A Clinician’s Guide to the DSM-5-TR _ ___________________________________________________________
APA published a revision of the manual DSM-II [10]. This revision was like DSM-I in many ways, and it increased the number of psychological diagnoses to 182 disorders. DSM-II also no longer made use of the term reaction, which was used throughout much of DSM-I to indicate that all mental disor- ders were reactions to environmental factors [11]. For example, there was a section on schizophrenic reaction, which implied that psychotic symptoms arose from environmental stressors such as insufficient mothering. DSM-II was still heavily influ- enced by psychodynamic theory, and disorders such as neurosis and homosexuality continued to appear in the manual. In 1974, during the seventh printing of DSM-II, homosexuality was removed from the DSM, following controversy over the diagnosis and over data indicating that there were few differ- ences in the psychological adjustment between heterosexual and homosexual men [12]. In the mid-1970s, the DSM came under scrutiny by clinicians who questioned the DSM’s utility from both a clinical and a research perspective. Spitzer and Fleiss published a highly influential paper indicating that DSM-II diagnoses were unreli- able, meaning that they did not yield consistent results across diagnosticians and settings [13]. A vital aspect of a diagnosis involves consistent communication between clinicians about the diagnosis, and a diagnostic system that yields unreliable results across most diagnostic categories is a significant prob- lem. Thus, in 1974, only a few years after the publication of DSM-II, the decision was made to revise the DSM again, with Robert Spitzer as the chairman of the DSM-III task force. The primary goals for DSM-III were to make the DSM more consistent with the ICD, standardize diagnostic practices between the United States and other countries, and improve the standardization and validity of diagnoses. To make these improvements, the methods for establishing the diagnostic criteria for a disorder were changed. In previous versions of the DSM, diagnoses consisted of brief and sometimes vague descriptions of the disorder, with many descriptions being heavily influenced by theory rather than observable factors. In DSM-III, diagnoses were structured using the research diag- nostic criteria and the Feighner criteria, which were published scientific reports for how a psychiatric diagnostic system should be structured [14; 15]. It was here that many DSM diagnoses, like their current descriptions, began to fully appear, with the inclusion of diagnostic categories such as anxiety and affective disorders, schizophrenia, and antisocial personality disorder. When published in 1980, DSM-III contained 265 mental health diagnoses, which was a significant increase from DSM-II [16]. In addition to including more explicit diagnostic criteria, DSM-III introduced a multiaxial system that allowed for multiple facets of diagnosis and the notation of medical diagnoses, acknowledging that mental and physical health problems often co-occur. The multiaxial system also allowed attention to be given to more chronic disorders, with Axis II
diagnoses including mental retardation and personality disor- ders. Finally, DSM-III also included more textual descriptions of theoretically neutral disorders dispensed with previous theoretically driven diagnoses. Many of these changes resulted in DSM-III being a far more reliable tool than DSM-II and facilitated better communication among professionals about the disorders they were treating. DSM-III was revised in 1987 to DSM-III-R, and these changes primarily involved restructuring and renaming some diagnostic categories and removing certain controversial disorders, such as premenstrual dysphoric disorder [17]. The number of diagnos- tic categories in DSM-III-R increased to 292 diagnoses. In 1994, the fourth version of the DSM was published (DSM-IV) [18]. The task force for DSM-IV, chaired by Allen Frances, aimed to integrate more empirical evidence into the diagnostic system than had DSM-III [3; 19]. DSM-IV had extensive reviews of the existing literature and multicenter field trials that established diagnostic reliability rates and relevance to clinical practice. In addition to increasing the number of psychological disorders to 297, DSM-IV also added a criterion to many disorders that required the disorder to result in “clinically significant distress.” In 2000, DSM-IV was updated with changes primarily involv- ing text revisions and finalizing the five-axis multiaxial system (DSM-IV-TR) [20]. The purpose of including the multiaxial system was to encourage clinicians to think about the interac- tion among psychological, medical, and social factors and to distinguish between acute and chronic psychological disorders. Nineteen years elapsed between the publication of DSM-IV and the release of DSM-5. The revision process for DSM-5 began in 1999 and was a long one that involved substantial efforts by many key leaders in the field of psychopathology, considerable debate about what changes should or should not be made to diagnostic categories and criteria, and extensive field-testing of diagnoses for reliability [21]. In coordination with large health institutions, such as the National Institute of Mental Health and the World Health Organization, the APA began in 1999 to evaluate the strengths and weaknesses of DSM-IV. David Kupfer and Darrel Regier chaired the DSM-5 task force of 28 people, with 6 to 12 task force members assigned to each work group. Each work group was responsible for meeting in person and communicating frequently throughout the year to determine the changes that should be made for each assigned category (e.g., mood disorders, eating disorders, personality dis- orders). These work groups then drafted proposals for changes to each area, which were posted on the APA DSM-5 website (http://www.dsm5.org) for public evaluation and commentary. Field trials for potential DSM-5 diagnostic criteria began in 2011 to establish inter-rater reliability for all diagnoses. In December 2012, the APA Board of Trustees voted to approve DSM-5, published in May 2013. However, it is essential to remember that the DSM is a constantly evolving manual.
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