosis and qualify for insurance coverage, one must experience a sense of
mismatch between biological gender
and personal gender identification and
must experience related distress (dysphoria).
Disruptive, Impulse Control, and
Conduct Disorders
This category now houses disorders
that previously were included across
diagnostic categories. Oppositional defiant disorder and conduct disorder were
formerly classified alongside attention-deficit/hyperactivity disorder as
disruptive behavior disorders. Intermittent explosive disorder was classified as
an impulse control disorder NEC, and
Copyright © SLACK Incorporated
dyssocial personality disorder was classified exclusively under personality
disorders where it remains as a crosslisted diagnosis in the DSM-5.
Changes in the organization of
these disorders have resulted in few
comments in the literature. Anecdotally, there has been some discussion
about a distinction between willful
destruction or hurting another person and impulsive acts of violence, as
the two motivations require different
treatment approaches.
KEYPOINTS
Halter, M.J., Rolin-Kenny, D., & Dzurec, L.C. (2013). An Overview of the DSM-5: Changes,
Controversy, and Implications for Psychiatric Nursing. Journal of Psychosocial Nursing
and Mental Health Services, 51(4), 30-39.
1.
In May 2013, the Diagnostic and Statistical Manual of Mental Disorders (DSM) is
being published in its fifth edition.
2.
The DSM-5 will contain structural and diagnostic changes that have been the
subject of controversy.
3.
Revisions to the DSM-5 will impact the education, care, and research of
psychiatric nurses.
Do you agree with this article? Disagree? Have a comment or questions?
Send an e-mail to the Journal at jpn@healio.com.
Substance Related and Addictive
Disorders
This revised diagnostic category
eliminates the hard-to-distinguish
terms of abuse and dependence. With
the rationale that addictions exist on
a continuum, severity of diagnoses in
this category will be rated as mild,
moderate, or severe, based on standardized rating scales. In general, there
are a reduced number of symptoms required for diagnosis of disorders listed
in this category. Arguments in favor of
the relaxed criteria suggest that early
interventions could hinder the addiction problem, reduce or halt physical
problems, and save money by reducing long-term disability. However,
opponents of changes to this category
express concern that its use may lead
to inappropriate labeling and stigmatization among people with temporary
problems (e.g., many college students
who binge drink).
Gambling disorder broadens the definitions of addiction by including a behavioral, or process, addiction. Internet addiction was also considered, but
there was not enough research support
and it was moved to Section 3 for further study (APA, 2012b).
rocognitive was chosen to neutralize
dementia-related stigma.
The Neurocognitive Disorders will
be divided into major and mild types.
Major neurocognitive disorders are
characterized by substantial cognitive decline that results in curtailed
independence and functioning among
affected individuals. Mild neurocognitive disorders identify people whose
symptoms place them somewhere in
a gray zone between normal cognition
and those with noticeably significant
cognitive deterioration. Identifying
early-presenting symptoms among
those individuals may aid in earlier
interventions at a stage when some
disease-modifying therapies may be
most neuroprotective (Sperling et al.,
2011). Opponents of this revised diagnosis are concerned that the everyday
characteristic of forgetting in old age
will be pathologized and result in an
alarming rate of false positives suggesting serious impairments of cognition (Frances, 2012). Additionally,
why create anxiety when only limited,
non-curative, non-reversing treatments exist for dementia?
Neurocognitive Disorders
Disorders in this category were formerly listed under delirium, dementia,
and amnestic and other cognitive disorders. Although the problems that
are addressed in this revised category
remain the same, using the term neu-
moval of the Axis system eliminates
the suggestion of a causal dichotomy
between personality disorders and all
other psychiatric diagnoses (Skodol,
2012).
A tremendous overhaul was
planned for the personality disorders.
Four disorders—narcissistic, histrionic,
dependent, and schizoid—were slated
for removal. The diagnostic process
was planned to be a thorough, timeconsuming process and to include
a “Levels of Functioning Personality Scale.” This scale included paragraph-length narrative descriptions
for which clinicians would establish
a description/patient match, as well
as a 7-page severity scale that carefully rated negative affectivity, detachment, antagonism, disinhibition, and
psychoticism among affected individuals. A last-minute decision was made
to maintain all 10 DSM-IV-TR diagnoses and structure, minus the Axes.
The more complicated trait-specific
methodology is proposed for inclusion
in Section 3 for further study (APA,
2012b).
Paraphilic Disorders
Personality Disorders
In the DSM-IV-TR (APA, 2000),
Personality Disorders were listed as
problems on Axis II, suggesting that
they were unique from Axis I, physically based psychiatric diagnoses. Re-
Journal of Psychosocial Nursing • Vol. 51, No. 4, 2013
Paraphilias are disorders involving
the patient’s need for unusual sexual
stimulation, such as sadism or masochism, to achieve sexual arousal or orgasm. This group of disorders was listed in the Sexual and Gender Identity
37
section of earlier versions of the DSM.
