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The DSM-IV Text Revision: Rationale

and Potential Impact on Clinical Practice
Michael B. First, M.D.
Harold Alan Pincus, M.D.

One consequence of the longer interval between major revisions of the en years was disruptive to researchers
DSM (from seven years between DSM-III-R and DSM-IV to more than and was not necessarily justified by
15 years between DSM-IV and DSM-V) is that the accompanying de- the pace of psychiatric research. Giv-
scriptive text will become increasingly out of step with the psychiatric en these concerns, it was decided that
database. To remedy this problem, the DSM-IV Text Revision (DSM-IV- the interval between DSM-IV and the
TR) was published in July 2000. The main objectives of the revision were next revision would be much longer.
to review the DSM-IV text and make changes to reflect information The current plan is for DSM-V to be
newly available since the close of the initial DSM-IV literature review published no earlier than 2010. Thus
process in mid-1992; to correct errors and ambiguities that have been the interval between editions of the
identified in DSM-IV; and to update the diagnostic codes to reflect manual will be at least 16 years.
changes in the ICD-9-CM coding system the U.S. government uses offi- One consequence of the longer in-
cially for health care reporting. This paper reviews the rationale for the terval is the effect on the currency of
text revision and describes changes that may have an impact on the day- the DSM-IV text, which was based on
to-day use of DSM-IV. (Psychiatric Services 53:288–292, 2002) a literature review that extended to
mid-1992. To maintain continued
clinical utility and educational value,

I
n this paper we review the ration- was reviewed by leading experts in a revision of the DSM-IV text was be-
ale for the DSM-IV Text Revision the field. It should be noted that al- gun in 1996. Following the DSM-IV
and describe the objectives of its though the DSM text is in some ways precedent of making changes only if
developers as well as specific changes relatively comprehensive in its cover- they are supported by data (5),
in the text that may be of interest to age of diagnosis and classification, it is changes to the text were made on the
practitioners. not a substitute for a textbook of men- basis of a comprehensive review of
tal disorders, because it offers no in- the literature published since 1992
Rationale for the formation about the etiology of most that was relevant to the text cate-
DSM-IV Text Revision disorders, and treatment is not dis- gories. The text revision (6), called
An important element of DSM-IV (1) cussed at all. DSM-IV-TR to distinguish it from
is the descriptive text that accompa- Within a year of the publication of DSM-IV, was published in June 2000.
nies the criteria for each disorder. It is DSM-III-R (2) in 1987, work began on To avoid creating a “DSM-IV-R,”
useful in educating students, interns, DSM-IV so that its development could proposals to change the criteria sets
residents, practitioners, patients, and be coordinated with the ongoing de- were not considered, even in cases in
family members about the clinical velopment of the tenth revision of the which data published since 1992 sug-
presentation, course, prevalence, fa- International Classification of Dis- gested that criterion thresholds were
milial risk, and other aspects of each eases (ICD-10) (3). Some criticism was not optimally set. For example, sub-
disorder. As with the other elements voiced at the time about the rapid stantial data and a consensus among
of the DSM-IV, the development of pace of DSM revisions (4). Critics ar- researchers on eating disorders sup-
the text was informed by a compre- gued that undertaking an extensive port a change in the binge frequency
hensive literature review, and the text revision of the classification every sev- requirement for bulimia nervosa.
Several studies (7–9) have found that
the clinical characteristics and treat-
ment response of individuals who
Dr. First is associate professor of clinical psychiatry at the College of Physicians and Sur-
geons of Columbia University in New York City, editor of the DSM-IV Text Revision, and
have one or two binges a week are
cochair of the DSM-IV Text Revision work groups. Dr. Pincus is executive vice-chair of similar to those of individuals who
the department of psychiatry at the University of Pittsburgh and Western Psychiatric In- have two or more binges a week (the
stitute and Clinic and cochair of the DSM-IV Text Revision work groups. Send corre- current DSM-IV requirement), which
spondence to Dr. First at the New York State Psychiatric Institute, 1051 Riverside Drive, suggests that the current threshold is
Unit 60, New York, New York 10032 (e-mail, mbf2@columbia.edu). overly stringent. However, the advan-
288 PSYCHIATRIC SERVICES ♦ March 2002 Vol. 53 No. 3
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tages of updating criteria sets had to
be weighed against the costs, such as
those associated with revamping as-
sessment tools tied into DSM.
