PHILADELPHIA -- Reports here provided what may be the last public update on DSM-5, the next edition of American psychiatry's diagnostic guide, before it is formally released in May 2013.
Many changes have been made since the first draft of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders was put out for public comment in early 2010, according to workgroup leaders speaking at several heavily attended symposia at the American Psychiatric Association's (APA) annual meeting.
The current version, DSM-IV, was released in 1994.
The update effort has been led by DSM-5 task force chairman David Kupfer, MD, of the University of Pittsburgh, and APA research director Darrel Regier, MD, MPH.
The actual work of rewriting the manual fell to 13 workgroups, which tackled disorders in 20 categories. The final drafts are to be completed by August, then they must be approved by a scientific review committee and the task force leadership, and finally by the APA's governing bodies.
Kupfer said the final version has to be completed by December, when it's set to go to the printer. Its formal release is planned for the APA's annual meeting next May in San Francisco.
Here's a brief overview of the changes you can expect.
WHAT'S OUT
Kupfer and Regier gave the workgroups marching orders at the outset. These included:
- Eliminate "not otherwise specified" (NOS) diagnoses within categories
- Remove functional impairments as necessary components of the diagnostic criteria
- Use scientific evidence to justify classifications and criteria
To a great but not complete extent, the DSM-5 workgroups complied with those instructions. Every one of the dozens of disorder categories has been reorganized and/or rewritten to bring them into line with research conducted over the past 20 years. Often, the groups found no basis for classifications and diagnoses contained in DSM-IV. Here are highlights of what is set to be dumped in DSM-5:
Axes. DSM-IV's main organizational scheme was to divide disorders, contributing factors, and global functional assessments into 5 axes -- notably with Axis I containing clinical, substance-related, and learning disorders and Axis II comprising personality and certain other disability-based disorders.
The DSM-5 leadership determined early on that there was no scientific basis for this distinction, and so disorders in the new edition will be presented as a simple list of 20 chapters for disorder families.
NOS diagnoses. Most disorder families in DSM-IV included an NOS diagnosis that served as a catchall for patients who appeared to have some kind of disorder but who didn't fit into the established categories.
In practice, however, some of these became extremely popular. The head of the eating disorders workgroup, for example, cited data indicating that more than half of all patients diagnosed with an eating disorder were coded for "ED-NOS." Also, some disorders that were now well recognized and characterized were included in NOS categories, such as restless legs disorder.
In DSM-5, NOS categories are either gone entirely or replaced with NEC for "not elsewhere classified." NEC categories will include a list of "specifiers," each with a specific diagnostic code, that will convey clinical information. For example, Depressive Disorder NEC comes with 5 specifiers such as "short duration" that indicate the patient's clinical condition and why it doesn't meet criteria for one of the main depression syndromes.
Bereavement exclusion in major depression. One of the most controversial proposals in DSM-5 does away with the restriction that diagnosis of major depression cannot be given to patients reporting severe grief from the death of a loved one if the death occurred within the preceding two months.
As 鶹ý previously reported, the depression workgroup believes that there is no scientific justification to disqualify patients from diagnosis and treatment if they otherwise meet criteria for major depression.
But in a bow to critics, they have proposed to include a caveat in the checklist criteria for major depression noting that certain symptoms appear in normal grief but that others may warrant attention -- as did DSM-IV though in a different way.
Catatonia as a psychotic diagnosis. The group has reworked the diagnostic criteria for catatonia and removed it as a subtype of schizophrenia. Instead, catatonia is now a specifier in schizophrenia and several other psychiatric diagnoses. The DSM-IV diagnosis of catatonia related to a general medical condition will be retained, and DSM-5 will also create a new "Catatonia NEC" diagnosis for patients showing catatonia of uncertain origin or associated with neurodevelopmental conditions such as autism.
Gender identity disorder. Individuals who believe their biological gender doesn't match their gender identification will no longer be labeled with a disorder. Instead, if they seek psychiatric treatment, they can be labeled with "gender dysphoria."
The workgroup responsible for dealing with the hot-button issue considered a variety of other approaches, addressed later in this article. Ultimately they settled on a formal diagnosis -- potentially qualifying a patient for insurance-paid treatment if they want it -- but with a less pejorative name than "disorder."
