Navigating the Unknown: Conditions for Further Study From the DSM-V

The first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) was released in 1952. At the time, it was the definitive text on mental disorders, and it still is. The first edition included 128 disorders, a number that is dwarfed in comparison to later versions of the DSM. In 2013, the American Psychiatric Association (APA) released the fifth and latest edition (although some information has been added in updates since then). It included many more disorders than its predecessors. The DSM-V outlines and discusses diagnostic practices for a grand total of 357 disorders, and that does not include a set of potential disorders that are labeled “conditions for further study.”

The content of the DSM is determined by hundreds of researchers, editors, and administrators who evaluate emerging psychopathology. In the past, decisions have been made by around 20 committees, all of which are appointed by the APA. According to Slate, each of these groups focuses on a specific category of mental illness, such as mood disorders or anxiety disorders. The proposed disorders can be introduced through recent research, and others are taken from an appendix from the current edition of the DSM that contains the “conditions for further study” mentioned above.

In order to be included in the DSM, a new disorder has to meet a carefully defined list of criteria. Symptoms must be considered severe enough to “cause impairment or distress” and be different enough from categories that are already included. False positives have to be ruled out as well. To assess such disorders, committees review research that has been conducted to ensure the quantity and quality of supporting evidence, Slate reports. When there are questionable aspects to the research, the APA can commission field trials. Then, if the disorder is recommended, experts draft an explanation that is evaluated by mental health professionals and even the general public. The decision is ultimately made by a DSM task force who oversees revisions.

Further Study in the DSM-V

What about the conditions that do not make it into the DSM as official disorders? Those are usually included in the category of “conditions for further study” and kept on a waiting list of sorts. The appendix of the DSM-V includes a core of 8 conditions that require further study. These conditions rely on “proposed criteria [that are] presented for conditions on which future research is encouraged.” While they may become full-fledged disorders in future editions of the DSM, for now they are in a separate category, one that outlines diagnostic features, prevalence, risk, and more. The following conditions are those included in the DSM as unofficial diagnoses.

All information is taken from the Diagnostic and Statistical Manual of Mental Disorders-V. These proposed criteria sets are not intended for clinical use; only the criteria sets and disorders in Section II of DSM-V are officially recognized and can be used for clinical purposes.

Attenuated Psychosis Syndrome

This condition is psychosis-like, but below the threshold for a full psychotic disorder. Compared with psychotic disorders, the symptoms are less severe and more transient.

• Diagnostic features: Attenuated delusions; attenuated hallucinations; disorganized communications; distressed and impaired performance; relatively maintained insight
• Associated features: Magical thinking; perceptual aberrations; difficulty in concentration; excessive suspiciousness; anxiety; social withdrawal; disruption in sleep-wake cycle
• Prevalence: Unknown, with a slight male preponderance
• Development and course: Mid-to-late adolescence or early adulthood
• Risk and prognostic factors: Temperamental; genetic and physiological (family history)
• Functional consequences: Modest-to-moderate impairment in social and role functioning; substantial improvement over time; many continue to have mild symptoms and impairment, others have full recovery
• Differential diagnosis: Brief psychotic disorder; schizotypal personality disorder; depressive or bipolar disorders; anxiety disorders; bipolar II disorder; borderline personality disorder; adjustment reaction of adolescence; extreme end of perceptual aberration and magical thinking in the non-ill population; substance/medication-induced psychotic disorder; attention deficit hyperactivity disorder (ADHD)
• Comorbidity: Individuals often experience anxiety and/or depression; may progress to another diagnosis, including anxiety, depressive, bipolar, and personality disorders

Depressive Episodes With Short-Duration Hypomania

This condition features episodes that are of sufficient intensity to be categorized as hypomanic but do not meet the four-day duration requirement.

• Diagnostic features: At least one major depressive episode; two episodes of hypomania of two to three days in duration 
• Associated features: Both short-term hypomania and a major depressive episode; substance use disorders; family history of bipolar disorder
• Prevalence: Unclear; suggested 2.8 percent of the population; may be more common in females
• Development and course: Not fully determined
• Risk and prognostic factors: Genetic; physiological; family history of mania
• Functional consequences: Not fully determined
• Differential diagnosis: Bipolar II disorder; major depressive disorder; major depressive disorder with mixed features; bipolar I disorder; cyclothymic disorder
• Comorbidity: Short-duration hypomania

Persistent Complex Bereavement Disorder

This condition is only diagnosed if at least 12 months (six months in children) have elapsed since the death of someone with whom the bereaved had a close relationship. This time frame discriminates normal grief from persistent grief.

