This section provides an overview of the changes made to the text of Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). It should be noted that the following is not an exhaustive guide; changes in wording made for clarity and expansions of the differential diagnosis sections of the text are not included here. It should also be noted that the majority of paragraphs in DSM-IV were revised, indicating that, even after the literature review, most of the information in the original DSM-IV text was up-to-date.
Several paragraphs were added describing the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) text revision process, and additional clarifying text was added to the "Use of Clinical Judgment" section regarding the importance of the method of data collection in determining whether diagnostic criteria have been met.
The instructions for making a Global Assessment of Functioning (GAF) rating was greatly expanded. During discussions about applying the GAF to the current time frame, the elements of the scale were added and a four-step method for determining the GAF was provided.
Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence
Additional information was added regarding the association of certain etiological factors and comorbid symptoms and disorders (e.g., Fragile-X syndrome and Attention-Deficit/Hyperactivity Disorder).
Text was added to indicate that a thorough functional assessment of the individual's language ability can be made when standardized tests are unavailable or inappropriate (e.g., because the available tests were standardized only in limited populations). Prevalence and Course sections for Expressive Language Disorder, Mixed Receptive-Expressive Language Disorder, and Phonological Disorder were updated, as well as the Course section for Stuttering.
The text in the Diagnostic Features section was modified to highlight difficulties in the pragmatic aspects of language, which are especially important in higher functioning individuals. In addition, better examples of restricted, repetitive, and stereotyped patterns of behavior, interests, and activities were added. The text was also modified to reflect evidence that in up to a fifth of cases, parents retrospectively report relatively normal development for the first one or two years. The section about associated cognitive deficits and associated general medical conditions was updated. The range of prevalence figures was revised to reflect a number of more recent studies suggesting a higher prevalence. More specific information regarding sibling risk was added to Familial Pattern.
Text was added reflecting the finding that some cases of Rett's Disorder are associated with a specific genetic mutation.
Because of the limited data available about this newly introduced disorder, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) text for Asperger's Disorder provided little more than a restatement of the diagnostic criteria. Accordingly, the text for Asperger's Disorder was extensively revised in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Specific examples of the typical manifestations of the impairment in reciprocal social interaction and in restricted, repetitive behavior and interests was provided in order to better differentiate these individuals from those with Autistic Disorder. In addition, text was added to clarify that the requirement for no clinically significant delays in language does not imply that individuals with Asperger's Disorder do not have problems with communication. The Associated Features, Specific Age Features, Course, and Differential Diagnosis sections were greatly expanded.
Pervasive Developmental Disorder Not Otherwise Specified
The definition was changed to correct an error that inadvertently allowed this diagnosis to be made in cases in which there was a pervasive impairment in only one developmental area (e.g., in the development of reciprocal social interaction, communication skills, or stereotyped behaviors, interests, or activities). The definition now requires that there be impairment in reciprocal social interaction, which is associated with an impairment in communication skills or the presence of stereotyped behaviors, interests, or activities.
Many of the changes highlighted differences among the subtypes. For example, individuals with the Predominantly Inattentive and Combined Types tend to have academic deficits and school-related problems, whereas those with the Predominantly Hyperactive-Impulsive Type tend to have more peer rejection and accidental injuries, and gender ratio is less predominantly male in the Predominantly Inattentive Type. Additional information about Associated Features (e.g., variability in IQ, presence of family discord) and Specific Age Features (especially Attention-Deficit/Hyperactivity Disorder in adults) was included. Estimates of prevalence rates were revised upward, reflecting increased prevalence due to the inclusion of the Predominantly Hyperactive-Impulsive and Predominantly Inattentive Types in DSM-IV.
The list of risk factors for developing Conduct Disorder was expanded. The relationship between Oppositional Defiant Disorder and the subsequent development of Childhood-Onset Type of Conduct Disorder is noted in Course.
Oppositional Defiant Disorder
The Course section of the text clarified that although Childhood-Onset cases of Conduct Disorder are often preceded by Oppositional Defiant Disorder, many children with Oppositional Defiant Disorder do not go on to develop Conduct Disorder.
