The Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is the 2013
update to the American Psychiatric Association's (APA) classification and
diagnostic tool. In the United States the DSM serves as a universal authority
for psychiatric diagnosis. Treatment recommendations, as well as payment by
health care providers, are often determined by DSM classifications, so the
appearance of a new version has significant practical importance.
The DSM-5 was
published on May 18, 2013, superseding the DSM-IV-TR, which was published in
2000.
Overview
Mood disorders are emotional disturbances consisting of
prolonged periods of excessive sadness, excessive joyousness, or both. Mood
disorders are categorized as Depressive and Related Disorders and Bipolar and
Related Disorders. Anxiety and related disorders (see Anxiety and
Stressor-Related Disorders) also affect mood.
Sadness and joy (elation) are part of everyday life.
Sadness is a universal response to defeat, disappointment, and other
discouraging situations. Joy is a universal response to success, achievement,
and other encouraging situations. Grief, a form of sadness, is considered a
normal emotional response to a loss. Bereavement refers specifically to the
emotional response to death of a loved one.
A mood disorder is diagnosed when sadness or elation is
overly intense and persistent, is accompanied by a requisite number of other
mood disorder symptoms, and significantly impairs the person's capacity to
function. In such cases, intense sadness is termed depression, and intense
elation is termed mania. Depressive disorders are characterized by depression;
bipolar disorders are characterized by varying combinations of depression and
mania.
Lifetime risk of suicide for people with a depressive
disorder is 2 to 15%, depending on severity of the disorder. Risk is further increased
in the following cases:
* At the start of treatment, when psychomotor activity is
returning to normal but mood is still dark
* During mixed bipolar states
* At personally significant anniversaries
* By severe anxiety
* By alcohol and substance use
* Other complications include disability ranging from
mild to complete inability to function, maintain social interaction, and
participate in routine activities; impaired food intake; severe anxiety;
alcoholism; and other drug dependencies.
DSM-5 Changes
The DSM-5, released in May 2013, separates the mood
disorder chapter from the DSM-TR-IV into two sections: Depressive and Related
Disorders and Bipolar and Related Disorders. Bipolar Disorders falls in between
Depressive Disorders and Schizophrenia Spectrum and Related Disorders “in
recognition of their place as a bridge between the two diagnostic classes in
terms of symptomatology, family history and genetics”. Bipolar Disorders
underwent a few changes in the DSM-5, most notably the addition of more
specific symptomology related to hypomanic and mixed manic states. Depressive
Disorders unwent the most changes, the addition of three new disorders:
disruptive mood dysregulation disorder, persistent depressive disorder
(previously dysthymia), and premenstrual dysphoric disorder (previously in
Appendix B, the section for disorders needing further research). Disruptive
mood dysregulation disorder is meant as a diagnosis for children and
adolescents who would normally be diagnosed with bipolar disorder as a way to
limit the bipolar diagnosis in this age cohort. Major depressive disorder (MDD)
also underwent a notable change, in that the bereavement clause has been
removed. Those previously exempt from a diagnosis of MDD due to bereavement are
now candidates for the MDD diagnosis.
Bipolar and
Related Disorders Changes
Bipolar Disorders
To enhance the accuracy of diagnosis and facilitate
earlier detection in clinical settings, Criterion A for manic and hypomanic
episodes now includes an emphasis on changes in activity and energy as well as mood.
The DSM-IV diagnosis of bipolar I disorder, mixed episode, requiring that the
individual simultaneously meet full criteria for both mania and major
depressive episode, has been removed. Instead, anew specifier, “with mixed
features,” has been added that can be applied to episodes of mania or hypomania
when depressive features are present, and to episodes of depression in the
context of major depressive disorder or bipolar disorder when features of
mania/hypomania are present.
Other Specified
Bipolar and Related Disorder
DSM-5 allows the specification of particular conditions
for other specified bipolar and related disorder, including categorization for
individuals with a past history of a major depressive disorder who meet all criteria
for hypomania except the duration criterion (i.e., at least 4 consecutive
days). A second condition constituting another specified bipolar and related
disorder is that too few symptoms of hypomania are present to meet criteria for
the full bipolar II syndrome, although the duration is sufficient at four or
more days.
Anxious Distress
Specifier
In the chapter on bipolar and related disorders and the
chapter on depressive disorders, a specifier for anxious distress is delineated. This specifier is intended to
identify patients with anxiety symptoms that
are not part of the bipolar diagnostic criteria.
