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DSM-5 and School Psychology

Meet the New (and Improved?) DSM-5

By Shelley R. Hart, Christina M. Pate, & Stephen E. Brock

Contributing Editor's Note: This is the first of a series on the new DSM-5. Following its publication in May 2013, subsequent articles will review changes made to specific DSM-5 criteria, emphasizing changes that may be relevant in the school context. If any Communiqué reader is interested in contributing such an article, please contact Dr. Brock at brock@csus.edu. —Stephen E. Brock, PhD, NCSP

Clinical diagnosis is not a typical school psychologist activity. However, changes to the Diagnostic and Statistical Manual of Mental Disorders (DSM), the framework for diagnosis put forth by the American Psychiatric Association (APA), are important to consider. First published in 1952, major revisions are being proposed for this new edition (DSM-5), set to be unveiled at APA's annual convention in San Francisco in May, 2013. The process for updating the manual has taken more than a decade and has included an unprecedented level of transparency. It has also been wrought with controversy, in both the professional and the public sectors. This article will serve as a brief overview of the major proposed changes, along with a short discussion regarding related controversies.

Process of Development and Overall Changes to the DSM

Touted as an iterative process, the DSM-5 (yes, 5, as DSM will no longer employ Roman numerals) Task Force has received more than 13,000 comments via its three public comment periods and has field tested the criteria in 11 academic medical centers with more than 3,000 patients (Kupfer, 2012), as well as in what APA (2012) refers to as “routine clinical practices,” to encourage feedback and help drive revisions to proposed DSM-5 criteria. This process began in 1999 with a planning conference and joint sponsorship between APA and the National Institute of Mental Health (NIMH), which led to the development of the DSM-5 Task Force, 13 expert work groups, participation of the World Health Organization (WHO; responsible for the development of the International Classification of Diseases), and many additional planning meetings. A website was developed (www.dsm5.org) to provide informative resources, continuous updates, ongoing notifications about the structural changes and proposed revisions to the diagnostic criteria, and a forum for public feedback. Recently, the draft diagnostic criteria were removed from the website to avoid confusion as the revisions are being completed. The final criteria will be proposed by the expert work groups to the Task Force and two separate committees (the Scientific Review and Clinical and Public Health Committees), and finally submitted to the APA Board of Trustees.

There are several overall changes proposed for the meta-structure of the DSM (Bernstein, 2011). Previously, disorders were presented in a disconnected fashion, emphasizing discrete boundaries between them. With DSM-5, the diagnoses have been reorganized to reflect scientific advances in understanding the underlying symptoms of disorders and the interaction of genetics, biology, and environment on behavior and mental health. For example, bipolar disorder is proposed to become its own chapter rather than being subsumed under the mood disorders category, and is placed near schizophrenia spectrum and depressive disorders due to its relation to both. The disorders are also sequenced to incorporate a more developmental, lifespan approach (e.g., disorders typically diagnosed in childhood are listed first). Finally, there is a movement toward more dimensionality (i.e., disorders occurring along a continuum rather than existing as discrete entities or categories). For example, several spectrum diagnoses were added (see discussion below regarding autism spectrum disorder [ASD]).

Controversy Over Proposed Changes

Not only are there general changes to the metastructure of the DSM, but also specific changes to existing criteria and addition of new criteria. Table 1 identifies changes relevant to school-age individuals that are being proposed for the DSM-5.

Table 1. Proposed Additions of and Changes to Diagnoses Relevant to School-Age Youth

