250 words responseAnswer to this discussion: Are the research methods he/she selected appropriate for studying the disorders they chose? Support your opinions with scholarly information and reasoning. What alternative research design could be employed to study the disorders they discussed?the discussion you should answer it: “Hello class,One controversy in the article is Neurodevelopmental Disorders and how individuals with disorders such as dyslexia may not receive the academic accommodations or treatment they should be given. Another issue is the extended age range for the diagnosis of ADHD. The concern is increasing adult drug seeking. The new criteria for Autism Spectrum Disorders might decrease findings for individuals with specific levels of severity/functioning. One concern is because DSM-5 is letting go of the Global Assessment of Function (GAF) this assessment is often utilized by professionals for the confirmation of disorders such as PTSD which is more complex than just a few domains about level functioning in the WHODAS. Now the concern that I have is it minimizes the impact of other psychological symptoms and suffering and it will be a decrease in the number of individuals to receive treatment or compensation for trauma-related disorders.Another controversy in the article “An overview of the DSM-5: Changes, controversy, and implications for psychiatric nursing” are dealing with changes that occurred in Neurodevelopmental disorders, feeding, and eating disorders and sleep-wake disorder. Under the Neurodevelopmental disorders are some of the first disorders that can be detected as early as infancy to adolescence. The first change was the name mental retardation to intellectual development. In my opinion, the term mental retardation is an offensive term to use. Another controversy Suicidal Behavior Disorder was to be characterized by self-injurious behaviors that would result in death. This diagnosis would be given immediately following an attempt and would remain in place for 2 years, the time of greatest risk for reattempting suicide (Halter, Rolin-Kenny, Dzurec, 2013, p. 37). Suicidal behavior disorder needs to be taken seriously, diagnosis of such disorder and prevention of further harm could help patients, could also save their life. Naming this disorder will allow a history to be created and it can also be tracked in order to prevent reoccurrence. I think the concerns of labeling an individual suicidal can be harmful and stigmatizing, so a further review is necessary.Depressive Episodes with Short-Duration Hypomania exhibit dipolar behavior characterized by a hypomanic episode that lasts less than 4 days.Does ones environment play a significant role in the onset of an episode?An interview is one research method that could provide information pertaining to the research question. To determine an event, environment and factors that lead up to an episode and tracking over an extensive period will provide what factors should be trying to avoid to limit their episodes.”PS. the discussion address the following points:What are three controversies discussed in the Halter, Rolin-Kenny, & Dzurec (2013) article? Give your opinions about these controversies. From your point view, are these legitimate concerns? Why or why not?Name a disorder identified as requiring significantly more research and study from the DSM-5 section entitled, Conditions for Further Study (Section III of the DSM-5). Construct a research question that is pertinent to the disorder you selected.Briefly outline a research method that could be used to investigate the disorder based on one of the research methods presented in your textbook.
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Changes, Controversy, and Implications
for Psychiatric Nursing
Margaret Jordan Halter,
PhD, APRN, PMHCNS-BC;
and Laura Cox Dzurec,
Scheduled for publication in May 2013, the Diagnostic and Statistical Manual of
Mental Disorders, fifth edition (DSM-5), will guide clinical diagnoses, treatment
plans, medication choices and protocols, insurance reimbursements, and research
agendas throughout the United States. It will also serve as a reference manual for
clinicians around the world. This primary diagnostic source used by psychiatric
and mental health providers is undergoing significant change in organization and
content relative to the previous edition. This article provides a general overview of
what to expect in the DSM-5, highlighting major aspects of the revision. Included is
a list of the proposed diagnostic categories and an overview of some of the debate
and discussion accompanying the changes. Implications for psychiatric nurses and
psychiatric nursing are presented.
Copyright © SLACK Incorporated
© 2013 Shutterstock.com/Boffi
chiatric and mental health providers,
the DSM-5 is undergoing significant
change in organization and content
relative to the previous edition.
