Camille C.

Fernandez MS Clinical Psychology

Article Review:
Differences of Diagnostic and Statistical Manual of Mental Disorders — Fifth Edition
(DSM-5) between Diagnostic and Statistical Manual of Mental Disorders—Fourth Edition
Text Revision (DSM-IV-TR)

Article Summary
Several things have been revised in the new version of the DSM to take into account
the last two decades of research. These include the following:

Changes to the Multi-axial system or Elimination of Multi-Axial Diagnosis

The manual include approximately the same number of disorders that were included
in DSM-IV, DSM-5 has re-ordered DSM-IV’s sixteen chapters based on scientific and
clinical advances over the last two decades.

In prior versions of the DSM, the age-old system of five "Axes" or dimensions was used
for Diagnostic and treatment purposes. They were:
I) Clinical Syndromes/Disorders
II) Personality Disorders / Mental Retardation
III) Medical Conditions
IV) Psychosocial and Environmental Stressors
V) Global Assessment of Functioning

DSM-5 takes a non-axial documentation approach, combining the first three DSM-IV-TR
Axes into one list, while separate notations for Axes IV and V also have been made,
covering psychosocial and environmental factors, as well as disability.

Elimination of Multi-Axial Diagnosis

• Axis IV - psychosocial and environmental factors – are covered in the DSM-5 through
an expanded set of V codes.

• Axis V - CGAS and GAF - are replaced by separate measures of symptoms severity and
disability for individual disorders on DSM-5.

Re-ordering of the chapters and grouping of categories

Three major sections of the DSM-5:
Section I. Introduction and clear information on how to use the DSM.
Section II. Provides information and categorical diagnoses.
Section III provides self-assessment tools, as well as categories that require more
research.

Added dimensional assessments

In the DSM-IV, a person either had or did not have a particular symptom. Having
a certain number of symptoms was required to receive a diagnosis. In the DSM-5,
dimensional assessments are provided to clinicians as an aid to capture the full range of
symptoms, as well as the severity of a particular diagnosis, along with the ability to track
treatment progress.
The severity ratings are as follows:
Very severe
Severe
Moderate
Mild

Changes in Specific Disorders

Autism
There is now a single condition called autism spectrum disorder in the DSM-5,
which incorporates 4 previous separate disorders.

Childhood bipolar disorder

Has a new name in the DSM-5 called Disruptive Mood Dysregulation Disorder.
This can be diagnosed in children up to age 18 years who exhibit persistent irritability and
frequent episodes of extreme behavioral control.

ADHD
Attention deficit hyperactivity disorder (ADHD) has been modified on the DSM-5.
Emphasize that this disorder can continue into adulthood. The one “big” change (if you can
call it that) is that you can be diagnosed with ADHD as an adult if you meet one less
symptom than if you are a child.

Bereavement Exclusion
The bereavement exclusion in the DSM-IV was removed in the DSM-5.
Here are summary of the reasons why according to the DSM-5 revision:
First it remove the implication that bereavement typically lasts only 2 months when
both physicians and grief counselors recognize that the duration is more commonly 1–2
years.
Second, bereavement is recognized as a severe psychosocial stressor that can
precipitate a major depressive episode in a vulnerable individual, generally beginning soon
after the loss. When major depressive disorder occurs in the context of bereavement, it adds
an additional risk for suffering, feelings of worthlessness, suicidal ideation, poorer somatic
health, worse interpersonal and work functioning, and an increased risk for persistent
complex bereavement disorder, which is now described with explicit criteria in Conditions
for Further Study in DSM-5 Section III.
Third, bereavement-related major depression is most likely to occur in individuals
with past personal and family histories of major depressive episodes. It is genetically
influenced and is associated with similar personality characteristics, patterns of
comorbidity, and risks of chronicity and/or recurrence as non–bereavement-related major
depressive episodes.
Finally, the depressive symptoms associated with bereavement-related depression
respond to the same psychosocial and medication treatments as non–bereavement-related
depression. In the criteria for major depressive disorder, a detailed footnote has replaced
the more simplistic DSM-IV exclusion to aid clinicians in making the critical distinction
between the symptoms characteristic of bereavement and those of a major depressive
episode.

Post-traumatic stress disorder

In DSM-5 it includes four primary major symptom clusters: Re-experiencing,
Arousal, Avoidance, Persistent negative alterations in cognitions and mood.

Major and Mild Neurocognitive Disorder

Major Neurocognitive Disorder now subsumes dementia and the amnestic
disorder. But a new disorder, Mild Neurocognitive Disorder, was also added.

Changes in Terminologies
Terminologies in the DSM-IV:
Not Otherwise Specified (NOS) has been used as a “catch-all” for patients who didn’t fit
into the more specific categories. NOS language is eliminated in DSM-5.

Not Elsewhere Classified (NEC) On DSM-5 there will now be an option for designating
(NEC) which will typically include a list of specifier as to why the patient’s clinical
condition doesn’t meet a more specific disorder.

The phrase “general medical condition” is replaced in DSM-5 with “another medical
condition” where relevant across all disorders.

