APA Mulls Proposed Changes to DSM-5

Deborah Brauser

January 25, 2018

The American Psychiatric Association (APA) is considering five changes to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) in an add-on supplement that should be released later this year, the organization has announced.

The proposed changes include correcting International Classification of Diseases, Tenth Edition (ICD-10-CM) codes for several types of withdrawal; correcting the "omission of exclusion" of adjustment disorder in the definitions of other depressive and anxiety disorders; adding persistent trauma response to the list of examples under the heading, Other Trauma Disorders; adding "other types of hallucinations" in clinician-rated dimensions of psychotic symptom severity; and changing the wording from "sexual violation" to "sexual violence" in the trauma criteria for acute stress disorders.

These suggestions follow the first use of a process that allows anyone to suggest evidence-based changes to the manual, Philip Wang, MD, DrPH, deputy medical director and director of research at the APA, told Medscape Medical News.

Dr Philip Wang

A clinician will need to submit a proposal through the APA website, along with supportive data "documenting improvements in validity, evidence of reliability, and clinical utility," notes the organization.

"What you're seeing are the first proposals for revisions that have been disseminated in this new submission and review process," said Dr Wang. "We think this will really strengthen the scientific basis of any changes."

After "rigorous review" by a steering committee of experts, the current group of suggestions were posted on the APA's website with a 30-day public comment period that ended December 22. The proposals, along with a summary of the comments and further steering committee recommendations, will now be forwarded to the APA board of trustees for approval.

"Living Document"

The DSM-5 was first published by the APA as a 947-page manual in 2013, "after more than 10 years of effort by hundreds of international experts in all aspects of mental health," the organization notes.

In addition to the desk reference, the full library includes a DSM-5 guide to clinical cases, a study guide, and a pocket guide to child and adolescent mental health. In addition to a Spanish version of the full manual, 18 other translations are currently underway, including Chinese, French, German, Japanese, and Portuguese translations. There is also an interactive mobile app.

Changes to criteria and text in 2014 and 2015 were posted as approved on the APA's website and were collected in a 2016 supplement available as a PDF file or through the app. Also, a 56-page supplement was created in October 2017 to include the latest ICD-10-CM updates.

Two years before the publication of the desk reference, David Kupfer, MD, chair of the DSM-5 Task Force, told Medscape Medical News that it was important for the manual to be "a living document" that was easier to revise and that was both clinician- and education-friendly.

"We are determined to make the DSM-5 and its updates the most useful DSM that we've had so far," said Dr Kupfer at the time.

Dr Wang agrees, noting that revisions can now be submitted and made without waiting for set intervals.

"You don't have to wait a decade or 15 years anymore. You don't have to wait for a DSM-6," he said. "We hope this will allow changes to go through that are necessary and useful and that will help patients and help clinicians."

Five New Proposals

In the new group of suggested changes, proposal 1 seeks to add the following ICD-10-CM codes:

  • F11.93 for opioid withdrawal in the absence of an opioid use disorder,

  • F13.93 for sedative, hypnotic, or anxiolytic withdrawal, and

  • F15.93 for amphetamine or other stimulant withdrawal.

The above solutions "include medications taken under appropriate medical supervision and that have the potential to cause physiological dependence," states the proposal. In these cases, "an individual may develop withdrawal symptoms in the absence of a substance use disorder."

Proposal 2 would add versions of the phrase "...and do not meet criteria for adjustment disorder with depressed mood or with anxiety or adjustment disorder with mixed anxiety and depressed mood" to the definition sections for Other Specified Depressive Disorder (311), Unspecified Depressive Disorder (311), Other Specified Anxiety Disorder (300.09), and Unspecified Anxiety Disorder (300.00).

Proposal 3 would add a new example of possible presentations under Other Specified Trauma- and Stressor-Related Disorder (309.89): persistent response to trauma with symptoms reminiscent of postraumatic stress disorder (PTSD). Such symptoms include those that last longer than 6 months but don't meet the diagnostic threshold for PTSD itself.

In proposal 4, the phrase "or other types of hallucinations" would be added to the scores of 2 (mild), 3 (moderate), and 4 (severe) under the hallucinations domain on the Clinician-Rated Dimensions of Psychosis Symptom Severity chart.

This clarifies "that the rating is based on the severity of any type of hallucination that may be present" and is not based only on hearing voices.

Finally, proposal 5 calls for correcting an error in wording in diagnostic criteria A for Acute Stress Disorder (308.3). It strives to change "sexual violation" to "sexual violence," to match the criteria for PTSD. The new phrase will read, "Exposure to actual or threatened death, serious injury, or sexual violence in one (or more) of the following ways...."

"Strong Scientific Footing"

In the future, clinicians who want to suggest additional changes or clarifications to the manual should submit a proposal through the APA's website.

"Changes will be made on a rolling basis, as warranted by advances in the science of mental disorders," writes the organization.

Dr Wang noted that four main types of revisions can be proposed: changes to existing diagnostic criteria for a disorder, addition of a whole new diagnostic category or specifier, deletions of an existing category or specifier, and corrections/clarifications.

"There's a pretty clear submission form. Investigators have to give the reasons for their proposed change, and they have to describe the magnitude of the change," he said.

"What's new and helpful about the process is that the person also needs to give well-spelled-out data to support the reliability and utility of the change, as well as possible unintended consequences."

Those proposals with "sufficient supporting evidence" will then be made available for public comment.

"We think all of this will help ensure a strong scientific footing, as well as transparency," said Dr Wang.

The current proposed changes are posted in detail on the organization's website.

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