This article provides a general
overview of what to expect in the
DSM-5. It collates information provided previously on the APA website, information available in recently
published multi-disciplinary literature
and discussion regarding the changes
to the new manual, and APAs latest
announcements. A table of contents
included in a recent APA (2012a)
news release provides a summary of final decisions about the contents and
order of diagnostic categories included
in the DSM-5. In early 2013, the APA
launched a separate website devoted
to the DSM-5, which contains essential preview information regarding final changes (APA, 2013).
n December 1, 2012, the
American Psychiatric Associations (APA) Board of
Trustees approved the fifth edition of
the Diagnostic and Statistical Manual of
Mental Disorders (DSM-5). The publication will debut at the APAs annual
convention in May 2013. It will guide
clinical diagnoses, treatment plans,
medication choices and protocols, insurance reimbursements, and research
agendas throughout the United States
and will serve as a reference manual
for clinicians around the world. The
primary diagnostic source used by psy-
THE REVISED FORMAT OF THE DSM-5
The DSM-5 represents the first substantial revision to its clinical practice guidelines in more than 30 years.
Changes to this updated version were
structured in light of several overarching ideals. First, the manual was
planned to be a living document, amenable to updates as knowledge about
characteristics of psychiatric problems
and approaches to their management
improves. As a consequence, the bulky
Roman numeral format (e.g., DSM-I,
DSM-II, DSM-IV-Text Revision [TR])
that was previously used to indicate
manual updates will be abandoned in
favor of Arabic numerals (e.g., DSM5, DSM-5.1, DSM-5.2), which will
be easier to track over time. Ongoing
revisions to individual diagnoses and
diagnostic categories are planned to be
based on current evidence. If changes
are made electronically, as they are in
the Oxford English Dictionary and in
course catalogs in many universities,
regular and frequent updates will become more feasible and affordable.
Journal of Psychosocial Nursing Vol. 51, No. 4, 2013
The 20 diagnostic categories in
the revised manual are purported to
be evidence-based (i.e., built on current best evidence informing decisions
about care for individual patients). Although research-based diagnosis is not
a new concept in the development of
diagnoses and criteria, the emphasis in
this manual was planned to be hardhitting. The leadership at APA sought
to provide diagnoses based on scientific evidence developed within the past
two decades (APA, 2012a).
Building on that evidence, the
DSM-5 aimed for increased crosscultural application. The DSM-IV-TR
(APA, 2000) included an abbreviated
list of Culture-Bound Syndromes
in the appendix. The current revision expands cultural considerations,
incorporating the Cultural Formulation Interview (CFI) (Bäärnhielm
& Scarpinati-Rosso, 2009), a standard
method for simple and efficient cultural
assessment, into criteria for diagnosis.
The 14-question CFI has the potential
to improve patient-centered care while
reducing racial and ethnic disparities
in treatment. Furthermore, it may help
providers screen and identify individuals
who would benefit from the presence of
Most DSM-5 disorder categories will
incorporate dimensional assessments
that will support appraisal of symptom severity for each individual client. Rather
than a simple yes or no decision related
to a symptoms existence, the clinician
can now identify the severity of symptoms on a scale of 3 or more ordinal-level
points, emphasizing patient self-assessment of symptom severity (Narrow &
Kuhl, 2011). Dimensional assessments
are drawn from tools already in use such
as scales from the Patient-Reported Outcomes Measurement Information System
(National Institutes of Health, n.d.). The
DSM-5 work groups also developed and
tested other measures that will be included in the manual.
DIAGNOSTIC CATEGORIES IN THE DSM-5
1. Neurodevelopmental Disorders
11. Elimination Disorders
2. Schizophrenia Spectrum and Other
12. Sleep-Wake Disorders
3. Bipolar and Related Disorders
13. Sexual Dysfunctions
4. Depressive Disorders
14. Gender Dysphoria
5. Anxiety Disorders
15. Disruptive, Impulse Control, and
6. Obsessive-Compulsive and Related
16. Substance Related and Addictive
7. Trauma and Stressor-Related
17. Neurocognitive Disorders
8. Dissociative Disorders
18. Personality Disorders
9. Somatic Symptom and Related
19. Paraphilic Disorders
10. Feeding and Eating Disorders
20. Other Disorders
Note. DSM = Diagnostic and Statistical Manual of Mental Disorders.
