The Pittsburgh Post-Gazette asked the American Psychiartic Association to comment on the new DSM 5. Here are the answers provided by Dr. William Narrow, research director for the DSM 5 Task Force.
What is the basic motivation for developing a DSM-V? In other words, why isn't the DSM-IV sufficient?
The process of revising DSM is not new; the manual has been periodically reviewed and revised since it was first published in 1952. The basic motivation behind these revisions is to ensure that the manual (and hence clinical care and research) keep pace with advances in our scientific understanding of psychiatric disorders. By defining mental disorders more accurately, we will be able to improve diagnosis and care. Revisions also facilitate new research which can improve our understanding of how mental disorders develop and present as well as how best to treat them.
The latest version of DSM (DSM-IV) was completed nearly two decades ago. It is no longer considered up-to-date because, since that time, there has been a wealth of new research and knowledge about the prevalence of mental disorders, how the brain functions, the physiology of the brain, and the lifelong influences of genes and environment on a person's health and behavior. In order to provide the most effective care for patients and to generate research that effectively strengthens our understanding of psychiatric disorders, the manual must be revised to reflect these advancements.
Some groups have recently criticized proposed revisions in the DSM-V out of fear they will lead to overdiagnosis of disorders that they feel do not have a strong evidence-based foundation, or overprescription of medications to treat those disorders. In particular, they are concerned about the categories of disruptive mood dysregulation disorder, and attenuated psychosis syndrome. Could you comment on why these categories have been added to the manual and whether you think they have a solid basis in clinically observed behavior?
Members of the DSM-5 Task Force and 13 Work Groups are mindful of concerns about misdiagnosis and inappropriate use of medication in clinical settings. This is precisely why, before deciding to include a proposed diagnosis or adopting a proposed change in a diagnosis, draft proposals are thoroughly vetted to ensure they are based on scientific findings (e.g., literature reviews, existing data sets). Furthermore, the DSM-5 Field Trials provide a rigorous testing of many proposals in "real world" clinical settings with actual patients and practitioners. Findings from these field tests will play a large role in the decision-making process of whether to adopt a proposed change. At this point, no proposals -- including those for disruptive mood dysregulation disorder and attenuated psychosis -- have been added to the manual.
Disruptive mood dysregulation disorder (DMDD) and attenuated psychosis syndrome (APS) are among the disorders that were examined in the DSM-5 Field Trials and have been the topic of lengthy discussion among work group and task force members. DMDD is a diagnosis that characterizes a group of highly symptomatic and disabled children who cannot be easily diagnosed through DSM-IV. (In other words, these are children whose behaviors go well beyond having typical "temper tantrums.") It is suspected that because of the lack of a better diagnosis, these children have been diagnosed as having bipolar disorder, which has contributed to the surge in pediatric bipolar diagnoses over the past two decades, and concerns about inappropriate treatment. The need for a better diagnosis and treatment for these children is being examined along with the level of scientific evidence for the new disorder, in order to make a final decision as whether DMDD should be added to the main section of the manual or whether it should be considered as a potential disorder needing further research. Results from the field trials will contribute to this decision.
Regarding attenuated psychosis syndrome, it is clear that a prodromal state does exist for schizophrenia such that individuals experience subtle changes in thinking, behavior, and social functioning as the psychotic disorder develops. The clinical difficulty is that the prodromal phase of schizophrenia can mimic the early phases of other mental disorders. However, formal designation of an attenuated psychosis syndrome in DSM would mean a greater likelihood that clinicians will recognize the syndrome (a combination of low-level psychotic symptoms, distress, social dysfunction, and treatment-seeking), and be able to follow the symptoms over time and intervene when needed. Many clinical centers around the world are seeing such patients and studying their outcomes and how to treat them. Such treatments have involved family supportive therapy, psychotherapy, Omega-3-Fatty Acids, and some psychotropic medications. Because of potential long-term side effects, the current practice has generally been to withhold antipsychotic medication treatments for patients with this syndrome until a full psychotic disorder emerges--currently in about 20% of patients with this syndrome. As with all proposals that were field tested, the reliability, feasibility, and clinical utility of this draft diagnosis is still being examined, and no firm decisions will be made until later this year.
Do you think the final form of the DSM-V will differ substantially from the current draft version?
There is currently no draft version of DSM-5. The information on the DSM-5 Web site consists of proposed DSM-5 diagnostic criteria and assessment instruments, along with rationales for all changes that have been proposed. The first draft version of the DSM-5, which also includes explanatory text for each disorder and introductory chapters, is currently being developed. We anticipate that many of the proposed changes will be officially adopted. Most notable among these is the proposed change in chapter organization to better reflected a developmental, lifespan approach as well as purported neuroscientific and genetic linkages between diagnostic categories (e.g., placement of the psychosis chapter alongside the bipolar disorders chapter, then followed by the mood disorders chapter). We also anticipate that the proposed inclusion of dimensional assessments will be accepted for DSM-5, although these too were field tested and results are currently being examined. Proposed changes that are considered minimal (e.g., minor changes in wording or criteria) that did not require field testing and, at this point, appear to be sufficiently supported by findings from the literature have a high likelihood of being adopted.
