What’s New in DSM-5

The new DSM is here, and—now what? Most of the expected changes that have been written about for months and even years—the unification of the autism spectrum diagnosis, a new alternative to pediatric bipolar disorder, a less restrictive approach to traumatic stress in children—are there. Many other things have been added or changed.

DMDD: Of the new diagnoses, the most visible is probably disruptive mood dysregulation disorder, or DMDD. Why a new disorder? Essentially, to respond to the concern that many chronically irritable children with impairing tantrums and rages were being diagnosed with bipolar disorder, though they didn’t experience the manic episodes characteristic of bipolar. Researchers found that these kids had symptoms and a course of illness distinct from kids with more classic bipolar, and from adults with the disorder. The creation of DMDD is a step towards developing better interventions for these children, who really don’t respond well to the standard treatments for bipolar.

Asperger’s: There has also been a lot of talk about changes in the autism diagnosis, and the disappearance of Asperger’s syndrome. The idea here is that all of the separate autism spectrum disorders are really only different presentations of one disorder—the new autism spectrum disorder (ASD). To allay a great deal of public concern about children losing their services, the psychiatrists have specified that current diagnoses will be grandfathered in, benefits will be stable, and the new diagnostic criteria are not expected to reduce the number of children on the spectrum.

PTSD: Post-traumatic stress disorder will be a little easier to diagnose in young kids because of evidence that kids exposed to trauma can benefit mightily from the treatment a diagnosis affords.

Learning disorders: Dyslexia and other learning disorders become one diagnosis: “specific learning disorder,” with qualifiers for difficulty with reading, math, etc. This change has its basis in the scientific understanding of learning disorders, but it is also something that parents should be aware of for when the new terminology makes its way to the classroom.

The fact is that the effect of this book on clinical practice, on who is or isn’t now diagnosed with this or that disorder, will unfold over a long period. So what does the new DSM do now? One thing it does is tell the story of a profession constantly learning from the people it serves and looking for new ways to understand and help them. Beyond the criteria themselves, there is a wealth of detail about the different ways these disorders appear in different people.

One of the most striking things about the new manual is how much effort has gone into explaining why certain things are changing, and why it is organized how it is. For years the psychiatric establishment has described successive DSMs as attempts to create a common language and provide consistency—”reliability” in science speak—for clinicians and researchers across the field. But here the goal reveals itself to be not only a common language but a deeper understanding of what the language signifies.

Take, for instance, the entry on ADHD and the “Diagnostic Features” section that elaborates on the criteria. “Confirmation of substantial symptoms across settings typically cannot be done accurately without consulting informants who have seen the individual in those settings,” the authors write. This is not only a clinical reminder; it is an appeal to abandon hasty, poorly informed diagnosis. It is an assertion that underneath the diagnostic criteria lies a complex syndrome that presents differently in different people. The authors continue:

Typically, symptoms vary depending on context within a given setting. Signs of the disorder may be minimal or absent when the individual is receiving frequent rewards for appropriate behavior, is under close supervision, is in a novel setting, is engaged in especially interesting activities, has consistent external stimulation (e,g,, via electronic screens), or is interacting in one-on-one situations (e.g., the clinician’s office).

I sense a possible objection here—aren’t you pathologizing normal behavior? But what I see is the application of clinical experience, within the framework of a classification scheme. The media is fond of stories linking ADHD and screens and video games. Here in the DSM, it’s nice to see an inversion: We don’t really know how screens affect kids in the long run. But how a child behaves around electronic stimulation is clinically relevant, the authors say. This nuance is refreshing.

Similarly, the loosening of the age criteria for signs of ADHD to appear—from  age 7 to 12—can be seen as relaxing criteria to capture more individuals. But here’s the reasoning: “An earlier age at onset is not specified because of the difficulties in establishing precise childhood onset retrospectively,” the authors write. “Adult recall of childhood symptoms tends to be unreliable, and it is beneficial to obtain ancillary information.”

This highlights the DSM-5’s developmental approach to psychiatric disorders: kids have it, of course, but adults also have it, and it can be and is diagnosed in adulthood. The criteria shouldn’t stand in the way of gathering the necessary information to identify a disorder that changes over time. And the change highlights the critical fact that reporting needs to be rigorous in diagnoses.

The takeaway for me is that if you really read this document, it can offer up more than a common language for a profession, but an effort to analyze a vast amount of close clinical observation and put it to use in improving diagnosis and treatment. Amid a move to define disorders strictly by their root biological causes, what the DSM-5 offers is highly nuanced view of psychopathology across the lifespan, as it presents to clinicians.

Perhaps “the brain never read that book,” as the popular phrase goes, but people do, and the stories it tells go beyond classification and make up the most nuanced summary we have of what we know now—and on what we mean when we say things about psychiatric disorders.