DSM-5

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The next (fifth) edition of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM), commonly called DSM-5 (previously known as DSM-V until the APA decided to abandon the Roman Numerals), is currently in consultation, planning and preparation. It is due for publication in May 2013 and will supersede the DSM-IV which was last revised in 2000. APA has an official development website for posting of draft versions of the DSM-5.

Development of DSM-5

In 1999, a DSM–V Research Planning Conference, sponsored jointly by APA and the National Institute of Mental Health (NIMH), was held to set the research priorities. Research Planning Work Groups produced "white papers" on the research needed to inform and shape the DSM-V

, and the resulting work and recommendations were reported in an APA monograph and peer-reviewed literature. There were six workgroups, each focusing on a broad topic: Nomenclature, Neuroscience and Genetics, Developmental Issues and Diagnosis, Personality and Relational Disorders, Mental Disorders and Disability, and Cross-Cultural Issues. Three additional white papers were also due by 2004 concerning gender issues, diagnostic issues in the geriatric population, and mental disorders in infants and young children. The white papers have been followed by a series of conferences to produce recommendations relating to specific disorders and issues, with attendance limited to 25 invited researchers.

On July 23, 2007, the APA announced the task force that will oversee the development of DSM-5. The DSM-5 Task Force consists of 27 members, including a chair and vice chair, who collectively represent research scientists from psychiatry and other disciplines, clinical care providers, and consumer and family advocates. Scientists working on the revision of the DSM have experience in research, clinical care, biology, genetics, statistics, epidemiology, public health, and consumer advocacy. They have interests ranging from cross-cultural medicine and genetics to geriatric issues, ethics and addiction. The APA Board of Trustees required that all task force nominees disclose any competing interests or potentially conflicting relationships with entities that have an interest in psychiatric diagnoses and treatments as a precondition to appointment to the task force. The APA made all task force members' disclosures available during the announcement of the task force. Several individuals were ruled ineligible for task force appointments due to their competing interests. Future announcements will include naming the workgroups on specific categories of disorders and their research-based recommendations on updating various disorders and definitions.

Owing to criticism over the perceived proliferation of diagnoses in the current edition of the DSM, David Kupfer, M.D., who is the DSM-5 Task Force chair and is shepherding the DSM's revision, said in an interview: "One of the raps against psychiatry is that you and I are the only two people in the U.S. without a psychiatric diagnosis."

First draft diagnostic criteria for DSM-5

The first draft diagnostic criteria for DSM-5 has now been released. Revisions include the following:

1. The recommendation of new categories for learning disorders and a single diagnostic category, “autism spectrum disorders” that will incorporate the current diagnoses of autistic disorders, Asperger’s Syndrome, childhood disintegrative disorder and pervasive developmental disorder (not otherwise specified). Work group members have also recommended that the diagnostic term “mental retardation” be changed to “intellectual disability,” bringing the DSM criteria into alignment with terminology used by other disciplines.
2. Eliminating the current categories substance abuse and dependence, replacing them with the new category “addiction and related disorders.” This will include substance use disorders, with each drug identified in its own category. Eliminating the category of dependence will better differentiate between the compulsive drug-seeking behavior of addiction and normal responses of tolerance and withdrawal that some patients experience when using prescribed medications that affect the central nervous system.
3. Creating a new category of “behavioral addictions,” in which gambling will be the sole disorder. Internet addiction was considered for this category, but work group members decided there was insufficient research data to do so, so they recommended it be included in the manual’s appendix instead, with a goal of encouraging additional study.
4. New suicide scales for adults and adolescents to help clinicians identify those individuals most at risk, with a goal of enhancing interventions across a broad range of mental disorders; the scales include research-based criteria such as impulsive behavior and heavy drinking in teens.
5. Consideration of a new “risk syndromes” category, with information to help clinicians identify earlier stages of some serious mental disorders, such as neurocognitive disorder (dementia) and psychosis.
6. A proposed new diagnostic category, temper dysregulation with dysphoria (TDD), within the Mood Disorders section of the manual. The new criteria are based on a decade of research on severe mood dysregulation, and may help clinicians better differentiate children with these symptoms from those with bipolar disorder or oppositional defiant disorder.
7. New recognition of binge eating disorder and improved criteria for anorexia nervosa and bulimia nervosa, as well as recommended changes in the definitions of some eating disorders now described as beginning in infancy and childhood to emphasize that they may also develop in older individuals.

