dsm v progress
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DSM V in the making..
Dr Subas Pradhan
The Shrink’s Bible
Understanding 50 Years of Understanding 50 Years of ChangeChange
DSM-II: 182 disorders
DSM-IV: 365 disorders
494 pages
134 pages
567 pages
DSM-III: 265 disorders
DSM-III-R: 265 disorders
DSM-IV-TR: 365 disorders
886 pages
943 pages
In 50 years: 800% increase in the number of diagnoses
The Future of the DSM: The Future of the DSM: Towards DSMTowards DSM -V -V
The begining:
http://www.dsm5.org/
Repairing an aeroplane while it’s flying!!
DSM 5 in last decade.. 2004-2007: “The Future of Psychiatric Diagnosis: Refining the
Research Agenda” APA/NIH/WHO global research planning conferences. “Phase 2: Refining the Research Agenda for DSM-5: NIH Conference Series”
April 2006: Drs. David Kupfer and Darrel Regier are appointed as chair and vice-chair, respectively, of the DSM-5 Task Force. Other key appointments included Dr. William Narrow, Research Director, and Dr. Maritza Rubio-Stipec, Statistics and Methods Director.
July 2007: DSM-5 Work Group Chairs are appointed. Assembling of DSM-5 Work Groups begins.
May 2008: DSM-5 Work Group members announced. APA Names DSM-5 Work Group Members.
Phase 1 Field Trial ..2010 January– May 2010: Site Recruitment for Field Trial
Testing. February – May 2010: Pilot Testing for DSM-5 Field
Trials. May 2010 – March 2011: DSM-5 Field Trials, Phase 1.
The first phase of DSM-5 field trials will begin in May 2010 and is scheduled to run for 10 months.
Initial text for DSM-5 & case studies will also be
developed, which will be published after DSM-5’s release in a series of case books.
DSM 5 in 2011 March – April 2011: Revisions to Proposed Criteria. These revised criteria and
measures will be tested in a second phase of field trials. April – May 2011: Review of Revised Criteria. Revised proposed criteria will be
subjected to internal review, including a review by the DSM-5 Task Force and Research Group and by other relevant work groups.
May-July 2011: Online Posting of Revised Criteria. Following the internal review,
revised draft diagnostic criteria will be posted online for approximately one month to allow the public to provide feedback. This site will be closed for feedback by midnight on June 30, 2011.
August 2011 – February 2012: DSM-5 Field Trials, Phase II. The second phase of
field trials testing will focus on those diagnostic criteria and dimensional measures that required modification based on the results of the Phase I field trials. This time period will include data collection and analysis.
DSM 5 in 2012 February – August 2012: Prepare Final Draft Text. March 2012: Presentation of DSM-5 Structure to APA’s Board of Trustees.
August 2012: Final Review. The APA will release the revised draft criteria to the APA Assembly and Board of Trustees for final review.
September 2012: The National Center for Vital and Health Statistics’ Annual
ICD-10-CM Revision Conference. The final, approved overall structure of DSM-5 will be complete in time for this conference so that organization of ICD-10-CM can be aligned with DSM-5.
September – November 2012: Final Revisions to Draft Criteria. Work group
members will make their last round of revisions to draft criteria based on feedback from APA’s Assembly and Board of Trustees.
November 2012: APA Assembly Approval of DSM-5.
December 2012: APA Board of Trustees Approval of DSM-5. Following approval from the Board of Trustees, the final completed manuscript will be submitted to the APA’s publishing division, American Psychiatric Publishing, Inc.
May 2013: Publication of DSM-5. The release of DSM-5 will take
place during the APA’s 2013 Annual Meeting in San
Francisco, CA.