For the same reason, no changes
were considered in the “structure” of
DSM-IV, such as moving categories
currently in DSM-IV appendix B, the
appendix for “criteria sets and axes
provided for further study,” into the
main classification, regrouping the dis-
orders within DSM-IV, or changing
the multiaxial system.
Objectives of the
DSM-IV Text Revision
The text revision process had three
main objectives: to review the DSM-
IV text to ensure that all the informa-
tion is up-to-date and to make
changes to reflect information that
has become available since the close
of the initial DSM-IV literature re-
view process; to correct errors and
ambiguities that have been identified
in DSM-IV; and to update the diag-
nostic codes to reflect changes in the
ICD-9-CM coding system the U.S.
government uses officially for health
care reporting. Each of these objec-
tives is discussed below.
Review text and
update information
Reviewing and updating the text was
the primary objective of the text revi-
sion. Literature reviews were con-
ducted by members of the DSM-IV-
TR work groups using specific search
terms or subheadings, depending on
the database being searched, and fo-
cusing on articles published between
mid-1991 and 1998. For example,
searching for a particular disorder
and the term “comorbidity” might
yield articles relevant to the “associat-
ed features and disorders” section of
the text, and using the MEDLINE
subheading “epidemiology” might
generate articles potentially useful for
the “prevalence” section of the text.
Most of the changes made in the
DSM-IV text were in the “associated
features” sections, which include sub-
sections on associated laboratory
findings; culture, age, and gender fea-
tures; prevalence; course; and familial
pattern. A summary of the text
changes is included in appendix D of
DSM-IV-TR. The majority of the text
PSYCHIATRIC SERVICES ♦ March 2002 Vol. 53 No. 3
was left unchanged, because the liter-
ature review indicated that the infor-
mation contained in DSM-IV was up-
to-date. The proportion of changed
text also varied widely by disorder.
For some disorders, such as learning
disorders, there were no changes, and
for others, such as Asperger’s disor-
der, virtually the entire text was
rewritten.
Update codes to reflect ICD-9-CM
The diagnostic coding system that has
been in use in the United States for
all health-related reporting purposes
since 1979 is the International Classi-
fication of Diseases, Clinical Modifi-
cation, Ninth Revision (ICD-9-CM)
(10). Although the World Health Or-
ganization published the next revi-
sion, ICD-10, in 1992, the United
States has not yet officially imple-
mented ICD-10 or the clinical modi-
fication of ICD-10 (called ICD-10-
CM), primarily because of cost con-
cerns. When work began on DSM-IV-
TR in 1996, ICD-10-CM was expect-
ed to be implemented in 2000 or
2001; the text revision would have in-
cluded the new ICD-10-CM diagnos-
tic codes, and thus its publication
would have been especially timely.
However, because of the ongoing de-
lay of the implementation of ICD-10-
CM—current estimates are for im-
plementation in 2004 or 2005—
DSM-IV-TR includes the ICD-9-CM
codes.
Updates to the ICD-9-CM codes
are published yearly by the ICD-9-
CM coordination and maintenance
committee, and some of the updates
have affected DSM-IV. Changes
made in 1995 and 1996 were noted in
the 1996 edition of the DSM-IV Cod-
ing Update (11) and have been in-
cluded in copies of DSM-IV pub-
lished since that time. Since the 1996
Coding Update, four additional cod-
ing changes that effect DSM-IV
codes have been made and are in-
cluded in the DSM-IV-TR. Table 1
provides details.
