Intellectual disabilities
The DSM-5 removes the term "mental retardation" in favor of a diagnosis of intellectual disability. But the revisions go beyond the name change, according to Dr. Susan E. Swedo, who chaired the Neurodevelopmental Disorders Work Group for DSM-5.
The new definition is based not only on cognitive capacity, but also on adaptive functioning. The DSM-IV included four diagnostic codes for mental retardation: mild, moderate, severe, and profound. But the DSM-5 has only a single diagnosis of intellectual disability. The manual includes specifiers to use when grading the severity level. The specifiers also are based on both cognitive capacity and adaptive functioning.
Dr. Swedo predicted that because the new criteria are "real-world based," it will make it easier for primary care physicians to make a tentative diagnosis.
Autism spectrum disorder
The APA got a lot of attention when it announced plans to combine autistic disorder, Asperger’s disorder, and pervasive developmental disorder NOS into single spectrum called autism spectrum disorder (ASD). But the big change for psychiatrists will be the new criteria for assessing the severity of ASD.
The DSM-5 does not have an overall severity score for autism. Instead of mild, moderate, and severe, ASD is defined in terms of the level of support required. "We had grave concerns that if somebody got a mild autism diagnosis that it would deny [the patient] services," Dr. Swedo said. "If you meet threshold criteria for autism, you have an impairing condition and deserve help."
The DSM-5 also includes a specifier for when ASD is associated with a known medical or genetic condition or an environmental factor. This new specifier was included to encourage clinicians to include information about potential etiologic associations such as Fragile X syndrome, fetal alcohol exposure, and epilepsy.
The DSM-5 also includes a new diagnostic category outside of ASD called social communication disorder. The diagnosis is likely to be a good fit for children with severe attention-deficit/hyperactivity disorder (ADHD) and social skills deficits, Dr. Swedo said. One of the criteria for the disorder is that ASD must be ruled out.
Dr. Swedo said she does not expect psychiatrists to experience any confusion about which patients should receive a diagnosis of social communication disorder vs. ASD. During the pediatric field trials for the DSM-5, physicians moved very few children and adolescents with a pervasive developmental disorder (not otherwise specified) diagnosis into the social communication disorder category. Instead, they pick up a significant fraction of new patients, she said.
Somatic symptom disorders
The DSM-5 revamps the diagnostic criteria for somatic symptom disorders, bringing many different somatic conditions into a new disorder known as somatic symptom disorder. In previous versions of the DSM, the different diagnoses had overlapping boundaries, and the criteria ranged from too stringent to too loose, said Dr. Joel E. Dimsdale, chair of the Somatic Symptoms Work Group and professor emeritus of psychiatry at the University of California, San Diego. The result is that physicians felt uncomfortable using the somatoform diagnoses, and patients often went unrecognized and untreated, he said.
Another problem with the old versions of the DSM is that the focus for these conditions was on medically unexplained symptoms, Dr. Dimsdale said.
"It’s not a reliable distinction that clinicians agree about," he said. "It tends to foster an antagonism between the doctor and patient, and furthermore, it really encourages a mind-body split or dualism."
In the DSM-5, the new disorder known as somatic symptom disorder does not make medically unexplained symptoms central to the diagnosis. The major criteria for somatic symptom disorder are persistent (lasting 6 months or more), significant somatic symptoms that are associated with disproportionate thoughts, feelings, and behaviors, such as extreme levels of anxiety.
"I think doctors will have more confidence when they make that diagnosis," Dr. Dimsdale said.
And the new approach will be less alienating to patients, he said. "You will no longer be suggesting to a patient that his or her medical problems are imaginary, and that’s a significant improvement."
Commentary – Independent research review needed for DSM 5.1
Future editions of the DSM need to consider how outside social and economic forces are influencing mental health diagnosis, according to a commentary published in Health Affairs.
In the article, published on April 24, a group of experts in psychiatry, epidemiology, and social science called for the creation of an independent research review body to examine the scientific evidence on how institutional, social, and cultural factors contribute to variations in psychiatric diagnosis (doi:10.1377/hlthaff.2011.0596).
The experts assembled to revise the DSM have the necessary clinical expertise, but another group is needed to look at societal factors, such as how direct-to-consumer pharmaceutical advertising can affect the spikes in diagnoses or how insurance reimbursement rates can incentivize the diagnosis of more serious conditions, they wrote. The proposed research group also could look at the impact of environmental factors, such as the stress of living during a time of war.