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