What are the major changes in the DSM-5?

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was unveiled at the annual American Psychiatric Association (APA) meeting in San Francisco this past May. After nearly a decade of multi-level scientific, clinical, and public-health review, the new guidelines are ready for immediate use by the APA and in your own clinical practice.

The original DSM was published in 1952, with a fourth revision in 1994, and a text revision in 2000. To incorporate new research and advances in knowledge since the last revision, the APA recruited a task force and various study groups consisting of top researchers and clinicians worldwide. 


DSM-5 has been restructured to consist of three sections in addition to the Preface, Classification of Coding, and Appendix. The new manual has removed the multiaxial organization (Axes I-V) of disorders by combining the first three DSM-IV-TR axes into a single developmental list.

The nonaxial documentation includes all mental and personality disorders, including intellectual disability, with separate scales for measuring symptom severity and disability. The noteworthy changes address the name of disorders, enhance criteria to align all providers in accurately assessing patients, and identify the impact a diagnosis has on daily functioning. 


The brief review of the new three-part structure outlined below contains some of the key changes in DSM-5 that may impact your clinical practice.


Section 1: DSM-5 basics 


The introductory section of the new volume outlines the changes in the order that they appear. 


Section 2: Diagnostic criteria and codes


The previous multiaxial structure is now divided into topics with subtopics. The nonaxial documentation for diagnosis will combine the former Axes I, II, and III, with separate notations for psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V).


Substantial changes were made to the following disorders:


Intellectual disability. The federal law (Rosa’s Law) signed by President Obama on October 5, 2010, replaced the term “mental retardation” with “intellectual disability.” DSM-5 will adopt this diagnostic term to align with the rest of the medical, educational, and advocacy communities.

Intellectual disability is based on clinical assessment and standardized testing of intelligence. DSM-5 emphasizes that intelligence should be assessed across three domains of adaptive functioning:

1. Conceptual domain (language, reading, math)
2. Social domain (social judgment, interpersonal communication)
3. Practical domain (personal care, job responsibilities)

The intelligence quotient (IQ) will no longer be used as diagnostic criteria but is still recommended for assessment. Intellectual disability is suggested for individuals with an IQ score of approximately 70 or below (two standard deviations below the population). Severity can be specified as mild, moderate, severe, or profound. Severity is determined by adaptive functioning rather than cognitive capacity (i.e., IQ).


Related: Critics question the methodology and transparency of DSM-5

Autism spectrum disorder (ASD). A graded scale now combines the former four autism-related disorders: autistic, Asperger’s, childhood disintegrative, and pervasive developmental disorder. In DSM-5, ASD is a collective condition that reflects severity of symptoms encompassing deficits in social communication and interaction and restricted repetitive behaviors (RRBs), interests, and activities. (Note: If RRBs are not present, the diagnosis of social communication disorder is suggested.)


The new criteria will allow variation in symptoms and behaviors between individuals. Placing a patient on a spectrum rather than providing an individual diagnosis prevents inconsistency between clinicians and reduces the risk of misdiagnosis.

DSM-5 requires symptoms to be present from early childhood even if ASD is not assessed or diagnosed until later in life. A recent study found that 91% of children diagnosed with ASD using DSM-5 criteria were also diagnosed with one of the four DSM-IV autism related disorders.1 This study shows that most children will retain a diagnosis of ASD when converting to the new guidelines. 


Attention deficit hyperactivity disorder (ADHD). The DSM-5 criteria divide the 18 diagnostic symptoms from DSM-IV into inattention and hyperactivity. Key changes include: the addition of examples to aid in identifying the disorder across the lifespan; symptoms are now required to be present before age 12 years rather than age 7 years; a diagnosis of both ADHD and ASD is now permitted; the symptom threshold for ADHD in adults has been lowered to five symptoms (six for those younger); and ADHD is now listed as a neurodevelopmental disorder rather than a disruptive disorder. 


Specific learning disorder. All previous learning disorders are now combined into a single diagnosis, which acknowledges the fact that academic deficits commonly occur together. A coding specifier can be added to designate deficits in reading, mathematics, written expression, and learning disorder not otherwise specified. 


Catatonia. This diagnosis now requires three out of 12 catatonic symptoms for all contexts. Diagnosis can be made separately or as a specifier for bipolar, psychotic, or depressive disorders.


From the December 01, 2013 Issue of Clinical Advisor

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the handbook widely used by clinicians and psychiatrists in the United States to diagnose psychiatric illnesses. Published by the American Psychiatric Association (APA), the DSM covers all categories of mental health disorders for both adults and children.

It contains descriptions, symptoms, and other criteria necessary for diagnosing mental health disorders. It also contains statistics concerning who is most affected by different types of illnesses, the typical age of onset, the development and course of the disorders, risks and prognostic factors, and other related diagnostic issues.

Just as with medical conditions, certain government agencies and many insurance carriers require a specific diagnosis in order to approve payment for support or treatment of mental health conditions. Therefore, in addition to being used for psychiatric diagnosis and treatment recommendations, mental health professionals also use the DSM to classify patients for billing purposes.

This article discusses the history of the DSM and how the most recent edition compares to past editions.

The Diagnostic and Statistical Manual was first published in 1952. Since then, there have been several updates issued. In the DSM-I, there were 102 categories of diagnoses, increasing to 182 in the DSM-II, 265 in the DSM-III, and 297 in the DSM-IV.