Prevalence data were provided and comorbidity with Pervasive Developmental Disorders was noted.
Feeding Disorder of Infancy or Early Childhood
Changes were made in Prevalence (community prevalence is noted) and Course sections (persistence of decreased height and weight as compared to peers into adolescence).
The DSM-IV criteria set for Tic Disorders was corrected by eliminating the requirement for “clinically significant distress or impairment,” which was added to the majority of disorders in DSM-IV (Tic Disorders among them). There are a number of reasons why this criterion had been problematic in Tic Disorders, including that fact that it was at variance with clinical experience (i.e., most children with Tourette's do not experience marked distress or impairment), and that it hindered epidemiological research and family studies. Other changes in the text included an expanded description of the types of tics as well as an expansion of the Differential Diagnosis between tics and other types of movements, Associated Features (including comorbidity patterns), Specific Age Features (gender ratio), Prevalence, Course, and Familial Pattern.
Encopresis with functional constipation is the most common form. Text regarding physiological predispositions to constipation was updated and expanded.
New information about different mechanisms underlying the Diurnal Only Type was added. Associated Features (particularly predisposing factors), Prevalence, and Familial Pattern were updated.
Separation Anxiety Disorder
Prevalence and Course sections were updated to indicate a decrease in prevalence from childhood through adolescence and to indicate that most children with separation anxiety are free of an impairing Anxiety Disorder at extended follow-up.
Reactive Attachment Disorder
Associated Features (risk factors such as extreme neglect and institutional care) and Course (persistence of indiscriminant sociability) were updated.
Stereotyped Movement Disorder
Pathological skin picking was removed from the list of examples; such cases should be diagnosed as Impulse Control Disorder Not Otherwise Specified. Associated Features (e.g., clarification that the disorder can occur in non-developmentally-delayed populations) were modified.
Mental Disorders Due to a General Medical Condition
Personality Change Due to a General Medical Condition
A change was made to correct an error in the exclusion criterion, which did not allow a diagnosis of Personality Change Due to a General Medical Condition (GMC) to be given comorbidly with a diagnosis of dementia. This criterion was an unintended carryover from the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised (DSM-III-R), which excluded personality change in the presence of dementia because personality change was included in the diagnostic criteria for dementia. Clinically significant symptoms occurring along with dementia are diagnosed by coding the specific mental disorder due to a GMC on Axis I alongside the dementia. Thus, this exclusion was removed, allowing, for example, an individual with Alzheimer's disease who develops a change in personality to be given a comorbid diagnosis of Personality Change Due to Alzheimer's Disease.
The Diagnostic Features were updated to indicate that varied degrees of tolerance may develop to the different central nervous system effects of a substance, that tolerance may develop to phencyclidine, and that a past history of tolerance or withdrawal is associated with a worse clinical course (i.e., earlier onset, higher levels of substance intake, and greater numbers of substance-related problems).
Familial Pattern for Dependence/Abuse/Intoxication/Withdrawal
The text was updated to clarify that individuals who may be at higher risk for Alcohol Dependence because of a family history of Alcohol Dependence do not necessarily have a higher risk of developing Dependence on other substances.
Examples were added to help clarify when it is appropriate to diagnose Substance Intoxication or Substance Withdrawal versus a Substance-Induced Disorder With Onset During Intoxication or With Onset During Withdrawal.
The "Associated Features" section (e.g., risk of alcohol-related accidents, comorbidity with other disorders) was updated. A discussion of the laboratory test carbohydrate deficient transferrin (CDT), a widely-used state marker for heavy drinking, was added. In the "Specific Culture, Age, and Gender Features" section, text concerning the low rates of Dependence in Asians and the clinical course in women was expanded. Text regarding the prevalence of alcohol use, prevalence of alcohol-related complications, and the prevalence of Alcohol Dependence was expanded and updated.
Text regarding the prevalence of amphetamine use across different age groups and the prevalence of Dependence was expanded and updated.
