DSM-5 Heads to the Finish Line

The long-awaited fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, better known as the DSM-5, is set to be published next May, but critics continue to warn that the current proposals could lead to widespread misdiagnosis and a potential increase in the use of drug therapies.

The new manual takes a "developmental approach" to diagnosis, emphasizing the full lifespan of the patient, said Dr. David J. Kupfer, chair of the DSM-5 Task Force and a professor of psychiatry at the University of Pittsburgh.

Courtesy American Psychiatric Association

"That automatically invokes an earlier concern about diagnosis," he said. "It automatically invokes the issue of what are some of the risk factors."

It’s that push for the early identification of mental illness that has some clinicians concerned.

(See the related video here.)

Dr. Allen J. Frances, who chaired the DSM-IV task force and is a professor emeritus at Duke University, said several proposals in the draft DSM-5 would take the idea of early diagnosis too far, essentially pathologizing normal behavior. For instance, he said, the current draft would classify normal grief as major depressive disorder and elevate "temper tantrums" to the status of disruptive mood dysregulation disorder.

Diagnostic inflation and excessive use of psychotropic medications already are rampant, Dr. Frances said, and broadening the diagnostic criteria in the DSM will only worsen that trend.

The developers of the current manual are getting ahead of the science, he said. In order to move to a model of what Dr. Frances called "preventive psychiatry," there needs to be an accurate system for identification without a high percentage of false positives. The treatment options also need to be safe and effective. Those conditions haven’t been met for most of the proposals in the DSM-5, he said.

"There’s a desire to push the field ahead without having the foundation to do it," Dr. Frances said.

Some of those same concerns were expressed in an online petition posted by the Society for Humanistic Psychology (Division 32 of the American Psychological Association). To date, the petition has garnered support from more than 50 mental health organizations and more than 13,000 individuals.

But Dr. Kupfer defended the approach of the DSM-5, noting that in his clinical experience when an appropriate diagnosis is made earlier, there is less medical and psychiatric comorbidity.

"At any point in the age span, if we can make an earlier diagnosis, we would be better off," Dr. Kupfer said.

He added that the developmental approach in the draft DSM-5 would not automatically lead to the increased use of medication. Dr. Kupfer said a lot of work on non–pharmacologic treatments for early intervention has been done and that clinicians might just need to focus more on those options.

One proposal in the DSM-5 draft that was especially controversial was the plan to create a new diagnosis of attenuated psychosis syndrome. To qualify for the new diagnosis, patients would need to have relatively intact reality testing but exhibit delusions/delusional ideas, or hallucinations, or disorganized speech at least once a week for the past month. The idea was to describe a condition with the recent onset of modest, psychotic-like symptoms and clinically relevant distress and disability.

But after field tests failed to garner enough cases to adequately test the reliability of the diagnosis, the DSM-5’s Psychotic Disorders Work Group opted to put the new diagnosis in Section III of the manual, an appendix that describes diagnoses in need of further research.

Donna Rockwell, Psy.D., a clinical psychologist and a member of the executive board of the Society for Humanistic Psychology, said the concern with the attenuated psychosis syndrome proposal was that it was so sweeping that it could attach an inaccurate diagnosis to teenagers who were simply "quirky" or who might actually have Asperger’s syndrome.

Although some critics of the plan were worried that the diagnosis would unnecessarily put more teens on antipsychotics, Dr. Rockwell said she was also concerned about the impact of the label itself. Once diagnosed with attenuated psychosis syndrome, the psychotic label would follow the patient through life, Dr. Rockwell said. The diagnosis could potentially become a self-fulfilling prophecy in which patients would start to act out the behaviors expected of them, she said.

"There’s great concern among the psychological community that this is psychiatric overkill," Dr. Rockwell said.

Dr. William T. Carpenter Jr., chair of the DSM-5’s Psychotic Disorders Work Group, said he and his colleagues do not want to unnecessarily pathologize young people. But he said they hoped to avoid that type of unintended consequence, since patients getting this diagnosis would have sought clinical care after demonstrating distress and disability.

