New framework proposed for manual of mental disorders

The revisions reflect the knowledge we have gained since the last DSM was published in 1994," said David Kupfer, M.D., chair of the DSM-5 Task Force. "They should facilitate more comprehensive diagnosis and treatment approaches for patients and encourage research across diagnostic criteria."

The changes re-order the existing manual’s 16 chapters based on underlying vulnerabilities as well as symptom characteristics, which currently result in many patients being diagnosed with multiple disorders within and across disorder groups. The chapters are arranged by general categories such as neurodevelopmental, emotional and somatic to reflect the potential commonalities in etiology within larger disorder groups.

"The sequence of chapters builds on what we have learned about the brain, behavior and genetics over the past two decades," noted Steven Hyman, M.D., former director of the National Institute of Mental Health and a member of the DSM-5 Task Force.

Public comment is invited through June 15 on the draft framework and the latest proposed revisions to diagnostic criteria, both available on http://www.dsm5.org . During an initial public review and comment period last year—an unprecedented occurrence in both the field of psychiatry and in medicine—the APA received more than 8,000 written responses from clinicians, researchers and family and patient advocates. All of the responses were considered as part of the manual’s reorganization.

Today’s release marks another stage in the development of DSM-5. Rigorous scientific scrutiny is shaping this 14-year project, with the involvement of nearly 500 experts from the United States and abroad. Publication is scheduled for 2013.

The manual’s new organization combines certain disorders under more comprehensive chapter
headings while breaking others out from their previous categories. One example is obsessivecompulsive disorder (OCD), long considered to be an anxiety-driven disorder.

Recent studies have shown that OCD and several related disorders involve distinct neurocircuits, and so they are now listed as a separate grouping—a move that could advance understanding of their root causes.

There are other notable changes. Disorders previously listed under a single rubric of infancy, childhood and adolescence have been integrated into other chapters, in line with the goal of making DSM more developmentally focused. In addition, research findings linking schizophrenia and schizotypal personality disorder into a "schizophrenia spectrum" will be reflected in this next edition.

"The schizophrenia spectrum designation is supported by studies showing how these disorders tend to aggregate within families," said Darrel Regier, M.D., M.P.H., vice chair of the DSM-5 Task Force and executive director of the American Psychiatric Institute for Research and Education. "It will help clinicians to correctly diagnose patients by making clear the common features that fall within the spectrum."

To date, reports on the deliberations and progress of the task force and 13 work groups have been presented at international conferences, through more than 100 papers and via the DSM-5 website. After last year’s public comment period, the work groups continued to amend and refine some categories of disorders.

The first round of field trials is now testing the new diagnostic criteria in real-world settings, including at nearly a dozen larger academic and clinical centers; almost 3,900 mental health professionals in individual practice and smaller settings also will participate before the trials conclude. Another public comment period on the criteria will then follow.

The DSM-5 framework and diagnostic criteria will be determined by 2012 and submitted to the APA’s Board of Trustees for review and approval.

"At every stage," said Kupfer, "DSM-5 is benefiting from a depth of research and a breadth of expertise and diverse opinions that will immeasurably strengthen the final document."

Provided by American Psychiatric Association