APA Releases Proposed Draft of the DSM-5

Caroline Cassels

February 10, 2010

February 10, 2010 — The long-awaited draft of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has been released by the American Psychiatric Association (APA).

The draft of the new edition, which represents a decade of work by the APA in reviewing and revising the DSM, is now available for public review and comment on the DSM-5 Web site (www.dsm5.org) until April 20. After that it will be further reviewed and refined before the APA conducts 3 phases of field trials to test some of the proposed diagnostic criteria in real-world settings before the final version is published in May 2013.

"This has been a massive effort on the part of a very dedicated team and is now ready for review. It is important to remember that this is not a final document — the DSM-5 is still a work in progress. As we now enter the next phase of this process, we are inviting health professionals, consumers of mental health services, and their family members to visit the [DSM-5] Web site to review and comment on the draft criteria," David J. Kupfer, MD, chair of the DSM-5 Task Force, told reporters attending a press conference.

Members of 13 work groups, representing different categories of psychiatric diagnoses, have reviewed a wide body of scientific research in the field and consulted with a number of expert advisers to arrive at the proposed revisions to the manual.

The proposed revisions include the following:

  • A new category of autism spectrum disorders and a name change for mental retardation;

  • Elimination of the current categories of substance abuse and dependence and replacing them with the new category addiction and related disorders;

  • Creating a new category of behavioral addictions, in which gambling will be the sole disorder;

  • New suicide scales for adults and adolescents to help clinicians identify those individuals most at risk;

  • Consideration of a new risk syndromes category, with information to help clinicians identify earlier stages of some serious mental disorders, such as dementia and psychosis;

  • A proposed new diagnostic category, temper dysregulation with dysphoria (TDD), within the Mood Disorders section of the manual; and

  • New recognition of binge eating disorder and improved criteria for anorexia nervosa and bulimia nervosa.

Dimensional Assessments

In addition to proposed changes to specific diagnostic criteria, the APA is proposing that "dimensional assessments" be added to diagnostic evaluations of mental disorders. These assessments would allow clinicians to evaluate the severity of symptoms, as well as take into account "cross-cutting" symptoms that exist across a number of different diagnoses.

According to Darrel A Regier, MD, MPH, vice chair of the DSM-5 Task Force, one of the major challenges in accurately diagnosing mental health disorders is that the diagnostic criteria can sometime be too limiting.

In the current edition of the DSM, accurate diagnosis of a specific disorder hinges on meeting a specific list of symptoms that have lasted for a specific period. "Patients either meet the diagnostic threshold or they don't," said Dr. Regier.

But this approach, he added, does not always reflect the reality of mental illnesses, which often have a wide range of crossover symptoms. For instance, he said, an individual with schizophrenia may also present with insomnia or symptoms of depression and anxiety.

"These symptoms aren't part of the diagnostic criteria [for schizophrenia], but they can still affect patients' lives and treatment planning," said Dr. Regier.

Including dimensional symptoms would allow clinicians to more accurately capture individual patients' clinical status. In addition, the DSM-5 Task Force is also proposing more quantitative measures of mental disorders. Currently, said Dr. Regier, there is no way to assess severity of mental disorders and therefore no specified way of quantifying improvement.

"These are limitations that we are trying to address by having more quantitative measures on a continuum with cutoffs which would enable [clinicians] to assess whether or not a patient is in the mild, moderate, severe, very severe range," he said.

Furthermore, he added, such a rating scale would help physicians track patients' progress and encourage mental health professionals to document all symptoms and not just those tied to the primary diagnosis.

Name Change

The draft DSM-5 also includes a new category of autism spectrum disorders that will incorporate the current diagnosis of autistic disorder, Asperger's disorder, childhood disintegrative disorder, and pervasive developmental disorder (not otherwise specified).

According to Edwin H. Cook, MD, a member of the Neurodevelopmental Disorders Work Group, this proposed new category reflects the work group's recognition that "the symptoms of these disorders represent a continuum from mild to severe rather than being distinct disorders."

The work group is also recommending that the diagnostic term mental retardation be changed to intellectual disability to bring the DSM-5 in line with terms used in other disciplines.

Addiction and Related Disorders

The DSM-5 proposed revisions also include eliminating the current categories of substance abuse and dependence and replacing them with a new category of addiction and related disorders. This will include substance use disorders, with each drug identified as a category, such as alcohol use disorder.

According to Charles P. O'Brien, MD, PhD, chair of the Substance-Related Disorders Work Group, the term dependence is misleading because it is often confused with addiction, when in fact the tolerance and withdrawal patients experience are normal responses to prescribed medications that affect the central nervous system.