As for stigma, Dr. Carpenter said the self-stigma, and the stigma from family and friends when people begin to exhibit potential psychotic behaviors outweighs the impact of a medical diagnosis.

"Doctors don’t label," said Dr. Carpenter, professor of psychiatry and pharmacology at the University of Maryland in Baltimore. "Doctors diagnose, take care of, and treat. That’s not to say that something cannot be stigmatizing, but ‘labeling’ kind of gets right into the antipsychiatry component of it."

The third public comment period for the DSM-5 closed on June 15. Since then, members of the 13 DSM-5 Work Groups have been formulating their final recommendations. In addition to the public comments, the work groups are considering data from a field trial of the proposals and research reviews.

Once the work groups are finished, their final revisions will be reviewed by the DSM-5 Task Force, as well as the Scientific Review Committee and the Clinical and Public Health Committee. The Task Force will make its recommendations to the American Psychiatric Association’s Board of Trustees, which has the final say in the process.

Dr. Kupfer cautions that anything could change during the final review of the DSM-5 draft this fall, here are some of the most recent proposed changes:

Autism Spectrum Disorder

As currently proposed, the DSM-5 would create a new name for the category – autism spectrum disorder – that would include autistic disorder, Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified. Combining these conditions into a single spectrum disorder is a "better reflection of the state of knowledge about pathology and clinical presentation," according to the Neurodevelopment Disorders Work Group.

Major Depressive Episode

The Mood Disorders Work Group is seeking to eliminate the traditional bereavement exclusion that was part of the criteria for major depressive episodes. They made the change because of evidence of the significant similarities between bereavement-related depression and depression caused by other stressors. However, the work group added a footnote to clarifying that normal bereavement might resemble a depressive episode but that a major depressive episode would be characterized by feelings of worthlessness, suicidal ideas, psychomotor retardation, and severe impairment of overall function.

Disruptive Dysregulation Disorder

The draft DSM-5 features a new disorder called disruptive mood dysregulation disorder, which originally was proposed as temper dysregulation disorder. The proposed disorder is characterized by severe temper outbursts that are out of proportion in intensity or duration to the situation. To be eligible for this diagnosis, the patient should have outbursts three or more times a week, on average, and be persistently irritable or angry between these episodes. To avoid confusion from overlapping symptoms with oppositional defiant disorder, the Mood Disorders Work Group recommended that youth who meet criteria for both disorders should only be assigned the diagnosis of disruptive mood dysregulation disorder, which is the more severe diagnosis.

Binge Eating Disorder

The Eating Disorders Work Group members are proposing that the binge eating disorder be moved out of the DSM appendix and into the main manual. They decided to recommend binge eating disorder as a stand-alone diagnosis after a literature review showed that the condition runs in families and that it has a distinct demographic profile. The literature also showed that binge eating disorder had a better response to specialized treatments than to generic behavioral weight loss treatment.

Suicidal Behavior Disorder

The DSM-5 draft includes a new diagnosis called suicidal behavior disorder that would apply to a person who has attempted suicide in the last 24 months. Non–suicidal self-injury does not count as suicidal behavior under this definition, but having one or more acts of non-suicidal self-injury is not incompatible with the diagnosis. Having a separate diagnosis for suicidal behavior should improve the assessment of preventive measures and drug safety monitoring, according to the draft proposal.

But even as the more than decade-long process of developing the DSM-5 comes to a close, Dr. Kupfer said the document will not be fixed. Instead, the Task Force has been promoting the DSM-5 as a "living document" that can be more easily changed in the future to keep up with the latest scientific developments. Dr. Kupfer said there will likely be a DSM 5.1 at some point.

In addition to updates to the DSM-5, the APA is planning to produce another version of the manual that can be used in primary care practices. Plans are still being drawn up, but field trials designed to test the utility of the diagnoses in the primary care setting could occur in 2013 or 2014, Dr. Kupfer said.

