Introduction to the

Diagnostic and
Statistical Manual of
Mental Disorders
Learning Objectives

◦ Learn the origins of the current classification system

of mental disorders
◦ Understand how to use the Diagnostic and Statistical
Manual of Mental Disorders.
◦ Learn the step by step process of performing a
diagnosis based on the DSM-5.
The Diagnostic and Statistical Manual
of Mental Disorders (DSM-5)
What is the DSM-5?

◦ A classification of mental disorders with associated

criteria to facilitate more reliable diagnoses of these
disorders.
◦ Considered a standard reference for clinical practice
in the mental health field.
◦ Intended to serve as a practical, functional, and
flexible guide for organizing information that can aide
in the accurate diagnosis and treatment of mental
disorders.
◦ A tool for clinicians, an essential educational resource
for students and practitioners, and a reference for
researchers in the field.
History of the DSM

• DSM-I – published in 1952, outline the diagnostic

criteria for all the mental disorders recognized by the
psychiatric community at the time. Criteria were
vague descriptions heavily influenced by
psychoanalytic theory.
• DSM-II – published in 1968, descriptions were similar to
DSM-I, abstract and theoretically based with low
reliability in diagnosing mental disorders.
• DSM-III – published in 1980, contained diagnostic
criteria to specify meaning of the categories.
Introduced the first multiaxial system.
• Mental disorder categories
• Personality and/or intellectual disorders
• Medical condition
• Psychosocial stressors
• Adaptive functioning.
History of the DSM

◦ DSM-III-R – published in 1987, similar to DSM-III in

terms of the multiaxial system, diagnostic criteria
usage, and organization of mental disorders, but
offered specific changes in the classification system.
◦ DSM-IV – published in 1994, grew to 383 categories of
mental disorders, retained the multiaxial system of
diagnosis.
◦ DSM-IV-TR – published in 2000, supportive narrative
text for the manual was revised and updated.
◦ DSM-5 – published in 2013, added some diagnoses
and modified criteria for others, attempted to
incorporate a continuum or dimensional perspective
on mental disorders.
Continuing debates about the DSM

◦ Reifying diagnosis – once the diagnosis is made, people

tend to see it as real and true rather than as a product of a
set of judgments about how symptoms tend to occur
together.
◦ Category or continuum – older versions of the DSM adapts
a categorical approach (defined normality and
psychopathology explicitly), DSM 5 introduces a
dimensional perspective on disorders; all behaviors fall
along a continuum and that most disorders represent
extremes along this continuum.
◦ Differentiating mental disorders from one another –
overlaps in symptoms exists in several disorders, the
problem of comorbidity.
◦ Assessing cultural issues – different cultures have distinct
ways of conceptualizing mental disorders, some disorders
that are defined in one culture do not seem to occur in
others.
Categorical vs. Dimensional
Classification
◦ Patients do not fit in any category given the artificial
boundaries of symptoms.
◦ Patients do not achieve enough severity or duration of
symptoms to qualify for the full picture, despite suffering
from similar consequences as those with the whole
syndrome.
◦ Many patients fulfill criteria for several conditions because
of symptom overlap or comorbidity.
Is the DSM
reliable?
The reliability of the classification system of
the DSM continues to be a challenge.
Elements of Diagnosis from the DSM-5

◦ Diagnostic criteria – offered as guidelines for making

diagnoses, and use should be informed by clinical
judgment. A final diagnosis is made based on the
clinical interview, text descriptions, criteria and clinical
judgment.
◦ Subtypes – define mutually exclusive and jointly
exhaustive phenomenological subgroupings within a
diagnosis indicated by “specify whether”
◦ Specifiers – provide a more homogeneous
subgrouping of individuals with disorders who share
the same features indicated by “specify or specify if”
◦ Course – specifies the course of the mental disorder
(e.g. in partial remission, in full remission)
Elements of Diagnosis from the DSM-5

◦ Severity specifiers – guides clinicians in rating the intensity,

frequency, duration, symptom count or other severity
indicator.
◦ Descriptive features – conveys additional information that
can inform treatment planning.
◦ Principal Diagnosis – the condition established after study
to be chiefly responsible for occasioning the admission of
the individual or the reason for visit.
◦ Provisional Diagnosis – used when there is a strong
presumption that the full criteria will be met for a disorder
but not enough information is available to make a firm
diagnosis.
◦ Coding and reporting procedures – each disorder is
accompanied by an identifying diagnostic and statistical
code, typically used by institutions and agencies for data
collection and billing purposes.
Diagnostic Criteria of the DSM-5