Specific Age Features was expanded to include information about the increased sensitivity of the elderly to the effects of caffeine. A "Prevalence" section was added that describes patterns of caffeine use, and the "Course" section has been expanded and updated.
Updated information regarding mechanisms of action was added to the introductory section. The text for Cannabis Dependence was updated to clarify that evidence of physiological dependence is seen in chronic users and may be associated with more severe cannabis-related problems. Text regarding the prevalence of cannabis use across different age groups and the prevalence of Dependence was expanded and updated. A discussion regarding whether cannabis use is a precursor to other drug use (i.e., its role as a “gateway drug”) was added to the "Course" section.
The complications of severe Cocaine Intoxication were updated and expanded, and Specific Culture and Gender Features were also updated. Text regarding the prevalence of cocaine use across different age groups and the prevalence of Dependence and Abuse was expanded and updated.
A discussion of the physiological changes associated with intoxication (e.g., increases in blood glucose) was added. Text regarding the prevalence of hallucinogen use across different age groups and the prevalence of Dependence and Abuse was expanded and updated.
Additional information was added to the sections on Associated Laboratory Findings (e.g., urine assay for a metabolite of toluene) and Associated Physical Examination and General Medical Conditions (e.g., an expanded list of respiratory complications and possible association between benzene and acute myelocytic leukemia). Text regarding the prevalence of different types of inhalant use among different age and other demographic groups was added.
Specific Culture, Age, and Gender Features were updated (e.g., data about increased nicotine blood levels in African-Americans were added). Text regarding the prevalence of smoking and other tobacco use in various groups and the prevalence of Nicotine Dependence was updated. The "Course" section was also revised based on new data.
Text regarding hepatitis screening tests was added to Associated Laboratory Findings, and death rates from medical complications were added to Associated General Medical Conditions. Specific Gender Features (i.e., gender ratio), and Course (i.e., remission rates) were updated. Text regarding the prevalence of different patterns of opioid use among different age and other demographic groups was updated and expanded.
Text regarding the prevalence of different patterns of phencyclidine use among different age groups was updated and expanded.
Sedative, Hypnotic, and Anxiolytic-Related Disorders
Text regarding patterns of use among different age groups and the prevalence of Dependence and Abuse was updated.
Examples were added to clarify the appropriate use of this category.
Schizophrenia and Other Psychotic Disorders
The introduction was updated to emphasize that psychotic symptoms are not necessarily considered to be core features of the disorders included in this section, nor do they necessarily have a common etiology.
The "Associated Features" section was updated and expanded to include additional information about anosognosia (lack of insight), risk factors for suicidal and violent behavior, and comorbidity with other mental disorders. The "Associated Laboratory Findings" section was also updated to include separate discussions of structural and functional neuroimaging, neuropsychological deficits, and neurophysiological abnormalities. The "Specific Culture, Age, and Gender Features" section was updated to include an expanded discussion concerning overdiagnosis of Schizophrenia in certain racial groups, updated information regarding late-onset cases, and updated text regarding gender differences. The "Prevalence" section of the text was updated to include additional information and geographic and historical variations in incidence. The "Familial Pattern" section introduced the concept of “schizophrenia spectrum" (i.e., the range of disorders that are more likely in the relatives of individuals with Schizophrenia).
The introduction was updated to indicate limited stability and prognostic value of the subtypes.
Updated prevalence information was provided, including contrasting rates in developed and developing countries. A brief "Familial Pattern" section was added, indicating a possible increased risk of Schizophrenia in relatives of individuals with Schizophreniform Disorder.
Specific Gender Features (e.g., elevated rates in woman are mostly accounted for by increased incidence of the Depressive Type) and Course (e.g., association of stressors with a better prognosis) were updated.
The "Course" section was updated.
Brief Psychotic Disorder
The "Prevalence" section was updated to note that although this disorder is rarely seen in developed countries, psychotic episodes of slightly longer duration (1 to 6 months) are more common in developing countries.
Psychotic Disorder Due to a General Medical Condition
The list of etiological general medical conditions has been updated and new sections were added for Prevalence and Course.