The long-awaited fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, better known as the DSM-5, is set to be published next May, but critics continue to warn that the current proposals could lead to widespread misdiagnosis and a potential increase in the use of drug therapies.

The new manual takes a "developmental approach" to diagnosis, emphasizing the full lifespan of the patient, said Dr. David J. Kupfer, chair of the DSM-5 Task Force and a professor of psychiatry at the University of Pittsburgh.

Courtesy American Psychiatric Association

"That automatically invokes an earlier concern about diagnosis," he said. "It automatically invokes the issue of what are some of the risk factors."

It’s that push for the early identification of mental illness that has some clinicians concerned.

(See the related video here.)

Dr. Allen J. Frances, who chaired the DSM-IV task force and is a professor emeritus at Duke University, said several proposals in the draft DSM-5 would take the idea of early diagnosis too far, essentially pathologizing normal behavior. For instance, he said, the current draft would classify normal grief as major depressive disorder and elevate "temper tantrums" to the status of disruptive mood dysregulation disorder.

Diagnostic inflation and excessive use of psychotropic medications already are rampant, Dr. Frances said, and broadening the diagnostic criteria in the DSM will only worsen that trend.

The developers of the current manual are getting ahead of the science, he said. In order to move to a model of what Dr. Frances called "preventive psychiatry," there needs to be an accurate system for identification without a high percentage of false positives. The treatment options also need to be safe and effective. Those conditions haven’t been met for most of the proposals in the DSM-5, he said.

"There’s a desire to push the field ahead without having the foundation to do it," Dr. Frances said.

Some of those same concerns were expressed in an online petition posted by the Society for Humanistic Psychology (Division 32 of the American Psychological Association). To date, the petition has garnered support from more than 50 mental health organizations and more than 13,000 individuals.

But Dr. Kupfer defended the approach of the DSM-5, noting that in his clinical experience when an appropriate diagnosis is made earlier, there is less medical and psychiatric comorbidity.

"At any point in the age span, if we can make an earlier diagnosis, we would be better off," Dr. Kupfer said.

He added that the developmental approach in the draft DSM-5 would not automatically lead to the increased use of medication. Dr. Kupfer said a lot of work on non–pharmacologic treatments for early intervention has been done and that clinicians might just need to focus more on those options.

One proposal in the DSM-5 draft that was especially controversial was the plan to create a new diagnosis of attenuated psychosis syndrome. To qualify for the new diagnosis, patients would need to have relatively intact reality testing but exhibit delusions/delusional ideas, or hallucinations, or disorganized speech at least once a week for the past month. The idea was to describe a condition with the recent onset of modest, psychotic-like symptoms and clinically relevant distress and disability.

But after field tests failed to garner enough cases to adequately test the reliability of the diagnosis, the DSM-5’s Psychotic Disorders Work Group opted to put the new diagnosis in Section III of the manual, an appendix that describes diagnoses in need of further research.

Donna Rockwell, Psy.D., a clinical psychologist and a member of the executive board of the Society for Humanistic Psychology, said the concern with the attenuated psychosis syndrome proposal was that it was so sweeping that it could attach an inaccurate diagnosis to teenagers who were simply "quirky" or who might actually have Asperger’s syndrome.

Although some critics of the plan were worried that the diagnosis would unnecessarily put more teens on antipsychotics, Dr. Rockwell said she was also concerned about the impact of the label itself. Once diagnosed with attenuated psychosis syndrome, the psychotic label would follow the patient through life, Dr. Rockwell said. The diagnosis could potentially become a self-fulfilling prophecy in which patients would start to act out the behaviors expected of them, she said.

"There’s great concern among the psychological community that this is psychiatric overkill," Dr. Rockwell said.

Dr. William T. Carpenter Jr., chair of the DSM-5’s Psychotic Disorders Work Group, said he and his colleagues do not want to unnecessarily pathologize young people. But he said they hoped to avoid that type of unintended consequence, since patients getting this diagnosis would have sought clinical care after demonstrating distress and disability.