Article Critique Review

Points of Agreement
As opposed to gathering issue completely as past adaptations had done, related
disarranges and parts are currently assembled together on DSM-5 in light of fundamental
vulnerabilities and indication attributes. DSM-5's section structure, criteria amendments,
and content framework effectively address age and advancement as a major aspect of
finding and order. Culture is similarly discussed more explicitly to bring greater attention
to cultural variations in symptom presentations. DSM-5 represents an opportunity to better
integrate neuroscience and the wealth of findings from neuroimaging, genetics, cognitive
research, and the like, that have emerged over the past several decades – all of which are
vital to diagnosis and treatment development. DSM-5 will be more amenable to updates in
psychiatry and neuroscience, making it a “living document” and less susceptible to
becoming outdated than its predecessors.
Points of Disagreement
DSM-IV’s organizational structure failed to reflect shared features or symptoms of
related disorders and diagnostic groups (like psychotic disorders with bipolar disorders, or
internalizing (depressive, anxiety, somatic) and externalizing (impulse control, conduct,
substance use) disorders. DSM-5 restructuring better reflects these interrelationships,
within and across diagnostic chapters DSM-IV does not adequately address the lifespan
perspective, including variations of symptom presentations across the developmental
trajectory, or cultural perspectives. The multi-axial system in DSM-IV is not required to
make a mental disorder diagnosis and has not been universally used in DSM-5.

Points for Improvement

With the loss of the multi-axial system, some of the structure associated with its
use is also lost the loss of the multi-axial system in the DSM-5 provides both opportunities
and challenges to counselors. Moving forward, counselors should continue to develop
methods for assessing and documenting aspects of the multi-axial system that have been
eliminated. With this change comes an opportunity to reaffirm holistic and integrated views
of clients and to provide leadership for other mental health professions and professionals
regarding how to incorporate this perspective into diagnostic practices. The loss of the
multi-axial framework in the DSM-5 gives both open doors and difficulties to guides. With
the loss of the multi-axial framework, a portion of the structure related with its utilization
is additionally lost. Pushing ahead, advisors ought to keep on developing techniques for
evaluating and recording parts of the multi-axial framework that have been disposed of.
With this change comes a chance to reaffirm all-encompassing and coordinated
perspectives of customers and to give authority to other psychological well-being callings
and experts in regards to how to fuse this point of view into symptomatic practices.
 Analysis

Changes to the Multi-axial system or Elimination of Multi-Axial Diagnosis

The progressions to the multi-axial framework allows the DSM-5 to align to the
World Health Organization's (WHO) International Classification of Diseases, eleventh
edition (ICD-11). These changes are relied upon to help enhance correspondence and the
common use of diagnoses across disorders within chapters. (APA, 2013). Ultimately, the
purpose is to improve diagnostic and treatment approaches, and signal shared
commonalities in etiology within larger disorder groups.

Elimination of Multi-Axial Diagnosis

Elimination of the Multi-Axial Diagnosis in the DSM-IV the V codes on DSM-5

overhauled permit clinicians to show different conditions that might be a concentration of
clinical consideration or influence analysis, course, prognosis or treatment of a mental
disorder. The substitution of Axis V on DSM-IV by separated measures in DSM-5 had an
inevitable change to the World Health Organization Disability Assessment Schedule
(WHO DAS 2.0) is foreseen for estimation of Disability, in any case it is not yet prescribed
for use by APA until it has been concentrated further. (APA, 2013)

Changes in Specific Disorders

Childhood bipolar disorder

The progressions made in the childhood bipolar disorder in the DSM-5 was
planned to address issues of over-diagnosis and over-treatment of bipolar in children. In
DSM-5 it was named as Disruptive Mood Dysregulation Disorder.

Attention deficit hyperactivity disorder

The changes of DSM-5 weakens the criteria marginally for adults, the criteria are
also strengthened at the same time. For example, the cross-situational prerequisite has been
fortified to "a few" side effects in each setting you can't be determined to have ADHD on
the off chance that it just occurs in one setting, for example, at work. The criteria were
likewise casual a bit as the indications now need to had showed up before age 12, rather
than before age 7.

Post-traumatic stress disorder

The DSM-5 are more focused on the behavioral symptoms accompanied in the
PTSD. It have been lowered for children and adolescents. Furthermore, separate criteria
have been added for children age 6 years or younger.

Major and Mild Neurocognitive Disorder

Changes of the neurocognitive disorder in the DSM-5 help improve for early
detection in Dementia Disorder (Kufter, 2013)
Changes in Terminologies:
The progressions and changes made to the DSM-5 were finished with watchful
thought of sexual orientation, race, and ethnicity.

Conclusion

The concentration of the progressions and changes of the DSM was to ensure the
manual is helpful to the individuals who determine and treat people to have emotional
instability, and to the people being dealt with. Jeffrey Lieberman (2013) states that “DSM-
5 is not a pop-brain science book expected for customers: It is a guide, an associate to help
clinicians to help encourage treatment." Remarking on the twirling discussion with respect
to the DSM-5, that the indicative framework isn't sufficient, Dr. Lieberman also stated, “It
can’t create the knowledge, it reflects the current state of our knowledge.”

References:

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental

disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.

American Psychiatric Association (2000). Diagnostic and statistical manual of mental

disorders (4th ed., Text Revision). Washington, DC: Author.

Lieberman, Insel issue joint statement about DSM-5 and RDoC. Psychiatric News,
Tuesday; May 14th, 2013.

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM–5),
published by the American Psychiatric Association (2013) Retrieved November 19, 2018
from https://psychcentral.com/blog/archives/2013/05/18/dsm-5-released-the-big-changes/