DSM5 ChapterNewly Proposed DiagnosesChanges to Existing Diagnoses
Neurodevelopmental Disorders
  • Specific Learning Disorder Social
  • Communication Disorder
  • Mental Retardation/Intellectual Development Disorder
  • Autism Spectrum Disorder
  • Attention Deficit Hyperactivity Disorder
  • Chronic Tic Disorder
Bipolar and Related Disorders
  • Bipolar Disorder
Depressive Disorders
  • Mixed Anxiety / Depression
  • Disruptive Mood Disregulation Disorder
  • Major Depressive Episode
Anxiety Disorders
  • Adjustment Disorder
  • Specific Phobia / Social Phobia / Social Anxiety Disorder
  • Generalized Anxiety Disorder
  • Panic Disorder & Panic Attack
  • Agoraphobia
  • Separation Anxiety Disorder
Obsessive Compulsive (OC) and Related Disorders
  • Skin Picking Disorder and Hair Pulling Disorder
  • Substance-Induced OC or Related Disorders
  • OC or Related Disorder Attributable to Another Medical Condition
  • Body Dismorphic Disorder
Trauma and Stressor-Related Disorders
  • Persistent Complex Bereavement Disorder
  • PTSD in preschool subtype
  • PTSD dissociative symptoms subtype
  • Acute Stress Disorder
Dissociative Disorders
  • Dissociative Amnesia
  • Depersonalization/Derealization Disorder
  • Dissociative Identity Disorder
Somatic Symptom Disorders
  • Complex Somatic Disorder
  • Simple Somatic Disorder
  • Functional Neurological Symptom Disorder
Feeding and Eating Disorders
  • Avoidant / Restrictive Food Intake Disorder
Sleep-Wake Disorders
  • Hypersomnolence Disorders subtypes
  • Circadian Rhythm Sleep-Wake Disorders
Gender Dysphoria
  • Gender Dysphoria
Disruptive, Impulse and Conduct Disorder
  • Oppositional Defiant Disorder (frequency) Intermittent Explosive Disorder
  • Conduct Disorder
  • Callous and Unemotional Specifier
Substance Use and Addictive Disorders
  • Hallucinogen Persisting Perception Disorder
  • Neurobehavioral Disorder Associated with Prenatal Alcohol Exposure
  • Caffeine Use Disorder
  • Internet Use Disorder
  • Reorganized according to substance (previously categorized by use, intoxication, withdrawal)
  • Several renamed
Other Disorders
  • Suicidal Behavior Disorder
  • Non-Suicidal Self-Injury Disorder

Despite, or perhaps due to, the unprecedented level of transparency and purported responsiveness to elicited feedback with this revision of the DSM, the proposed manual and the process itself have not been without controversy. The main issues at the heart of this controversy are validity, reliability, sensitivity, and specificity. Practitioners and researchers alike want to ensure that (a) a disorder is a true or valid clinical entity, (b) if an individual sees two separate clinicians he or she will walk away with the same diagnosis (i.e., it can be reliably diagnosed), and (c) if an individual really has the disorder, he or she is diagnosed (sensitivity), but if the individual does not, he or she is not diagnosed (specificity).

Some argue that proposed changes will inappropriately increase the prevalence of diagnoses, overly and unnecessarily pathologizing individuals within our society (e.g., Strakowski & Frances, 2012), while others have argued the exact opposite will take place (Cary, 2012). The former concern arises over the perception of lowered thresholds of diagnostic criteria (e.g., number of required days experiencing symptoms) and disorders that were proposed (most notably psychosis risk, which was subsequently dropped). The latter concern is associated with efforts to increase diagnostic specificity (which in turn lowers sensitivity) and may result in the exclusion of individuals who would have previously been diagnosed (using DSM-IV-TR criteria) and may require treatment (see autism spectrum disorder below).

Field trial testing of the disorders has demonstrated mixed results. DSM-5 Task Force leaders stress that the results indicate the prevalence of disorders will not change and that, in fact, the changes will result in a better balance between sensitivity and specificity (Kupfer, 2012). Interestingly, several diagnoses with few changes from DSM-IV-TR to DSM-5 demonstrated low interrater reliability (e.g., major depressive disorder; Brauser, 2012, May), perhaps pointing to the more rigorous scientific methodology applied to the field trials for DSM-5 versus DSM-IV-TR. Several newly proposed diagnoses also demonstrated low reliability (e.g., disruptive mood dysregulation disorder); however, the majority of disorders purportedly fall within the acceptable range of most medical diagnoses (Kraemer, Kupfer, Clarke, Narrow, & Regier, 2012).

Autism spectrum disorder. The best way to illustrate the controversy surrounding DSM-5 is with the salient example of ASD (which, following the release of DSM-5 will be the subject of another Communiqué article). While we will not know for sure until May 2013 exactly what the changes to criteria will be, from what the APA has previously posted on the DSM-5 webpage, two major shifts from DSM-IV-TR to DSM-5 are anticipated. The first is in line with the overall shift evident in DSM-5 to incorporate more dimensionality into the diagnostic process. Reflecting this, the categories of autistic disorder, Asperger disorder, childhood disintegrative disorder and pervasive developmental disorder–not otherwise specified (PDD–NOS), previously subsumed under the general category of PDD, will likely be captured within one spectrum disorder— ASD. In other words, there would no longer be separate diagnostic categories for autistic disorder, Asperger disorder, and PDD-NOS.