Depressive
Disorders Changes
DSM-5 contains several new depressive disorders,
including disruptive mood dysregulation disorder
and premenstrual dysphoric disorder. To address concerns
about potential overdiagnosis and overtreatment of bipolar disorder in
children, a new diagnosis, disruptive mood dysregulation disorder, is included for
children up to age 18 years who exhibit persistent irritability and frequent
episodes of extreme behavioral dyscontrol. Based on strong scientific evidence,
premenstrual dysphoric disorder has been moved from DSM-IV Appendix B,
“Criteria Sets and Axes Provided for Further Study,” to the main body of DSM-5.
Finally, DSM-5 conceptualizes chronic forms of depression in a somewhat modified
way.
What was referred to as dysthymia in DSM-IV now falls
under the category of persistent depressive disorder, which includes both
chronic major depressive disorder and the previous dysthymic disorder. An inability
to find scientifically meaningful differences between these two conditions led
to their combination with specifiers included to identify different pathways to
the diagnosis and to provide continuity with DSM-IV.
Major Depressive
Disorder
Neither the core criterion symptoms applied to the
diagnosis of major depressive episode nor the requisite duration of at least 2
weeks has changed from DSM-IV. Criterion A for a major depressive episode in
DSM-5 is identical to that of DSM-IV, as is the requirement for clinically
significant distress or impairment in social, occupational, or other important
areas of life, although this is now listed as Criterion B rather than Criterion
C. The coexistence within a major depressive episode of at least three manic symptoms
(insufficient to satisfy criteria for a manic episode) is now acknowledged by
the specifier “with mixed features.” The presence of mixed features in an
episode of major depressive disorder increases the likelihood that the illness
exists in a bipolar spectrum; however, if the individual concerned has never
met criteria for a manic or hypomanic episode, the diagnosis of major
depressive disorder is retained.
Bereavement
Exclusion
In DSM-IV, there was an exclusion criterion for a major
depressive episode that was applied to depressive symptoms lasting less than 2
months following the death of a loved one (i.e., the bereavement exclusion).
This exclusion is omitted in DSM-5 for several reasons. The first is to remove
the implication that bereavement typically lasts only 2 months when both
physicians and grief counselors recognize that the duration is more commonly
1–2 years. Second, bereavement is recognized as a severe psychosocial stressor
that can precipitate a major depressive episode in a vulnerable individual,
generally beginning soon after the loss. When major depressive disorder occurs
in the context of bereavement, it adds an additional risk for suffering,
feelings of worthlessness, suicidal ideation, poorer somatic health, worse
interpersonal and work functioning, and an increased risk for persistent
complex bereavement disorder, which is now described with explicit criteria in
Conditions for
Further Study in DSM-5 Section III. Third,
bereavement-related major depression is most likely to occur in individuals
with past personal and family histories of major depressive episodes. It is
genetically influenced and is associated with similar personality
characteristics, patterns of comorbidity, and risks of chronicity and/or
recurrence as non–bereavement-related major depressive episodes. Finally, the
depressive symptoms associated with bereavement-related depression respond to
the same psychosocial and medication treatments as non–bereavement-related
depression. In the criteria for major depressive disorder, a detailed footnote has
replaced the more simplistic DSM-IV exclusion to aid clinicians in making the
critical distinction between the symptoms characteristic of bereavement and
those of a major depressive episode. Thus, although most people experiencing
the loss of a loved one experience bereavement without developing a major
depressive episode, evidence does not support the separation of loss of a loved
one from other stressors in terms of its likelihood of precipitating a major
depressive episode or the relative likelihood that the symptoms will remit
spontaneously.
Specifiers for
Depressive Disorders
Suicidality represents a critical concern in psychiatry.
Thus, the clinician is given guidance on assessment of suicidal thinking,
plans, and the presence of other risk factors in order to make a determination of
the prominence of suicide prevention in treatment planning for a given
individual. A new specifier to indicate the presence of mixed symptoms has been
added across both the bipolar and the depressive disorders, allowing for the
possibility of manic features in individuals with a diagnosis of unipolar
depression.
A substantial body of research conducted over the last
two decades points to the importance of anxiety as relevant to prognosis and
treatment decision making. The “with anxious distress” specifier gives the
clinician an opportunity to rate the severity of anxious distress in all
individuals with bipolar or depressive disorders.
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