Will DSM-5 make us feel dysphoric? Conceptualisation(s) of dysphoria in the most recent classification of mental disorders

DSM Digest

Dysphoria (or dysphoric mood) is a psychopathological concept with the most fascinating, but chequered history. Over the years, dysphoria has referred to a wide variety of phenomena and disorders: a mild depression, a mood disorder that occurs during a particular period of the menstrual cycle, a component of mixed episodes of bipolar disorder, a personality-based mood disorder (‘hysteroid dysphoria’), a constellation of side effects of antipsychotic medications (‘neuroleptic dysphoria’) and dissatisfaction with one’s appearance or one’s gender (Starcevic, 2007). Calls have been made to define dysphoria more rigorously, but more recently the boundaries of the concept seem to have become even more blurred. This is exemplified in the most recent product of the manufacturing of psychiatric diagnoses, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association, 2013).

What is dysphoria (dysphoric mood) according to DSM-5?

The glossary of technical terms in the DSM-5 provides two definitions of dysphoria. The first one is unchanged from the DSM-IV-TR (American Psychiatric Association, 2000) and describes ‘dysphoric mood’ as ‘an unpleasant mood, such as sadness, anxiety, or irritability’ (p. 824). The second definition of ‘dysphoria (dysphoric mood)’, new to DSM-5, is that it is ‘a condition in which a person experiences intense feelings of depression, discontent, and in some cases indifference to the world around them’ (p. 821).

These definitions are so obviously incongruous that it is baffling that the architects of the DSM-5 have not noticed it. The only agreement between the definitions seems to be about dysphoria being a mood. Other components of the definitions only create confusion, as follows:

• Is dysphoria a disorder (‘a condition’) or only a symptom (‘dysphoric mood’)? Related to this dilemma is the uncertainty about the course of dysphoria. Is it a mood disorder that tends to persist without treatment or a more fleeting affective state?

• How specific and broad is dysphoric mood? Does it include ‘sadness, anxiety, or irritability’ or just some of these? In other words, can someone feel anxious and still be labelled as dysphoric? Is irritability synonymous with dysphoria? What constitutes dysphoric mood other than its characterisation as an unpleasant state?

• How severe or ‘intense’ should an ‘unpleasant mood’ be to qualify as dysphoria?

• What is the relationship between dysphoria and depression? Is dysphoria a type of depression?

• If dysphoria is a ‘condition’ consisting of depression, discontent and (in some cases) indifference, why is it not listed as one of the diagnostic categories in DSM-5?

This confusion looms large and should not be ignored as just another DSM-5 peculiarity. After all, if psychiatry is to be taken seriously, it must show a good grasp of its terminology. The problem with dysphoria is further compounded by an arbitrary and inconsistent usage of this term elsewhere in DSM-5.

Which ‘dysphoric disorders’ are included in DSM-5?

There are two disorders in DSM-5 that refer to dysphoria in their name: premenstrual dysphoric disorder and gender dysphoria. The former is placed in the group of depressive disorders, whereas the latter is in its own category (or chapter) of mental disorders.

Premenstrual dysphoric disorder existed in the previous edition of the DSM, but in DSM-5 has been elevated from a condition requiring further study to an official diagnostic category. Although it was classified as a depressive disorder, its diagnostic criteria include a variety of emotional states (irritability/anger, depressed mood, anxiety and ‘marked affective lability’), with only one of them having to be present to make the diagnosis. Additional criteria include many features of a depressive disorder, so that premenstrual dysphoric disorder then denotes either a depression that is akin to major depressive disorder or depression with prominent irritability/anger, anxiety or mood instability. Labelling this condition as ‘dysphoric’ reinforces the notion that dysphoria is a nonspecific, unpleasant emotional state, and it might be more accurate to refer to it as a premenstrual emotional or mood disorder. Alternative terms are a ‘predominantly psychological subtype’ or a ‘mixed’ subtype with psychological and physical symptoms of the core premenstrual disorder, as recently suggested by a group of experts (Ismail et al., 2013).

Gender dysphoria was previously known as gender identity disorder, and in DSM-5 it refers to ‘the distress that may accompany the incongruence between one’s experienced or expressed gender and one’s assigned gender’ (p. 451). It is also defined as ‘an individual’s affective/cognitive discontent with the assigned gender’ (p. 451). The DSM-5 designation is preferred because it ‘focuses on dysphoria as the clinical problem, not identity per se’ (p. 451). Also, gender dysphoria is apparently less stigmatising than gender identity disorder as a diagnostic term (Ehrbar, 2010). In this case, gender dysphoria is not a mood or depressive disorder, while dysphoria is used to possibly avoid stigma and more broadly to denote a temporary or occasional distress about incongruence with one’s own gender. Terms such as ‘gender discontent’ or ‘distressing gender incongruence’ seem to be more precise than gender dysphoria. Additionally, terms that seem less stigmatising should not be used at the expense of introducing or amplifying ambiguity and what is politically correct may be descriptively incorrect.

Is there an alternative?

Dysphoria remains defined vaguely and inconsistently, thereby increasing confusion. There is no justification to use one term – dysphoria – to refer to distress, discontent, depression and almost any other unpleasant emotional state. Unfortunately, the terminological trends tend to perpetuate themselves and it is not inconceivable to end up with an embarrassingly chaotic situation regarding the meaning, significance and implications of terms ‘dysphoria’ and ‘dysphoric’. What can be done to avert this?

One possibility is to try to develop a sound and coherent concept of dysphoria. Thus, dysphoria was conceptualised as a complex emotional state that consists of discontent, unhappiness, irritability and a tendency to blame others, and experience and express negative feelings in an interpersonal domain (Starcevic, 2007); indeed, an instrument was developed to measure the severity of dysphoria in accordance with this conceptualisation (Berle and Starcevic, 2012). In a parallel conceptual development, dysphoria was postulated to arise from a matrix of personality disturbance as an emotional state that literally ‘does not fit’ and is accompanied by tension, irritability and urge (Rossi Monti, 2012). The validity and clinical utility of these conceptualisations of dysphoria remain to be tested and the corresponding studies are currently underway.

In the meantime, the term dysphoria should be used sparingly, if at all. Even when reference is made to the official DSM-5 diagnoses of premenstrual dysphoric disorder and gender dysphoria, clinicians would do well to emphasise the general nature of the condition when appropriate (e.g. premenstrual emotional or mood disorder or premenstrual disorder with predominantly psychological symptoms), point out the specific features of the particular patients (e.g. premenstrual irritability or premenstrual mood instability) and specify the unique characteristic of the disorder such as a distressing incongruence with one’s gender. Doing so would decrease the risk of terminological confusion and increase diagnostic clarity.