What's Missing From the DSM-5?

Abstract image of woman's profile
Roy Scott/Getty Images

The Diagnostic and Statistical Manual of Mental Disorders is published by the American Psychiatric Association and is used by psychiatrists and clinical psychologists to diagnose mental disorders. The first edition of the DSM was published in 1952. While it has gone through a number of revisions over the intervening years, it remains the definitive text on mental disorders.

Today's version of the diagnostic manual, the DSM-5, was published in May of 2013 and describes many different disorders including mood disorders, bipolar and related disorders, anxiety disorders, feeding and eating disorders, and substance use disorders.

Despite the number of disorders included in the current version of the DSM, there are still some things that you won't find in the manual. Certain conditions, while still diagnosed by some doctors and psychiatrists, are not formally recognized as distinct disorders in the DSM-5.

Which Conditions Are Not Listed in the DSM-5?

While the DSM contains a large number of disorders, it is not a necessarily exhaustive list of every condition that might exist. Some of the conditions currently not recognized in the DSM-5 include:

  • Orthorexia
  • Sex addiction
  • Asperger's syndrome
  • Parental alienation syndrome
  • Pathological demand avoidance
  • Internet addiction
  • Sensory processing disorder
  • Misophonia

Why exactly are some conditions listed in the DSM while others are not? In many cases, it comes down to the amount of research available on the suspected disorder.

For example, while internet addiction is a proposed diagnosis, there is still a great deal of controversy over whether it should be considered a discrete condition or if it may be a manifestation of another disorder.

Some experts argue that internet addiction features many of the symptoms associated with other disorders that are recognized by the DSM, including excessive use, negative consequences associated with use, withdrawal, and tolerance.

Others suggest that it is premature to consider it a distinct diagnosis and that the term 'addiction' itself has become overused.

"If every gratified craving from heroin to designer handbags is a symptom of 'addiction,' then the term explains everything and nothing," noted one commentator.

In short, the conditions listed in the DSM typically have a long history of research with plenty of empirical data on symptoms, prevalence, and treatments to back up their inclusion. For many of the proposed disorders missing in the DSM, this research simply is not there—at least not yet.

Orthorexia as an Example

Consider the condition orthorexia. The term orthorexia was first coined in 1996 and is usually defined as an obsession with healthy eating. According to the proposed diagnostic criteria presented by the doctor who first identified the condition, orthorexia symptoms include a preoccupation with a restrictive diet designed to achieve optimal health. Such dietary restrictions often involve the elimination or restriction of entire food groups. When these self-imposed rules are violated, the individual may be left with extreme feelings of anxiety, shame, and fear of disease. Such symptoms can lead to severe weight loss, malnutrition, stress, and body image issues.

But you won't find these symptoms discussed in the DSM-5. That's because orthorexia is not recognized as an official disorder in the DSM.

Why is this? Orthorexia is a relatively new label applied to a condition that has not received a tremendous amount of research. Dr. Stephen Bratman, the physician who initially proposed the condition, did not think of it as a serious diagnosis until he discovered that people not only identified with the proposed diagnosis, but that some might actually be dying from it.

While there is a lack of empirical studies on the symptoms and prevalence of orthorexia, Dr. Bratman and others suggest that there is sufficient anecdotal evidence to encourage further research and possible consideration as a distinct condition.

How Do New Disorders Make it into the DSM?

So what does the DSM committee look for when determining which disorders should be included in the diagnostic manual?

Revisions to the manual were influenced by the latest research in neuroscience, problems that had been identified in the previous version of the manual, and a desire to better align the manual with the latest version of the International Classification of Diseases.

Early on in the revision process, more than 400 experts from diverse fields including psychiatry, psychology, epidemiology, primary care, neurology, pediatrics, and research participated in a series of international conferences that resulted in the production of monographs designed to help inform the DSM-5 Task Force as they built proposals for changes to the diagnostic manual.

Once a disorder has been proposed for conclusion, the committee reviews the existing research on the condition and may even commission studies to further explore the proposed disorder. The decision then ultimately rests with the DSM task force.

The process of adding new disorders is not without controversy. According to one study, more than half of the experts in charge of compiling the DSM-IV had financial ties to the pharmaceutical industry. Such connections trouble critics, who feel that the inclusion of some disorders may be more linked to their potential to generate big bucks for drug companies. Disorders such as generalized anxiety disorder and social anxiety disorder, these critics charge, may be present at least in part because they encourage prescribing high-profit anti-depressant and anti-anxiety drugs.

What If You Have a Condition That Isn't in the DSM-5?

So what does it mean for patients who have symptoms of a condition not recognized by the official diagnostic manual? For some people, it might mean the difference between receiving mental health treatment and not having access to care. The DSM helps provide clinicians, doctors, and psychiatrists a shared language for discussing mental disorders, but it also plays an important role in insurance reimbursement. A diagnosis is often a requirement in order to receive insurance payment for mental health services. In some cases, patients may only be able to pay for treatment if they receive a diagnosis recognized by the DSM-5.