In the DSM-5, each diagnosis within
the Paraphilias category will include
the word disorder. For example, exhibitionism will be labeled exhibitionistic
disorder. The work group assigned to
this category sought to distinguish the
mild and socially harmless paraphilias
from the severe paraphilias, which are
distressing to those afflicted and/or are
potentially dangerous to others (Dreger, 2010). Risk-assessing specifiers
have been developed to indicate level
of threat to others posed by individuals
diagnosed with a paraphilic disorder,
designating whether the individual is
in a controlled environment, and if
the individual is in remission. Remission is defined as having no distress,
functional impairment, or recurring
behavior for 5 years in an uncontrolled
environment.
Other Disorders
Two disorders were proposed for
this section. The first was non-suicidal
self-injury disorder, a diagnosis intended to differentiate patients who
engaged in intentional self-inflicted
damage to the surface of the body
from those mutilating with serious
suicidal intent. Unsuccessful field
trials resulted in the removal of this
problem as an official disorder (Regier
et al., 2012).
The other disorder, suicidal behavior disorder, was to be characterized
by self-injurious behaviors that would
result in death. This diagnosis would
be given immediately following an attempt and would remain in place for
2 years, the time of greatest risk for
reattempting suicide. Proponents believed that naming this disorder was a
way to track risk, as a history of suicide attempts is the most predictive
indicator of future suicidal behavior
(Runeson, Tidemalm, Dahlin, Lichtenstein, & Långström, 2010). Opponents believed that the diagnosis
was stigmatizing and unnecessary because being suicidal is almost always
accompanied by other symptoms or
clinical diagnoses, particularly major
38
depression. Both of these proposed
disorders were moved to Section 3 of
the DSM-5 for further study (APA,
2012b).
THE DSM-5 AND ITS RELEVANCE TO
PSYCHIATRIC NURSING
The DSM-5 is a medical publication, yet the implications for advanced
practice psychiatric and general psychiatric nurses alike are substantial.
The accurate diagnosis of individuals
with mental illness is essential to practicing nurses and is the foundation for
treatment planning, management of
psychotropic medications, and psychotherapeutic interventions. Nurse
researchers will be involved in testing
psychiatric diagnoses and developing
relevant epidemiological and intervention studies. Nursing textbooks
will be revised based on the new nomenclature. Nurse educators will incorporate the revised content into
their classrooms.
CONCLUSION
A Google search with keywords
“DSM-5 + controversy” results in
more than 600,000 citations that attest to the complicated nature of such
an ambitious task. Opponents of the
DSM-5 changes assert that proposed
revisions resulted in greater controversy than earlier editions. This may
be true; however, it is likely that expanded public awareness and media
interest were a product of electronic
communication and exponentially increased instantaneous discussion and
debate about the DSM. Hopefully, this
same process will result in increased
scrutiny and transparency in its continued development.
Predictions of epidemic numbers
of people diagnosed with and stigmatized by psychiatric conditions will be
tested in the years to come. Research
of the categories and the disorders will
be moved from clinical trials to evaluation in real-time clinical practice and
applied by psychiatric nurses and other professionals in various settings. Future articles in the Journal of Psychoso-
cial Nursing and Mental Health Services
will likely address the implications and
applications of changes in the DSM-5
in greater detail and provide updates
on how the new diagnostic criteria
impact the clinical, research, and educational work of psychiatric-mental health
nurses.
REFERENCES
American Psychiatric Association. (1980).
Diagnostic and statistical manual of mental
disorders (3rd ed.). Washington, DC: Author.
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC:
Author.
American Psychiatric Association. (2010).
DSM-5: Options being considered for ADHD.
Retrieved
from
http://www.dsm5.org/
Proposed%20Revision%20Attachments/
APA%20Options%20for%20ADHD.pdf
American Psychiatric Association. (2012a).
American Psychiatric Association Board of
Trustees approves DSM-5 [Press release].
Retrieved from http://www.psychiatrictimes.com/all/editorial/psychiatrictimes/
pdfs/2012-apa-dsm5-final.pdf
American Psychiatric Association. (2012b).
DSM-5 development: Frequently asked questions. Retrieved from http://www.dsm5.org/
about/pages/faq.aspx
American Psychiatric Association. (2013).
DSM-5. Retrieved from http://www.psychiatry.org/dsm5
Bäärnhielm, S., & Scarpinati-Rosso, M.