• Diagnostic features: Persistent yearning/longing for the deceased; intense sorrow; frequent crying; preoccupation with the deceased; preoccupation with the manner in which the person died; difficulty in accepting the individual has died; disbelief that the individual has died; distressing memories of the deceased; anger over the loss; maladaptive appraisals about oneself in relation to the deceased or the death; excessive avoidance of reminders of the loss; desire to die; distrust of others; isolation; diminished sense of identity; difficulty engaging
• Associated features: Some individuals experience hallucinations of the deceased (auditory or visual) in which they temporarily perceive the deceased’s presence; diverse somatic complaints including those experienced by the deceased
• Prevalence: Approximately 2.4-4.8 percent; more prevalent in females
• Development and course: Can occur at any age, beginning after the age of 1 year; symptoms usually begin within the initial months, though there may be a delay; response is different in children than in adults
• Risk and prognostic factors: Environmental (increased dependence on the deceased person prior to death, death of a child); genetic and psychological (heightened risk if the bereaved individual is female)
• Functional consequences: Deficits in work and social functioning; harmful health behaviors; marked increase in risk for serious medical conditions; reduced quality of life
• Differential diagnosis: Normal grief; depressive disorders; post-traumatic stress disorder (PTSD); separation anxiety disorder
• Comorbidity: Major depressive disorder; PTSD; substance use disorders

Neurobehavioral Disorder Associated With Prenatal Alcohol Exposure

This condition is a new clarifying term, intended to encompass the full range of developmental disabilities associated with exposure to alcohol in utero.

• Diagnostic features: Impairment in neurocognitive, behavioral and adaptive functioning; a clinical diagnosis of fetal alcohol syndrome; marked impairment in global intellectual performance or neurocognitive impairment in any of the following areas: executive functioning, learning, memory, and/or visual-spatial reasoning; impairments in self-regulation
• Associated features: Vary depending on age, degree of alcohol exposure, and the individual’s environment; ongoing parental alcohol or substance misuse, parental mental illness, exposure to domestic or community violence, neglect or abuse, disrupted caregiving relationships, multiple out-of-home placements, lack of continuity in medical or mental health care
• Prevalence: Unknown; estimated prevalence rates of clinical conditions associated with prenatal alcohol exposure are 2-5 percent in the United States
• Development and course: Varies according to developmental age; about one-half of young children prenatally exposed to alcohol show marked development delay in the first three years of life; other children may not exhibit signs until preschool or school age
• Risk and prognostic factors: Suicide is a high-risk outcome; rates increase significantly in late adolescence and early adulthood
• Functional consequences: Decrements in adaptive behavior; maladaptive behavior with lifelong consequences; disrupted school experiences; poor employment records; trouble with the law; confinement; dependent living conditions
• Differential diagnosis: Disorders that are attributable to the physiological effects associated with postnatal use of a substance, another medical condition or environmental neglect; genetic and teratogenic conditions
• Comorbidity: Mental health problems in more than 90 percent of individuals; ADHD; oppositional defiant disorder and conduct disorder; mood symptoms; increased risk for later tobacco, alcohol, and other substance abuse

Suicidal Behavior Disorder

Suicidal behavior is often categorized in terms of violence of the method. Generally, overdoses with legal or illegal substances are considered nonviolent in method, whereas jumping, gunshot wounds, and other methods are considered violent. Another dimension is medical consequences of this behavior, with high-lethality attempts being defined as those requiring medical hospitalization. An additional dimension considered includes the degree of planning versus impulsivity.

