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DSM‐5 (DSM-5)

Chapter · January 2015

DOI: 10.1002/9781118625392.wbecp308


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Meghan A Marty Daniel L Segal

University of Colorado Colorado Springs University of Colorado Colorado Springs


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DSM-5 publication of the original DSM in 1952. More
recently, the DSM-IV was published in 1994
Meghan A. Marty1 and Daniel L. Segal2 and in 2000 a “text revision” of the manual
1 Veterans Affairs Palo Alto Health Care System, U.S.A.
(DSM-IV-TR) was published, which slightly
and 2 University of Colorado at Colorado Springs, U.S.A. updated some of the content in the manual.
Empirical research and extensive literature
The Diagnostic and statistical manual of mental reviews have guided refinements in the diag-
disorders (DSM), published by the American nostic manual and its continued development.
Psychiatric Association, is a compendium of In 1999, an initial DSM-5 research planning
mental disorders, a listing of the diagnostic conference was convened, which set research
criteria used to diagnose them, and a detailed priorities in an effort to expand the scientific
system for their definition, organization, and basis for mental health diagnoses and classifi-
classification. This entry includes informa- cation. Between 2006 and 2008, the diagnostic
tion on: (a) the planning and development workgroups were assembled, comprising more
of the fifth edition of the manual (DSM-5), than 160 clinicians and researchers from psy-
(b) the general features of the DSM-5 and chiatry, psychology, social work, psychiatric
changes from previous editions, (c) multicul- nursing, pediatrics, and neurology. In an effort
tural and diversity issues in the DSM-5, and to ensure broad perspectives were consid-
(d) limitations and criticisms of the DSM-5. ered, the work-group members represented
Mental disorder refers to “a health condition more than 90 academic and mental health
characterized by significant dysfunction in an institutions throughout the world, and approx-
individual’s cognitions, emotions, or behaviors imately 30% of the work-group members
that reflects a disturbance in the psycholog- were from countries other than the United
ical, biological, or developmental processes States. Additionally, more than 300 advis-
underlying mental functioning” (American ers, known for their expertise in a particular
Psychiatric Association, 2012). Diagnosis field, provided knowledge to the workgroup
refers to the identification and labeling of a members.
mental disorder by examination and analysis Each of the diagnostic workgroups con-
(Segal & Coolidge, 2001). Mental health pro- ducted extensive literature reviews, performed
fessionals diagnose individuals based on the secondary data analyses, solicited feedback
symptoms that they report experiencing and from colleagues and professionals, and ulti-
the signs of disorders with which they present. mately developed the new diagnostic criteria
Whereas the DSM aids professionals in under- in their respective areas. Several general prin-
standing, diagnosing, and communicating ciples were established to guide the decisions
about mental disorders through its provision made by the workgroups about what should be
of explicit diagnostic criteria and an official included, removed, or changed in the revised
classification system, no information about manual. These principles included consid-
treatment is included. eration of the clinical utility of and research
evidence for the revisions, continuity with
the previous edition of the manual when
Planning and Development of the
possible, and no predetermined constraints
on the amount of change permitted. Addi-
The DSM-5 is the latest incarnation of the tionally, the workgroups were asked to clarify
manual in an evolving process that began with the boundaries between mental disorders,

The Encyclopedia of Clinical Psychology, First Edition. Edited by Robin L. Cautin and Scott O. Lilienfeld.
© 2015 John Wiley & Sons, Inc. Published 2015 by John Wiley & Sons, Inc.
DOI: 10.1002/9781118625392.wbecp0308
2 DSM-5