As for stigma, Dr. Carpenter said the self-stigma, and the stigma from family and friends when people begin to exhibit potential psychotic behaviors outweighs the impact of a medical diagnosis.

"Doctors don’t label," said Dr. Carpenter, professor of psychiatry and pharmacology at the University of Maryland in Baltimore. "Doctors diagnose, take care of, and treat. That’s not to say that something cannot be stigmatizing, but ‘labeling’ kind of gets right into the antipsychiatry component of it."

The third public comment period for the DSM-5 closed on June 15. Since then, members of the 13 DSM-5 Work Groups have been formulating their final recommendations. In addition to the public comments, the work groups are considering data from a field trial of the proposals and research reviews.

Once the work groups are finished, their final revisions will be reviewed by the DSM-5 Task Force, as well as the Scientific Review Committee and the Clinical and Public Health Committee. The Task Force will make its recommendations to the American Psychiatric Association’s Board of Trustees, which has the final say in the process.

Dr. Kupfer cautions that anything could change during the final review of the DSM-5 draft this fall, here are some of the most recent proposed changes:

Autism Spectrum Disorder

As currently proposed, the DSM-5 would create a new name for the category – autism spectrum disorder – that would include autistic disorder, Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified. Combining these conditions into a single spectrum disorder is a "better reflection of the state of knowledge about pathology and clinical presentation," according to the Neurodevelopment Disorders Work Group.

Major Depressive Episode

The Mood Disorders Work Group is seeking to eliminate the traditional bereavement exclusion that was part of the criteria for major depressive episodes. They made the change because of evidence of the significant similarities between bereavement-related depression and depression caused by other stressors. However, the work group added a footnote to clarifying that normal bereavement might resemble a depressive episode but that a major depressive episode would be characterized by feelings of worthlessness, suicidal ideas, psychomotor retardation, and severe impairment of overall function.

Disruptive Dysregulation Disorder

The draft DSM-5 features a new disorder called disruptive mood dysregulation disorder, which originally was proposed as temper dysregulation disorder. The proposed disorder is characterized by severe temper outbursts that are out of proportion in intensity or duration to the situation. To be eligible for this diagnosis, the patient should have outbursts three or more times a week, on average, and be persistently irritable or angry between these episodes. To avoid confusion from overlapping symptoms with oppositional defiant disorder, the Mood Disorders Work Group recommended that youth who meet criteria for both disorders should only be assigned the diagnosis of disruptive mood dysregulation disorder, which is the more severe diagnosis.

Binge Eating Disorder

The Eating Disorders Work Group members are proposing that the binge eating disorder be moved out of the DSM appendix and into the main manual. They decided to recommend binge eating disorder as a stand-alone diagnosis after a literature review showed that the condition runs in families and that it has a distinct demographic profile. The literature also showed that binge eating disorder had a better response to specialized treatments than to generic behavioral weight loss treatment.

Suicidal Behavior Disorder

The DSM-5 draft includes a new diagnosis called suicidal behavior disorder that would apply to a person who has attempted suicide in the last 24 months. Non–suicidal self-injury does not count as suicidal behavior under this definition, but having one or more acts of non-suicidal self-injury is not incompatible with the diagnosis. Having a separate diagnosis for suicidal behavior should improve the assessment of preventive measures and drug safety monitoring, according to the draft proposal.

But even as the more than decade-long process of developing the DSM-5 comes to a close, Dr. Kupfer said the document will not be fixed. Instead, the Task Force has been promoting the DSM-5 as a "living document" that can be more easily changed in the future to keep up with the latest scientific developments. Dr. Kupfer said there will likely be a DSM 5.1 at some point.

In addition to updates to the DSM-5, the APA is planning to produce another version of the manual that can be used in primary care practices. Plans are still being drawn up, but field trials designed to test the utility of the diagnoses in the primary care setting could occur in 2013 or 2014, Dr. Kupfer said.

