The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), is the 2013 update to the Diagnostic and Statistical Manual of Mental Disorders, the taxonomic and diagnostic tool published by the American Psychiatric Association (APA). In 2022, a revised version (DSM-5-TR) was published. In the United States, the DSM serves as the principal authority for psychiatric diagnoses. Treatment recommendations, as well as payment by health insurance companies, are often determined by DSM classifications, so the appearance of a new version has practical importance. However, some providers instead rely on the International Classification of Diseases (ICD), and scientific studies often measure changes in symptom scale scores rather than changes in DSM-5 criteria to determine the real-world effects of mental health interventions. The DSM-5 is the only DSM to use an Arabic numeral instead of a Roman numeral in its title, as well as the only living document version of a DSM.
The DSM-5 is not a major revision of the DSM-IV-TR, but the two have significant differences. Changes in the DSM-5 include the re-conceptualization of Asperger syndrome from a distinct disorder to an autism spectrum disorder; the elimination of subtypes of schizophrenia; the deletion of the "bereavement exclusion" for depressive disorders; the renaming and reconceptualization of gender identity disorder to gender dysphoria; the inclusion of binge eating disorder as a discrete eating disorder; the renaming and reconceptualization of paraphilias, now called paraphilic disorders; the removal of the five-axis system; and the splitting of disorders not otherwise specified into other specified disorders and unspecified disorders.
Many authorities criticized the fifth edition both before and after it was published. Critics assert, for example, that many DSM-5 revisions or additions lack empirical support; that inter-rater reliability is low for many disorders; that several sections contain poorly written, confusing, or contradictory information; and that the pharmaceutical industry may have unduly influenced the manual's content, given the industry association of many DSM-5 workgroup participants. The APA itself has published that the inter-rater reliability is low for many disorders, including major depressive disorder and generalized anxiety disorder.
Content and structure The DSM-5 is divided into three sections, using Roman numerals to designate each section.
Section I: DSM-5 basics Section I describes DSM-5 chapter organization, its change from the multiaxial system, and Section III's dimensional assessments. The DSM-5 dissolved the chapter that includes "disorders usually first diagnosed in infancy, childhood, or adolescence" opting to list them in other chapters. A note under Anxiety Disorders says that the "sequential order" of at least some DSM-5 chapters has significance that reflects the relationships between diagnoses.
The introductory section describes the process of DSM revision, including field trials, public and professional review, and expert review. It states its goal is to harmonize with the International Classification of Diseases (ICD) systems and share organizational structures as much as is feasible. Concern about the categorical system of diagnosis is expressed, but the conclusion is the reality that alternative definitions for most disorders are scientifically premature.
Section II: Diagnostic criteria and codes Section II contains chapters describing types of mental disorders, such as dissociative, neurodevelopmental, and personality disorders. The chapters begin with a description of the group of disorders in question, followed by the specific diagnoses, such as dissociative identity disorder or autism spectrum disorder. For each disorder, a set of diagnostic criteria is presented, followed by descriptions regarding things such as of diagnostic features and prevalence, as well as a list of other disorders to consider for a differential diagnosis, along with descriptions of the differences between these.
Section III: Emerging measures and models Section III includes dimensional measures for the assessment of symptoms, criteria for the cultural formulation of disorders and the Alternative DSM-5 Model for Personality Disordersa hybrid-dimensional-categorical model of personality disorders, as well as a description of the currently studied clinical conditions. It presents selected tools and research techniques focused on diagnosis, taking into account the sociocultural context.
Alternative DSM-5 Model for Personality Disorders
Conditions for further study These conditions and criteria are set forth to encourage future research and are not meant for clinical use. This chapter includes the following conditions: Attenuated psychosis syndrome Depressive episodes with short-duration hypomania Persistent complex bereavement disorder Caffeine use disorder Internet gaming disorder Neurobehavioral disorder associated with prenatal alcohol exposure Suicidal behavior disorder Non-suicidal self-injury
Changes from DSM-IV DSM-5 replaces the Not Otherwise Specified (NOS) categories with two options: other specified disorder and unspecified disorder to increase the utility to the clinician. The first allows the clinician to specify the reason that the criteria for a specific disorder are not met; the second allows the clinician the option to forgo specification.
DSM-5 has discarded the multiaxial system of diagnosis (formerly Axis I, Axis II, Axis III), listing all disorders in Section II. It has replaced Axis IV with significant psychosocial and contextual features and dropped Axis V (Global Assessment of Functioning, known as GAF). The World Health Organization's Disability Assessment Schedule is added to Section III (Emerging measures and models) under Assessment Measures, as a suggested, but not required, method to assess functioning.
