Susan Jeffrey

May 26, 2009

May 26, 2009 (San Francisco, California) — Work toward a fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) is progressing, and although efforts are still ongoing to thrash out a variety of contentious issues, field trials of some of the new diagnostic criteria are expected to begin soon.

Dr. David Kupfer

David Kupfer, MD, from the University of Pittsburgh School of Medicine, in Pennsylvania, and chair of the DSM-V task force, told attendees here at the American Psychiatric Association (APA) 162nd Annual Meeting that the task force and working groups are considering the design of these field trials and trying to prioritize which are the most urgent questions to be answered, so that the feasibility and clinical utility of newly revised diagnostic criteria can be "test-driven" in the field.

"As you can see, the clock is ticking, and we need to begin these really very soon after the APA meetings, because we really need to complete them by 2010," said Dr. Kupfer. Field trials could include use of "gold-standard" patients, where video clips are generated of either real patients or actors portraying patients to illustrate particular diagnoses, he noted, although more traditional approaches are also being considered.

The timetable remains the same, though, with a target of publication in 2012. "Most of us involved would like a couple more years, but we know that's not going to happen," Dr. Kupfer said. The "only thing we also have going for us," he added is the potential to make DSM-V a "living document," allowing rapid updates as important future research findings become available.

Dimensional Assessments

One of the biggest changes anticipated in the DSM-V is the addition of dimensional assessments, William Narrow, MD, research director of the DSM-V task force for the APA, told Medscape Psychiatry.

"The extent to which it will be incorporated into the DSM has not been decided finally, but we definitely expect that the DSM-V will go beyond what DSM-IV and DSM-III gave us, which was categorical assessments with strict diagnostic criteria," Dr. Narrow said. "We're expecting that we'll be giving clinicians and researchers the opportunity to assess their patients beyond the strict categories and to use dimensional assessment of severity of a range of different symptoms that go along with these disorders."

For example, clinicians would be able to assess the extent of anxiety that comes with major depressive disorder. "Currently, there are no anxiety criteria in the assessment of major depressive disorder, although we know that anxiety and depression often travel together — they're highly comorbid."

Other likely new aspects include the notion that there is development of psychiatric conditions across the lifespan, and more attention is being given to cross-cultural issues, Dr. Kupfer added. "Even though this is not a guide that is for the world, it is used around the world," he told Medscape Psychiatry in an interview. "But even within the United States, we have so much diversity that we have to begin to account for it and also take a much harder look at how the criteria are set up for women vs men."

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Dr. William Narrow Discusses Progress of DSM-V

There is also discussion on the overall "matrix" around which the diagnostic manual is predicated, including how to organize various disorders in relation to each other. "We need to maintain a continuity with previous editions; on the other hand, given the fact that there are so many advances and so much has happened since 1994, we have set up no a priori constraints on the degree of change that might eventually occur between DSM-IV and DSM-V," he said.

Thorny Issues

Before the manual can be completed, though, a host of thorny questions remain to be answered. One of these issues was reflected in a symposium here, which was given over to the dilemma of whether or not to include gender-identity disorder as a diagnosis in DSM-V. To many, including protesters who met outside the Moscone Center here, "different is not a disease."

Dr. Narrow said that the APA has been receiving feedback from the transgender community since the work groups for the DSM-V were announced at last year's annual meeting. "There's a lot of concern about the treatment that gender-identity disorder entails and also concern about the disorder itself," Dr. Narrow said. "Is it actually a mental disorder vs a physical disorder, or is it a normal variation of human behavior?"

The APA DSM-V work group has been "listening very closely to these concerns, and I think we do understand them and are working very hard to address them," he added. The symposium here was another opportunity to meet with leaders of the transgender community about these issues.

He feels, though, that the real controversy is less about the diagnosis and more about the treatment, particularly of children, he said. For adults, the treatments, including hormone therapy and surgery, are not typical psychiatric treatments and indeed are not done by psychiatrists.

These issues those do not relate to diagnosis, which is where the DSM-V working group's focus lies, he pointed out. "Of course, diagnosis and treatment are linked, but the DSM doesn't give treatment guidance on any disorder. I think it's much easier to come to an understanding on the diagnosis," he added. "Whatever's decided, not everyone is going to agree with it, but I just think the level of emotion around the diagnostic issues is a little bit less."

During this process, however, it has become clear to the APA that the treatment of gender-identity disorder has not been well synthesized, Dr. Narrow notes. A separate task force has been established to review the evidence base to see whether the literature is sufficient to develop a treatment guideline.

Dr. Jack Drescher

Jack Drescher, MD, from New York Medical College, State University of New York (SUNY)–Downstate New York University and a member of the sexual- and gender identity–disorders work group, explained why gender-identity disorder was put in DSM-III in 1980. "At the time, most psychiatrists didn't believe that there was such a thing as a transsexual as a phenomenon where the treatment is reassignment," he told Medscape Psychiatry. "So the actual motivation for putting it into the diagnostic manual was to try to create access to care."

The guiding principle in medicine is first, do no harm, he said. "The harm of retention of the diagnosis is stigma, and the harm of removal is potential loss of access to care," Dr. Drescher said. "So that's the dilemma, how to create a situation where access can be not only available but increased, and discrimination can be reduced. How we'll resolve that remains to be seen."