consider symptoms that occur across differ- be related to one another, reflecting advances
ent diagnoses, demonstrate the strength of in the scientific understanding of mental disor-
the empirical evidence for the recommended ders. Section 3 includes conditions that require
changes, and clarify the boundaries among further research, assessment measures, cultural
specific mental disorders and normal psycho- formulations, a glossary, and a description of
logical functioning. an alternative model for diagnosing personality
Early drafts of the DSM-5 were opened disorder (see below).
for public review; the American Psychiatric According to the DSM-5, individuals with
Association designated three time periods a particular diagnosis (e.g., major depressive
during which the general public was invited to disorder) need not exhibit identical features,
comment on the new diagnostic criteria. Field although they should present with certain car-
trials were conducted between 2010 and 2011 dinal symptoms (e.g., either depressed mood
to test the new diagnostic criteria for feasibility, or anhedonia). In the DSM-5, the criteria for
clinical utility, reliability, and validity in both many mental disorders are polythetic, mean-
academic and nonacademic clinical practice ing that an individual must meet a minimum
settings. The release of the final, approved number of symptoms to be diagnosed, but
DSM-5 occurred in May 2013. The manual not all symptoms need be present (e.g., five of
is expected to become a living document, nine symptoms must be present to diagnose
reflecting more frequent revisions. Thus, the depression). Use of polythetic criteria allows
traditional Roman numeral was dropped from for some variation among people with the
the title so that future changes prior to the same disorder. However, individuals with the
manual’s next complete revision will be sig- same disorder should have a similar history in
nified as DSM-5.1, DSM-5.2, and so forth. some areas, for example a typical age of onset,
Although far from perfect, the DSM functions prognosis, and common comorbid conditions.
as one of the most comprehensive and thor- Consistent with previous editions, the DSM-5
ough manuals used to classify and diagnose primarily relies on a categorical approach
mental disorders. The only major competitor to diagnosis so that individuals either have
in the developed world is the World Health the disorder (i.e., they meet criteria, they are
Organization’s International Classification of diagnosable) or they do not (despite possibly
Diseases (ICD), which is in its tenth edition. having several symptoms but not enough to
The ICD is also currently undergoing revision meet formal criteria).
and is expected to be widely compatible with Notably absent from the DSM-5 is the use
the DSM-5. of the multiaxial system. Clinical disorders,
personality disorders, and general medical
General Features of the DSM-5 conditions (formerly Axes I, II, and III) are
combined into a nonaxial documentation,
Section 1 of the DSM-5 provides an introduc- with separate notations for psychosocial and
tion and includes information on how to use contextual factors (formerly Axis IV) and
the manual. In Section 2, mental disorders disability (formerly Axis V). Regarding the
are grouped into 22 diagnostic categories. former Axis V, the Global Assessment of
The structural organization of the DSM-5 is Functioning scale has been replaced with the
revised from the previous edition, such that World Health Organization Disability Assess-
the individual disorders within a category are ment Schedule (WHODAS) which provides
arranged in a developmental lifestyle fashion, a global measure of disability. The WHODAS
with disorders typically associated with child- is based on the International Classification of
hood presented first. Additionally, the order Functioning, Disability and Health (ICF) for
of the diagnostic categories is designed to use across all of medicine and health care, and
closely position diagnostic areas that seem to is located in Section 3 of the DSM-5 with other
DSM-5 3

new assessment measures. An added feature “Major Neurocognitive Disorder,” with sub-
in the DSM-5 is the more prominent use of types of each identifying the etiology of the
dimensional and crosscutting assessments. cognitive dysfunction (e.g., Major Neurocog-
Dimensional assessments are proposed for nitive Disorder due to Alzheimer’s Disease).
inclusion within some existing categorical Consistent with the manual’s new dimen-
diagnoses, with the goal of providing addi- sional approach, Asperger’s disorder has been
tional information that assists clinicians in subsumed in a new diagnosis called “Autism
assessment, treatment planning, and treatment Spectrum Disorder,” which allows for dimen-
monitoring. For example, among individuals sional ratings of severity of the symptoms on
with schizophrenia, the severity of the primary a continuum from mild to severe. In addition,
symptoms of psychosis, including delusions, there are a few newly classified disorders, such
hallucinations, disorganized speech, abnormal as Hoarding Disorder, which falls under the
psychomotor behavior, and negative symp- “Obsessive-Compulsive and Related Disor-
toms, may be rated on a dimensional five-point ders” category. Finally, some clinical disorders
scale ranging from 0 (not present) to 4 (present such as Non-Suicidal Self Injury Disorder
and severe). Cross-cutting assessment refers to and Persistent Complex Bereavement Dis-
the measurement of important clinical areas order are included in the manual under a
that may be relevant beyond specific diagnos- section designated for disorders that require
tic areas, such as depressed mood, anxiety, further study (in the previously mentioned
Section 3).
substance use, or sleep problems. Such clinical
areas may be relevant for prognosis, treatment Personality Disorders
planning, assessment of outcome, or refine- Personality disorders are inflexible and
ment of diagnosis, and may be evaluated and maladaptive patterns of behavior reflecting
monitored throughout the course of treatment. extreme variants of normal personality traits
Clinical Disorders that have become rigid and dysfunctional. Ten
prototypical personality disorders were listed
The bulk of the DSM-5 comprises 22 broad
in the DSM-IV-TR, including the antisocial,
clusters under which specific clinical disorders
avoidant, borderline, dependent, histrionic,
are subsumed. Examples of clinical disorders narcissistic, obsessive-compulsive, paranoid,
include bipolar disorder, generalized anxiety schizoid, and schizotypal personality disor-
disorder, schizophrenia, and anorexia nervosa. ders. Substantial comorbidity and overlap exist
In general, many of the main diagnostic cate- among the personality disorders. The DSM-5
gories remain largely the same in the DSM-5 Personality and Personality Disorders Work
as in the previous edition of the manual, Group proposed substantial changes in the
although some new categories were created way clinicians assess and diagnose personality
(e.g., Neurodevelopmental Disorders; Bipolar pathology. However, after extensive debate and
and Related Disorders, Gender Dysphoria, critique of the proposed changes, the DSM-5
Obsessive-Compulsive and Related Disorders). included the 10 standard personality disorders
Other modifications included moving sev- in the main text of the manual and relegated
eral disorders from one category to another, most of the proposed changes to the latter
renaming some disorders, and deleting some portion of the manual so that the changes can
disorders that had questionable reliability be studied more fully. Nonetheless, the pro-
or validity, reflecting advances in empirical posal is available for current use if the clinician
research and understanding of mental-health wishes.
disorders. For example, disorders that were The workgroup initially recommended the
formally classified as “Dementia” are now previous 10 categories be reduced to six spe-
renamed “Mild Neurocognitive Disorder” or cific personality disorder types, including
4 DSM-5

