APA releases proposed draft diagnostic criteria for DSM-5

New proposed changes posted for leading manual of mental disorders

The American Psychiatric Association today released the proposed draft diagnostic criteria for the fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM). The draft criteria represent content changes under consideration for DSM, which is the standard classification of mental disorders used by mental health and other health professionals, and is used for diagnostic and research purposes.

"These draft criteria represent a decade of work by the APA in reviewing and revising DSM," said APA President Alan Schatzberg, M.D. "But it is important to note that DSM-5 is still very much a work in progress - and these proposed revisions are by no means final." The proposed diagnostic criteria will be available for public comment until April 20, and will be reviewed and refined over the next two years. During this time, the APA will conduct three phases of field trials to test some of the proposed diagnostic criteria in real-world clinical settings.

Proposed revisions

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 advisors to arrive at their proposed revisions to DSM. Among the draft revisions are the following:

• The recommendation of new categories for learning disorders and a single diagnostic category, "autism spectrum disorders" that will incorporate the current diagnoses of autistic disorder, Asperger's disorder, childhood disintegrative disorder and pervasive developmental disorder (not otherwise specified). Work group members have also recommended that the diagnostic term "mental retardation" be changed to "intellectual disability," bringing the DSM criteria into alignment with terminology used by other disciplines.
• Eliminating the current categories substance abuse and dependence, replacing them with the new category "addiction and related disorders." This will include substance use disorders, with each drug identified in its own category.
• Eliminating the category of dependence will better differentiate between the compulsive drug-seeking behavior of addiction and normal responses of tolerance and withdrawal that some patients experience when using prescribed medications that affect the central nervous system.
• Creating a new category of "behavioral addictions," in which gambling will be the sole disorder. Internet addiction was considered for this category, but work group members decided there was insufficient research data to do so, so they recommended it be included in the manual's appendix instead, with a goal of encouraging additional study.
• New suicide scales for adults and adolescents to help clinicians identify those individuals most at risk, with a goal of enhancing interventions across a broad range of mental disorders; the scales include research-based criteria such as impulsive behavior and heavy drinking in teens.
• Consideration of a new "risk syndromes" category, with information to help clinicians identify earlier stages of some serious mental disorders, such as neurocognitive disorder (dementia) and psychosis.
• A proposed new diagnostic category, temper dysregulation with dysphoria (TDD), within the Mood Disorders section of the manual. The new criteria are based on a decade of research on severe mood dysregulation, and may help clinicians better differentiate children with these symptoms from those with bipolar disorder or oppositional defiant disorder.
• New recognition of binge eating disorder and improved criteria for anorexia nervosa and bulimia nervosa, as well as recommended changes in the definitions of some eating disorders now described as beginning in infancy and childhood to emphasize that they may also develop in older individuals.

The APA has prepared detailed press releases on each of these topics, which are available on the DSM-5 Web site.

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 would permit clinicians to evaluate the severity of symptoms, as well as take into account "cross-cutting" symptoms that exist across a number of different diagnoses (such as insomnia or anxiety).

"We know that anxiety is often associated with depression, for example, but the current DSM doesn't have a good system for capturing symptoms that don't fit neatly into a single diagnosis, said David Kupfer, M.D., chair of the DSM-5 Task Force. "Dimensional assessments represent an important benefit for clinicians evaluating and treating patients with mental illness. It may help them better evaluate how a patient is improving with treatment, help them address symptoms that affect a patient's quality of life and better assess patients whose symptoms may not yet be severe - leading to earlier effective treatment."

Careful Consideration of Gender, Race and Ethnicity

The process for developing the proposed diagnostic criteria for DSM-5 has included careful consideration of how gender, race and ethnicity may affect the diagnosis of mental illness. The team has sought significant involvement of women, members of diverse racial and ethnic groups, and international researchers and clinicians. The APA also designated a specific study group to review and research these issues, and ensure they were taken into account in the development of diagnostic criteria.

The Gender and Cross-Cultural Study Group reviewed epidemiological data sets from the United States and other countries to determine if there were significant differences in incidence of mental illness among different subgroups (e.g., gender, race and ethnicity) that might indicate a bias in currently-used diagnostic criteria, including conducting meta-analyses (additional analyses combining data from different studies). Group members reviewed the literature from a broad range of international researchers who have explored issues of gender, ethnic and racial differences for specific diagnostic categories of mental illness. The study group also considered whether there was widespread cultural bias in criteria for specific diagnoses.

As a result of this process, the study group has tried to determine whether the diagnostic categories of mental illness in DSM need changes in order to be sensitive to the various ways in which gender, race and culture affect the expression of symptoms.

Public Review of Proposed Revisions

The resulting recommendations for revisions to the current DSM are being posted on the APA's Web site for the manual, www.DSM5.org, for public review and written comment. These comments will be reviewed and considered by the relevant DSM-5 Work Groups.

"The process for developing DSM-5 continues to be deliberative, thoughtful and inclusive," explained Dr. Kupfer. "It is our job to review and consider the significant advances that have been made in neuroscience and behavioral science over the past two decades. The APA is committed to developing a manual that is both based on the best science available and useful to clinicians and researchers."

Overview of DSM-5 Development Process

The last edition of DSM was published in 1994. Beginning in 2000, during the initial phase of revising DSM, the APA engaged almost 400 international research investigators in 13 NIH supported conferences. In order to invite comments from the wider research, clinical and consumer communities, the APA launched a DSM-5 Prelude Web site in 2004 to garner questions, comments, and research findings during the revision process.

Starting in 2007, the DSM-5 Task Force and Work Groups, made up of over 160 world-renowned clinicians and researchers, were tasked with building on the previous seven years of scientific reviews, conducting additional focused reviews, and garnering input from a wide range of advisors as the basis for proposing draft criteria. In addition to the work groups in diagnostic categories, there were study groups assigned to review gender, age and cross-cultural issues.

Based on the upcoming comments to the draft criteria and findings of the field trials, the work groups will propose final revisions to the diagnostic criteria in 2012. The final draft of DSM-5 will be submitted to the APA's Assembly and Board of Trustees for their review and approval. A release of the final, approved DSM-5 is expected in May 2013.