DSM-V draft open for comments until April 20, 2010

By James Bradshaw, Senior Editor
March 1, 2010 - Last updated: May 31, 2011

The long-awaited draft of the DSM-V was released Feb. 10, giving critics more than three years to grouse before the scheduled publication in May 2013 – but only two months to offer initial suggestions for revisions.

The draft of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) is open for all to review and to submit written comments at www.dsm5.org until April 20.

The 13 work groups that prepared the draft will then consider revisions, and field trials will be conducted in three phases over the next two years to permit further refinement.

The final draft of “the Bible” for diagnosing mental disorders is to be submitted to the assembly and board of trustees of the American Psychiatric Association (ApA) for review and anticipated approval in 2012.

ApA President Alan Schatzberg, M.D., stressed that the manual remains “very much a work in progress” that is open for further revision after receiving suggestions from all types of mental health practitioners, including psychiatrists, psychologists, social workers, therapists and counselors, including those who treat alcoholism, drug addiction and problem gambling.

The ApA publicized posting the draft for comments through a series of news releases, press conferences and an hour-long telebriefing for reporters Feb. 9 with Schatzberg and 10 leaders of the DSM task force and working groups. (Interestingly, all material, including the website itself, refers to the proposed revision as “DSM-5” rather than the traditional “DSM-V,” which uses the Roman numeral designation.)

David J. Kupfer, M.D., chair of the DSM-5 Task Force, said it is hoped the revised edition will take into account “what was and was not working well” in the DSM-IV while maintaining continuity wherever possible.

Kupfer also emphasized that “dimensional assessments” of the severity of symptoms are being added to many disorders to take into account “cross-cutting” in which many symptoms, such as insomnia or anxiety, exist across a number of different diagnoses.

Kimberly Yonkers, M.D., chair of the gender and cross-cultural study group, said every effort was made to be sensitive to and aware of concerns that racial, gender or cultural differences can affect presenting symptoms in many disorders.

Schatzberg said a comment period of just over two months may seem abbreviated, but the enhanced communication capability of the Internet will allow broader input from mental health practitioners and academics in all fields compared to previous DSM editions when printed copies of drafts were distributed only to a select audience or those who specifically requested them.

Major proposed changes underscored are:

  • A single diagnostic category of “autism spectrum disorders” to incorporate current diagnoses of autistic disorder, Asperger’s disorder, childhood disintegrative disorder and pervasive developmental disorder (not otherwise specified). Severity would be gauged both by IQ and impairments in adaptive functioning. It is also suggested that the term “mental retardation” be changed to “intellectual disability.”
  • Replacing the current categories of substance abuse and dependence with “addiction and related disorders.” The intent is that eliminating the category of dependence may allow better differentiation between the compulsive drug-seeking behavior of addiction and normal responses of tolerance and withdrawal sometimes associated with prescribed medications.
  • Creating a new category of “behavioral addictions,” in which gambling will be the sole disorder. Internet addiction, which fell short of inclusion because of insufficient research data, is recommended to be outlined in the appendix to encourage further study.
  • New suicide scales for adults and adolescents to help clinicians identify those most at risk across a broad spectrum of mental disorders. David Shaffer, M.D., a member of the work group on disorders in childhood and adolescence, pointed out for example that heavy drinking and impulsive behaviors in young males are clearly associated with increased risks of suicide.
  • Consideration of a new “risk syndromes” category to help identify earlier stages of disorders such as neurocognitive disorder (dementia) and psychoses such as schizophrenia.
  • A new diagnostic category, temper dysregulation with dysphoria within the Mood Disorders section of the manual, which it is hoped will help better differentiate children with these symptoms from those with bipolar disorder or oppositional defiant disorder.
  • Recognition of binge eating disorder and improved criteria for diagnosing anorexia nervosa and bulimia nervosa.

George M. Kapalka, Ph.D., an associate professor at Monmouth University in West Long Branch, N.J., who wrote an article for the November/December issue of The National Psychologist commending the value of the DSM despite its faults, reviewed the draft quickly to meet this edition’s deadline and found benefits and weaknesses.

An area that he found “most disturbing” is the proposed definition of mental illness, which specifies a disorder must reflect an underlying “psychobiological” condition. Kapalka said specifying a biologic component could be interpreted as furthering the contention that all mental illnesses are “biologic” and best treated by mental health professionals with medical backgrounds, i.e. psychiatrists.

He said he also has questions about the risk syndromes category. “This is extremely controversial,” Kapalka said. Such diagnoses raise issues such as what is the rate of false positives and the risks of improperly treating those falsely diagnosed. Problems could arise from improper treatment or simply from the labeling effects of a diagnoses.

He said there are areas of definite improvement, for example, recognizing the diagnosis of binge eating that was in the DSM-IV only as an appendix item warranting further study. He said the new category of anxiety and compulsive-obsessive disorder also can be a better way to look at overlapping symptoms of disorders formerly listed separately.

Another major change Kapalka approved of is the proposed replacement of the three-cluster classification of personality disorders with one employing five divisions: antisocial/psychopathic, avoidant, borderline, obsessive/compulsive and schizopypal. He said the diagnosis of schizoid will be subsumed into schizopypal.

If the change in diagnoses for children reduces the number of children labeled as bipolar that will be a great help in reducing the overmedication of children, Kapalka said.

He said past DSM editions demonstrate that there can be substantial changes between drafts and the final versions, and non-psychiatrists who treat mental disorders should make a strong effort to influence the outcome in areas they consider important.

“I think it would be beneficial for APA (American Psychological Association) to form a task force or committee to study this,” Kapalka said.

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