Changes made to disorders
Neurodevelopmental disorders
"Mental retardation" was renamed "intellectual disability (intellectual developmental disorder)". Speech or language disorders are now called communication disorders—which include language disorder (formerly expressive language disorder and mixed receptive-expressive language disorder), speech sound disorder (formerly phonological disorder), childhood-onset fluency disorder (stuttering), and a new condition characterized by impaired social verbal and nonverbal communication called social (pragmatic) communication disorder. Autism spectrum disorder (ASD) is a new diagnosis that incorporates the former diagnoses of classic autism, Asperger disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (PDD-NOS). The DSM-5 organizes the symptoms of ASD into two groups: impaired social communication and/or interaction, and restricted and/or repetitive behaviors. The DSM-5 assigns three "severity levels" for ASD, with people in level 1 "requiring support", level 2 "requiring substantial support", and level 3 "requiring very substantial support". The updated classification under ASD reflects a dimensional approach, allowing clinicians to rate symptom severity instead of fitting patients into narrowly defined categories. This change also aimed to simplify diagnosis and improve access to services.American Psychiatric Association. (2013). *Diagnostic and Statistical Manual of Mental Disorders (5th ed.)*. Arlington, VA: American Psychiatric Publishing.Lord, C., Elsabbagh, M., Baird, G., & Veenstra-VanderWeele, J. (2018). Autism spectrum disorder. *The Lancet*, 392(10146), 508–520. https://doi.org/10.1016/S0140-6736(18)31129-2 Attention deficit hyperactivity disorder (ADHD) no longer specifies autism as an exclusionary diagnosis. The requisite age of symptom onset was changed from 7 years old to 12 years old, and symptom thresholds were reduced for diagnosis of ADHD as an adolescent or adult. "Specific Learning Disorder" encompasses shortcomings in academic skill development, including dyslexia and dyscalculia. A new sub-category, motor disorders, encompasses developmental coordination disorder, stereotypic movement disorder, and the tic disorders including Tourette syndrome.
Schizophrenia spectrum and other psychotic disorders All subtypes of schizophrenia (paranoid, disorganized, catatonic, undifferentiated, and residual) were removed from the DSM-5 in favor of a severity-based rating approach. A major mood episode is required for schizoaffective disorder (for a majority of the disorder's duration after criterion A [related to delusions, hallucinations, disorganized speech or behavior, and negative symptoms such as avolition] is met). Criteria for delusional disorder changed, and it is no longer separate from shared delusional disorder. Catatonia in all contexts requires 3 of a total of 12 symptoms. Catatonia may be a specifier for depressive, bipolar, and psychotic disorders; part of another medical condition; or of another specified diagnosis.
Bipolar and related disorders New specifier "with mixed features" can be applied to bipolar I disorder, bipolar II disorder, bipolar disorder NED (not elsewhere defined, previously called "NOS", not otherwise specified) and MDD. Allows other specified bipolar and related disorder for particular conditions. Anxiety symptoms are a specifier (called "anxious distress") added to bipolar disorder and to depressive disorders (but are not part of the bipolar diagnostic criteria).
Depressive disorders The bereavement exclusion in DSM-IV was removed from depressive disorders in DSM-5. New disruptive mood dysregulation disorder (DMDD) for children up to age 18 years. Premenstrual dysphoric disorder moved from an appendix for further study, and became a disorder. Specifiers were added for mixed symptoms and for anxiety, along with guidance to physicians for suicidality. The term dysthymia now also would be called persistent depressive disorder.
Anxiety disorders For the various forms of phobias and anxiety disorders, DSM-5 removes the requirement that the subject (formerly, over 18 years old) "must recognize that their fear and anxiety are excessive or unreasonable". Also, the duration of at least 6 months now applies to everyone (not only to children). Panic attack became a specifier for all DSM-5 disorders. Panic disorder and agoraphobia became two separate disorders. Specific types of phobias became specifiers but are otherwise unchanged. The generalized specifier for social anxiety disorder (formerly, social phobia) changed in favor of a performance only (i.e., public speaking or performance) specifier. Separation anxiety disorder and selective mutism are now classified as anxiety disorders (rather than disorders of early onset).
Obsessive-compulsive and related disorders A new chapter on obsessive-compulsive and related disorders includes four new disorders: excoriation (skin-picking) disorder, hoarding disorder, substance-/medication-induced obsessive-compulsive and related disorder, and obsessive-compulsive and related disorder due to another medical condition. Trichotillomania (hair-pulling disorder) moved from "impulse-control disorders not elsewhere classified" in DSM-IV, to an obsessive-compulsive disorder in DSM-5. A specifier was expanded (and added to body dysmorphic disorder and hoarding disorder) to allow for good or fair insight, poor insight, and "absent insight/delusional" (i.e., complete conviction that obsessive-compulsive disorder beliefs are true). Criteria were added to body dysmorphic disorder to describe repetitive behaviors or mental acts that may arise with perceived defects or flaws in physical appearance. The DSM-IV specifier "with obsessive-compulsive symptoms" moved from anxiety disorders to this new category for obsessive-compulsive and related disorders.