Adapted from American Psychiatric Association (2013).
Cross-cutting assessments are included as a psychiatric version of
general medicines review of systems and are meant to be conducted
without regard to a specific diagnosis
(Kuhl, Kupfer, & Regier, 2011). It is
well known that some symptoms (e.g.,
sleep deprivation) are present across
numerous disorders. Detailed, clinically significant assessments will prompt
more in-depth follow up of the initial
clinician- administered assessments.
Diagnostic categories and diagnoses
included in the DSM-5 incorporate objective measures based on knowledge
emerging from recent innovations and
advancements in neurodiagnostics, including measurements available through
genetic work-ups, neuroimaging, or
neurochemistry. Some sleep disorders
categorized in the DSM-5 will include a
requirement for polysomnography prior
to formal diagnosis (Gever, 2012). Narcolepsy/hypocretin deficiency (formerly
known as narcolepsy) will require measurement of hypocretin in the cerebrospinal fluid. Such techniques may represent
the dawn of a new era through which
objective measurements validate the existence of underlying causes, illuminating
previously unrecognized physical pathology. The potential for stigma reduction as
a consequence of more exacting diagnostic criteria is an exciting prospect emerging from the changes in the DSM-5.
Additionally, across diagnostic
groups, the use of functional impairment as a criterion for diagnosis has
been reduced, but not eliminated.
Diagnoses such as autism and other
disorders involving neuropsychiatric
deficits will retain functional diagnostic criteria, as functional impairment
is a cornerstone of these disorders
(Gever, 2012). For other conditions,
functionality may be included in the
dimensional assessments rather than
in diagnostic criteria.
In the previous edition of the DSM,
the not otherwise specified (NOS) diagnoses tended to be catchall categories.
For example, more than half of all eating
disorders were listed in the Eating Disorder NOS diagnostic classification (Gever,
2012). In the new manual, NOS will be
replaced with not elsewhere classified
(NEC). Although this sounds similar to
the previous system, the inclusion of a
requisite list of specifiers, each with a specific diagnostic code, refines and streamlines the process and conveys important,
distinct clinical information. For example, depressive disorder NEC may involve any one or any combination of five
specifiers, such as short duration, that
indicate the patients clinical condition
and provide rationale as to why the presenting condition does not meet criteria
for one of the main depressive syndromes.
Finally, one of most notable changes in the forthcoming DSM-5 pertains
to the axis system. Beginning in 1980,
the DSM-III (APA, 1980) adopted the
following categories, or axes, to organize diagnostic conceptualization:
l Axis I: Major mental disorders.
l Axis II: Personality disorders and
l Axis III: Acute medical conditions.
l Axis IV: Environmental factors
contributing to the disorder.
l Axis V: Global Assessment of
Functioning Scale (GAF).
DSM-5 authors concluded that
there was no scientific basis for these
categories; thus, the new version will
retire the five axes. The categories in
the DSM-5 are at once simpler and
more complex. Specifically, Axes I, II,
and III will be collapsed into a single
axis that contains all of the psychiatric
and medical diagnoses. This approach
is congruent with the system used by
the International Classification of Diseases (ICD) (World Health Organization [WHO], 2010b). Additionally,
the DSM-5 will likely incorporate clinician use of a 15-page ICD checklist
(WHO, 2010b) for assessment of psychosocial and contextual factors previously assessed on Axis IV.
The traditional Axis V GAF score
has been criticized for mixing symptom severity with functional severity.
It may be replaced by the WHO Disability Assessment Schedule (WHODAS) (WHO, 2010a). WHODAS is
a 36-item measure that addresses six
domainscognition, mobility, selfCopyright © SLACK Incorporated
care, getting along with others, life
activities, and participation. Selfadministration takes 5 to 10 minutes,
and clinician administration takes 20
These conceptual changes to the
manuals organization and method of
content delivery provide the context
for changes to specific diagnoses and
diagnostic categories. The discussion
that follows addresses each of the diagnostic categories in the DSM-5 individually.