The second major change would potentially come from the proposal to combine social and communication impairments into one criterion. This would result in three requirements for social communication and social interaction deficits (all three of which would need to be met) across contexts in (a) social–emotional reciprocity, (b) nonverbal communicative behaviors used for social interaction, and (c) development and maintenance of relationships.

Two of the following four requirements would need to be met for restricted, repetitive patterns of behavior, interests, or activities: (a) stereotyped or repetitive speech, motor movements, or use of objects; (b) excessive adherence to routines, ritualized patterns of verbal or nonverbal behavior, or excessive resistance to change; (c) highly restricted, fixated interests that are abnormal in intensity or focus; and (d) hyper- or hypo-reactivity to sensory input or unusual interest in sensory aspects of environment. As those of you familiar with current criteria will note, the addition of sensory issues to diagnostic criteria would be new.

As articulated by the DSM-5 Work Group on Neurodevelopmental Disorders, the goal for these proposed changes was to (a) alleviate a somewhat confusing and arbitrary differentiation process (e.g., autism or Asperger), (b) to increase sensitivity and specificity (i.e., improve the identification of true and not-true ASD), and (c) to highlight individual and specific patterns of needs—that is, symptoms and strengths or impairments (e.g., level 3 severity for social communication impairments, requiring very substantial support, but level 1 severity for repetitive behaviors requiring much less support; APA, 2012; Brauser, 2012, January; Happé, 2011). As a result of these proposed changes, under DSM-5 there would be only 11 different ways to meet ASD criteria (vs. the 2,027 different paths to a PDD diagnosis under DSM-IV-TR criteria; McPartland, Reichow, & Volkmar, 2012).

While recent editorials have been published to either support (Ozonoff, 2012) or call for more research on the proposed changes (Tsai, 2012), the main disputed concern sprouts from the fear of a potential narrowing of the diagnosis, essentially excluding individuals captured with the current criteria. As such, several recent studies comparing diagnostic criteria in archived samples have been conducted to investigate the issue of sensitivity and specificity (e.g., Frazier et al., 2012; Huerta, Bishop, Duncan, Hus, & Lord, 2012; Mattila et al., 2011). Of particular early concern were results indicating the potential exclusion of high functioning individuals with autism or Asperger disorder (Mattila et al., 2011; in other words, it has been suggested that proposed DSM-5 criteria increase the risk for false negatives). Interestingly, Mattila and colleagues' results were based on an early draft of the criteria, and when using criteria more closely aligned with the current criteria, a dramatic improvement was found in classification (96% versus 46% were correctly classified). Similarly, when symptom requirement was relaxed to more closely converge on the current proposed criteria, sensitivity of DSM-5 criteria was similar to that of the DSM-IV-TR (Frazier et al., 2012). Again, following the publication of DSM-5 in May of 2013, a specific article on changes to ASD will appear in Communiqué to further explore the final changes to this diagnosis. Look for more on this topic in the future.

Conclusions

Ultimately, as was the case under the rule of the DSM-IV-TR, the new DSM-5 criteria will not directly impact the provision of services to students identified under educational law (i.e., the Individuals with Disabilities Improvement Act [IDEA] of 2004). An educational qualification as a student with autism (§300.8(c)(1)(i); IDEA, 2004) will probably not change with the advent of the new DSM-5 ASD criteria. However, as with all mental health changes that take place in the larger community, it is likely that these changes will both directly and indirectly effect school psychology and the school community. While DSM should not direct our actions, it absolutely should direct our attention. While not carrying the same authority as education codes and regulations, a DSM label is clearly relevant to school psychologists.

Unfortunately, no system of classifying human behavior or experience can ever be perfect. As school psychologists, we often struggle with the imperfect classification system in place through IDEA. It is yet to be determined if the new DSM will be a dramatic improvement over the old DSM as some hope, or if the changes will do more harm than good as others fear. It is most likely that the reality will lie somewhere in between, as was the case with DSM-IV-TR, and as is the case with IDEA. In any case, DSM is moving forward and school psychologists interested in further examining the issues are encouraged to explore the DSM-5 website (www.dsm5.org).