Dimensional Assessments
In addition to proposed changes to specific diagnostic criteria, the APA is proposing that “dimensional assessments” be added to diagnostic evaluations of mental disorders. These would permit clinicians to evaluate the severity of symptoms, as well as take into account ”crosscutting” symptoms.

Careful Consideration of Gender, Race and Ethnicity
The process for developing the proposed diagnostic criteria for DSM-5 has included careful consideration of how gender, race and ethnicity may affect the diagnosis of mental illness.

Proposed changes to DSM-IV diagnoses

Asperger syndrome

Main article: Asperger syndrome

There have been proposals to eliminate Asperger's syndrome as a separate disorder, and instead merge it under autism spectrum disorders (ASD). Under the proposed new classification, clinicians would rate the severity of clinical presentation of ASD as severe, moderate or mild. However, this proposal has inspired much controversy amongst Asperger's Syndrome specialists such as Tony Attwood and Simon Baron-Cohen and opposition groups, such as "Keep Asperger's Syndrome in the DSM-V."

Attention Deficit Hyperactivity Disorder

Main article: Attention Deficit Hyperactivity Disorder

There has been a proposal to increase the diagnostic criteria for the age when symptoms became present. The proposal would change the diagnostic criteria from symptoms being present before seven years of age to symptoms being present before twelve years of age. The new diagnostic criteria would read: "B. Several noticeable inattentive or hyperactive-impulsive symptoms were present by age 12."

There has been a proposal that for the Inattentive type and Hyperactive/Impulsive type, a minimum of only four symptoms need to be met if a person is 17 years of age or older. The current DSM-IV-TR criteria of meeting a minimum of six symptoms for the Inattentive type or Hyperactive/Impulsive Type would still apply for those 16 years of age or younger.

Bipolar disorder

Main article: Bipolar disorder

There have been proposals to include further and more accurate sub-typing for bipolar disorder (Akiskal and Ghaemi, 2006).

There have been proposals for more stringent criteria for the diagnosis of bipolar disorder in children with a new diagnosis temper dysregulation disorder with dysphoria proposed.

Dissociative identity disorder

Main article: Dissociative identity disorder

Proposed changes to the controversial dissociative identity disorder diagnosis include adding a new diagnostic criterion: "C. Causes clinically significant distress or impairment in social, occupational, or other important areas of functioning." This phrase, which occurs in several other diagnostic criteria, is proposed for inclusion in 300.14 as part of a proposed merger of dissociative trance disorder with DID. Criterion C would be included to "help differentiate normative cultural experiences from psychopathology". For example, professionals would be able to take shamanism, which involves voluntary possession trance states, into consideration, rather than diagnosing those who report it as having a mental disorder.

Hypersexual disorder

Main article: Hypersexual disorder

Hypersexual Disorder is proposed as a new category to be added. The diagnosis would apply when a person experiences several of the indicated symptoms (extreme amounts of time spent in the sexual activity, using the sexual activity in response to low mood or stress, failed attempts to reduce the behaviors, etc.). Moreover, it would apply only when the problem lasted six months or more, when person experienced significant distress or impairment in major life areas because of it, and when the problem was not directly caused by a medication or drugs, as well as other criteria. Under the proposal, an official diagnosis would also specify which behavior(s) are problematic in the case: masturbation, pornography use, cybersex, etc.

The label “hypersexual disorder” was reportedly chosen because it did not imply any specific theory for what causes hypersexuality, which remains unknown. A proposal to add sexual addiction to the DSM system has been rejected by the APA, as not enough evidence suggested to them that the condition is analogous to substance addictions, as that name would imply.