Substance abuse. DSM-IV created separate diagnoses for "abuse" and "dependence" in people having problems with mind-altering substances such as marijuana and narcotics. The DSM-5 workgroup in this area agreed that the vast amount of research conducted in recent decades pointed to substance-related problems as occurring on a continuum, such that the abuse-dependence distinction was purely arbitrary.
Hence, DSM-5 will instead feature "substance use disorders" as the diagnosis for people with such problems.
Also out are physical tolerance and withdrawal symptoms as criteria for a disorder diagnosis. O'Brien noted that these reflect the body's adaptation to chemicals and are not necessary to a diagnosis.
WHAT'S IN (or STILL IN)
In a commentary delivered to APA meeting attendees, Norman Sartorius, MD, of the World Health Organization, remarked on "the irresistible tendency to introduce new names" when revising diagnostic criteria. And indeed, the DSM-5 workgroups were unable to resist it.
But Sartorius also noted that new names can be beneficial -- as long as they are accompanied by preparation and education.
In addition to new names, some entirely new disorders and methods of diagnosing them are slated to appear in DSM-5.
Dimensions. Perhaps the most important conceptual innovation in DSM-5 is its use of dimensional assessments in most disorder categories. These are indicators of severity for certain symptoms. They may be common "cross-cutting" features that appear in conjunction with many disorders, such as suicide risk and anxiety. Or they may be specific to a particular disorder, such as the frequency of flashbacks in PTSD.
Biomarkers. For the first time, results of objective testing will be part of the formal diagnostic criteria in psychiatry. Many sleep-wake disorders in DSM-5 will require polysomnography for a diagnosis. Also, narcolepsy is set to become narcolepsy/hypocretin deficiency, with the latter condition diagnosed on the basis of hypocretin measurements in cerebrospinal fluid.
Functional impairments. Despite the leadership's wish to eliminate functional impairments and patient distress as necessary requirements for diagnoses, some of the DSM-5 workgroups found that they couldn't get rid of them.
For example, an autism diagnosis will still require "symptoms [that] together limit and impair everyday functioning." Similarly, proposed criteria for PTSD include "the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning."
Regier acknowledged to 鶹ý that impairments are part and parcel of some disorders, particularly those defined by neuropsychiatric deficits. But for many categories -- especially the personality disorders -- functional impairments were transferred from the checklist criteria into the dimensional assessments.
Disruptive Mood Dysregulation Disorder. This is the controversial new designation for children showing persistent foul temper punctuated by bursts of rage. When first proposed, it was widely derided as an attempt to medicalize "toddler tantrums" (even though the criteria clearly stated it was for children older than 5.)
But the workgroup stuck to its guns, although it did drop the name "temper dysregulation with dysphoria" that they had initially proposed.
Autism Spectrum Disorder. This was another controversial move, insofar as it combined Asperger's syndrome with overt autism, as well as two other DSM-IV categories, into a single disorder. Many in the autism community have been unhappy with the proposal -- one member of the workgroup in this area quit in protest -- but the remaining members were adamant that the change was justified and that many of the criticisms were simply wrong.
"Craving." A key innovation in the diagnosis of substance use disorders is a requirement that the patient report or demonstrate craving for the particular substance. Workgroup chairman Charles O'Brien, MD, of the University of Pennsylvania, said this is the key symptom that separates addiction from mere heavy use.
He added that a wealth of recent research has established that craving can be measured -- he had hoped that an objective test might be included in the DSM-5 criteria, but his workgroup felt it was not ready quite yet.
Premenstrual Dysphoric Disorder. Promoted from DSM-IV's appendix to be a full-fledged diagnosis in the depressive disorders family.
Binge Eating Disorder. Promoted from the DSM-IV appendix into the eating disorders.
WHAT DIDN'T MAKE IT
Not everything that was initially considered for DSM-5 ended up in the near-final draft reviewed at the APA meeting. Some proposals left by the wayside include the following.
Other addictions. Despite substantial pressure both within and outside psychiatry, the relevant workgroup rejected proposals to recognize addictions to sex, food, the Internet, and caffeine as diagnosable disorders.
O'Brien said the group recognized that, anecdotally, many people meet most of the criteria for addiction to these behaviors. But the DSM-5 emphasis on scientific justification precluded listing them. Said O'Brien, "We looked at sex addiction, but there was no science at all. None."
