Amidst much controversy, the Diagnostic and Statistical Manual, 5th edition (DSM 5) has been launched. The Task Force and study groups consisted of multiple psychiatrists, psychologists, and one Advanced Practice Nurse. There were also opportunities to comment online and to be involved in field trials. The general theme for the development of this newest edition of the manual which started as a classification of inpatient psychiatric patients in the 1800s, was to develop revisions that addressed shortcomings of the DSM IV-TR. To that end, structure as well as criteria have changed in several areas. However, the diagnostic process continues to be mostly subjective from self reports of clients, significant others and the clinician’s training and expertise with minimal objective data. But Section III for emerging measures brings hope that there is movement toward adding objective measures and perhaps genetic and brain imaging data will also someday be included.
Structural changes in the manual reflect a lifespan perspective and the multiaxel structure has been eliminated. All diagnoses are listed together with the presenting or treatment focused diagnosis listed first. This integration of Axis I, II, and III from the DSMIV-TR and the coordination with the ICD 9 and 10 represent movement toward integrated treatment for psychiatric clients. Axis IV and V have been eliminated. For further specificity of diagnostic criteria, subtypes and specifiers are coded in fourth, fifth, or sixth digits.
Describing the specific changes to all criteria are beyond the scope of this article, but the main areas will be presented. The most significant changes are in the Neurodevelopmental Disorders. Autism Spectrum Disorder combines DSM IV Autistic Disorder, Asperger’s Disorder, Childhood Disintegrative Disorder, Rett’s Disorder, and Pervasive Developmental Disorder not otherwise specified. This grouping has led to concerns of over as well as under-diagnosing children due to the limited time available for Pediatric Nurse Practitioners and Pediatric Physicians who frequently make the initial diagnosis/referral. Another change for children involves the creation of a new diagnosis, Disruptive Mood Dysregulation Disorder, to address the over diagnosis of Bipolar Disorder.
Additional changes included a new category for Obsessive Compulsive and Related Disorders and Trauma and Stressor Related Disorders. It was also quite pleasing to see the addition of an anxious distress specifier which can be added across diagnoses. For Schizophrenia, there were changes to reflect recent research to conceptualize Schizoaffective Disorder as longitudinal rather than cross sectional. For more details on the changes, see DSM 5 Appendix.
As an Advanced Practice Psychiatric Nurse (APPN), I am pleased with some of these changes that reflect current research and am aware of the need to learn the details of the DSM 5 to facilitate communication, research, and reimbursement. However, as we work with clients to understand the tapestry of their lives, there must be more than cookbook diagnostic criteria. It remains that many symptoms cross diagnostic categories and only by adding a theory-based case conceptualization and concordance with clients can effective treatment be achieved. In our textbook, Advanced Practice Psychiatric Nursing: Integrating Psychotherapy, Psychopharmacology, and Complementary/Alternative Approaches, Joyce Fitzpatrick and I enlisted 30 additional practitioners and researchers who share this view about treatment. Although, the text refers to the DSM periodically, it is organized around syndromes (groups of symptoms) often seen in practice, not diagnoses. This approach reflects the reality of psychiatric nursing practice---a holistic approach which recognizes the individual experience as well as strengths of clients. So as we think about the DSM 5, it will not dramatically change practice, but we will need to invest energy into learning the changes.
Kathleen R. Tusaie, PhD, APRN-BC, is Professor and Lead Faculty for the Psychiatric Nurse Practitioner track at The University of Akron School of Nursing. Dr. Tusaie's research focuses upon resilience across settings and populations. She has numerous journal articles, columns, and presentations. In addition to teaching, Dr. Tusaie maintains a private practice for psychotherapy and psychopharmacology.