Correcting errors and
significant ambiguities
In the years since DSM-IV was pub-
lished, several errors and problems
have been identified in the definition
of some disorders and in the imple-
mentation of specifiers and other di-
agnostic conventions. Although major
changes to criteria sets were off lim-
its, the text revision was an opportu-
nity to correct such errors. Because
each of these changes may have an
impact on the day-to-day use of
DSM-IV, they are discussed in some
detail below.
Clarification of the definition of
pervasive developmental disor-
der not otherwise specified. In
DSM-IV, major changes were made
in the category of pervasive develop-
mental disorders. The changes were
based in part on a large multisite in-
ternational field trial. However, an
editorial change was made in the de-
scription of pervasive developmental
disorder not otherwise specified
(PDDNOS) during the final phase of
production of DSM-IV that had an
unintended effect on the definition of
this disorder. Instead of requiring
“impairment in the development of
reciprocal social interaction and of
verbal and nonverbal communication
skills,” as DSM-III-R indicated,
DSM-IV states that the “category
should be used when there is a severe
and pervasive impairment of recipro-
cal social interaction or verbal and
nonverbal communication skills, or
when stereotyped behavior, interests,
and activities are present.” Thus a
child with an impairment in only one
area—for example, a child with
stereotyped behavior, interests, and
activities but without evidence of dis-
turbed social interactions—could
theoretically qualify for a diagnosis of
PDDNOS.
To assess the impact of the DSM-IV
rewording, Volkmar and colleagues
(12) conducted a series of reanalyses
of the DSM-IV data from the
autism–pervasive developmental dis-
order field trial. When clinicians’
judgment of the presence or absence
of PDDNOS was used as the stan-
dard, the DSM-IV wording for this
disorder had a sensitivity of .98. How-
ever, the specificity was only .26—
that is, about 75 percent of children
identified by clinicians as not having
the disorder (true negatives) were in-
correctly identified as having it accord-
ing to DSM-IV. These results lend
support to the concern that the DSM-
IV wording inappropriately broadened
289
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Table 1
Crosswalk between DSM-IV codes and revised codes in the DSM-IV Text Revi-
sion (DSM-IV-TR)
DSM-IV code
290.xx Dementia of the Alzheimer’s type,
with early onset (also code 331.0,
Alzheimer’s disease on axis III)
.10 uncomplicated
.11 with delirium
.12 with delusions
.13 with depressed mood
Specify if: with behavioral disturbance
290.xx Dementia of the Alzheimer’s type,
with late onset (also code 331.0, Alz-
heimer’s disease on axis III)
.0 uncomplicated
.3 with delirium
.20 with delusions
.21 with depressed mood
Specify if: with behavioral disturbance
294.1 Dementia due to HIV disease (also
code 042, HIV infection on axis III)
294.1 Dementia due to head trauma (also
code 854.00, head injury on axis III)
294.1 Dementia due to Parkinson’s disease
(also code 332.0, Parkinson’s disease
on axis III)
294.1 Dementia due to Huntington’s
disease (also code 333.4, Huntington’s
disease on axis III)
290.10 Dementia due to Pick’s disease
(also code 331.1, Pick’s disease on
axis III)
290.10 Dementia due to Creutzfeldt-
Jakob disease (also code 046.1,
Creutzfeldt-Jakob disease on axis III)
294.1 Dementia due to ... [indicate the
general medical condition not listed
above] (also code the general medical
condition on axis III)
305.10 Nicotine dependence
290
DSM-IV-TR code
294.xx Dementia of the Alzheimer’s type,
with early onset (also code 331.0,
Alzheimer’s disease on axis III)
.10 without behavioral disturbance
.11 with behavioral disturbance
(Indicate comorbid Alzheimer’s-induced
psychiatric symptomatology by listing
the appropriate mental disorder due
to a general medical condition on axis
I; for example, code 293.81, psychotic