A major issue with the DSM has been around validity. In response to this, the National Institute of Mental Health (NIMH) launched the Research Domain Criteria (RDoC) project to transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system they feel will be more biologically based.

In 2013, then-NIMH director Thomas Insel and APA president-elect Jeffrey Lieberman issued a joint statement saying that the DSM-5 represents "the best information currently available for clinical diagnosis of mental disorders." They went on to say that both the DSM-5 and RDoC represent "complementary, not competing, frameworks" for the classification and treatment of mental disorders.

The National Institute on Mental Health also notes that the RDoC is not meant to be a diagnostic tool and should not be used to replace other diagnostic systems (such as the DSM). Instead, its goal is to serve as a framework for research on mental disorders in order to better understand mental health.

The DSM has gone through many changes since it was first published in the early 1950s.

The DSM-III introduced a multiaxial or multidimensional approach for diagnosing mental disorders. 

The multiaxial approach was intended to help clinicians and psychiatrists make comprehensive evaluations of a client's level of functioning because mental illnesses often impact many different life areas.

It described disorders using five DSM "axes" or dimensions to ensure that all factors—psychological, biological, and environmental—were considered when making a mental health diagnosis.

Axis I consisted of mental health and substance use disorders that cause significant impairment. Disorders were grouped into different categories such as mood disorders, anxiety disorders, and eating disorders.

Axis II was reserved for what we now call intellectual development disorders (intellectual disability) and personality disorders, such as antisocial personality disorder and histrionic personality disorder. Personality disorders cause significant problems in how a person relates to the world, while intellectual development disorders are characterized by intellectual impairment and deficits in other areas such as self-care and interpersonal skills.

Axis III was used for medical conditions that influence or worsen Axis I and Axis II disorders. Some examples include HIV/AIDS and brain injuries.

Any social or environmental problems that may impact Axis I or Axis II disorders were accounted for in this axis. These include such things as unemployment, relocation, divorce, or the death of a loved one.

Axis V is where the clinician gives their impression of the client's overall level of functioning. Based on this assessment, clinicians could better understand how the other four axes interacted and the effect on the individual's life.

Up to and including the DSM-IV-TR, the multiaxial system was used to help clinicians fully evaluate the biological, environmental, and psychological factors that can play a role in a mental health condition.

The fifth edition of the DSM contains a number of significant changes from the earlier DSM-IV and DSM-IV-TR. The most immediately obvious change is the shift from using Roman numerals to Arabic numbers in the name (i.e., it is now written as DSM-5, not DSM-V).

Perhaps most notably, the DSM-5 eliminated the multiaxial system. Instead, the DSM-5 lists categories of disorders along with a number of different related disorders. Example categories in the DSM-5 include anxiety disorders, bipolar and related disorders, depressive disorders, feeding and eating disorders, obsessive-compulsive and related disorders, and personality disorders.

A few other changes that came with the DSM-5 included:

While the DSM is an important tool, only those who have received specialized training and possess sufficient experience are qualified to diagnose and treat mental illnesses.

A number of significant changes were made in the DSM-5 compared to previous editions. The DSM-5 eliminated the multiaxial system. Some disorders were eliminated or changed, while several new conditions were added.

The DSM, fifth edition, text revision (DSM-5-TR) contains revised criteria for more than 70 disorders. The DSM-5-TR also includes the addition of a new diagnosis called prolonged grief disorder.

There are new codes added to the DSM-5-TR that will allow clinicians to document suicidal behavior and nonsuicidal self-injury in patients that don't have another psychiatric diagnosis.

The DSM-5-TR uses more specific language to avoid reader confusion. For instance, it revised the wording of criterion A in autism spectrum disorder from "as manifested by the following" to "as manifested by all of the following" to indicate that all symptoms must be present in order for a diagnosis to be made.

The parenthetical "(social phobia)" next to social anxiety disorder was removed. The term "intellectual disability" was revised to intellectual development disorder. The DSM-5-TR also made significant revisions to terms surrounding gender dysphoria.

Used in DSM-5

• Desired gender

• Cross-sex medical procedure

• Natal male

• Natal female

Used in DSM-5-TR

• Experienced gender

• Gender affirming medical procedure

• Individual assigned male at birth

• Individual assigned female at birth

The DSM-5-TR also made changes aimed at reducing racial and cultural biases. These revisions include:

• The term "race" was replaced with "racialized" to call out that race is socially constructed.
• The term "ethnoracial" is used to refer to categories like Hispanic, White, and African American.
• The terms "minority" and "non-White" are not used because they imply that Whiteness is prioritized over other social groups.
• The term "Caucasian" is not used. The APA notes that this term is based on erroneous views about the geographic origin of people who are called Caucasian.
• The term Latinx is used instead of Latino/Latina for gender inclusivity.

The DSM-5-TR also notes how symptoms of certain conditions manifest differently in people from varying demographic groups.

The DSM-5-TR revised criteria for 70 disorders as well as added a new diagnosis, prolonged grief disorder. This new edition of the DSM also revised language surrounding gender dysphoria and race.

When making a diagnosis, a doctor may rely on a variety of information sources including interviews, screening tools, psychological assessments, lab tests, and physical exams to learn more about the nature of your symptoms and how they are affecting you. A healthcare provider or mental health professional will then utilize the information they have learned to make a diagnosis based on DSM criteria.