There are a few minor and almost no major changes in DSM-5 that the patients and professional need to be aware of.
1. The most remarkable structural change of the Fifth Edition is getting rid of 5-axial system. Good riddance!
The old classification grouped diagnoses down into independent dimensions called axes:
Axis I: all diagnoses except mental retardation and personality disorder
Axis II: personality disorders and mental retardation
Axis III: acute medical conditions
Axis IV: psychosocial and environmental factors making things worse
Axis V: Global Assessment of Functioning (GAF), or a number between 0 and 100 that reflects patients' well-being.
The new classification combines the axes together and let them rate the disorders by severity. In addition the NOS (not otherwise specified) label is changed to NED (not elsewhere defined).
2. The diagnosis Mental Retardation is changed to intellectual disability (intellectual developmental disorder)
3. Autism Spectrum Disorder is the new name and a single category for autistic disorder, Asperger disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (PDD-NOS). Probably a bad idea, in my opinion, as the same diagnosis will be given to a child with mild social deficit and severely autistic, nonverbal, and not functional one. In addition, it would be impossible to find out that there might be more than one disorder in this group, as all of them will carry the same name.
4. Binge Eating Disorder is a newcomer to the group - anorexia nervosa, bulimia nervosa, and eating disorder NOS - three different conditions which ended up in the Eating Disorders group only because they have something to do with food. There does not seems to be a good reason to add another one.
5. Disruptive Mood Dysregulation Disorder (DMDD) is a new category and infact a welcome addition. Moodiness, anger, and emotional outbursts in children have been subject of diagnostic controversy for the last two decades. Unfortunately, the issue was hijacked by some unscrupulous members in academia in tandem with a couple of profit seeking pharmaceutical companies. Previous decade saw forty fold increase in diagnosis of pediatric bipolar disorders. While some children develop bipolar illness as they grow up, overwhelming majority do not. In children, common reason for "manic behavior" is immaturity of the brain, partly responsible for control of emotions (Executive Function Network located mostly, but not exclusively, in pre-frontal area of the brain), while emotions themselves are mild or moderate. By analogy, a car collision might be explained either by revved up engine or failed breaks, but rarely by two failures at a time. Children's "breaks" are commonly weak, while extremes of emotions (frequently diagnosed in adults as Intermittent Explosive Disorder or Mania) are relatively rare. DMDD brings "sanity" into the insane world of pediatric bipolar disorders and redirects our focus on weak inhibition vs. excessive "excitation".
6. New to the DSM-5 is bringing together obsessive-compulsive and other disorders previously found under category of Impulse Control Disorder (OCD, Body Dysmorphic Disorder, trichotillomania - hair pulling, Intermittent Explosive disorder, etc.) into a broader class of disorders. Two new conditions which also include adding excoriation (skin-picking) and hoarding disorder to the group. In my opinion, that was a premature move. Compulsion (an irresistible urge to behave in a certain way) and impulsiveness (acting suddenly on impulse without reflection) are not the same: one can have, the other, both, or neither one. Lumping these distinctly different disorders into one category is premature and unfounded.
7. In personality Disorders category, all 10 original (DSM-IV) disorders remained, but the axes boundaries separating them from other psychiatric disorders were removed. Sharp division between personality disorders has always been seen as artificial, nevertheless, the committee, after long deliberation, left them intact. To my regret, Depressive Personality Disorder (DPD), so common in clinical practice was not resurrected. Originally included in DSM II, DPD was never recognized as a distinct entity in subsequent editions, and only showed up in the Appendix B of DSM-IV TR for consideration for later studies.
8. The new umbrella category, or chapter, in DSM-5 is titled Trauma- and Stressor-Related Disorders and includes posttraumatic stress disorder (PTSD) and a new diagnostic sub-type for pre-school children. The significance and reliability of the new subtype will take time to validate.
9. The new specifier "with mixed features" can be used now with bipolar disorders and Major Depressive disorder (MDD). Mood is divided into predominant (depression, mania, or hypomania) and secondary (subclinical). This development, in my view, will broaden the application of mood disorder diagnosis and will allow flexibility in description of nuances of mood fluctuation. Bereavement exclusion, reserved for depressive symptoms lasting less than 2 months after a loss, has been removed from MDD criteria in DSM-5. Although depression is almost universal and predictable reaction to death of a loved one, it is virtually impossible to separate it from a any other stress induced depressive episode.
10. Substance abuse and substance dependency, separate criteria in the previous edition, were combined in to substance use in DSM-5, each substance use divided into mild, moderate, and severe subtypes.
11. To avoid stigmatizing patients with dementia, DSM-5 introduced neurocognitive disorders in its place. The new edition distinguishes different types of these disorders: Alzheimer disease, Lewy body disease, Parkinson disease, HIV infection, and vascular disease. The disorders are divided into mild and major degree of impairment. I believe it is a move in the right direction. As the population ages, we need better understanding of various types of amnesia, cognitive decline and neuronal degeneration. Studying these diseases will allow better understanding and, prediction of natural course, prevention and treatment.
12. DSM manual, probably in reverence to the psychoanalytical past, always paid excessive attention to sexual perversions, disproportionate to their prevalence and impact. In this edition, while keeping criteria unchanged, the committee advised to discriminate between paraphilic behavior and paraphilic diseases.
13. During the DSM -5 writing other disorders were considered. Among them were Relational disorder, Developmental Trauma Disorder, Parental Alienation Syndrome, Internet Addiction Disorder, Male-to-Eunuch Gender Identity Disorder, Disorders of Extreme Stress, Not Otherwise Specified, etc. Thankfully, they didn't make it.
DSM, despite its new Arabic vs. Roman numeral - 5, is still the same hodge-podge of random symptoms, syndromes, and their clusters with various labels, grouped not by their intrinsic similarities but superficial likeness, e.g. having to do with eating, eliminating, having childhood onset, related to sex, happening soon after "an event", etc. Until the committee and the APA recognize fundamental weakness and confusion of their approach to classification, professionals and patients alike will keep using the document, as Allen Frances, M.D (the chair of the DSM-IV edition) put it, "cautiously, if at all."
In conclusion, I would like share a classification from "certain Chinese Encyclopedia" from Jorge Luis Borges `s The Celestial Emporium of Benevolent Knowledge which, in my opinion, accurately reflects the DSM committee's attempt to organize psychiatric disorders:
"The animals are divided into: those that belong to the Emperor, embalmed, those that trained, suckling pigs, mermaids, fabulous, stray dogs, those that are included in the present classification, those that tremble as if they were mad, innumerable ones, those drawn with a very fine camel hair brush, et cetera, those that have just broken a pitcher, those that from a long way off look like flies."