Major Depressive Episode
The "Associated Laboratory Findings" section of the text was updated and expanded to include additional neurobiological abnormalities (e.g., alterations in neuropeptides and other hormones in response to challenge tests) and functional brain imaging results. The "Specific Gender Features" section was updated to clarify that increased risk in women emerges during adolescence and may coincide with puberty.
Major Depressive Disorder
Associated General Medical Conditions text was updated to emphasize that comorbid general medical conditions worsen the course of Major Depressive Disorder. The "Specific Age Features" section was expanded to include information about laboratory findings (e.g., evidence of subcortical white matter hyperintensities) in late-onset depression. Changes in the "Familial Pattern" section indicate increased risk of Anxiety Disorders in offspring of those with depression.
The "Course" section was updated to indicate that the outcome of Dysthymic Disorder is significantly better with active treatment. Changes to Familial Pattern indicate elevated rates of both Dysthymic Disorder and Major Depressive Disorder in relatives of those with Dysthymic Disorder.
Bipolar I and Bipolar II Disorder
The "Associated Mental Disorders" section was expanded to include information on the comorbidity of Bipolar I Disorder and Alcohol and other Substance Use Disorders. Associated Laboratory Findings were updated to reflect increased rates of certain brain lesions in individuals with Bipolar I Disorder as a group. The "Associated General Medical Conditions" section was expanded to clarify the relationship between Bipolar I and Bipolar II Disorder and thyroid dysfunction (i.e., association between hypofunction and rapid cycling, and hyperthyroidism precipitating episodes in those with pre-existing Mood Disorder). Specific Gender Features were updated to reflect gender differences in Rapid Cycling, types of episodes, and risk for mixed episodes. The relationship between age at onset and family history was noted in Familial Pattern of Bipolar I Disorder.
Bipolar Disorder Not Otherwise Specified (NOS)
An additional example was added to clarify that individuals with chronic dysthymia who also experience occasional hypomanic episodes do not qualify for a diagnosis of either Dysthymic Disorder (because of the hypomanic episodes) or Cyclothymic Disorder (because the hypomanic episodes are too infrequent).
The text was expanded to provide a breakdown of the causes of catatonia.
The original statement that individuals with Melancholic Features are more likely to respond to somatic treatment was incorrect and was replaced by text that emphasizes the need for active treatment given the low placebo response rate.
The "Associated Features" section was updated and text was added to highlight the differentiation of this subtype from “baby blues.”
Updated text included prevalence data and the potential association between cycling rate and antidepressant therapy.
The text describing the three types of Panic Attacks (i.e., unexpected, situationally-bound, and situationally-predisposed) was updated to clarify the nature of the triggers, the association between these types and particular Anxiety Disorders, and Differential Diagnosis.
The relationship between Panic Attacks and potential triggers in Panic Disorder was updated (i.e., situational triggers may be either external or internal and "unexpected" means that the individual does not immediately associate the attack with a situational trigger). The list of associated general medical conditions was expanded, the "Prevalence" section was expanded to include rates in clinical samples, and the "Familial Pattern" section was updated to include information from more recent studies (e.g., relationship between age at onset of proband and risk in first-degree relatives). Finally, the "Differential Diagnosis" section was expanded to include situations in which the person may not be able to identify the cues triggering a Panic Attack (e.g., cognitions or physiological symptoms similar to those that occurred at the time of the traumatic event in Posttraumatic Stress Disorder).
Additional information regarding comorbidity, relative frequency of subtypes in community settings, gender ratio, course (e.g., having Specific Phobia in adolescence increases the chance of having Specific Phobia in adulthood but not other mental disorders), and Familial Pattern was provided.
Sections on Associated Features (i.e., suicidal ideation) and comorbidity with other mental disorders were updated. The "Associated Laboratory Findings" section was updated to clarify that no laboratory test has been found to be diagnostic of Social Phobia (i.e., original text suggesting a differential response to lactate infusion has been deleted).