For some people, not seeing their condition in the DSM-5 can add to feelings of alienation. While some people find the labeling of mental conditions limiting and overly stigmatizing, others find it helpful and feel that inclusion in the DSM represents that their symptoms are recognized by the medical community. An official diagnosis offers hope to these patients, who may finally feel that they have found not only an explanation that accounts for their symptoms, but also the possibility that they can successfully cope with or recover from their disorder.

Changes in the Latest Edition of the DSM

In the most recent edition of the diagnostic manual, some previously recognized disorders were actually removed. Asperger's syndrome, for example, was considered a separate diagnosis in the DSM-IV, but has been absorbed under the umbrella of Autism Spectrum Disorders in the DSM-5. This decision created considerable controversy as many feared it might potentially mean losing their diagnosis and ultimately lead to a loss of various types of essential services.

Another change was the removal of the "not otherwise specified" diagnosis from the DSM-5. This diagnosis covered patients who had some of the symptoms of a disorder but did not meet the full set of criteria. In the DSM-5, the 'not otherwise specified' option has either been removed for most categories of disorders, or replaced with 'other specified disorder' or 'unspecified disorder.'

Symptoms that fail to meet the diagnostic criteria for a recognized mental disorder may fall under the broad category of "other mental disorders." The DSM-5 recognizes four disorders in this category:

  • Other specified mental disorder due to a medical condition
  • Uunspecified mental disorder due to a medical condition
  • Other specified mental disorder
  • Unspecified mental disorder

The catch-all category of "unspecified mental disorder" also drew criticism from some psychiatrists and psychologists for what they feel is a lack of precision. The only criterion for receiving the diagnosis is that the patient does not "meet the full criteria for any mental disorder." This, they suggest, might mean that people fail to receive a correct and more specific diagnosis which might ultimately lead to them not receiving the right treatment for their condition.

While many substance use disorders are recognized in the DSM, those involving food, sex, caffeine, and the Internet didn't make the cut in the current edition. However, both caffeine use and internet gaming are listed as conditions that need further research and may be considered in future updates to the manual.

Conditions for Further Study

Are there other conditions that might deserve future inclusion in the DSM? The manual also includes a section on "conditions for further study." While these conditions are not accepted as distinct disorders in the current version of the DSM, the manual recognizes that they warrant further investigation and may be included in future editions of the manual depending upon the  evidence presented.

This section of the DSM-5 can be thought of as almost something of a waiting list. Research on these conditions is considered limited at the present time, but further study into things such as prevalence, diagnostic criteria, and risk factors is encouraged.

Which disorders are currently listed in this section of the DSM-5? There are currently eight different conditions identified as needing further study:

  • Attenuated Psychosis Syndrome
  • Depressive Episodes With Short-Duration Hypomania
  • Persistent Complex Bereavement Disorders
  • Neurobehavioral Disorder Associated With Prenatal Alcohol Exposure
  • Suicidal Behavior Disorder
  • Nonsuicidal Self-Injury
  • Caffeine Use Disorder
  • Internet Gaming Disorder

While these conditions may not be recognized as discrete disorders at this time, they may end up becoming full-fledged diagnoses in future versions of the DSM.

What's Next? Real-Time Updates to the DSM

One criticism of the DSM is that the manual itself often does not keep pace with current research on different disorders. While the most recent edition of the manual was published in 2013, its predecessor, the DSM-IV, was nearly 20 years old by the time the fifth edition was released.

Writing for STAT, psychiatrist Michael B. First explains that the APA's goal is to make it easier to update the manual in order to reflect the latest research and other changes in the field of psychiatry. First is a member of the APA's new DSM Steering Committee, which hopes to take advantage of the immediacy of digital publishing to keep the DSM more up-to-date. The goal is to develop a model that allows the diagnostic manual to continually improve and base updates upon solid data and empirical evidence.

In doing so, they hope that the future of the DSM will fully reflect scientific advances more quickly than the older revision processes, which will ultimately serve to help psychiatrists, clinical psychologists, and other mental health care providers better serve their patients.

A Word From Verywell

While the DSM-5 may not include every condition that might exist, it is an important tool for accurately diagnosing and treating mental illness. Some conditions may not currently appear in the manual, but that might change in future editions if the research warrants their inclusion.

If you feel that you have the symptoms of a disorder that may or may not be listed in the DSM, consult your health care provider for further evaluation in order to receive a diagnosis and treatment.

Sources:

American Psychiatric Association. DSM History.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Dunn, T & Bratman, S. On orthorexia nervosa: A review of the literature and proposed diagnostic criteria. Eating Behaviors. 2016;21:11-7

Pies, R. Should DSM-V designate "internet addition" a mental disorder? Psychiatry. 2009; 6(2): 31-37.

Regier, DA, Kuhl, EA, & Kupfer, DJ. The DSM-5: Classification and criteria changes. World Psychiatry. 2013; 12(2): 92-98.

Continue Reading