disorder due to Alzheimer’s disease)
294.xx Dementia of the Alzheimer’s type,
with late onset (also code 331.0, Alz-
heimer’s disease on axis III)
.10 without behavioral disturbance
.11 with behavioral disturbance
(Indicate comorbid Alzheimer’s-induced
psychiatric symptomatology by listing
the appropriate mental disorder due
to a general medical condition on axis
I; for example, code 293.81, psychotic
disorder due to Alzheimer’s disease)
294.xx Dementia due to HIV disease (also
code 042, HIV infection on axis III)
.10 without behavioral disturbance
.11 with behavioral disturbance
294.xx Dementia due to head trauma (also
code 854.00, head injury on axis III)
.10 without behavioral disturbance
.11 with behavioral disturbance
294.xx Dementia due to Parkinson’s dis-
ease (also code 332.0, Parkinson’s dis-
ease on axis III)
.10 without behavioral disturbance
.11 with behavioral disturbance
294.xx Dementia due to Huntington’s
disease (also code 333.4, Huntington’s
disease on axis III)
.10 without behavioral disturbance
.11 with behavioral disturbance
294.xx Dementia due to Pick’s disease
(also code 331.1, Pick’s disease on
axis III)
.10 without behavioral disturbance
.11 with behavioral disturbance
294.xx Dementia due to Creutzfeldt-
Jakob disease (also code 046.1,
Creutzfeldt-Jakob disease on axis III)
.10 without behavioral disturbance
.11 with behavioral disturbance
294.xx Dementia due to ... [indicate the
general medical condition not listed
above] (also code the general medical
condition on axis III)
.10 without behavioral disturbance
.11 with behavioral disturbance
305.1 Nicotine dependence
PSYCHIATRIC SERVICES
the construct of PDDNOS. If the di-
agnosis requires impairment in the
social area and either problems in
communication or restricted inter-
est—that is, if at least two types of
problems must be present, one of
which must be from the social area—
the sensitivity was .89 and the speci-
ficity .56.
These results supported a change
in the wording of PDDNOS to revert
to the original construct. The new
wording in DSM-IV-TR is as follows:
“This category should be used when
there is a severe and pervasive im-
pairment in the development of re-
ciprocal social interaction associated
with impairment in either verbal and
nonverbal communication skills, or
with the presence of stereotyped be-
havior, interests, and activities, but
the criteria are not met for a specific
Pervasive Developmental Disorder,
Schizophrenia, Schizotypal Personali-
ty Disorder, or Avoidant Personality
Disorder.”
Removal of the clinical signifi-
cance criterion from the criteria
sets for tic disorders. A clinical sig-
nificance criterion—“the disturbance
causes clinically significant distress or
impairment”—was added to the cri-
teria sets of a majority of disorders in
DSM-IV, tic disorders among them,
to emphasize that a mental disorder
should not be diagnosed in trivial cas-
es, such as when the disturbance is so
mild that it has little impact on the pa-
tient. The addition of the clinical sig-
nificance criterion has been the focus
of some criticism (13).
According to DSM-IV criteria, a di-
agnosis of tic disorder can be made
only after it is established that the tic
causes clinically significant distress or
impairment in the child. After the
publication of DSM-IV, concerns
about the appropriateness of this cri-
terion were raised by clinicians, re-
searchers (14), and patient advocacy
groups, such as the Tourette Syn-
drome Association. For example, cli-
nicians have expressed concerns
about not making a diagnosis in the
case of a child whose presentation
clearly meets the tic symptomatology
criteria for Tourette’s disorder but
who does not have significant impair-
ment or distress from the tic, a situa-
tion quite common in clinical prac-
♦ March 2002 Vol. 53 No. 3
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tice. Thus this criterion has been
eliminated from the criteria sets for
Tourette’s disorder, chronic vocal or
motor tic disorder, and transient tic
disorder.
