New DSM Available for Comments

Long Awaited First Draft of  New Edition of Mental Disorder Manual Is Online

The first new draft of the Diagnostic Statistical Manual 5th edition ( DSM V) has been released and is available online for review and for comments by psychiatrists and any other interested persons.. This is the book that is used world wide to define and describe mental disorders. The final product will come out after further revision and is scheduled for publication in  2012. The process of preparing this massive undertaking, although not without some controversy, has really been quite remarkable.

Remarkable Preparation Process

I had an inside of view of the efforts to make this a balanced fair non prejudiced process as I was on the Board of Trustees of the American Psychiatric  Association for two years during my term as Speaker of the Assembly. The leadership and the various committee chairs and members of subcommittees were chosen very carefully not only to pick the people with the best expertise but also with extraordinary efforts to examine that they did not have any outside vested interests which could interfere with this process.

In addition efforts were made to balance the choices among equally outstanding experts to be sure that various underrepresented groups including women and minorities were properly represented. The multiyear process of studying and examining the diagnostic categories also included authorizing and supporting various research projects such as  multi-centered field trials conducted across the country. The study of mental disorders can’t be done in a test tube but nevertheless great efforts were made to use the scientific method of randomized double blind studies whenever possible to draw valid conclusions.

There also was a special Gender and Cross-Cultural Group which reviewed the data from various countries and cultures as well as the emerging DSM V. They did not find any evidence of bias in the diagnostic criteria.

Preliminary Draft is Presented Online for Comments

The presentation of the new findings, which as mentioned, is still subject to some change depending on the comments and any new data which becomes available. The information about the proposed DSM V is presented online in a clear understandable manner despite the complexity of the overall process.

There are four online buttons, which will offer information on each diagnostic entity. They are as follows:

1. Existing DSM IV -The current  diagnostic nomenclature and descriptions are presented.

2. Proposed Revision DSM V changes of currently listed diagnosis and criteria  including a description of any new ones. Not all were changed.

3. Rationale used for new diagnosis or for revision of old one. This might include a discussion of the perceived clinical needs for this new listing or for the revision of the old one. It also  presents the research on which the decisions which led to this change were based .

4. Severity- A method for evaluating the severity of  various conditions was presented often using a scale which had been tested for a particular diagnosis.

A Few Examples of New Changes in DSM V

Those interested in a particular diagnostic category  will want to examine that section of the proposed DSM V in detail. I will comment on four components at this time

Mulitaxial Categories Will Be Changed

It is being recommended that Axes I, II, and III  of the current system be changed into one axis that contains all psychiatric and general medical diagnoses whereas previously psychiatric disorders, personality disorders and medical  conditions were all listed separately. Axis IV is currently where clinicians document psychosocial and environmental problems, such as whether a patient is having housing or economic problems or problems with his/her primary support group. The exact form of this axis is still under consideration with the hope to make it closely method used in the World Health Organization  (WHO) International Family of Classifications known as ICD 10 , Similarly the current Axis V which allows clinicians to rate a patient’s overall level of functioning will probably end up using  the above system in which disorders and their associated disabilities are conceptually distinct and assessed separately

Subtypes of Schizophrenia Eliminated

No longer will the term schizophrenia  paranoid type be used. In fact all the subtypes of schizophrenia have been dropped  based on studies which showed that the value of using subypes were unfounded. Instead schizophrenia would be defined based on the presence of delusions, hallucinations , disorganization, and abnormalities in speech and psychomotor behavior as well as the presence of negative symptoms such as restricted affect. The presence of paranoia would be described under delusions  as would  the other previous subtypes would be used in the appropriate criteria category. There also was a new category called Psychosis Risk Syndrome which is based on the research, which showed certain symptoms, and behavior could be identified in young people and therefore treated which might prevent the development of schizophrenia. This change might encourage innovative important treatment but some people are concerned that this  new category might label (or stigmatize) young people who would not develop this major psychiatric disorder.

Changing Bipolar Disorder Criteria in Children

There would be a new childhood condition  called Temper Dysregulation Disorders with Dysphoria. . This would encompass aggressive irritable children who have been given diagnosis of Bipolar Disorder and did not turn out to have this disorder as they grew older. Many people have been concerned that such children unnecessarily received antipsychotic drugs, which cause weight gain, and metabolic changes that could have been harmful to them

Asperger Disorder Eliminated.

The diagnostic category of Autism Spectrum Disorder  will encompass what was previously called Asperger Disorder. Many clinicians had been doing this already for the past few years. Studies have shown that the old term was used loosely with little agreement as to specific criteria. Previously defined autism and Asperger Syndrome were found to occur in the same families although there still is no clear evidence of the cause of them . The new proposed criteria for Autism Spectrum Disorder will have clear criteria for the dimensions of severity that include language functioning and intellectual level or disability. The writers of the proposed DSM V recognize that there may be some individuals with subclinical features of this condition who may want to use the term ‘Asperger Disorder’ to understand themselves better or a doctor to understand a patient when comparing a patient to the old literature or  case reports  which used the terms Asperger Type or Kanner Type.

DSM V Proposal Welcomes Comments

There is a lot more to digest than I have touched upon in this piece. The authors of DSMV have put a tremendous amount of work in this project. It will not be issued until next year. There is still time to make comments and suggestions. Not only must this readjustment of diagnostic categories and criteria be useful for future research but it must meet the needs of the clinicians who are working with patients on an everyday basis. I hope all interested parties will review the  the current draft and send any comments or  suggestions to  the DSM V website ( prior to their April 20^th deadline )  as well as commenting here.