The long-awaited fifth edition of the Diagnostic and Statistical Manual of Mental Disorders, better known as the DSM-5, is set to be published next May, but critics continue to warn that the current proposals could lead to widespread misdiagnosis and a potential increase in the use of drug therapies.

The new manual takes a "developmental approach" to diagnosis, emphasizing the full lifespan of the patient, said Dr. David J. Kupfer, chair of the DSM-5 Task Force and a professor of psychiatry at the University of Pittsburgh.

Courtesy American Psychiatric Association

"That automatically invokes an earlier concern about diagnosis," he said. "It automatically invokes the issue of what are some of the risk factors."

It’s that push for the early identification of mental illness that has some clinicians concerned.

(See the related video here.)

Dr. Allen J. Frances, who chaired the DSM-IV task force and is a professor emeritus at Duke University, said several proposals in the draft DSM-5 would take the idea of early diagnosis too far, essentially pathologizing normal behavior. For instance, he said, the current draft would classify normal grief as major depressive disorder and elevate "temper tantrums" to the status of disruptive mood dysregulation disorder.

Diagnostic inflation and excessive use of psychotropic medications already are rampant, Dr. Frances said, and broadening the diagnostic criteria in the DSM will only worsen that trend.

The developers of the current manual are getting ahead of the science, he said. In order to move to a model of what Dr. Frances called "preventive psychiatry," there needs to be an accurate system for identification without a high percentage of false positives. The treatment options also need to be safe and effective. Those conditions haven’t been met for most of the proposals in the DSM-5, he said.

"There’s a desire to push the field ahead without having the foundation to do it," Dr. Frances said.

Some of those same concerns were expressed in an online petition posted by the Society for Humanistic Psychology (Division 32 of the American Psychological Association). To date, the petition has garnered support from more than 50 mental health organizations and more than 13,000 individuals.

But Dr. Kupfer defended the approach of the DSM-5, noting that in his clinical experience when an appropriate diagnosis is made earlier, there is less medical and psychiatric comorbidity.

"At any point in the age span, if we can make an earlier diagnosis, we would be better off," Dr. Kupfer said.

He added that the developmental approach in the draft DSM-5 would not automatically lead to the increased use of medication. Dr. Kupfer said a lot of work on non–pharmacologic treatments for early intervention has been done and that clinicians might just need to focus more on those options.

One proposal in the DSM-5 draft that was especially controversial was the plan to create a new diagnosis of attenuated psychosis syndrome. To qualify for the new diagnosis, patients would need to have relatively intact reality testing but exhibit delusions/delusional ideas, or hallucinations, or disorganized speech at least once a week for the past month. The idea was to describe a condition with the recent onset of modest, psychotic-like symptoms and clinically relevant distress and disability.

But after field tests failed to garner enough cases to adequately test the reliability of the diagnosis, the DSM-5’s Psychotic Disorders Work Group opted to put the new diagnosis in Section III of the manual, an appendix that describes diagnoses in need of further research.

Donna Rockwell, Psy.D., a clinical psychologist and a member of the executive board of the Society for Humanistic Psychology, said the concern with the attenuated psychosis syndrome proposal was that it was so sweeping that it could attach an inaccurate diagnosis to teenagers who were simply "quirky" or who might actually have Asperger’s syndrome.

Although some critics of the plan were worried that the diagnosis would unnecessarily put more teens on antipsychotics, Dr. Rockwell said she was also concerned about the impact of the label itself. Once diagnosed with attenuated psychosis syndrome, the psychotic label would follow the patient through life, Dr. Rockwell said. The diagnosis could potentially become a self-fulfilling prophecy in which patients would start to act out the behaviors expected of them, she said.

"There’s great concern among the psychological community that this is psychiatric overkill," Dr. Rockwell said.

Dr. William T. Carpenter Jr., chair of the DSM-5’s Psychotic Disorders Work Group, said he and his colleagues do not want to unnecessarily pathologize young people. But he said they hoped to avoid that type of unintended consequence, since patients getting this diagnosis would have sought clinical care after demonstrating distress and disability.