Pilgrim's Progress

During the DSM-V symposium, members of 3 of the working groups were called on to update attendees on their progress and touched on some of the sticking points they have been experiencing.

Katherine A. Phillips, MD, from Butler Hospital and the Alpert Medical School of Brown University, in Providence, Rhode Island, is chair of the anxiety-disorders working group, an umbrella that includes obsessive-compulsive spectrum disorders as well as posttraumatic and dissociative disorders.

One potential change being considered by their group is what might be called "supraordinate dimensions," she said, that would apply to all patients regardless of their diagnosis. One possible such dimension is anxiety, which can be relevant to all patients, and perhaps specifically panic attacks. "Panic attacks are a marker of greater severity of illness and greater morbidity," she noted. Other dimensions that might be added include severity or level of avoidance.

"We are thinking about the possibility of adding dimensional specifiers to [obsessive-compulsive disorder] OCD that are specific to OCD," she noted. A large body of evidence suggests that hoarding and contamination are dimensions of OCD, she noted, but they are also considering the addition of hoarding as a separate diagnosis in DSM-V. "It differs in some important ways from OCD," Dr. Phillips said.

Posttraumatic stress disorder is being looked at particularly closely because "there's a huge amount of new data," she added. Here, developmental dimensions may have to also be considered closely, and a field trial of their diagnostic criteria in this area will certainly be done, she said.

Dr. William Carpenter

William T. Carpenter, Jr., MD, from the University of Maryland in Baltimore and head of the psychotic-disorders work group, which includes schizophrenia, outlined several main changes being considered in this area that might be controversial.

One of these questions is whether to retain schizoaffective disorder as a diagnostic entity. "We had hoped to get rid of schizoaffective as a diagnostic category because we don't think it's valid and we don't think it's reliable," he said. "On the other hand, we think it's absolutely indispensable to clinical practice," he added wryly, drawing a laugh from the audience.

In field trials, they hope to try to modify the criteria for this diagnosis to see whether they can make it more reliable and simultaneously will test dimensions, such as reality distortion, disorganization of thought, cognitive impairment, depression, mania, and anxiety, in an effort to capture what clinicians may need to know without having to use "what is perhaps not a valid scientific entity such as schizoaffective."

They also plan to propose the addition of a risk syndrome for psychosis paralleling others in medicine such as hyperlipidemia or hyperglycemia. There's "a whole growth industry in our field," Dr. Carpenter noted, in identifying the prodrome to psychosis in young people at high risk for conversion to psychotic disorders, including schizophrenia.

"It's probably critical that we have a way to identify these clinically, to move to an earlier intervention, but there are questions about how you distinguish them from the normal [healthy] population and whether can we do this without creating more harm than good. The immediate concern is stigma and the possibility that there would be use of antipsychotic medications where the risks substantially outweigh the benefit."

Dr. Jan Fawcett

Finally, Jan Fawcett, MD, from the University of New Mexico School of Medicine, in Albuquerque, chair of the mood-disorders work group, reported on their progress. "In general, the problems we're grappling with in the mood disorders are boundary problems," Dr. Fawcett said. For example, the boundary between bipolar and unipolar disorder is an issue "of great contention" in the literature, he pointed out.

The mood-disorders group also includes a subgroup looking at the problem of how to help clinicians categorize degree of suicide risk," he noted, "trying to come up with some sort of a mechanism for doing that."

In this setting, 1 of the main dimensions being considered is that of anxiety. "As you know, the predictors of outcome of mood disorders are often things like anxiety," he noted. "We know that the presence of high anxiety in depression is showing more and more to predict suicidal behavior."

Biomarkers Not Ready for Prime Time?

One aspect that is early in its evolution but where the literature is being examined closely is the potential for incorporating biomarkers and genetic information in the diagnosis of psychiatric disorders.

"We are giving a lot of thought to that," Dr. Phillips said. "There have been such amazing advances in neuroscience, and yet, is the field ready to incorporate endophenotypic information, neurobiological information? Our thinking is to incorporate it to the extent that we can. I think this varies depending on which disorders you're talking about, but speaking for our work group, it's not clear that there are enough replicable, sensitive, specific findings from neurobiology that would allow us to incorporate findings directly into the diagnostic criteria, but our literature reviews are still in progress."

She suggested that the text of the manual would be a great place to incorporate this kind of information and eventually may help in optimally grouping disorders in future editions of DSM.

Dr. Kupfer pointed out that the working group looking at diagnostic criteria for neurocognitive disorders, such Alzheimer's disease, other dementias, and mild cognitive impairment, includes neurologists as well as psychiatrists, "and it's very exciting to see the back and forth with this," he said.

This also has implications for the International Classification of Diseases, where the physical aspects of Alzheimer's disease are listed in the neurology section and the behavioral aspects in the mental-health section, Dr. Kupfer added. He is hoping there will not just be "crosswalks" between these conditions in the new manual, but a much more integrated approach, he said.

The APA has launched a Web site to track the development of the manual; background information as well as working group reports are posted at http://www.dsmv.org.

American Psychiatric Association 162nd Annual Meeting.

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