Shrink Rap News: DSM-5 Is Culmination of a 14-Year Odyssey

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In case you missed the big news, the 'American Psychiatric Association's Board of Trustees has voted on and approved the final diagnostic criteria for the fifth edition of the Diagnostic and Statistical Manual, or DSM-5, paving the way for publication in May 2013.

I know, you're shocked. The DSM-5 has been 14 years in the making, with more than 1,500 expert reviewers, multiple committees, work groups, meetings, revisions, and $25 million spent when all is said and done. So, there was little surprise when the board met Dec. 1 and made the final approvals for publication.

I am on the APA assembly, which is its deliberative body. We met in November to vote affirmatively on the recommendations of the Assembly DSM-5 Task Force to approve the new manual to date. At that time, most of the criteria sets had been finalized.

The scientific reviews began in 1999 across 13 National Institutes of Health--supported conferences, followed by a prelude to the DSM-5 website in 2004 for additional input and development. Specific work groups began meeting 5 years ago for more focused reviews, and in 2010 the first draft was publicly released, with two subsequent revisions leading up to the present. In addition to the extensive scientific review, there were reviews based on effects on clinical practice, public health, and forensics.

I won't provide an exhaustive review of the DSM-5 changes; you will get plenty of these in the months leading up to the May publication date. I will share the aspects that stand out for me so far.

First, you will notice that the multi-axial system is going away. No more dividing things up into Axis I (mental illness), Axis II (personality and developmental), Axis III ("medical"), Axis IV (essentially social problems), and Axis V (global assessment of functioning or GAF). This system was the embodiment of the "biopsy-chosocial" formulation.

In today's era of integration of psychiatry into mainstream medicine and attempts to destigmatize, it makes sense to me to include mental illnesses among all the other conditions a person might have rather than setting them off in their own special section. I found the GAF to not be very useful, as it had turned into an unreliable metric for many reasons.

The number of diagnoses will remain about the same, but some of the names, organization, and criteria will have been revised based on the latest research and conceptualizations. Newly distilled diagnoses include autism spectrum disorder, binge eating disorder, hoarding disorder, and skin-picking disorder. The dementia diagnoses have been reworked.

The old diagnoses of substance abuse and substance dependence were restructured and combined into substance use disorder. I found that differentiation between abuse and dependence was not terribly useful, and that these things existed along a spectrum that changes over time for each specific person.

The new, broader diagnosis emphasizes impairment combined with elements of abuse, including overuse, trouble quitting, craving, negative consequences, dangerous use, tolerance, and withdrawal. …