DIAGNOSTIC CATEGORIES AND
The DSM-5 lists approximately the
same number of disorders as the DSM-IVTR, roughly 300 across 20 diagnostic categories. The sequencing of the diagnostic
categories specified in the new manual
generally follows a neurodevelopmental
life span approach, as do the disorders
identified within category listings. In
other words, categories generally follow a
sequence from problems that typically are
diagnosed in childhood through those
typical of adolescents, adults, and finally,
The DSM-5 authors also sought to arrange disorders by relatedness, taking into
account similar vulnerabilities and characteristic symptoms for disorders listed
within individual categories. For example, schizophrenia and bipolar disorder
are listed in succession, as individuals affected by one of these two disorders may
share common genetic variations and
overlapping manifestations (Craddock,
ODonovan, & Owen, 2005). Likewise,
depression is listed immediately before
anxiety, reflecting the long-recognized
interrelationship of these two disorders.
Finalized categories in the DSM-5 are
summarized in the Table (APA, 2013).
The care and forethought characterizing
development of the 20 diagnostic categories and the diagnoses within them
does not imply that they have been met
with universal agreement in the mental
health community. The following discussion highlights some of the controversies
accompanying the diagnostic changes in
the DSM-5, in addition to summarizing
the diagnoses slated for inclusion within
each diagnostic category.
As noted, diagnostic categories in
the DSM-5 are arranged across the life
span, beginning with infancy. The Neurodevelopmental Disorders category was
formerly identified as Disorders Usually
First Evident in Infancy, Childhood, and
In the DSM-IV-TR, intellectual developmental disorder was called mental retardation. The revised name aligns the DSM-5
with federal legislative language (Moran,
2013b). Impairment in adaptive functioning will be coupled with intelligence quotient to serve as the dual bases for diagnosis (Sederer, 2011). Severity measures
for mild, moderate, severe, and profound
intellectual disability will be included.
Specific learning disorders, formerly learning disorders, will group the
neurodevelopmental disorders that
previously stood alonedyslexia,
dyscalculia, and disorder of written
expressioninto a single problem.
Problems will be grouped in diagnostic
statements descriptive of the patients
presenting symptoms (i.e., a specific
learning disorder with dyslexia). Opponents of this new system fear individuals with dyslexia, in particular, will be disadvantaged due to the
absence of a freestanding diagnostic
label. They believe that this change
may limit treatment options, as well
as restrict educational supports, legal
rights, and continued insurance coverage (Burgess, 2012).
Autism spectrum disorders now combines the subcategories of autistic disorder, Aspergers disorder, childhood
disintegrative disorder, and pervasive
developmental disorder NOS, into one
broad label. These changes are based
on evidence from clinical field trials
that suggest clinicians make diagnoses
based on similar presenting problems
quite differently (Moran, 2013b). The
Neurodevelopmental Disorders Work
Group concluded that distinctions
Journal of Psychosocial Nursing Vol. 51, No. 4, 2013
between the disorders tend to be in
terms of overall severity rather than in
terms of symptoms. Another change is
removing the requirement of symptom
onset before age 3; the new criterion
is expanded to early childhood. Also,
the DSM-IV-TR (APA, 2000) criteria
included three separate behavioral dimensionssocial reciprocity, deficits
in communication, and restricted, repetitive behaviors and interests. The
DSM-5 collapses the three behavioral
dimensions into two domains by combining communication and social interaction into a single domain of social
communication or social reciprocity.
The second is restrictive or repetitive
behaviors that may be current or historical.
A significant controversy regarding
autism spectrum disorders is that people
with a previous diagnosis of Aspergers disorder may be stigmatized with an autism
diagnosis, which might likely be termed
mild autism. Opponents of the change
suggest that this higher functioning subset could lose funding for services due to
tighter diagnostic criteria (Willingham,
2012). There are disparities in services offered to affected individuals by diagnosis;
a diagnosis of autism is eligible for speech,
occupational, physical, and behavioral
therapies, whereas funding for other diagnoses within the Neurodevelopmental
Disorders category is significantly less.
