"Good morning to all on DSM-V territory!" David
Goldberg, M.D., of the Institute of Psychiatry at King's College, London,
breezily announced on March 5.
Steven Hyman, M.D.: "There is an enormous amount of comorbidity
[in persons with mental disorders]. This represents a problem in the
Photos: Joan Arehart-Treichel
In truth, it was the Crowne Plaza Hotel in New York City. But figuratively
it was "DSM-V territory" since he and other
psychiatric scientists were there to address the framework of the next edition
of the world-famous Diagnostic and Statistical Manual of Mental Disorders
Moreover, the three-day symposium, sponsored by the American
Psychopathological Association and attended by about 100 psychiatric
scientists, underscored some of the challenging conceptual questions facing
the experts who are crafting the fifth edition of the 57-year-old
DSM. (In fact, all of the scientists who spoke at the symposium are
involved in the development of DSM-V.)
First, what is a mental disorder? Is it symptoms? disease? functional
disability? Should variants in behavior be considered disorders, and if so,
how much variation? There are no simple answers to this question, Norman
Sartorius, M.D., Ph.D., a past director of the World Health Organization's
Division of Mental Health, indicated.
Furthermore, "We are still focused on similarities of symptoms,
signs, and course rather than underlying principles," said Steven Hyman,
M.D., a former director of the National Institute of Mental Health and
currently provost of Harvard University, because the causes of most mental
disorders, with a few exceptions, are not yet clear. Hyman is a member of the
DSM-V Task Force.
Hyman also noted that with the rapid advances in psychiatric genetics, the
processes underlying various mental disorders seem to be becoming more rather
than less complex. For example, while certain genes appear to underlie bipolar
disorder, and others to underlie schizophrenia, a number of the same genes
show strong links to both conditions, a recent study
Darrel Regier, M.D.: "[The definition of a mental disorder] has
not been determined yet [for DSM-V]. It is an imprecise art coming to
such a definition."
So what will the definition of a mental disorder in DSM-V be?"
It has not been determined yet," Darrel Regier, M.D., vice chair
of the DSM-V Task Force, avowed. "It is an imprecise art coming
to such a definition." Regier is also director of research at APA,
executive director of the American Psychiatric Institute for Research and
Education, and president of the American Psychopathological Association.
Yet if mental disorders end up being classified essentially on the basis of
symptoms, should those symptoms be categorized, or should they be presented in
a dimensional manner, or perhaps both (See Taking Symptoms to New Dimensions)?
"I think simultaneous use of both methods can provide information
that either alone cannot provide," said Ellen Frank, Ph.D., of the
University of Pittsburgh Department of Psychiatry.
Regier indicated that he too would like to see dimensions added to the
categorization of mental disorders. So did John Helzer, M.D., a professor of
psychiatry at the University of Vermont. "DSM-V is certainly
going to be a top-down categorical system," as it has been in the past,
he predicted, but using simple scales to determine whether patients' symptoms
are mild, moderate, or severe would enhance the accuracy of various diagnoses,
Ellen Frank, Ph.D: "I think simultaneous use of both [the
categorical approach to mental disorders and the continuous or spectral
approach] can provide information that either alone cannot
How to manage the dimensional with the categorical "promises to be
one of the more revolutionary aspects of DSM-V," Wilson
Compton, M.D., of the National Institute on Drug Abuse and a member of the
DSM-V Task Force, stated.
Also pressing is the question of how mental disorders should be grouped in
DSM-V, that is, on the basis of similar symptoms, signs, and course
or on the basis of similar origins? Hyman favors the latter. True, the genes
underlying most mental disorders seem to be incredibly complex, he conceded,
and thus grouping disorders on the basis of genetic origin is out of the
question at this point. But another possibility, he said, might be to group
mental disorders on the basis of "shared neural circuits." For
instance, both human and rodent studies have shown that the amygdala is
hyperactive in various types of anxiety disorders. So mental disorders that
involve an overly vigilant amygdala might be grouped together in
What about the impact of culture, race, and gender on psychiatric
disorders? Should DSM-V take them into consideration? Certainly,
James Jackson, Ph.D., a social scientist at the University of Michigan
Institute for Social Research and a member of a DSM-V work group,
indicated. Yet he admitted that the subject is "complex." For
example, he and his colleagues found, in some 25,000 American subjects, not
only that race influenced the prevalence of mood disorders, but that its
influence was modified by factors such as gender and whether a person had
immigrated to the United States, and at what age.
In brief, as a social scientist, "Race really messes up your
models!" Jackson asserted, which brought some chuckles from the
James Jackson, Ph.D.: "In a perfect world, we would have a
biological marker for this or that disorder. But we do not."
Then there is a related vexing question: Should DSM-V take note of
the impact of life development on mental disorders? Although it has been known
for years that clinical presentations change with age, the evidence that this
is the case has been growing increasingly robust of late, Daniel Pine, M.D.,
an anxiety disorder specialist at the National Institute of Mental Health and
chair of a DSM-V work group, observed. For instance, one study
tracked some 700 children with anxiety problems and found that while most of
these problems were transient, a minority were not. Thus, "I would like
a clearer recognition in DSM-V [than in DSM-IV] that a
diagnosis is only a snapshot in time, and if we can do that, it will be a big
step forward," Pine said.
But the dilemma is how to include information of this nature in
DSM-V. A possible solution, Pine said, might be to introduce a new
feature—an age-related expression of the same symptoms for a disorder.
For example, the symptoms of attention-deficit/hyperactivity disorder (ADHD)
express themselves in children differently from in adults.
Another possibility, he said, might be to include developmental norms for
each disorder—say, that irritability in children may reflect depression
or that adolescents with ADHD tend to be less hyperactive than younger
children with the disorder.
Finally, DSM is used by an incredible range of people, William
Narrow, M.D., associate director of APA's Office of Research and director of
research for DSM-V, pointed out—for example, at the National
Institutes of Health, the Food and Drug Administration, and the Social
Security Administration; in the health insurance industry and the legal
system; and on Capitol Hill. But DSM is, and should remain, first and
foremost a clinical tool, he maintained.
Certainly this symposium was not the first to address the paradigm of
DSM-V, nor will it be the last, since work on the next edition
started a decade ago and is expected to continue until the edition's
publication in 2012, Regier stressed. Summing up the goal of the meeting, he
said that "the challenge is to conserve the wisdom of our predecessors,
but to also be astute about some new developments." ▪