Catatonia as a psychotic diagnosis. The group has reworked the diagnostic criteria for catatonia and removed it as a subtype of schizophrenia. Instead, catatonia is now a specifier in schizophrenia and several other psychiatric diagnoses. The DSM-IV diagnosis of catatonia related to a general medical condition will be retained, and DSM-5 will also create a new “Catatonia NEC” diagnosis for patients showing catatonia of uncertain origin or associated with neurodevelopmental conditions such as autism.

Gender identity disorder. Individuals who believe their biological gender doesn’t match their gender identification will no longer be labeled with a disorder. Instead, if they seek psychiatric treatment, they can be labeled with “gender dysphoria.”

The workgroup responsible for dealing with the hot-button issue considered a variety of other approaches, addressed later in this article. Ultimately they settled on a formal diagnosis - potentially qualifying a patient for insurance-paid treatment if they want it - but with a less pejorative name than “disorder.”

Substance abuse. DSM-IV created separate diagnoses for “abuse” and “dependence” in people having problems with mind-altering substances such as marijuana and narcotics. The DSM-5 workgroup in this area agreed that the vast amount of research conducted in recent decades pointed to substance-related problems as occurring on a continuum, such that the abuse-dependence distinction was purely arbitrary.

Hence, DSM-5 will instead feature “substance use disorders” as the diagnosis for people with such problems.

Also out are physical tolerance and withdrawal symptoms as criteria for a disorder diagnosis. O’Brien noted that these reflect the body’s adaptation to chemicals and are not necessary to a diagnosis.

WHAT’S IN (or STILL IN)

In a commentary delivered to APA meeting attendees, Norman Sartorius, MD, of the World Health Organization, remarked on “the irresistible tendency to introduce new names” when revising diagnostic criteria. And indeed, the DSM-5 workgroups were unable to resist it.

But Sartorius also noted that new names can be beneficial - as long as they are accompanied by preparation and education.

In addition to new names, some entirely new disorders and methods of diagnosing them are slated to appear in DSM-5.

Dimensions. Perhaps the most important conceptual innovation in DSM-5 is its use of dimensional assessments in most disorder categories. These are indicators of severity for certain symptoms. They may be common “cross-cutting” features that appear in conjunction with many disorders, such as suicide risk and anxiety. Or they may be specific to a particular disorder, such as the frequency of flashbacks in PTSD.

Biomarkers. For the first time, results of objective testing will be part of the formal diagnostic criteria in psychiatry. Many sleep-wake disorders in DSM-5 will require polysomnography for a diagnosis. Also, narcolepsy is set to become narcolepsy/hypocretin deficiency, with the latter condition diagnosed on the basis of hypocretin measurements in cerebrospinal fluid.

Functional impairments. Despite the leadership’s wish to eliminate functional impairments and patient distress as necessary requirements for diagnoses, some of the DSM-5 workgroups found that they couldn’t get rid of them.