Are there particular areas of the DSM-V that you anticipate will be changed, and if so, in what way?
In addition to the changes noted in the question above, we anticipate that the diagnostic category for personality disorders will likely undergo significant revision. The Personality and Personality Disorders Work Group have put forth proposed criteria that define personality pathology in a broader, more dimensional manner than the current "yes/no" approach in DSM-IV (that is, you either have a personality disorder or you do not; there is not currently a way to characterize a patient's personality traits and features in a detailed and clinically meaningful way). These changes would still allow clinicians to diagnose personality disorders currently recognized by DSM-IV (e.g., antisocial, borderline, narcissistic, schizotypal, avoidant). However, if adopted, the revised personality disorders section would allow clinicians to rate other important factors such as personality traits. It is important to emphasize that these changes have not been officially adopted. However, it is likely that this section of the manual will undergo revision to some degree -- the extent of which is largely dependent on field trial outcomes.
Another area likely to undergo change concerns the neurodevelopmental disorders. Inclusion of the proposed diagnosis of autism spectrum disorder better reflects the fact that symptoms of these disorders (i.e., autistic disorder, Asperger's disorder, pervasive developmental disorder not otherwise specified, and child disintegrative disorder) occur on a continuum from mild to severe, rather than as separate, distinct conditions. This proposal should also help clinicians make the diagnosis more accurately, and in particular, alleviate difficulties in correctly diagnosing Asperger's disorder caused by DSM-IV's unclear criteria. Furthermore, it should assist researchers in better understanding these disorders and develop appropriate and effective treatment. Although we anticipate this change will be supported by the field trials as it is by the scientific literature, it too is still under examination and no firm decisions have been reached as of yet.
As a final example, the Substance-Related Disorders Work Group has proposed to eliminate the current category of Substance-Related Disorders, and replace it with a new category, Substance Use and Addictive Disorders. This category will include the substance use disorders (e.g., alcohol use disorder), in place of separate designations for substance abuse and dependence. One reason for dropping the term "dependence" in this revision is that the term can be misleading and is frequently confused with the term "addiction." The tolerance and withdrawal that patients experience with dependence are normal responses to prescribed medications that affect the central nervous system and do not necessarily indicate the presence of an addiction. By revising and clarifying these criteria, the work group hopes to alleviate some of the widespread misunderstanding around these issues.
Some of the concerns cited in the Humanistic Psychology group's on-line petition are that vulnerable groups, particularly children and older people, may be at risk of being wrongly labeled with a behavioral disorder. Could you respond to that?
We echo the concerns from mental health specialty organizations and advocacy groups that some groups, such as older adults and young children, present diagnostic challenges and that DSM-5 should take measures to address this. Accordingly, we have proposed a new diagnostic chapter organization that eliminates a separate chapter for childhood diagnoses, and integrates all age groups into each chapter. This structure better reflects a lifespan approach, i.e., the majority of mental disorders begin in childhood or adolescence and persist into adulthood, and that disorders associated with older age can be present in non-geriatric age groups. Each diagnostic chapter will be reorganized to bring greater attention to age-related matters by use of specific chapter subheadings (e.g., diagnosis across the lifespan; other age-related considerations). Finally, work groups have actively revised their criteria, where appropriate, to better delineate ways in which criteria may manifest differently in different age groups. For example, proposed diagnostic criteria for attention-deficit/hyperactivity disorder include descriptions of how impulsivity, distractibility, and hyperactivity may manifest differently in adults versus young children and adolescents. Special work groups have been formed to address diagnostic issues in both child and adolescent and geriatric populations.
Some of the criticism seems to revolve around the old issue of whether the manual is too focused on pharmacological treatment or a psychbiological explanation for behavior disorders. Do you think the manual has such a slant, and how much of this controversy reflects older arguments between prescribing psychotropic medications, which is limited to psychiatry, vs. using talk therapy, which is dominated by psychology and social work?
By definition, DSM is a manual focused on diagnosis -- not treatment. Concerns that DSM is too biologically focused reflect ongoing discussions across the mental health field about the etiology and treatment of psychiatric disorders. However, the manual itself is not invested in representing any particular point-of-view or theory and is intent on reflecting the latest findings from scientific study. Our current understanding of etiology is much more complex than previously when there were arguments over "nature or nurture". We are now learning about the complex interaction between genetic, temperamental, and personality vulnerabilities and environmental exposures such as acute trauma, chronic stress, early parenting experiences, and community-level variables in the development and expression of mental (as well as other medical) disorders.
William E. Narrow, M.D., M.P.H.
Associate Director, Division of Research
Research Director, DSM-5 Task Force
American Psychiatric Association