(2009). The cultural formulation: A model to combine nosology and patients’ life
context in psychiatric diagnostic practice. Transcultural Psychiatry, 46, 406-428.
doi:10.1177/1363461509342946
Bland, B.L., Lanius, R., Vermetten, E., Lowenstein, R.J., & Spiegel, D. (2012). Where are we
going? An update on assessment, treatment,
and neurobiological research in dissociative
disorders as we move toward the DSM-5.
Journal of Trauma and Dissociation, 13, 9-31.
doi:10.1080/15299732.2011.620687
Boysen, G.A. (2011). The scientific status of
childhood dissociative identity disorder:
A review of published research. Psychotherapy and Psychosomatics, 80, 329-334.
doi:10.1159/000323403
Burgess, T. (2012). Steven Spielberg helps to
bring dyslexia and legal rights into the news.
Retrieved from http://www.examiner.com/
article/steven-spielberg-helps-to-bring-dyslexia-and-legal-rights-into-the-news
Copyright © SLACK Incorporated
Cannon, T.D., Cadenhead, K., Cornblatt, B.,
Woods, S.W., Addington J., Walker, E.,…
Heinssen, R. (2008). Prediction of psychosis in youth at high clinical risk: A multisite longitudinal study in North America.
Archives of General Psychiatry, 65, 28-37.
doi:10.1001/archgenpsychiatry.2007.3
Carpenter, W.T., & van Os, J. (2011). Should
attenuated psychosis syndrome be a DSM5 diagnosis? American Journal of Psychiatry, 168, 460-463. doi:10.1176/appi.
ajp.2011.10121816
Chapman, S. (2012). Somatic symptom disorder
could capture millions more under mental health
diagnosis. Retrieved from http://dxrevisionwatch.com/2012/05/26/somatic-symptomdisorder-could-capture-millions-more-under-mental-health-diagnosis/
Craddock, M., O’Donovan, M.C., & Owen,
M.J. (2005). The genetics of schizophrenia
and bipolar disorder: Dissecting psychosis.
Journal of Medical Genetics, 42, 193-204.
Dreger, A. (2010, February 19). Of kinks, crimes,
and kinds: The paraphilias proposal for the
DSM-5. Hastings Center Bioethics Forum.
Retrieved from http://www.thehastingscenter.org/Bioethicsforum/Post.aspx?id=4494
Frances, A. (2012, December 3). DSM is guide
not bible: Simply ignore its ten worst changes.
Retrieved from http://www.psychologytoday.
com/blog/dsm5-in-distress/201212/dsm-5-isguide-not-bible-ignore-its-ten-worst-changes
Friedman, M.J., Resick, P.A., Bryant, R.A.,
Strain, J., Horowitz, M., & Spiegel, D.
(2011). Classification of trauma and stressor-related disorders in the DSM-5. Depression and Anxiety, 28, 737-749. doi:10.1002/
da.20845
Gever, J. (2012, May 10). DSM-5: What’s in,
what’s out. Retrieved from http://www.
medpagetoday.com/MeetingCoverage/
APA/32619
Jagodzinski, M. (2011). The study of the prevalence of Desnos symptoms in traumatized
children (Senior Honors Theses, paper 262,
Eastern Michigan University). Retrieved
from http://commons.emich.edu/honors/262
Kafka, M.P. (2009). Hypersexual disorder: A
proposed diagnosis for DSM-V. Archives of
Sexual Behavior, 39, 377-400. doi:10.1007/
s10508-009-9574-7
Kaplan, S.L. (2012). Your child does not have
bipolar disorder. Retrieved from http://www.
psychologytoday.com/blog/your-child-doesnot-have-bipolar-disorder/201212/smallunicornsupdate-dsm-5-bipolar-disorder--0
Kleinman, A. (2012). Culture, bereavement,
and psychiatry. Lancet, 379, 608-609.
Kuhl, E.A., Kupfer, D.J., & Regier, D.A. (2011).
Patient-centered revisions to the DSM-5.
Virtual Mentor, 13, 873-879. doi:10.1001/
virtualmentor.2011.13.12.stas1-1112
Margulies, D.M., Weintraub, S., Basile, J., Grover, P.J., & Carlson, G.A. (2012). Will disruptive mood dysregulation disorder reduce
false diagnosis of bipolar disorder in children? Bipolar Disorder, 14, 488-496. doi:10.
1111/j.1399-5618.2012.01029
Moran, M. (2013a). DSM-5 fine-tunes diagnostic criteria for psychosis, bipolar disorders.
Psychiatric News, 48(3), 10-11.
Moran, M. (2013b). DSM-5 provides new take
on neurodevelopment disorders. Psychiatric News, 48(2), 6-23. doi:10.1176/appi.
pn.2013.1b11
Narrow, W.E., & Kuhl, E.A. (2011). Dimensional approaches to psychiatric diagnosis in
DSM-5. Journal of Mental Health Policy Economics, 14, 197-200.