In the DSM-IV-TR, attention-deficit/
hyperactivity disorder symptoms were
only significant if they occurred before
age 7. Opponents of this criterion suggest
that this age for symptom manifestation
was arbitrary and not based on evidence.
Many reports have shown symptom onset among children older than 7 (APA,
2010). DSM-5 criteria thus extend diagnostic inclusion criteria to age 12.
Allen Frances (2012), chair of the
DSM-IV Task Force, reinforced an argument posed by those in opposition to the
new learning disorders characterizations.
He suggests that changes to the DSM
would result in inflation of children diagnosed with attention-deficit disorder. He
contends that the altered age criterion
would result in an easier-to-gain adult
diagnosis and increase the potential for
psychostimulant drug abuse.
Schizophrenia Spectrum and Other
Previously listed under the category of schizophrenia, disorders sharing
schizophrenia-like symptoms and underlying causes are listed in the DSM-5 as
schizophrenia spectrum disorders, roughly
arranged from least to most severe. This
change is one of the least controversial
in the new manual. Also, catatonic, disorganized, paranoid, residual, and undifferentiated have been removed as subtypes
of schizophrenia; however, catatonia will
be retained as a specifier throughout the
DSM-5 diagnostic categories.
Dimensional ratings for schizophrenia that would allow clinicians to rate
symptoms in terms of severity on a 0 to
5 scale were developed. However, they
were ultimately rejected as potentially
burdensome and not adequately tested
(Moran, 2013a). They will reside in
Section 3, an area in the appendix reserved for diagnoses requiring further
research (APA, 2012b) and may be
used in clinical settings.
One disorder that was proposed,
but not accepted, was attenuated psychosis syndrome. Individuals who develop attenuated psychotic symptoms
accompanied by dysfunction at school
and at home are thought to be more
likely than individuals in the general
population to develop schizophrenia
or other psychotic disorders within 2
years of symptom onset (Carpenter &
van Os, 2011). Proponents of making attenuated psychosis syndrome
a specific disorder believe that early
detection of symptoms and follow-up
treatment are neuroprotective and
helpful in reducing severity, neurobiological decompensation, and subsequent long-term disability. Opponents
of the diagnosis noted that although
35% of individuals with prodromal
psychotic states convert to psychosis
within 2 years, 65% do not (Cannon
et al., 2008). This proposed diagnosis
could result in too many false posi34
tives that could broaden stigma. Early
pharmacological treatment is argued
by opponents to expose people to unnecessary and potentially damaging
antipsychotic therapy. Consequently,
the diagnosis was moved to Section 3
of the DSM-5.
Bipolar and Related Disorders
Previously listed under mood disorders
along with major depressive disorder, the
bipolar and related disorders now emphasize
core symptoms of increased energy/activ-
disorders is that
people with a previous
diagnosis of Aspergers
disorder may be
stigmatized with an
which might likely be
termed mild autism.
ity for both hypomanic and manic episodes. The diagnosis will be made on the
basis of a set of criteria that is consistent
across the life span, despite arguments
that the criteria are too stringent for children and adolescents (Kaplan, 2012).
Specifiers have been added to bipolar disorder. One is anxious distress
(Moran, 2013a). The rationale for this
addition is that anxiety is a serious
complication of bipolar disorder and
must be addressed. Also, a mixed state
specifier replaces the fully mixed type
of bipolar disorder, which was rarely
seen. The mixed state specifier will
apply to individuals who have major
depression along with three manic
symptoms, and to individuals who
have mania along with three depressive symptoms.
As noted above, depressive disorders were previously listed under the
mood disorders. Disruptive mood dysregulation disorder is a new diagnosis
within this revised category. Disruptive mood dysregulation is characterized by qualities similar to, but more
severe than, those of oppositional defiant disorder. The diagnosis applies to
6- to 18-year-olds who have outbursts
up to four times per week that are out
of proportion to what is happening in
the environment. Previousl …
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