Abnormal Psychology. William J. Ray

      During the 1970s, there were a variety of changes in issues of importance to both the scientific and larger lay community that influenced the next version of the DSM. In the scientific study of psychopathology, there was an increased emphasis on greater precision in describing the signs and symptoms associated with a particular psychopathology. In addition, there was an emphasis on differentiating one disorder from another as well as on using experimental research to inform these definitions. There was also an understanding that some individuals manifest a particular disorder in different ways. For example, as noted earlier in this chapter, some individuals with schizophrenia will hear voices, while others will have visual hallucinations.

      When DSM–III was released in 1980, it included a number of major changes from DSM–I and DSM–II (see Blashfield et al., 2010). One major change was that it sought to rely on observable evidence to create a scientific system rather than just focus on the interpretations of experts in the field. Another change was that DSM–III described disorders in terms of specific criteria rather than the more general descriptions of a disorder seen in DSM–I and DSM–II. DSM–III also introduced a five-level system or axes to give a more complete picture of the person. Axis I described the individual’s psychopathological symptoms. Axis II described the person’s personality or mental retardation. Axis III described any medical disorders that the person had. Axis IV described significant environmental factors in the person’s life. Lastly, Axis V described the person’s level of functioning and any significant role impairment. Overall, DSM–III sought to be theory neutral and only use observable terms. DSM–III was adopted in a number of countries and translated into 16 languages. In 1987, DSM–III was revised in terms of diagnostic criteria and referred to as DSM–III–R.

      In 1994, DSM–IV was released. One goal of this release was to coordinate this revision with ICD-10. There was also an attempt to increase the scientific evidence underlying the diagnostic criteria for each specific disorder. To achieve this goal, a steering committee composed of 27 members oversaw the work of 13 different work groups. The task of the work groups was a three-step process. The first step was to extensively review the scientific literature related to a particular disorder. The second step was to utilize and reanalyze descriptive data from researchers who studied particular disorders. The third step was to conduct a series of field trials using the diagnostic criteria and to modify the criteria based on these trials. DSM–IV was expanded in 2000 with the publication of DSM–IV–TR (TR stands for text revision). DSM–IV–TR did not make major changes to the diagnostic criteria but did expand the text information describing each disorder.

      DSM–5: The Current Version

      DSM–5 was released in May of 2013, and the rationale for the changes can be viewed at the website www.psychiatry.org/dsm5. You may note that DSM went from using Roman numerals in previous editions to Arabic numerals for this edition. According to the DSM–5 development website (www.dsm5.org), DSM–5 sought to expand the scientific basis of diagnosis begun in DSM–III by working with the NIMH. An initial conference was held in 1999. Participants developed a series of reports that sought to examine a variety of broad topics beyond diagnosis itself. These topics included developmental issues, gaps in the current system, disability and impairment, neuroscience, nomenclature, and cross-cultural issues. In later papers, age and gender issues were also considered. Further, international organizations such as the WHO offered input into the composition of DSM–5, and 13 conferences were held.

      This 5th edition of DSM presents the initial usage of dimensional assessments. As noted earlier, dimensional assessment is designed to determine the severity of a particular symptom on a continuum, or range, rather than just acknowledging its presence or absence. In addition, what have been considered to be separate disorders may be better viewed as part of a spectrum. For example, although individuals with autism, childhood disintegrative disorder, pervasive developmental disorder, and Asperger’s syndrome may vary in their symptoms and abilities, there are similarities to the disorders. Thus, it would be more accurate to describe autism as falling on a spectrum ranging from mild to severe. In DMS–5, the term Asperger’s is no longer used. Another example is bipolar disorder. Someone diagnosed with bipolar disorder may have a number of severe mood episodes involving mania and depression or just a few. In either case, there is a single category of either having the disorder or not. Dimensional analysis allows for more accurate representation of the disorder by reflecting the severity of the conditions. However, as you will see throughout this book, DSM–5 still has a number of disorders that use a categorical definition. That is, if the person meets the criteria, the person has the disorder, and if they do not meet the criteria, they would not be considered to have the disorder. The following table shows the diagnostic criteria for diagnosing a specific phobia. As you can see in Table 4.2, DSM–5 lists a number of different criteria, including duration and intensity, for the clinical diagnosis to be made.

      The DSM–5 suggests that every case begins with a careful clinical history as well as the social, psychological, and biological factors that have contributed to the development of the disorder. It is important to understand the nature of the distress that the person is experiencing, since distress is a critical component of a DSM disorder. It is also important to understand if the distress and the individual’s behavior should be considered as part of a mental disorder or simply as deviant from the individual’s cultural, religious, or other significant groups. Thus, DSM–5 is more than just a list of symptoms to be checked off by the mental health professional. It is seen as a manual for organizing types of symptoms, which can suggest treatment approaches. However, DSM–5 does not specify any particular treatment. Although DSM–5 suggests that the person be considered within a larger context, it dropped the multiaxial system seen in DSM–III and DSM–IV. A clinician may continue to note cultural, environmental, and other conditions related to a given disorder, but Axes III, IV, and V are now eliminated. Further, personality disorders are no longer described on a separate axis (Axis II).

       Table 4.2DSM–5

      Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (Copyright 2013). American Psychiatric Association. All Rights Reserved

      Another change from previous versions is in the organization of DSM–5. The placement of disorders is based on underlying vulnerabilities as well as symptom characteristics. The chapters are organized by general categories such as neurodevelopmental, emotional, and somatic to reflect how a variety of disorders may have some common underlying similarities. Recent advances in brain imaging, genetics, and the neurosciences have suggested similarities not understood previously. For example, genetic research suggests a closer connection between schizophrenia and bipolar disorder than previously assumed. However, these still remain as separate disorders in DSM–5. A detailed list of changes from DSM–IV to DSM–5 can be found on the website (www.psychiatry.org/dsm5).

      Since DSM-5 is used in a variety of settings, it carries with it a number of difficulties (Frances & Widiger, 2012). DSM–5 is used by mental health professionals as a means to assess individuals. It has traditionally been used by researchers to study psychopathology. Further, our legal system uses it in court trials in which the outcomes can depend on whether the person is experiencing a mental disorder. All of these usages carry with them different types of demands. The research seeks to understand underlying processes of a disorder, whereas the clinician seeks to know how to use the diagnosis to define treatment and induce change. As you will see in later chapters, cultural considerations also play a role. For example, in earlier editions of the DSM, homosexuality was considered a disorder that could be treated. In later chapters of this text, where I discuss the details of specific disorders, I will include occasional Understanding Changes in DSM–5 feature boxes