However, Internet gaming addiction will be listed in DSM-5's Section III, the equivalent of the DSM-IV appendix, indicating that more research is needed and wanted.
The word "addiction." In fact, it is not used in any DSM-5 names. Instead, they are labeled "use disorders," as in "opioid use disorder." O'Brien said this choice was made over his objection. "They're addictions," he said. "That's the word people are going to use." But others in his group thought the word "disorder" was less pejorative and stigmatizing.
Mixed anxiety-depression. Many patients present with both types of symptoms, creating a diagnostic dilemma -- are they anxious with depression or depressed with anxiety? Early in DSM-5 it was decided to split the difference and create a new diagnosis that included both.
But, as they say in Hollywood, it didn't test well with audiences. In particular, field trials of the proposed definition found that different clinicians interpreted the criteria differently, leading to reliability scores near zero. The condition will go into Section III in DSM-5.
Attenuated psychosis syndrome. This was to be the home for patients with low-level hallucinations and thinking disturbances. Proponents thought that, if someone comes to a psychiatrist with such symptoms, they should receive some type of treatment for which a diagnosis would be needed. Some research also suggested that these symptoms often -- though not always -- precede a full-blown psychotic episode.
But the concept was criticized because it might give patients who might never go on to more severe symptoms the "psychotic" label, and perhaps antipsychotic drug therapy, with little research to back up its effectiveness.
In the end, it was decided to put the condition in Section III after field testing failed to determine whether the criteria were reliable -- confidence intervals were too broad to mean anything.
Posttraumatic Stress Injury. Some in the military and veterans community had lobbied to replace the word "disorder" in PTSD's name with "injury," as less pejorative and permanent-seeming. The workgroup on trauma- and stressor-related disorders did not do so, but they did rewrite its definition considerably -- in particular, adding 9 dimensional assessments to the checklist criteria and splitting PTSD in children from PTSD in adolescents and adults.
Transgenderism as a V code. In seeking to destigmatize what was called gender identity disorder in DSM-IV, one proposal was to list it -- with or without a new name -- as a so-called V code. In DSM-IV, this was a chart code used to flag items of clinical interest that were not diagnosable or treatable conditions in their own right -- such as problems at school or noncompliance with treatment.
It was rejected, as were suggestions that the condition be dropped from DSM-5 altogether.
Other proposed diagnoses. Many additional conditions proposed for inclusion in DSM-5 will be placed in Section III with the hope of attracting more research. These include the following:
- Body integrity disorder (wanting healthy limbs cut off because "it feels right")
- Male-to-eunuch disorder (wanting surgery to become asexual)
- Hypersexual behavior (wanting to have sex all the time)
- Persistent Complicated Bereavement Disorder (prolonged or severe grief that does not meet criteria for major depression)
- Skin-picking syndrome
- Olfactory reference syndrome (believing one smells bad)
WHAT TO LOOK FORWARD TO
Publication of DSM-5 next May is not the end of the process. Here's a peek at what lies down the road.
Primary care version. When DSM-5 comes out, it will be a weighty document like its predecessors. Not only will it include the diagnostic criteria for many dozens of diseases, many of them rare, it will also come with long text explanations for each diagnosis that primary care physicians do not need for everyday practice. DSM-5 officials said they expect to produce a slimmer, trimmer primary care version in 2014.
Code changes. The DSM-5 will also include ICD-9 codes for the individual diagnostic codes, with codes for the U.S. implementation of ICD-10 included as well, probably in parentheses, Regier said.
But the recent delay in ICD-10's implementation -- at least until 2014, perhaps later -- creates some uncertainty for DSM-5.
Regier said that, although he had no inside knowledge, the government may decide to skip ICD-10 altogether, instead going straight to ICD-11, which is to be released internationally in 2015. If that were to happen, DSM-5 would likely be reissued with those codes.
He emphasized that the DSM-5 task force has been working with the developers of ICD-11 to ensure that their respective products are relatively synchronized.
New governance for continued revision. With the completion of what Kupfer has called "DSM-5.0" later this year, a structure within APA to oversee its subsequent revision -- expected to be a more continuous process than in the past -- must be created.
The APA's outgoing president, John Oldham, MD, said no plan has yet been developed for DSM-5.1 and beyond. He said the organization would begin to address that in the near future, although finishing version 5.0 remains the top priority.