National Institutes of Health. (n.d.). PROMIS:
Dynamic tools to measure health outcomes from
the patient perspective. Retrieved from http://
www.nihpromis.org/measures/measureshome
Odlaug, B.L., & Grant, J.E. (2010). Pathologic skin picking. The American Journal
of Drug and Alcohol Abuse, 36, 296-303.
doi:10.3109/00952991003747543
Regier, D.A., Narrow, W.E., Clarke, D.E., Kraemer, H.C., Kuramoto, S.J., Kuhl, E.A., &
Kupfer, D.J. (2013). DSM-5 field trials in
the United States and Canada, Part II: Testretest reliability of selected categorical diagnoses. American Journal of Psychiatry. Advance online publication. doi:10.1176/appi.
ajp.2012.12070999
Rettner, R. (2012, December 7). Sex addiction
not an official disorder, DSM says. Huffington
Post. Retrieved from http://www.huffingtonpost.com/2012/12/07/sex-addiction-dsmofficial-disorder_n_2258027.html
Reynolds, C.F. (2011). Troubled sleep, troubled minds, and DSM-5. Archives of General Psychiatry, 68, 990-991. doi:10.1001/
archgenpsychiatry.2011.104
Runeson, B., Tidemalm, D., Dahlin, M., Lichtenstein, P., & Långström, N. (2010). Method of
attempted suicide as predictor of subsequent
successful suicide: National long term cohort study. BMJ, 341, c3222. Retrieved from
http://www.bmj.com/content/341/bmj.c3222
Sederer, L.I. (2011). The DSM-5: The changes
ahead (part 2). Huffington Post. Retrieved
from http://www.huffingtonpost.com/lloydi-sederer-md/dsm-5_b_961966.html
Shear, K., Jin, R., Ruscio, A.M., Walters, E.E.,
& Kessler, R.C. (2006). Prevalence and cor-
Journal of Psychosocial Nursing • Vol. 51, No. 4, 2013
relates of estimated DSM-IV child and adult
separation anxiety disorder in the National
Comorbidity Survey Replication. American
Journal of Psychiatry, 163, 1074-1083.
Skodol, A.E. (2012). Personality disorders in
DSM-5. Annual Review of Clinical Psychology, 8, 317-344. doi:10.1146/annurevclinpsy-032511-143131
Sperling, R.A., Aisen, P.S., Beckett, L.A., Bennett, D.A., Craft, S., Fagan, A.M.,…Phelps,
C.H. (2011). Toward defining the preclinical stages of Alzheimer’s disease: Recommendations from the National Institute on
Aging–Alzheimer’s Association workgroups
on diagnostic guidelines for Alzheimer’s
disease. Alzheimer’s Dementia, 7, 280-292.
doi:10.1016/j.jalz.2011.03.003
Starcevic, V., Portman, M.E., & Beck, A.T.
(2012). Generalized anxiety disorder: Between neglect and an epidemic. Journal of
Nervous and Mental Disease, 200, 664-667.
doi:10.1097/NMD.0b013e318263f947
Tavris, C. (1993, November). Do you menstruate? If so, psychiatrists think you may be
nuts. Glamour, p. 172.
Willingham, E. (2012). New DSM criteria for
autism: Who will be left behind? Forbes.
Retrieved from http://www.forbes.com/sites/
emilywillingham/2012/10/11/new-dsm-5criteria-for-autism-who-will-be-left-behind/
World Health Organization. (2010a). ICD-10:
Version 2010. Retrieved from http://apps.
who.int/classifications/icd10/browse/2010/
en#/F40-F48
World Health Organization. (2010b). Measuring health and disability: WHODAS 2.0.
Retrieved from http://whqlibdoc.who.int/
publications/2010/9789241547598_eng.pdf
Dr. Halter is Associate Dean, Ashland University, Mansfield, Ohio; Dr. Rolin-Kenny is Assistant Professor, University of Texas at Austin,
School of Nursing, Austin, Texas; and Dr. Dzurec
is Dean and Professor, Kent State University,
Kent, Ohio.
Drs. Rolin-Kenny and Dzurec have disclosed
no conflicts of interest, financial or otherwise. Dr.
Halter receives travel support from Contemporary
Forums and royalties from Elsevier.
Address correspondence to Margaret Jordan
Halter, PhD, APRN, Associate Dean, Ashland
University, 1020 S. Trimble Road, Mansfield, OH
44906; e-mail: peggyhalter1@gmail.com.
Received: January 29, 2013
Accepted: February 7, 2013
Posted: March 6, 2013
doi:10.3928/02793695-20130226-02
39
Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.
Purchase answer to see full
attachment