Adjustment of wording of the
clinical significance criterion for
the paraphilias. In DSM-III-R, the
criteria sets for the paraphilias includ-
ed a clinical significance criterion—
“the person has acted on these urges,
or is markedly distressed by them”—
to indicate that the mere presence of
paraphilic sexual urges or fantasies
does not invariably warrant a diagno-
sis of a paraphilia. During the prepa-
ration of DSM-IV, the wording of this
criterion was adjusted as part of the
effort to adopt uniform wording for
the clinical significance criterion
across the disorders. The DSM-IV
wording is as follows: “the fantasies,
sexual urges, or behaviors cause clini-
cally significant distress or impair-
ment in social, occupational, or other
important areas of functioning.”
An unforeseen consequence of the
rewording was that it led to confusion
about the DSM-IV definition of pe-
dophilia (15). Specifically, the re-
placement of the DSM-III-R phrase
“acts on these urges” with the phrase
“causes clinically significant . . . im-
pairment” was misconstrued to repre-
sent a fundamental change in the def-
inition of pedophilia. Some readers
misunderstood the new wording as
greatly restricting the number of indi-
viduals who would receive a diagnosis
of pedophilia by requiring that these
persons be distressed by their behav-
ior in order to qualify for the diagnosis.
This implication was never intended,
as it is well recognized that many, if not
most, individuals with pedophilia are
not distressed by their pedophilic
urges, fantasies, and behaviors.
To remove any possible ambiguity
about whether acting out pedophilic
urges with others is sufficient for a di-
agnosis of pedophilia, the original
DSM-III-R wording has been reinstat-
ed for pedophilia as well as for para-
philias that involve a victim who is a
nonconsenting individual—voyeur-
ism, exhibitionism, and frotteurism.
Because some cases of sexual sadism
may not involve harm to a victim, such
as inflicting humiliation on a consent-
ing partner, the wording for sexual
PSYCHIATRIC SERVICES ♦ March 2002 Vol. 53 No. 3
sadism involves a hybrid of the DSM-
III-R and DSM-IV text. The DSM-IV-
TR version states: “the person has act-
ed on these urges with a nonconsent-
ing person, or the urges, sexual fan-
tasies, or behaviors cause marked dis-
tress or interpersonal difficulty.”
Change in coding conventions
for indicating clinically significant
psychiatric symptoms occurring
as part of a dementia. An ICD-9-
CM coding change has rendered the
subtypes for dementia of the Alz-
heimer’s type—that is, with delu-
sions, with depression, and with delir-
ium—obsolete. Now, all forms of de-
mentia of the Alzheimer’s type share
the same ICD-9-CM diagnostic code
(code 294.1). To indicate comorbid
psychiatric symptoms arising from
Alzheimer’s disease, the new conven-
tion is to code the mental disorder
that is due to Alzheimer’s disease on
axis I along with the dementia.
For example, under DSM-IV cod-
ing conventions, an individual with
dementia of the Alzheimer’s type who
suffers from the delusion that aides in
the nursing home are trying to poison
him would have been given a diagno-
sis of 290.20, dementia of the
Alzheimer’s type, late onset, with
delusions. In DSM-IV-TR, two diag-
noses would be assigned: 294.11, de-
mentia of the Alzheimer’s type with
behavioral disturbance, and 293.81,
psychotic disorder due to Alzheimer’s
disease, with delusions. The potential
list of secondary conditions to choose
from include psychotic, mood, and
anxiety disorder, personality change,
and sleep disorder due to a general
medical condition.