As for stigma, Dr. Carpenter said the self-stigma, and the stigma from family and friends when people begin to exhibit potential psychotic behaviors outweighs the impact of a medical diagnosis.

"Doctors don’t label," said Dr. Carpenter, professor of psychiatry and pharmacology at the University of Maryland in Baltimore. "Doctors diagnose, take care of, and treat. That’s not to say that something cannot be stigmatizing, but ‘labeling’ kind of gets right into the antipsychiatry component of it."

The third public comment period for the DSM-5 closed on June 15. Since then, members of the 13 DSM-5 Work Groups have been formulating their final recommendations. In addition to the public comments, the work groups are considering data from a field trial of the proposals and research reviews.

Once the work groups are finished, their final revisions will be reviewed by the DSM-5 Task Force, as well as the Scientific Review Committee and the Clinical and Public Health Committee. The Task Force will make its recommendations to the American Psychiatric Association’s Board of Trustees, which has the final say in the process.

Dr. Kupfer cautions that anything could change during the final review of the DSM-5 draft this fall, here are some of the most recent proposed changes:

Autism Spectrum Disorder

As currently proposed, the DSM-5 would create a new name for the category – autism spectrum disorder – that would include autistic disorder, Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified. Combining these conditions into a single spectrum disorder is a "better reflection of the state of knowledge about pathology and clinical presentation," according to the Neurodevelopment Disorders Work Group.

Major Depressive Episode

The Mood Disorders Work Group is seeking to eliminate the traditional bereavement exclusion that was part of the criteria for major depressive episodes. They made the change because of evidence of the significant similarities between bereavement-related depression and depression caused by other stressors. However, the work group added a footnote to clarifying that normal bereavement might resemble a depressive episode but that a major depressive episode would be characterized by feelings of worthlessness, suicidal ideas, psychomotor retardation, and severe impairment of overall function.

Disruptive Dysregulation Disorder

The draft DSM-5 features a new disorder called disruptive mood dysregulation disorder, which originally was proposed as temper dysregulation disorder. The proposed disorder is characterized by severe temper outbursts that are out of proportion in intensity or duration to the situation. To be eligible for this diagnosis, the patient should have outbursts three or more times a week, on average, and be persistently irritable or angry between these episodes. To avoid confusion from overlapping symptoms with oppositional defiant disorder, the Mood Disorders Work Group recommended that youth who meet criteria for both disorders should only be assigned the diagnosis of disruptive mood dysregulation disorder, which is the more severe diagnosis.

Binge Eating Disorder

The Eating Disorders Work Group members are proposing that the binge eating disorder be moved out of the DSM appendix and into the main manual. They decided to recommend binge eating disorder as a stand-alone diagnosis after a literature review showed that the condition runs in families and that it has a distinct demographic profile. The literature also showed that binge eating disorder had a better response to specialized treatments than to generic behavioral weight loss treatment.

Suicidal Behavior Disorder

The DSM-5 draft includes a new diagnosis called suicidal behavior disorder that would apply to a person who has attempted suicide in the last 24 months. Non–suicidal self-injury does not count as suicidal behavior under this definition, but having one or more acts of non-suicidal self-injury is not incompatible with the diagnosis. Having a separate diagnosis for suicidal behavior should improve the assessment of preventive measures and drug safety monitoring, according to the draft proposal.

But even as the more than decade-long process of developing the DSM-5 comes to a close, Dr. Kupfer said the document will not be fixed. Instead, the Task Force has been promoting the DSM-5 as a "living document" that can be more easily changed in the future to keep up with the latest scientific developments. Dr. Kupfer said there will likely be a DSM 5.1 at some point.

In addition to updates to the DSM-5, the APA is planning to produce another version of the manual that can be used in primary care practices. Plans are still being drawn up, but field trials designed to test the utility of the diagnoses in the primary care setting could occur in 2013 or 2014, Dr. Kupfer said.