References

American Psychiatric Association. (2012). DSM-5: The future of psychiatric diagnosis. Retrieved from http://www.dsm5.org/Pages/Default.aspx

Bernstein, C. A. (2011, March 4). Meta-structure in DSM-5 process. Psychiatric News, 46, 7–29. Retrieved from http://www.psychnews.psychiatryonline.org

Brauser, D. (2012, May 8). DSM-5 field trials generate mixed results. Retrieved from http://www.medscape.com/viewarticle/763519

Brauser, D. (2012, January 25). Concern over changes to autism criteria unfounded, says APA. Retrieved from http://www.medscape.com/viewarticle/757515

Cary, B. (2012, January 19). New definition of autism will exclude many, study suggests. New York Times, p. A1. Retrieved from http://www.nytimes.com/2012/01/20/health/research/new-autism-definitionwould-exclude-many-study-suggests.html?pagewanted=all&_r=0

Frazier, T. W., Youngstrom, E. A., Speer, L., Embacher, R., Law, P., Constantino, J., … Eng, C. (2012). Validation of proposed DSM-5 criteria for autism spectrum disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 51, 28–40. doi:10.1016/j. jaac.2011.09.021

Happé, F. (2011). Criteria, categories, and continua: Autism and related disorders in DSM-5. Journal of the American Academy of Child and Adolescent Psychiatry, 50, 540–542. doi:10.1016/j.jaac.2001.03.015

Huerta, M., Bishop, S. L., Duncan, A., Hus, V., & Lord, C. (2012). Application of DSM-5 criteria for autism spectrum disorder to three samples of children with DSM-IV diagnoses of pervasive developmental disorders. American Journal of Psychiatry, 169, 1056–1064. doi:10.1176/appi.ajp.2012.12020276

Individuals with Disabilities Education Improvement Act. (2004). Retrieved from http://www.ed.gov/about/offices/list/osers/osep/index.html

Kraemer, H. C., Kupfer, D. J., Clarke, D. E., Narrow, W. E., & Regier, D. A. (2012). DSM-5: How reliable is reliable enough? American Journal of Psychiatry, 169, 13–15. doi:10.1176/ appi.ajp.2011.11010050

Kupfer, D. J. (2012, June 1). Dr. Kupfer defends DSM-5. Retrieved from http://www.medscape.com/viewarticle/764735

Mattila, M. L., Kielinen, M., Linna, S. L., Jussila, K., Ebeling, H., Bloigu, R., … Moilanen, I. (2011). Autism spectrum disorders according to DSM-IV-TR and comparison with DSM-5 draft criteria: An epidemiological study. Journal of the American Academy of Child and Adolescent Psychiatry, 50, 583–592. doi:10.1016/j. jaac.2011.04.001

McPartland, J. C., Reichow, B., & Volkmar, F. R. (2012). Sensitivity and specificity of proposed DSM-5 diagnostic criteria for autism spectrum disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 51, 368–383. doi:10.1016/j.jaac.2012.01.007

Ozonoff, S. (2012). Editorial: DSM-5 and autism spectrum disorders: Two decades of perspectives from the JCPP. Journal of Child Psychology and Psychiatry, 53, e4–e6. doi:10.1111/j.1469-7610.2012.02587.x

Strakowski, S. M., & Frances, A. J. (2012, June 1). What's wrong with DSM-5? Retrieved from www.medscape.com/viewarticle/763886

Tsai, L. Y. (2012). Editorial: Sensitivity and specificity: DSM-IV versus DSM-5 criteria for autism spectrum disorders. American Journal of Psychiatry, 169, 1009-1011. doi:10.1176/appi. ajp.2012.12070922


Shelley R. Hart, PhD, is a NIMH postdoctoral fellow in the psychiatric epidemiology training program at Johns Hopkins University (Bloomberg School of Public Health, Department of Mental Health) in Baltimore, MD. Christina M. Pate, PhD, MEd, is a postdoctoral fellow in child/adolescent mental health services and service systems research (NIMH, T32) at the Johns Hopkins University (Bloomberg School of Public Health, Mental Health), visiting assistant professor (School of Education), and affiliated researcher (Systems Institute, School of Engineering). Stephen E. Brock, PhD, NCSP, is professor and school psychology program coordinator at California State University, Sacramento.