One complication that arises in
DSM-IV is the fact that the criteria
for personality change specifically
prohibit it from being diagnosed in
the presence of dementia. Criterion
D states: “The disturbance does not
occur exclusively during the course of
a delirium and does not meet criteria
for dementia.” This exclusion was an
inadvertent carryover from the DSM-
III-R criteria set for organic personal-
ity disorder, which had an identical
criterion D. Because the DSM-III-R
criteria for dementia included per-
sonality change as one of the defining
features, allowing organic personality
disorder to be diagnosed along with
dementia would have been redun-
dant. When personality change was
dropped from the criteria set for de-
mentia, a diagnosis of personality
change due to a general medical con-
dition should have been allowed along
with dementia. Thus criterion D in
personality change due to a general
medical condition has been changed
so that it excludes only delirium.
Clarification of the procedures
for making an axis V Global As-
sessment of Functioning rating.
Lack of detail on how to use the
Global Assessment of Functioning
(GAF) rating have led to misinterpre-
tations of how to apply the GAF. One
source of confusion is how to opera-
tionalize the “current” time frame for
the GAF. Does it refer strictly to how
the patient appears and functions
during the evaluation procedure? This
interpretation might result in a mis-
leadingly high GAF, given that some
individuals may experience transient
improvement in anticipation of re-
ceiving help. For clarity, the text now
includes a sentence specifying that
“in order to account for day-to-day
variability in functioning, the GAF
rating for the ‘current period’ is
sometimes operationalized as the
lowest level of functioning for the
past week.”
Another source of confusion in-
volves how to integrate the potential-
ly disparate contributions of a pa-
tient’s psychiatric symptoms and
functioning to the final GAF score.
For example, what should the final
GAF score be for a patient who is a
significant danger to himself, which
would justify a GAF rating below 20,
but is otherwise functioning well at
work and with his family, reflecting a
GAF rating above 60? Some clini-
cians mistakenly use an average of the
two, which in this case would result in
a GAF score around 40. In fact, the fi-
nal GAF score should always reflect
the lower of the two ratings. In this
case, the GAF score should be below
20, despite the patient’s higher social
and occupational functioning. A para-
graph has been added to the GAF in-
structions to clarify this convention.
Clarification of the concept of
polysubstance dependence. It is
not uncommon for clinicians to inap-
propriately use the term “polysub-
291
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stance dependence” in referring to
heavy drug users who are dependent
on a number of different types of sub-
stances. Instead, multiple comorbid
diagnoses of substance dependence,
one for each class of drug that the
person is dependent on, should be
given. For example, an individual
who smokes crack several times a
week, injects heroin daily, and smokes
several marijuana cigarettes a day
would receive three diagnoses—
crack dependence, heroin depend-
ence, and marijuana dependence—
and not a diagnosis of polysubstance
dependence.
A diagnosis of polysubstance de-
pendence should be given only in
clinical situations in which the pattern
of multiple drug use is such that it
does not meet the criteria for de-
pendence on any one class of drug. In
such a case, the only way to assign a
diagnosis of dependence is to consid-
er all the substances that the person
uses, taken together as a whole. To
clarify the appropriate use of this di-
agnosis, the text for polysubstance de-
pendence was revised to provide ex-
amples of situations in which this di-
agnosis might apply.
In making these revisions, however,
it became clear that more than one
interpretation of how to apply the
polysubstance dependence rule is
possible. One interpretation, which is
operationalized in the Structured
Clinical Interview for DSM-IV (16),
focuses on periods of indiscriminate
use of a variety of substances. Anoth-
er interpretation is analogous to the
concept of “mixed personality disor-
der”—that is, one or two dependence
criteria are met for a single class of
drug, but full criteria for dependence
are met only when the drug classes
are grouped together as a whole.
Since both interpretations are cov-
ered by the construct of polysub-
stance dependence, the revised text
includes elements of both.
Conclusions
The DSM-IV Text Revision should
help preserve the clinical and educa-
tional utility of the descriptive text
through the extended period between
major revisions of the DSM by re-
flecting research findings that have
been published since DSM-IV. ♦
292
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Journal to Implement “Paperless”
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