• Diagnostic features: A suicide attempt; early remission if the suicidal behavior occurred 12-24 months prior to evaluation; high risk for further suicide attempts and death in the 24 months after the attempt
• Associated features: Not fully determined
• Prevalence: Not fully determined
• Development and course: Can occur at any time in the life span; rarely seen in children under the age of five
• Risk and prognostic factors: Approximately 25-30 percent of persons will make more attempts; significant variability in frequency, method, and lethality of attempts
• Functional consequences: Medical conditions such as lacerations, skeletal trauma, cardiopulmonary instability; hepatic failure
• Differential diagnosis: Not fully determined
• Comorbidity: A variety of mental disorders, such as bipolar disorder, major depressive disorder, schizophrenia, schizoaffective disorder, anxiety disorders, borderline personality disorder, antisocial personality disorder, eating disorders, and adjustment disorders; rarely manifested by individuals with no discernible pathology

Nonsuicidal Self-Injury

The essential feature of nonsuicidal self-injury is that the individual repeatedly inflicts shallow, yet painful injuries to the surface of his or her body.

• Diagnostic features: Most commonly, the purpose is to reduce negative emotions, such as tension, anxiety, and self-reproach, or to resolve an interpersonal difficulty; in some cases, the injury is conceived of as a deserved self-punishment
• Associated features: Associated with a sense of urgency and craving; behavioral pattern resembling addiction; injury most often inflicted with a sharp object; common areas of injury include the frontal area of the thighs and the dorsal side of the forearm
• Prevalence: Unclear, due to lack of self-reporting
• Development and course: Often starts in early teen years; can continue for many years; hospital admission reaches a peak at 20-29 years of age and then declines
• Risk and prognostic factors: Male and female rates are closer to each other than in suicidal behavior disorder; two theories of pathology exist, based on learning theory (positive or negative reinforcement) and self-punishment
• Functional consequences: Blood-borne disease transmission
• Differential diagnosis: Borderline personality disorder; suicidal behavior disorder; trichotillomania; stereotypic self-injury; excoriation
• Comorbidity: Not fully determined

Caffeine Use Disorder

Caffeine use disorder is characterized by the continued use of caffeine and failure to control use despite negative physical and/or psychological consequences.

• Diagnostic features: Heart, stomach, and urinary problems; anxiety, depression, insomnia, irritability, and difficulty thinking; withdrawal
• Associated features: Individuals have often been told by physicians and medical professionals to reduce or eliminate use; unsuccessful efforts to control use; use despite knowledge of problems caused by caffeine
• Prevalence: Unclear; some evidence suggests that 30 percent of current caffeine users may have met DSM-IV-TR criteria for a diagnosis of caffeine use disorder
• Development and course: A wide range of daily caffeine intake; consumers of various types of caffeinated products and medications; there has been no longitudinal or cross-sectional life span research on caffeine use disorder; it has been identified in both adolescents and adults
• Risk and prognostic factors: Genetic and physiological; heritable effects of caffeine use (or heavy use) shared with alcohol and smoking
• Functional consequences: Caffeine withdrawal produces functional impairment; caffeine intoxication may include symptoms of nausea and vomiting; significant disruptions in daily activities may occur during abstinence
• Differential diagnosis: Non-problematic use of caffeine; other stimulant use disorder; anxiety disorders
• Comorbidity: Daily cigarette smoking; family or personal history of alcohol use disorder; features may be associated with major depression, generalized anxiety disorder, panic disorder, adult antisocial personality disorder, and substance use disorders

Internet Gaming Disorder

There are no well-researched subtypes for internet gaming disorder to date. It most often involves specific internet games, but could involve non-internet computerized games as well, although these have been less researched.

• Diagnostic features: Persistent and recurrent participation in computer gaming, typically group games, for many hours; these games involve competition between groups of players
• Associated features: No consistent personality types associated with internet gaming disorder have been identified
• Prevalence: Unclear; appears to be highest in Asian countries and in male adolescents 12-20 years of age
• Development and course: Not fully determined
• Risk and prognostic factors: Environmental (computer availability with internet connection); genetic and physiological (adolescent males seem to be at greatest risk)
• Functional consequences: School failure; job loss; marriage failure; declining grades; decrease in normal school, social, and family activities
• Differential diagnosis: Not fully determined
• Comorbidity: Neglected health; major depressive disorder; ADHD; obsessive-compulsive disorder

Psychology Education at Concordia University, St. Paul

For those interested in the DSM and related psychology topics, an online degree from Concordia University, St. Paul is an ideal place to start. The online Bachelor of Arts in Psychology program provides a solid educational foundation for continued education through graduate study. Students gain a comprehensive understanding of psychology concepts and applications that prepares them to meet their future career goals.