A Guide to DSM-5

Bret S. Stetka, MD; Christoph U. Correll, MD

May 21, 2013

Section 3 Disorders

Section 3 of DSM-5 includes self-assessment tools intended to better incorporate patient perspective, as well as cultural differences, into clinical assessment and care. Also included are a number of conditions requiring further research before consideration as official diagnoses. As mentioned previously, the alternative, trait-based personality disorder classification system was ultimately moved to Section 3 (see page 8).

Because of the frequent co-occurrence of depressive and anxiety disorders, as well as the potential for concurrent treatment response of both conditions, this diagnostic hybrid had been considered for the main text of DSM-5, but it performed poorly in the field trials (see page 2).

Another new diagnosis that ultimately was included in Section 3, "attenuated psychotic symptoms syndrome," had the same reliability as schizophrenia in the DSM-5 field trials. However, there was significant concern in the psychiatric community that including the condition in Section 2 would risk overmedicalizing often nonspecific phenomena that transition to psychosis in only 20%-30% of individuals over a period of 1-3 years. Moreover, in the field trials, the attenuated psychotic symptoms syndrome was assessed only in academic centers, some of which had been involved in research on this topic, and interviews were probably conducted with more time than is usually available in busy clinical settings. Still, considering attenuated psychotic symptoms syndrome as a new condition that warrants study as a potentially important diagnostic entity will hopefully contribute to enabling targeted prevention in the future.

Whereas in DSM-IV non-suicidal self-injury (NSSI) was considered a symptom of borderline personality disorder (BPD), in the revised manual it is recognized as a distinct condition. Research suggests that NSSI can occur independent of BPD, such as in patients with depression or even in those with no other diagnosable psychopathology. Criteria for NSSI require 5 or more days of intentional self-inflicted damage to the surface of the body without suicidal intent within the past year. Patients also must engage in the self-injurious behavior with at least 1 of the following expectations: to seek relief from a negative feeling or cognitive state, to resolve an interpersonal difficulty, or to induce a positive state. The behavior must also be associated with 1 of the following criteria: interpersonal difficulty or negative feelings and thoughts eg, depression, anxiety), premeditation, and ruminating on (non-suicidal) self-injury. Socially sanctioned behaviors, like body piercing and tattooing, do not qualify for the diagnosis, nor do scab picking or nail biting. Important to note is that patients who express suicidal behavior within the past 24 months, but who don't qualify for another psychiatric disorder, now fall under the new "suicidal behavior" diagnosis category.

Finally, Internet gaming disorder is also included in Section 3. It is distinct from Internet gambling disorder, which is categorized as the only non-substance-related addictive disorder. To qualify for Internet gaming disorder, patients must meet at least 5 of the 9 following criteria within the past year: (1) preoccupation with games; (2) psychological withdrawal symptoms (eg, anxiety, irritability); (3) tolerance (the need to spend an increasing amount of time playing games); (4) unsuccessful attempts to control or limit game participation; (5) loss of interest in previous hobbies; (6) continued use despite knowledge of problem; (7) deceiving family members and/or therapists; (8) use of Internet games to escape a negative mood; and (9) has jeopardized or lost a relationship, job, or educational opportunity. Despite its name, the new diagnosis can apply to non-Web-based games as well.

Time and research will tell whether this condition has sufficient neuropathologic and clinical similarities to other addictive disorders to be included in the Substance-Related and Addictive Disorder chapter in Section 2, as the second non-substance-related disorder.