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Association News
APA Makes DSM-5 Proposals Available for Comment
Psychiatric News
Volume 45 Number 5 page 1-19

The much-anticipated draft revisions proposed for DSM-5 have been posted online for view and comment by psychiatrists, mental health professionals, and the public, APA announced in February.

Substantial changes to the current diagnostic criteria have been proposed by 13 work groups based on accumulated research evidence. Sugested changes include the consolidation and elimination of numerous diagnoses and the addition of several new ones. These proposed revisions and rationale for them are posted at <www.dsm5.org>.

"APA has been preparing for the revision of DSM-IV for more than a decade," said David Kupfer, M.D., chair of the DSM-5 Task Force, at a February 9 press conference.

"It is important to remember this is not a final document," he emphasized. "DSM-5 is still a work in progress."

One of the major changes to the manual is the introduction of dimensional assessments in addition to specific diagnoses. Dimensional assessments are designed to help clinicians more reliably and quantitatively measure symptom clusters.

The current diagnostic criteria provide a dichotomous determination of psychiatric disorders. "People either meet these criteria or they don't," Darrel Regier, M.D., M.P.H., vice chair of the DSM-5 Task Force and director of research at APA, explained at the press conference. However, the criteria "do not always fit the reality that someone with a mental disorder experiences," he noted. For example, a patient with schizophrenia may also have symptoms of depression or insomnia. The dimensional assessments are expected to allow clinicians to more precisely characterize a patient's symptoms.

Another major change to the manual is providing quantitative tools to measure the severity of psychiatric disorders, Regier said. These rating scales will enable clinicians to monitor and document patients' symptom changes over time and guide the choice of appropriate treatment.

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Within specific diagnostic classifications, major changes have been suggested in various areas. The Neurodevelopmental Disorders Work Group proposed to combine the current diagnoses of autistic disorder, Asperger's disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (NOS) into a single category of autism spectrum disorders, recognizing that these separate diagnoses are in fact on a continuum, with differences in severity assessed in the constituent criteria domains—social interaction/communication and repetitive behaviors/fixated interests.

Substance-related disorders are also undergoing major restructuring. The separate diagnoses for substance abuse and dependence are proposed to be eliminated, according to Charles O'Brien, M.D., Ph.D., chair of the Substance-Related-Disorders Work Group. These diagnoses are being consolidated into one category called substance use disorders, with assessments for varying symptom severity.

O'Brien explained at the press conference that the diagnosis of "dependence" caused confusion since its introduction, as it has a different meaning in other specialties where it is used to refer to physiological tolerance to pain medications. The elimination of this terminology is expected to undo this confusion.

That work group has also proposed to rename the "substance-related disorders" diagnostic group as "addiction and related disorders." Parallel to addiction to substances, behavioral addiction is recommended as a separate category. Only gambling addiction is proposed for inclusion in behavioral addiction. The work group decided not to recommend sex and Internet addictions as official diagnoses because of a lack of sufficient research evidence, O'Brien explained.

The section on personality disorders will undergo perhaps the biggest overhaul of all DSM sections. The work group dealing with that category is recommending that the current 11 personality disorders be consolidated into one diagnostic category with a set of general criteria characterized by impairments in personality functioning, pathological traits, and prominent pathological personality types. The Personality and Personality Disorders Work Group has proposed five prototypes of personality disorders as well as dimensional symptom measurements to assess functional-impairment severity.

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Some of the proposed revisions involve areas that are already controversial, such as childhood bipolar disorder. The Disorders in Childhood and Adolescence Work Group has proposed a new diagnosis—temper dysregulation disorder with dysphoria that would include symptoms of bipolar disorder in children.

In the past decade, epidemiological studies have reported a rapid rise in the number of pediatric patients, including very young children, being diagnosed with bipolar disorder. These children tend to have a mix of symptoms including "very severe outbursts of loss of control coupled with mood disturbances,... [which] have not been adequately captured in the past," said David Shaffer, M.D., a work group member, at the press conference. Long-term follow-up studies have shown that when young patients diagnosed with bipolar disorder grew up, they were diagnosed with depression, but rarely with bipolar disorder, Shaffer pointed out.

"We hope [the proposed new diagnosis] will allow people who are thinking about making the diagnosis of bipolar NOS to think again, because there doesn't seem to be any basis for calling this syndrome a version of bipolar disorder," said Shaffer.

In addition, binge-eating disorder has been recommended by the Eating Disorders Work Group to be officially recognized as a diagnosis. Binge-eating disorder has been considered a psychiatric diagnosis for decades and was listed in the appendix of DSM-IV as a possible diagnosis warranting further research.

At the press conference, B. Timothy Walsh, M.D., chair of the Eating Disorders Work Group, emphasized that the proposed diagnostic criteria are not meant to capture people who merely overeat and struggle with weight. "This disorder is characterized by current, persistent, and repeated episodes of the consumption of large amounts of food associated with loss of control and very strong feelings of embarrassment and guilt," said Walsh. The criteria are very similar to bulimia but without the element of purging following a binge.

At present, people who present with these symptoms are usually diagnosed with eating disorder NOS, Walsh explained. The "literally hundreds of studies" published since its inclusion in a DSM-IV appendix allow the work group to feel confident about formalizing this diagnosis, he said.

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APA President Alan Schatzberg, M.D., stressed that the goal of the DSM-5 development process is to refine the diagnostic criteria and help clinicians avoid misdiagnosing or overdiagnosing psychiatric disorders.

"The new criteria are intended to be clearer on the threshold for severity and for impairment or distress that needs to be met [to make a diagnosis] and should assist in reducing the number of patients who received potential diagnoses," Schatzberg told Psychiatric News. He also believes that "the clarification about childhood bipolar disorder, and temper dysregulation disorder will drastically reduce the numbers of kids who had been called bipolar." Further, the elimination of "dependence" from substance-use disorders is expected to remove the confusion over diagnosing patients with normal physiological tolerance to opioid medications, he noted.

To ensure the transparency of the DSM-5 development process, APA members, other psychiatrists, mental health professionals, medical professionals, and the public are invited to review and comment on the draft criteria. After the public-comment period closes on April 20, the DSM-5 work groups will review the comments. Field trials will then test the proposed criteria, with changes, in both specialty mental health and primary care settings starting in July. The field trials are expected to be concluded in July 2011. Data obtained from these field trials will be incorporated into later drafts.

The final draft of DSM-5 will be submitted to the APA Assembly and Board of Trustees for review and final approval. The new manual is expected to be published in May 2013. blacksquare

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