The DSM-IV-TR includes "Sexual Disorder—Not Otherwise Specified" (Sexual Disorder NOS), which applies to, among other conditions, “distress about a pattern of repeated sexual relationships involving a succession of lovers who are experienced by the individual only as things to be used.”

Oppositional Defiant Disorder

Main article: Oppositional Defiant Disorder

It is proposed that the eight symptoms of Oppositional Defiant Disorder should be divided into the following categories: Angry/Irritable Mood; Defiant/Headstrong Behavior; and Vindictiveness. However, just as in the DSM-IV-TR, four of these symptoms need to be present to meet diagnostic criteria. The minimum four symptoms can come from all (or even just one or two) of the three categories.

It is proposed that a section be added to the diagnostic criteria for Oppositional Defiant Disorder stating that for children under 5 years of age, oppositional behavior "must occur on most days for a period of at least six months". For children 5 years or older, oppositional behavior "must occur at least once per week for at least six months". The current criteria states that four or more symptoms must be present for at least 6 months. The proposed change adds the criterion of frequency of symptoms and also delineates required frequency by the age of the child.

Personality disorders

Main article: Personality disorder

Major changes have been proposed in the assessment and diagnosis of personality disorders. These include a revamped definition of personality disorder and a dimensional rather than a categorical approach based on the severity of dysfunctional personality trait domains (negative emotionality, introversion, antagonism, disinhibition, compulsivity, and schizotypy). In addition, patients would be assessed on how much they match each of five prototypic personality disorder types: antisocial/psychopathic, avoidant, borderline, obsessive-compulsive, and schizotypal with their criteria being derived directly from the dimensional personality trait domains. Some former personality disorders, like narcissistic personality disorder and histrionic personality disorder, will be submerged under facets of various personality type domains (in this case, the narcissism and histrionism facets of antagonism).

Pica

Main article: Pica (disorder)

It is proposed that Pica is reclassified from the "Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence" classification to the "Eating Disorders" classification.

It is proposed that the wording of "non-food substances" be added alongside the current DSM-IV-TR wording of "non-nutritive substances". "Non-food" was added to further clarify that items consumed are not just merely lacking nutrients (diet soda, according to the DSM-V committee, is an example of a non-nutritive substance), but are actual non-foodstuffs.

Posttraumatic stress disorder

Main article: Posttraumatic_stress_disorder#DSM-5_proposed_diagnostic_criteria_changes

Various criteria changes are proposed.

Schizophrenia

Main article: Schizophrenia

The following disorders are proposed for deletion from DSM-5:

• 295.30 Schizophrenia - Paranoid Type
• 295.10 Schizophrenia - Disorganized Type
• 295.20 Schizophrenia - Catatonic Type
• 295.90 Schizophrenia - Undifferentiated Type
• 295.60 Schizophrenia - Residual Type
• 297.3 Shared Psychotic Disorder

Somatoform disorder

Main article: Somatoform disorder

Additional proposed somatoform disorders are:

• Abridged somatization disorder - at least 4 unexplained somatic complaints in men and 6 in women
• Multisomatoform disorder - at least 3 unexplained somatic complaints from the PRIME-MD scale for at least 2 years of active symptoms

These disorders have been proposed because the recognized somatoform disorders are either too restrictive or too broad. In a study of 119 primary care patients, the following prevalences were found:

• Somatization disorder - 1%
• Abridged somatization disorder - 6%
• Multisomatoform disorder - 24%
• Undifferentiated somatoform disorder - 79%

Proposed new DSM-5 diagnoses

The proposed new DSM-5 diagnoses include the following:

• Absexual
• Complex post-traumatic stress disorder
• Depressive personality disorder
• Negativistic (passive-aggressive) personality disorder
• Relational disorder
• Sluggish cognitive tempo
• Binge Eating

Criticism of DSM-5

Robert Spitzer, the head of the DSM-III task force, has publicly criticized the APA for mandating that DSM-5 task force members sign a nondisclosure agreement, effectively conducting the whole process in secret: “When I first heard about this agreement, I just went bonkers. Transparency is necessary if the document is to have credibility, and, in time, you’re going to have people complaining all over the place that they didn’t have the opportunity to challenge anything.” Allen Frances expressed a similar concern.

