Major Restructuring Proposed for DSM-5

Deborah Brauser

May 04, 2011

May 4, 2011 — Clinicians will notice a significant new structuring of chapters and categories in the upcoming Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), the American Psychiatric Association (APA) announced today.

The APA has released a newly proposed organizational framework for the DSM-5 on its Web site and is inviting comments through June 15 from anyone who plans to use the manual for diagnostic and research purposes.

"The revisions reflect the knowledge we have gained since the last DSM was published in 1994. They should facilitate more comprehensive diagnostic and treatment approaches for patients and encourage research across diagnostic criteria," said David Kupfer, MD, chair of the DSM-5 Task Force, in a release.

"The sequence of chapters builds on what we have learned about the brain, behavior, and genetics over the past decades," added Steven Hyman, MD, former director of the National Institute of Mental Health and member of the DSM-5 Task Force, in the same release.

More Developmentally Focused

There are currently 16 chapters in the DSM-IV, representing 16 major diagnostic classes. The proposed revisions for the new manual would reorder these chapters to better reflect both underlying vulnerabilities and symptom characteristics.

In other words, the new chapters will be arranged "by general categories, such as neurodevelopmental, emotional, and somatic, to reflect the potential commonalities in etiology within larger disorder groups," according to the release.

Although some disorders will now be located under these more comprehensive headings, others will be "broken out" from categories they have been listed under in the past. For example, obsessive-compulsive disorder will now be grouped with other conditions involving neurocircuitry instead of under the heading "anxiety disorders."

In addition, schizophrenia and schizotypal personality disorder will be grouped under "schizophrenia spectrum."

This spectrum designation "is supported by studies showing how these disorders tend to aggregate within families," said Darrel Regier, MD, MPH, vice-chair of the DSM-5 Task Force.

"It will help clinicians to correctly diagnose patients by making clear the common features that fall within the spectrum," added Dr. Regier, who is also the executive director of the American Psychiatric Institute for Research and Education.

As part of its goal to make the manual more developmentally focused, the DSM-5 will also integrate several conditions previously listed under the "disorders usually first diagnosed in infancy, childhood, or adolescence" into other chapters.

14 Years of Work

During a public review period last year of an early manual draft, the APA received more than 8000 written responses from clinicians, researchers, and family and patient advocates. These responses contributed to the new framework reorganization.

As reported last October by Medscape Medical News, field trials are currently being conducted to test the new diagnostic criteria in real-world settings and will be followed by another public comment period.

The final DSM-5 framework and diagnostic criteria are scheduled to be determined by 2012. After undergoing review and approval by the APA's Board of Trustees, publication is expected in 2013 — making it a 14-year project.

"At every stage, DSM-5 is benefitting from a depth of research and a breadth of expertise and diverse opinions that will immeasurably strengthen the final document," concluded Dr. Kupfer.

The proposed new framework for DSM-5 is located on the APA's Web site.

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