Updates to the DSM-5 and How We Diagnose Depression

How is the DSM-5 different from the DSM-IV?

DSM-5 and Depression
American Psychological Association

The Diagnostic and Statistical Manual of Mental Disorders is a handbook that provides guidelines for clinicians in diagnosing psychiatric illnesses. The latest edition, commonly known as the DSM-5, was released by the American Psychiatric Association on May 18, 2013, at its annual meeting in San Francisco. It replaced the DSM-IV, which had been in use since 1994.

The following changes are relevant to the diagnosis of depression:

Which New Mood Disorders Have Been Added?

One major area of change in the DSM-5 is the addition of new depressive disorders, including disruptive mood dysregulation disorder and premenstrual dysphoric disorder.

Disruptive mood dysregulation disorder is a diagnosis reserved for children between 6 and 18 years of age who show persistent irritability and frequent episodes of extremely out-of-control behavior. This new diagnosis was added to address concerns about the potential over-diagnosis and over-treatment of bipolar disorder in children.

Premenstrual dysphoric disorder (PMDD), which previously appeared in Appendix B of the DSM-IV under "Criteria Sets and Axes Provided for Further Study," has been moved to the main body of the DSM-5. PMDD is a more severe form of premenstrual syndrome (PMS), which is characterized by strong emotional symptoms such as depression, anxiety, moodiness, and irritability.

Have Any Disorders Been Removed?

Another area of change is in how chronic forms of depression are conceptualized and distinguished from episodic depression. What was once referred to as dysthymia, or dysthymic disorder, is now included under the umbrella of persistent depressive disorder (PDD) and includes both chronic major depression and dysthymia.

This move was based upon the fact that there do not appear to be any scientifically meaningful differences between the two conditions; in fact, it appears that depression's quality of either being chronic or episodic may be a better distinguishing feature in identifying different types of depression.

There Have Been Minimal Changes to the Diagnostic Criteria for Major Depressive Disorder

No major changes were made to the diagnostic criteria for major depressive disorder. The core symptoms, as well as the requirement for the symptoms to have lasted for at least two weeks, remain the same. Criterion A for a major depressive episode is the same in both editions, as well as the requirement for clinically significant distress or impairment in one's day-to-day life, although this is now listed as Criterion B rather than Criterion C.

The Bereavement Exclusion Was Removed

The DSM-5 removed what was known as the bereavement exclusion for major depressive episodes. In the past, any major depressive episode following the death of a loved one that lasted less than two months was not classified as a major depressive episode.

By leaving out this exclusion, the new edition of the DSM acknowledges that there is no scientifically valid reason for treating the grieving process differently from any other stressor that might trigger a depressive episode.

In lieu of the bereavement exclusion, the new edition includes a detailed footnote to help clinicians distinguish between normal grief and a major depressive episode so they can make a better decision about whether a particular individual may benefit from treatment.

New Specifiers Were Added

The DSM-5 has added some new specifiers to further clarify diagnoses:

  • With Mixed Features - This new specifier can be present in bipolar and depressive disorders. It allows for the presence of manic symptoms as part of the depression diagnosis in patients who do not meet the full criteria for a manic episode.
  • With Anxious Distress - This specifier was added due to the fact that the presence of anxiety can impact prognosis, treatment choices, and the patient's response to them.

In addition, guidance was provided to clinicians for the assessment of suicidal thinking, plans, and risk factors so that they can better determine just how prominent a role suicide prevention should play in an individual patient's treatment.

Source:

"Highlights of Changes from DSM-IV-TR to DSM-5". American Psychiatric Association. May 17, 2013. Accessed: May 27, 2013.

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