Although the APA has since instituted a disclosure policy for DSM-5 task force members, many still believe the Association has not gone far enough in its efforts to be transparent and to protect against industry influence. In a recent Point/Counterpoint article, Lisa Cosgrove, PhD and Harold J. Bursztajn, MD noted that "the fact that 70% of the task force members have reported direct industry ties---an increase of almost 14% over the percentage of DSM-IV task force members who had industry ties---shows that disclosure policies alone, especially those that rely on an honor system, are not enough and that more specific safeguards are needed."

David Kupfer, MD, chair of the DSM-5 task force, and Darrel A. Regier, MD, MPH, Vice Chair of the task force, whose industry ties are disclosed with those of the task force, countered that "collaborative relationships among government, academia, and industry are vital to the current and future development of pharmacological treatments for mental disorders." They asserted that the development of DSM-5 is the "most inclusive and transparent developmental process in the 60-year history of DSM." The developments to this new version can be viewed on [2]. Perhaps as an effort towards this transparency, public input is requested for the first time in the history of the manual. Until June 15, 2011, members of the general public can sign up at the DSM-V website and provide feedback on the various proposed changes.

In June 2009 Allen Frances, head of the DSM-IV task force, issued strongly worded criticisms of the processes leading to DSM-5 and the risk of "serious, subtle, (…) ubiquitous" and "dangerous" unintended consequences such as new "false 'epidemics'". He writes that "the work on DSM-V has displayed the most unhappy combination of soaring ambition and weak methodology" and is concerned about the task force's "inexplicably closed and secretive process.". His and Spitzer's concerns about the contract that the APA drew up for consultants to sign, agreeing not to discuss drafts of the fifth edition beyond the task force and committees, have also been aired and debated.

The appointment, in May 2008, of two of the taskforce members, Kenneth Zucker and Ray Blanchard, has led to an internet petition to remove them. According to MSNBC, "The petition accuses Zucker of having engaged in 'junk science' and promoting 'hurtful theories' during his career." According to The Gay City News, "Dr. Ray Blanchard, a psychiatry professor at the University of Toronto, is deemed offensive for his theories that some types of transsexuality are paraphilias, or sexual urges. In this model, transsexuality is not an essential aspect of the individual, but a misdirected sexual impulse." Blanchard responded, "Naturally, it's very disappointing to me there seems to be so much misinformation about me on the Internet. [They didn't distort] my views, they completely reversed my views." Zucker "rejects the junk-science charge, saying there 'has to be an empirical basis to modify anything' in the DSM. As for hurting people, 'in my own career, my primary motivation in working with children, adolescents and families is to help them with the distress and suffering they are experiencing, whatever the reasons they are having these struggles. I want to help people feel better about themselves, not hurt them.'"

Borderline personality disorder controversy

The Treatment and Research Advancements National Association for Personality Disorders (TARA-APD) campaigns to change the name and designation of borderline personality disorder in DSM-5. The paper How Advocacy is Bringing BPD into the Light reports that "the name BPD is confusing, imparts no relevant or descriptive information, and reinforces existing stigma...". There is also discussion about changing Borderline Personality Disorder, an Axis II diagnosis (personality disorders and mental retardation), to an Axis I diagnosis (clinical disorders).

More radical criticisms

Some authors believe that the problem is not simply of a few criteria to be deleted or modified. For example, a Kuhnian reformulation of the diagnostic debate suggested that apparently trivial problems of the DSM, like the extremely high rates of comorbidity, might fruitfully be analysed as Kuhnian anomalies leading the DSM system to a scientific crisis. As a consequence, a radical rethinking of the concept of mental disorder, acknowledging for its constructive nature, was proposed. Based on similar views, several revolutionary approaches were proposed, ranging from dimensional diagnosis to various forms of etiopathogenetic diagnosis (a nice example from a cognitive point of view can be found in ).

External links

• Official DSM-5 Development Website
• Topic Center from Psychiatric Times: DSM-V