Information regarding comorbidity with other mental disorders was updated. The "Specific Age Features" section was updated to include a brief section on the subset of children who develop Obsessive-Compulsive Disorder in association with Group A beta-hemolytic streptococcal infections. Additional information was added to draw on the increased body of data regarding children with Obsessive-Compulsive Disorder (e.g., comorbid disorders, prevalence). The "Prevalence" section was updated and expanded to include prevalence rates in children.
Posttraumatic Stress Disorder
Associated features, comorbidity with other mental disorders, associations with general medical conditions, prevalence rates, and course (e.g., symptom reactivation in response to reminders of trauma, life stressors, or new traumatic events) were updated. A brief "Familial Pattern" section was added, describing evidence of a heritable component to the transmission of Posttraumatic Stress Disorder and the relationship between having a history of depression in first-degree relatives and increased vulnerability to developing Posttraumatic Stress Disorder.
Acute Stress Disorder
Additional information regarding progression to Posttraumatic Stress Disorder and a range of prevalence rates in individuals exposed to severe traumas were provided.
Generalized Anxiety Disorder
Prevalence in clinical settings and Familial Pattern (i.e., evidence from twin studies suggesting a genetic contribution) were updated.
Somatoform and Factitious Disorders
Associated General Medical Conditions was updated to clarify that some individuals with Somatization Disorder have objective signs that are part of a comorbid medical condition.
The "Prevalence" section was expanded to include rates in certain general medical settings.
The "Associated Features" text section on the risk of iatrogenic Substance Dependence was updated and expanded to include factors that minimize the likelihood of developing iatrogenic Substance Dependence. In addition, text on associated sleep problems was also expanded. Text addressing the prevalence of Pain Disorder in clinical settings as well as additional information about Course Features was included.
Associated Features and Disorders, Prevalence, and Course (i.e., factors associated with better prognosis) were updated.
Body Dysmorphic Disorder
Body build and muscularity were added to the list of body site preoccupations. The "Associated Features" section was updated to include additional information about lack of insight and efforts to correct or hide the defects. Reported prevalence rates in clinical settings were included.
The revised text for the Predominantly Physical Signs and Symptoms Type more clearly differentiates Munchausen's syndrome (the most severe and chronic form of Factitious Disorder) and less severe, more transient forms. Specific Gender Features, Prevalence, and Course features were updated.
Dissociative Identity Disorder
The text was modified to indicate that cases of Dissociative Identity Disorder have been documented in a variety of cultures around the world.
The "Associated Features" and "Course" sections were updated.
Sexual and Gender Identity Disorders
Introductory text was added to clarify the definitions of the terms gender identity, gender dysphoria, and sexual orientation.
Associated Features and Prevalence data were expanded and updated.
The clinical significance criteria were revised to clarify that, for Pedophilia, Voyeurism, Exhibitionism, and Frotteurism, if the person has acted on these urges, or the urges or sexual fantasies cause marked distress or interpersonal difficulty, then by definition there is clinical significance. For Sexual Sadism, if the person has acted on these urges with a non-consenting person, or the urges, sexual fantasies, or behaviors cause marked distress or interpersonal difficulty, then the clinical significance criterion is met. For the remaining Paraphilias, the clinical significance criterion is met if the behavior, sexual urges, or fantasies cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. Of course, to qualify for the specific diagnosis, the particular pattern of paraphilic arousal must also be present.
Gender Identity Disorder
Additional information was included to clarify how the subtypes (based on sexual attraction) differ in terms of Associated Features and Course.
Associated Features were updated to include comorbidity with Personality Disorders. Prevalence were updated to include figures for males. Course features were updated to clarify the relationship between Anorexia Nervosa and Bulimia Nervosa.
The "Course" section were updated to include some information regarding the long-term outcome of Bulimia Nervosa.
Associated Descriptive Features (e.g., functional impairment), Associated Laboratory Findings (e.g., lack of daytime sleepiness as measured by the Multiple Sleep Latency Test [MSLT], presence of substantial discrepancies between subjective report and polysomnographic measures of sleep quality), Specific Age Features (e.g., in the elderly), Prevalence (e.g., rates of the disorder in the general population), Course (text on chronicity), and Familial Pattern sections were updated.
