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The new American Psychiatric Association’s (APA) “Diagnostic and Statistical Manual (DSM) of Mental Disorders”, Fifth Edition, Text Revision (DSM‑5‑TR) was released in March. It’s been nine years since the publication DSM 5, so an update was overdue.
The APA believes that this is the “most comprehensive, current, and critical resource for clinical practice available to today’s mental health clinicians”.1 The APA Chief Executive Officer and Medical Director opined that it will be “of enormous benefit to practitioners, researchers, academic institutions, and health systems.”2 These are bold claims, but like its predecessor DSM‑5, published in 2013, it is not without its critics.3
The most striking change is the inclusion of prolonged grief disorder4, a condition already included in International Classification of Diseases (ICD)‑115. Described as “timely and important” because of the death toll from the COVID‑19 pandemic, disruption of social rituals, and formal support services for those bereaved,6 the inclusion of prolonged grief disorder has also been described as adding to “confusion and stigmatisation”.7
More generally, there are changes concerning prevalence, risk and prognostic factors, culture-related features and diagnostic markers for most disorders. Equally important are the revisions in language. These are not only technical (e.g., abolition of the term “neuroleptic” to describe anti-psychotic medication) but also recognises that some terminology was outdated, even in DSM‑5.
Intellectual disability becomes intellectual developmental disorder, while conversion disorder is now functional neurological disorder. Other changes such as “desired gender” becoming “experienced gender” and “cross-sex medical procedure” changing to “gender-affirming medical procedure” are small steps in the right direction.
The criteria for a number of disorders have also been updated but the degree to which these will actually impact on clinical practice has yet to become clear.8
Adding suicidal behaviour and non-suicidal self-injury to the “other conditions that might be the focus of clinical attention” chapter is useful. These problems are important in planning management regardless of the presence or absence of a disorder.
Aligning these problems and other disorders with ICD‑10‑CM codes highlights another potential criticism of the text. ICD‑10‑CM stands for “International Classification of Diseases”, 10th Edition, Clinical Modification. These codes are used by U.S. statistical agencies and are mandated by the U.S. Health Care Financing Administration for purposes of reimbursement under the Medicare system.9
Questions of medical hegemony and self-interest are never far away.10 However, they are presented, the ICD and DSM are not pure, disinterested products of science but evolving social constructs born of a mixture of competing forces.
You can understand a psychiatrist being interested in how many angels the APA can dance on the head of any particular pin, but what broader interest is this to insurers?
Perhaps the principal benefit of widely accepted classifications is that they provide a level playing field for insurer and insured. It is helpful to have information on risk and prognosis available in one place and applied to a consistent set of categories. These categories can be used at underwriting to understand the risk profile of the applicant, bring clarity to exclusions when considered, be used to benchmark and audit decisions and provide a common language to understand the longer-term experience of a product. Everyone knows what is being talked about.
As far as claims, being clear what is, and what is not, diagnosable as a mental illness under the terms of the policy is useful in a field where the language is notoriously slippery.11 It helps to understand the claimant’s prognosis and ensure that any risks for chronicity are included in claims tools and/or clearly recognised when these are not in use.
The DSM‑5‑TR makes no claim to be a repository of management guidelines. These will vary from market to market and need to be tailored to the individual claimant, but the DSM can help highlight those areas where dedicated input is required.
The update may bring controversy in some areas, but in many circumstances it could help bring clarity in a complicated world.
All endnotes last accessed on 20 June 2022.