This term, said Dr. O'Brien "caused a lot of confusion and caused a lot of people with pain to be undertreated, and so we're eliminating that bad terminology," said Dr. O'Brien.

The work group is also recommending a new category of behavioral addictions, in which gambling would be the sole disorder. On the basis of current research, which includes evidence of brain and behavioral changes, said Dr. O'Brien, members of the work group thought that gambling disorder should be included in this category. Internet addiction was also seriously considered, but it was decided that at this time it does not meet diagnostic inclusion criteria. However, the work group is recommending that Internet addiction be placed in the DSM-5 appendix to stimulate future research, he said.

In addition, said Dr. O'Brien, there is a proposed new category separate from substance use disorder — miscellaneous discontinuation syndromes. This will include 2 categories of antidepressant medications — tricyclic and selective serotonin reuptake inhibitors.

This phenomenon occurs when an individual is not "addicted" in the sense that they engage in compulsive drug-seeking behavior but rather when they abruptly stop a medication and experience unpleasant, sometimes serious withdrawal symptoms.

New Suicide Scales

The proposed DSM-5 will include 2 new suicide scales for assessing suicide risk — one for adolescents and one for adults. According to David Shaffer, MD, a member of the Disorders in Childhood and Adolescence Work Group, there are a number of scales used to evaluate suicide, and evaluation of suicide risk is not always included in the written record.

The use of a single research-based scale and accompanying record of assessment may help clinicians better assess suicide risk and lead to earlier identification and treatment of mental disorders, said Dr. Shaffer.

Dr. Shaffer announced that the work group is also recommending a new diagnostic category of TDD within the Mood Disorders section of the manual. Criteria for the proposed diagnosis of TDD include severe, recurrent outbursts of temper occurring 3 or more times per week that are grossly out of proportion to the situation or provocation that interferes significantly with functioning. Between outbursts, the child's mood is persistently negative — irritable, angry, and/or sad. Only children older than 6 years will be assigned the diagnosis, and children with distinct manic episodes found in bipolar disorder will be excluded.

Risk Syndromes Category

In a bid to facilitate earlier diagnosis of mental disorders, the APA is also considering adding a risk syndromes category. This category would include psychosis risk syndrome and minor neurocognitive disorder.

"Given the severity of psychotic disorders and the evidence that early treatment may mitigate long-term consequences, we believe it is important to help clinicians begin to recognize these conditions as early as possible," said William Carpenter, MD, chair of the Psychotic Disorders Work Group.

However, said Dr. Carpenter, the work group is recommending that the risk syndrome designation be made only for individuals whose symptoms are distressing or disabling enough to lead to seeking help.

During the next 2 years, said Dr. Carpenter, his group will determine whether there is sufficient research data to warrant inclusion of psychosis risk syndrome in the final edition of the DSM-5 or whether it should be included in the manual's appendix for further study.

The APA is also considered a new diagnosis of minor neurocognitive disorder to identify individuals at greatest risk for dementia. Ronald Petersen, MD, PhD, a member of the Neurocognitive Disorders Work Group, said this patient population would include those who do not meet criteria for major neurocognitive disorder (dementia) but who are at risk of progressing in the future.

"We are proposing to put some cognitive standards on the degree of impairment and make sure the person has had a decline from a previous level of function. The rationale for pursuing this in neurocognitive disorders comes from the fact that a great deal of research in recent years has shown that these risk syndromes, like mild cognitive impairment, are likely to progress to major neurocognitive disorder, and we may be able to intervene at an earlier stage to prevent damage to the central nervous system.

Dr. Petersen pointed out that although currently there are few pharmaceutical treatments for dementia, a growing body of data indicate that lifestyle modifications may be useful in slowing or preventing disease progression, particularly in the early stages.

Binge Eating Disorder Officially Recognized

Finally, the APA is calling for binge eating disorder to be officially recognized in the DSM-5. Timothy Walsh, MD, chair of the Eating Disorders Work Group, said binge eating disorder is distinct from the overeating that plagues many Americans and has unique psychological characteristics.

Individuals who currently present to clinicians with this condition receive a diagnosis of eating disorder (not otherwise specified). On the basis of an extensive body of research, the characteristics, course, and outcomes of binge eating disorder have been well described.

"We are quite confident that compared to other folks [who overeat] and struggle with weight, people with binge eating disorder are clearly more distressed, have more symptoms of anxiety and mood disturbance, and a lower quality of life. There are indications that their treatment may be better provided if it is done in a somewhat different way than other folks with similar weight problems, so it is for these reasons that the Eating Disorders Work Group is recommending that binge eating disorder now be formally recognized in the DSM-5," said Dr. Walsh.

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