antisocial, avoidant, borderline, narcissistic, adopted in DSM-5, it is likely that many of

obsessive-compulsive, and schizotypal. One the proposed changes will be revisited in
additional type, Personality Disorder Trait future editions of the manual especially as the
Specified (PDTS) was suggested to replace research base continues to clarify whether the
the former Personality Disorder Not Oth- proposed modifications increase diagnostic
erwise Specified diagnosis. The workgroup utility and validity.
also proposed that the DSM-5 criteria should
incorporate a dimensional approach, such that Multicultural and Diversity Issues
in order to be diagnosed with a personality in the DSM-5
disorder an individual must have impairment
in two areas of personality functioning: self During the DSM-5 development process, study
and interpersonal. Impairment of self is related groups on gender and cross-cultural issues and
to identity and self-directedness, whereas on lifespan developmental approaches were
interpersonal impairment is related to one’s included. In addition, there was an effort to
capacity for empathy and intimacy. Levels of include international experts in the revision
impairment in these areas are supposed to process, as well as a variety of clinical settings
be rated along a continuum from 0 (healthy during the field trials, to ensure a wide pool
functioning) to 4 (extreme impairment). Finally, of information on cultural factors in psy-
the workgroup proposed and defined five chopathology and diagnosis. Such information
broad personality trait domains, including is necessary to help clinicians and researchers
negative affectivity, detachment, antagonism, diagnose individuals outside the majority cul-
disinhibition versus compulsivity, and psy- ture. The DSM-5 provides an updated version
choticism. Within these five broad domains are of the Outline for Cultural Formulation that
component trait facets, which vary by disorder. was introduced in DSM-IV. This Outline pro-
It was suggested that the personality domain vides a framework for assessing information
in DSM-5 be used to describe the personality about the role of culture in an individual’s
characteristics of all patients, whether or not mental health problems. Specifically, the Out-
they have a clinically significant personality line calls for a thorough assessment of five
disorder. The workgroup’s full proposal is content areas, including the cultural identity
available for use in Section 3. of the individual, cultural conceptualizations
In response to these suggested major changes of distress, psychosocial stressors and cul-
to the Personality Disorders category in tural features of vulnerability and resiliency,
DSM-5, there has been substantial and some- cultural features of the relationship between
times contentious debate in the literature clinician and client, and an overall cultural
regarding many of these modifications. Most assessment.
of the criticisms center around questions about The DSM-5 Outline also presents an
the empirical basis for many of the changes, approach to assessment using the Cultural
the perceived arbitrariness of the changes, Formulation Interview (CFI). The CFI con-
and the perceived limited clinical utility and tains a set of 16 questions that clinicians may
unnecessary complexity of the changes (e.g., use during a clinical intake assessment to elicit
Livesley, 2012; Zimmerman, 2011). Concerns information from a client about the possible
among researchers continue to exist about the impact of culture on different aspects of care.
limited relevance of some diagnostic criteria It is designed to be used regardless of the
for personality disorders as applied to older client’s cultural background or the clinician’s
adults and the unique context of later life (Bal- cultural background or theoretical orientation.
sis, Segal, & Donahue, 2009; Segal, Coolidge, & The CFI emphasizes four main domains: (a)
Rosowsky, 2006). Although no major changes cultural definition of the problem; (b) cultural
in the personality disorders were formally perceptions of cause, context, and support;
DSM-5 5