Proposed Field Trials
Minor Neurocognitive Disorder Major Neurocognitive Disorder Autism Spectrum Disorder Learning Disabilities Intellectual Disabilities ADHD (in children and adults) Callous/Unemotional Specifier for Conduct
Disorder Oppositional Defiant Disorder (linked to
Field Trial for Temper Dysregulation Disorder)
Temper Dysregulation Disorder Non-Suicidal Self Injury Preschool PTSD Psychotic Risk Syndrome Schizoaffective Disorder Psychotic Disorder Major Depressive Disorder Anxious Depression Bipolar Disorder
Generalized Anxiety Disorder Agoraphobia PTSD Obsessive-Compulsive Disorder Hoarding Nicotine (Tobacco Use Disorder) Alcohol Use Disorder Cannabis Use Disorder Opioid Use Disorder Complex Somatic Symptom Disorder Binge Eating Disorder Avoidant/Restrictive Food Intake Disorder Primary Insomnia Hypersexual Disorder Gender Incongruence (in children,
adolescents and adults) Sexual Interest Arousal Disorder Schizotypal Personality Disorder Antisocial Personality Disorder Borderline Personality Disorder General Criteria for Personality Disorder
Proposed Draft Revisions to DSM Disorders and Criteria
• Structural, Cross-Cutting, and General Classification Issues for DSM-5
Adjustment DisordersAnxiety DisordersDelirium, Dementia, Amnestic, and Other Cognitive DisordersDisorders Usually First Diagnosed in Infancy, Childhood, or AdolescenceDissociative DisordersEating DisordersFactitious DisordersImpulse-Control Disorders Not Elsewhere ClassifiedMental Disorders Due to a General Medical Condition Not Elsewhere ClassifiedMood DisordersOther Clinical Conditions That May Be a Focus of Clinical AttentionPersonality and Personality DisordersSchizophrenia and Other Psychotic DisordersSexual and Gender Identity DisordersSleep DisordersSomatoform DisordersSubstance-Related Disorders
General format of DSM-5 website
Proposed Revision Rationale Severity DSM IV
Structural, Cross-Cutting, and General Classification Issues for DSM-5
use of the multi-axial system to record diagnoses and clinical variables of interest (collapsing axis-I,II,III into one)
consideration of factors that cut across all diagnoses (e.g., gender and cultural issues)
the use of dimensional measures to refine diagnostic assessment and treatment planning i.e. depression in many disorders
Adjustment Disorders
The work group is recommending that this disorder be included in a grouping of Trauma and Stress-Related Disorders
Specify if With PTSD-Like or ASD-Like symptoms: when the predominant manifestation is PTSD-like or ASD-like symptoms, but the PTSD/ASD stressor and/or symptom criteria are not met)
Anxiety Disorders
OCD as another diagnostic category Remove Agoraphobia without panic disorders Disorders Not Currently Listed in DSM-IV
– Substance-Induced (indicate substance) Tic Disorder – Tic Disorder Due to a General Medical Condition – Hoarding Disorder – Olfactory Reference Syndrome – Skin Picking Disorder
Conditions Proposed by Outside Sources
Apathy Syndrome Body Integrity Identity Disorder Complicated Grief Disorder Developmental Trauma Disorder Disorders of Extreme Stress Not Otherwise Specified Fetal Alcohol Syndrome Internet Addiction Male-to-Eunuch Gender Identity Disorder Melancholia Parental Alienation Disorder Seasonal Affective Disorder Sensory Processing Disorder
Delirium, Dementia, Amnestic, and Other Cognitive Disorders
1) Removing the term “Dementia” and adding “Major Neurocognitive Disorders”,
2) Adding a category of “Minor Neurocognitive Disorders”,
3) Categorizing behavioral disturbances, particularly the syndromes of psychosis and depression, associated with Neurocognitive Disorders, and
4) Selecting specific domains as well as measures of severity of cognitive functional impairment
Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence
New name for category, autism spectrum disorder, which includes autistic disorder (autism), Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified
Mental retardation- (Intellectual Disability) Code no longer based on IQ level
Disorders Usually First Diagnosed in Infancy,
Childhood, or Adolescence *Childhood Disorders Proposed for Possible
Reclassification in Another Diagnostic Category– Pica– Rumination Disorder– Feeding Disorder of Infancy or Early Childhood– Separation Anxiety Disorder
*Childhood Disorders Proposed for Possible Removal from DSM (No DSM-5 Criteria Proposed)
• Expressive Language Disorder• Mixed Receptive-Expressive Language Disorder• Communication Disorder Not Otherwise Specified• Rett's Disorder
Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence
Childhood Disorders Proposed to be Divided into New Childhood Disorders– Reactive Attachment Disorder of Infancy or Early Childhood
Childhood Disorders Proposed to be Subsumed Under Other Diagnoses (No DSM-5 Criteria Proposed)
– Disorder of Written Expression– Learning Disorder Not Otherwise Specified– Childhood Disintegrative Disorder– Asperger's Disorder– Pervasive Developmental Disorder Not Otherwise Specified
Childhood Disorders Not Currently Listed in DSM-IV
• Posttraumatic Stress Disorder in Preschool Children • Temper Dysregulation Disorder with Dysphoria • Callous and Unemotional Specifier for Conduct Disorder • Learning Disabilities • Non-Suicidal Self Injury • Non-Suicidal Self Injury Not Otherwise Specified • Language Impairment • Late Language Emergence • Specific Language Impairment • Social Communication Disorder • Voice Disorder
Factitious Disorder
The work group has proposed that this diagnosis be reclassified from Facitious Disorders to Somatic Symptom Disorders
Proposed Subtype: Factitious Disorder imposed on another
(previously, factitious disorder by proxy)
Mood Disorders Mood Disorders Being Recommended for
Removal or Reclassification-Mixed Episode
Mood Disorders Not Currently Listed in DSM-IV Mixed Anxiety Depression – Mixed Features Specifier Premenstrual Dysphoric Disorder
Mood Disorders Proposed for Possible Removal from DSM (No DSM-5 Criteria Proposed) Bipolar I Disorder - Most Recent Episode Mixed
Major Depressive Episode
The exclusion of symptoms judged better accounted for by Bereavement is removed because evidence does not support separation of loss of loved one from other stressors
"Do not include symptoms due to... mood-incongruent delusions or hallucinations" is eliminated because meaning and purpose are unclear.
Dysthymic Disorder
The work group is proposing that this disorder be renamed Chronic Depressive Disorder, and will not require the exclusion of a Major Depressive Episode.