◦ Neurodevelopmental Disorders
◦ Schizophrenia Spectrum Disorders and other Psychotic
Disorders
◦ Bipolar and Related Disorders
◦ Depressive Disorders
◦ Anxiety Disorders
◦ Obsessive-Compulsive and Related Disorders
◦ Trauma and Stressor-Related Disorders
◦ Feeding and Eating Disorders
◦ Elimination Disorders
◦ Sleep-wake Disorders
Diagnostic Criteria of the DSM-5

◦ Sexual Dysfunctions
◦ Gender Dysphoria
◦ Disruptive, Impulse Control and Conduct Disorders
◦ Substance-Related and Addictive Disorders
◦ Neurocognitive Disorders
◦ Personality Disorders
◦ Paraphilic Disorders
◦ Other Mental Disorders
◦ Medication-Induced Movement Disorders and other
Adverse Effects of Medication
◦ Other conditions that may be a focus of clinical attention
Challenges in Classifying the DSM 5
Disorder
◦ There’s a huge variation in the clinical presentation of
psychiatric disorders, sometimes symptoms overlap.
◦ Expert consensus remains the “gold standard” of diagnostic
validity and reliability.
◦ The DSM-5 underwent testing in the clinical and research
settings. Field trials were done to determine whether the
diagnostic criteria can be applied reliably and whether they
fit individual’s experiences.
Requirements for a Diagnosis

• Minimum number of symptoms

• Minimum duration of symptoms
• Clinical significance of symptoms
• Functional Impairment
• Distress
Step by Step Differential Diagnosis
Rule out Malingering and Factitious
Disorder

• Malingering – feigning of symptoms due to personal

gain (e.g. insurance claims, avoiding military/legal
responsibilities, obtaining drugs)
• Factitious disorder – motivation for deceptive
behavior is not external rewards.
• Clinicians should be suspicious in cases of:
• Clear external incentive to patient being diagnosed
• Presenting a cluster of symptoms that conform to lay perception of
mental illness
• Nature of symptoms sifts radically from one clinical encounter to
another
• When patient mimics symptoms that of a role model
• When patient is characteristically manipulative
Rule out Substance Etiology

• Determine whether the person has been using a

substance
• Determine whether there is an etiological relationship
between it and the psychiatric symptomatology
• Causal relationship between substance use and psychiatric
symptoms
• Substance use can be the consequence or associated feature
of psychiatric symptoms
• Substance use and symptoms are unrelated
Rule out Disorder due to General
Medical Condition

◦ Ruling out general medical etiology is one of the most

important and difficult distinctions in psychiatric
diagnosis
◦ Many individuals with general medical conditions
have resulting psychiatric symptoms as a
complication of the general medical condition.
◦ Many individuals with psychiatric symptoms have an
underlying general medical condition.
◦ Appropriate identification and treatment of the
underlying general medical condition can be crucial in
both avoiding medical complications and reducing
psychiatric symptomatology.
Determine Specific Primary
Disorder(s)

◦ Many of the diagnostic groupings in DSM-5 are

organized around the common presenting symptoms
precisely to facilitate the differential diagnosis.
Differentiate Adjustment Disorders
from the Residual Other Specified or
Unspecified Disorders
◦ Many clinical presentations do not conform to particular
symptom patterns or fall below the established
severity/duration thresholds to qualify for a specific diagnosis.
◦ If symptoms are severe enough to cause clinically significant
impairment or distress, a diagnosis is still warranted.
◦ Adjustment disorder – symptoms developed as a maladaptive
response to a psychosocial stressor
◦ Other specified mental disorder – symptoms cause clinical
distress or impairment but does not meet full criteria of a
disorder. Clinician chooses to communicate specific reason that
the presentation does not meet full criteria.
◦ Unspecified mental disorder - symptoms cause clinical distress
or impairment but does not meet full criteria of a disorder.
Clinician chooses not to specify the reason that the criteria is
not met for a mental disorder.
Establish the Boundary for No Mental
Disorder
◦ Clinically significant distress or impairment in
functioning.
◦ It is the question of what meets the criteria for clinical
significance.
◦ The boundary between disorder and normality can be
set only by clinical judgment and not by any hard-
and-fast rules.