Specific Age Features (e.g., in children), Prevalence, and Course were updated.
Text was added to clarify that some of the symptoms (i.e., hypnagogic and hypnopompic hallucinations and sleep paralysis) also occur in normal sleepers. The Associated Laboratory Findings (including HLA typing) and Course (age at onset versus age at presentation) were also updated. A "Specific Age Features" section was added to address issues in the diagnosis of Narcolepsy in children.
Breathing-Related Sleep Disorder
Associated Laboratory Findings, Physical Examination Findings (i.e., association between neck size and risk for obstructive sleep apnea), and Specific Age Features (i.e., in children) were updated.
Circadian Rhythm Sleep Disorder
Additional subtype-specific information regarding Associated Features, Associated Laboratory Findings, Associated General Medical Conditions, Specific Age Features, Prevalence, Course, and Familial Pattern were provided.
Dyssomnia Not Otherwise Specified
Greatly expanded descriptions of Restless Legs Syndrome and Periodic Limb Movements, two well-established Sleep Disorders included in the International Classification of Sleep Disorders, are now included.
Associated Descriptive Features (i.e., an association between frequent chronic nightmares and increased symptom measures of other psychopathology), Prevalence (e.g., rates of frequent nightmares in young adults), and Course information was updated.
"Associated Laboratory Findings," "Specific Gender Features," "Prevalence," "Course," and "Familial Pattern" sections were updated.
Sleep Disorders Related To Another Mental Disorder
Associated Laboratory Features were updated.
Impulse Control Disorders
Intermittent Explosive Disorder
Text was added clarifying that serious assaultive acts include verbal threats of physical assault to another individual. "Associated Features" (e.g., symptoms that precede or accompany the aggressive acts, such as tingling or tremors, as well as accompanying affect), "Associated Mental Disorders," and "Course" sections were updated. A "Familial Pattern" section was added indicating those disorders that may be more common among the first-degree relatives of individuals with Intermittent Explosive Disorder as compared to the general population.
Associated Features and Disorders, Specific Gender Features (i.e., gender ratio), and Familial Pattern (i.e., possible family history of Obsessive-Compulsive Disorder in first-degree relatives of individuals with Kleptomania) were updated.
Associated Features (e.g., childhood history of inattentive or hyperactive symptoms), Laboratory Findings (e.g., a variety of abnormalities reported in samples of males), and Prevalence sections (e.g., influence of availability of legalized gambling on the prevalence of Pathological Gambling) were updated.
"Associated Disorders," "Prevalence," and "Course" sections were updated.
Introductory Text for Personality Disorders
The text describing dimensional models were updated, presenting the dimensions in terms of some of the more important models.
Antisocial Personality Disorder
Associated Features text was updated to clarify that features that are part of the traditional conception of psychopathy may be more predictive of recidivism in settings (e.g., prisons) where criminal acts are likely to be non-specific.
Dependent Personality Disorder
The text for Gender-Associated Features was changed to remove the suggestions that reported gender difference is largely artifactual.
Borderline Personality Disorder
Text was added to the "Course" section to emphasize the fact that, contrary to many clinicians' preconceived notions, the prognosis for many individuals with Borderline Personality Disorder is good.
Obsessive-Compulsive Personality Disorder
The "Associated Features" section was updated to further clarify the relationship between Anxiety Disorders (especially Obsessive-Compulsive Disorder) and Obsessive-Compulsive Personality Disorder.
Associated Features text was updated to clarify comorbidity with other disorders. Prevalence was expanded to include rates in children and in particular clinical settings. Course now includes text about the risk of progression to other disorders.
Changes were made to several of the appendices. Small changes were made in the descriptive text for some of the research categories in Appendix B (e.g., postpsychotic depressive disorder of Schizophrenia, premenstrual dysphoric disorder, mixed anxiety depressive disorder) and the text for Medication-Induced Movement Disorders was updated to include atypical neuroleptics. Appendices E, F, and G were updated to correct for the International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) coding changes that have taken place over the past several years. A new Appendix K, containing the names of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) advisors, was also added.