(c) cultural factors affecting self-coping and lack of inclusiveness and transparency in the
past help-seeking behaviors; and (d) cultural revision process; the adoption of a dimen-
factors affecting current help-seeking behav- sional approach to diagnosis without sufficient
iors. Although culture purportedly refers to all empirical support; the use of newly developed
aspects of one’s membership in diverse social dimensional and cross-cutting assessments in
groups (e.g., ethnic groups, the military, faith the absence of evidence of reliability and valid-
communities), the CFI appears to emphasize ity; and limited attention to careful risk-benefit
the impact of race and ethnicity on one’s analyses regarding many of the changes. For
understanding of one’s difficulties. Additional a more complete discussion of strengths and
modules have been developed for populations criticisms of the DSM-5, interested readers
with unique needs, such as children, older are referred to Frances and Widiger (2012),
adults, and immigrants and refugees, which Kamens (2012), and Widiger and Gore (2012).
can be used to supplement the standard CFI.
SEE ALSO: Definition of Mental Disorder; DSM-I
Despite some apparent improvements, the
relevance of criteria for some mental disorders
Medical Model of Mental Disorders; Reification
among older adults is addressed in a limited
fashion in the DSM-5. Finally, a Glossary of References
Cultural Concepts of Distress is located in the
American Psychiatric Association. (2012).
Appendix, and includes information about
Definition of a mental disorder. Retrieved from
culture-bound syndromes, the cultures in
which they occur, and a description of the proposedrevision.aspx?rid=465
main psychopathological features. Balsis, S., Segal, D. L., & Donahue, C. (2009).
Revising the personality disorder diagnostic
Limitations and Criticisms criteria for the Diagnostic and statistical manual
of DSM-5 of mental disorders—fifth edition (DSM-5):
Consider the later life context. American Journal
Although anticipated to improve upon its of Orthopsychiatry, 79, 452–460.
predecessors and provide a state-of-the-art Frances, A. J., & Widiger, T. (2012). Psychiatric
manual for the diagnosis and classification of diagnosis: Lessons from the DSM past and
mental disorders, the DSM-5 has received some cautions for the DSM-5 future. Annual Review of
significant criticisms. A major criticism is the Clinical Psychology, 8, 109–130. doi:10.1146/
dramatic expansion of the boundaries of some annurev-clinpsy-032511-143102
Kamens, S. (2012). Controversial issues for the
categories, for example attention deficit hyper-
future DSM-5. Retrieved from http://www.
activity disorder (ADHD), potentially resulting
in numerous “false positive” diagnoses. A newsletters/humanistic/2010/01/dsm-v.aspx
related controversy regards the expansion in Livesley, J. (2012). Tradition versus empiricism in
the number of diagnosable mental disorders, the current DSM-5 proposal for revising the
potentially prompting unnecessary stigmatiza- classification of personality disorders. Criminal
tion, intervention, and expense. Indeed, across Behaviour and Mental Health, 22, 81–90.
editions of the DSM, more mental disorders doi:10.1002/cbm.1826
have been included in each successive version Segal, D. L., & Coolidge, F. L. (2001). Diagnosis and
as new disorders have been defined to fill in classification. In M. Hersen & V. B. Van Hasselt
(Eds.), Advanced abnormal psychology (2nd ed.,
the gaps between existing disorders. Such pro-
pp. 5–22). New York: Kluwer Academic/
liferation of newly minted disorders raises the Plenum.
question whether they truly represent distinct Segal, D. L., Coolidge, F. L., & Rosowsky, E. (2006).
forms of psychopathology or are merely vari- Personality disorders and older adults: Diagnosis,
ations of existing disorders. Other criticisms assessment, and treatment. Hoboken, NJ: John
include the American Psychiatric Association’s Wiley & Sons, Ltd.
6 DSM-5

Widiger, T. A., & Gore, W. L. (2012). Mental Hersen, M., & Beidel, D. C. (Eds.). (2012). Adult
disorders as discrete clinical conditions: psychopathology and diagnosis (6th ed.).
Dimensional versus categorical classification. In Hoboken, NJ: John Wiley & Sons.
M. Hersen & D. C. Beidel (Eds.), Adult Jones, K. D. (2012). Dimensional and cross-cutting
psychopathology and diagnosis (6th ed., pp. assessment in the DSM-5. Journal of Counseling
3–32). New York: John Wiley & Sons. and Development, 90, 481–487.
Zimmerman, M. (2011). A critique of the proposed doi:10.1002/j.1556-6676.2012.00059
prototype rating system for personality disorders Keeley, J. W., Burgess, D. R., & Blashfield, R. K.
in DSM-5. Journal of Personality Disorders, 25, (2008). Diagnostic and statistical manual of
206–221. doi:10.1521/pedi.2011.25.2.206 mental disorders (DSM). In S. F. Davis & W.
Buskist (Eds.), 21st Century Psychology (pp.
Further Reading 253–261). Thousand Oaks, CA: Sage Publishing.
Alarcón, R. D. (2009). Culture, cultural factors, and
psychiatric diagnosis: Review and projections.
World Psychiatry, 8, 131–139.

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