The category of major depression with chronic specifier to be combined with dysthymic disorder under the term “chronic depressive disorder”.
Depressive Disorder Not Otherwise Specified
Depressive Conditions Not Elsewhere Classified (Depressive CNEC) Depressive CNEC with insufficient information to
make a specific diagnosis. Subsyndromal Depressive CNEC
Prodromal depression. Subsyndromal depression that meets duration criteria but
not symptom count criteria for Major Depressive Episode (MDE.)
Mixed Subsyndromal Anxiety-Depressive Disorder. Other Depressive CNEC
Major Depressive Episode (MDE) superimposed on a psychotic disorder.
Recurrent Brief Depressive Disorder.
Schizophrenia and Other Psychotic Disorders
Schizophrenia and Other Psychotic Disorders Not Currently Listed in DSM-IV Attenuated Psychotic Symptoms Syndrome – Catatonia Specifier
Removing all sub-typing of schizophrenia! As it’s rarely used diagnostically (<5%), with
the exception of paranoid schizophrenia (50-75%) and, to a lesser extent, undifferentiated schizophrenia
Personality and Personality Disorders
Significant reformulation of the approach to the assessment and diagnosis of personality psychopathology Definition: Personality disorders represent
the failure to develop a sense of self-identity and the capacity for interpersonal functioning that are adaptive in the context of the individual’s cultural norms and expectations.
Personality and Personality Disorders
Work Group recommends 5 specific personality disorder types (Reduced from 10 in DSM IV to 5)– Antisocial/Psychopathic Type Avoidant Type Borderline Type Obsessive-Compulsive Type Schizotypal Type
Personality Traits
The Work Group recommends that patients be rated on 6 broad, higher order personality trait domains each comprised of several lower order, more specific trait facets.
Trait Domains: Negative Emotionality
Introversion
Antagonism
Disinhibition
Compulsivity
Schizotypy
Domains and Facets Negative Emotionality: Experiences a wide range of negative emotions
(e.g., anxiety, depression, guilt/ shame, worry, etc.), and the behavioral and interpersonal manifestations of those experiences
Trait facets: Emotional lability, anxiousness, submissiveness, separation insecurity, pessimism, low self-esteem, guilt/ shame, self-harm, depressivity, suspiciousness
Introversion: Withdrawal from other people, ranging from intimate relationships to the world at large; restricted affective experience and expression; limited hedonic capacity
Trait facets: Social withdrawal, social detachment, restricted affectivity, anhedonia, intimacy avoidance
Antagonism: Exhibits diverse manifestations of antipathy toward others, and a correspondingly exaggerated sense of self-importance
Trait facets: Callousness, manipulativeness, narcissism, histrionism, hostility, aggression, oppositionality, deceitfulness
Domains and Facets Disinhibition: Diverse manifestations of being present- (vs. future- or past-)
oriented, so that behavior is driven by current internal and external stimuli, rather than by past learning and consideration of future consequences
Trait facets: Impulsivity, distractibility, recklessness, irresponsibility
Compulsivity: The tendency to think and act according to a narrowly defined and unchanging ideal, and the expectation that this ideal should be adhered to by everyone
Trait facets: Perfectionism, perseveration, rigidity, orderliness, risk aversion
Schizotypy: Exhibits a range of odd or unusual behaviors and cognitions, including both process (e.g., perception) and content (e.g., beliefs)
Trait facets: Unusual perceptions, unusual beliefs, eccentricity, cognitive dysregulation, dissociation proneness
Substance-Related Disorders
Work group’s proposals is the recommendation that the diagnostic category include both substance use disorders and non-substance addictions
Gambling disorder has been moved into this category and there are other addiction-like behavioral disorders such as “Internet addiction”
Pathological gambling: The work group has proposed that this diagnosis be reclassified from Impulse-Control Disorders Not Elsewhere Classified to Substance-Related Disorders which will be renamed as Addiction and Related Disorders.
Sleep Disorders Sleep Disorders Not Currently Listed in DSM-IV
Kleine Levin Syndrome
Obstructive Sleep Apnea Hypopnea Syndrome (previously Breathing Related Sleep Disorder)
Primary Central Sleep Apnea (previously Breathing Related Sleep Disorder)
Primary Alveolar Hypoventilation (previously Breathing Related Sleep Disorder)
Rapid Eye Movement Behavior Disorder
Restless Legs Syndrome
Circadian Rhythm Sleep Disorder - Advanced Sleep Phase Type
Disorder of Arousal
Circadiam Rhythm Sleep Disorder - Free-Running Type
Circadiam Rhythm Sleep Disorder - Irregular Sleep-Wake Type
Criticisms of the DSMCriticisms of the DSMThe DSM More of a Political (and
economic) Art Than a Science Pharmaceutical companies have played a big part in maintaining a “medical model” classification systemWith profits to gain, pharmaceutical companies have readily funded researchThe writers of DSM have also benefited from the DSM’s medical model
The DSM Pathologizes “Normal” Behaviors
Smoking too much may lead to a diagnosis of “Nicotine Dependency Disorder,” a disorder now afflicting about 12.8% of the US adult population
More Criticisms of the More Criticisms of the DSMDSM
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