Diagnostic and Statistical Manual of Mental Disorders (DSM 5)
What is the DSM-5? What are differences between the DSM-5 and the DSM-4 as they pertain to chronic pain?
The Diagnostic and Statistical Manual of Mental Disorders , Fifth Edition (DSM-5) is the 2013 update to the American Psychiatric Association’s classification and diagnostic tool. DSM-5 classifications are used to determine psychiatric diagnoses, treatment recommendations, and payment in the United States. There are many differences between the DSM-4 and the DSM-5. The DSM-5 does not employ a multiaxial system as the DSM-4 did, and instead is divided into three sections. Section I is the introductory section. Section II is diagnostic criteria and codes, and Section III is emerging measures and models.
Some changes pertain to the field of pain medicine, specifically those changes having to do with somatoform disorders, which are now called somatic symptom and related disorders. Patients that present with chronic pain can now be diagnosed with somatic symptom disorder with predominant pain, psychological factors that affect other medical conditions, or with an adjustment disorder. “Psychological factors affecting other medical conditions” is a new diagnosis. These changes are based in large part on a movement away from an emphasis on medically unexplained symptoms, to a focus on the way patients present and interpret their somatic symptoms, rather than solely the symptoms themselves.
Mental disorders such as major depressive disorder and anxiety disorders may initially present with primarily somatic symptoms (e.g., pain). These disorders may fully account for the symptoms, or they may be concurrent with symptoms that have an identifiable organic etiology. Patients may suffer from major depressive disorder, dysthymia, or an anxiety disorder prior to the development of chronic pain. In others, these psychiatric illnesses arise as a consequence of chronic pain. In this case, a diagnosis of “depressive disorder due to another medical condition” or “anxiety disorder due to another medical condition” may be made.
The somatic symptom disorders and related disorders have multiple contributing factors: genetic and biological vulnerability, early traumatic experiences, presence of learned behaviors, and social and cultural norms that devalue and stigmatize psychological suffering versus physical suffering. This group of disorders is characterized by the prominent focus on somatic concerns and the tendency to initially present mainly in medical rather than mental health care settings. Psychological factors affecting other conditions is a common entity in the world of chronic pain; the presence of one or more clinically significant psychological or behavioral factors that adversely affect a medical condition by increasing the risk for suffering, death, or disability is necessary for this diagnosis. Although an individual may not have official psychiatric diagnoses, psychological factors can hamper their ability to recover appropriately from a period of acute pain as well as encourage their transition to a chronic pain state.