DSM-5

The next (fifth) edition of the American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM), commonly called DSM-V, is currently in consultation, planning and preparation. It is due for publication in May 2013 and will supersede the DSM-IV which was last revised in 2000.

Development of DSM-V

In 1999, a DSM–V Research Planning Conference, sponsored jointly by APA and the National Institute of Mental Health (NIMH), was held to set the research priorities. Research Planning Work Groups produced "white papers" on the research needed to inform and shape the DSM-IV, and the resulting work and recommendations were reported in an APA monograph and peer-reviewed literature. There were six workgroups, each focusing on a broad topic: Nomenclature, Neuroscience and Genetics, Developmental Issues and Diagnosis, Personality and Relational Disorders, Mental Disorders and Disability, and Cross-Cultural Issues. Three additional white papers were also due by 2004 concerning gender issues, diagnostic issues in the geriatric population, and mental disorders in infants and young children. The white papers have been followed by a series of conferences to produce recommendations relating to specific disorders and issues, with attendance limited to 25 invited researchers.

On July 23 2007, the APA announced the task force that will oversee the development of DSM-V. The DSM-V Task Force consists of 27 members, including a chair and vice chair, who collectively represent research scientists from psychiatry and other disciplines, clinical care providers, and consumer and family advocates. Scientists working on the revision of the DSM have experience in research, clinical care, biology, genetics, statistics, epidemiology, public health and consumer advocacy. They have interests ranging from cross-cultural medicine and genetics to geriatric issues, ethics and addiction. The APA Board of Trustees required that all task force nominees disclose any competing interests or potentially conflicting relationships with entities that have an interest in psychiatric diagnoses and treatments as a precondition to appointment to the task force. The APA made all task force members' disclosures available during the announcement of the task force. Several individuals were ruled ineligible for task force appointments due to their competing interests. Future announcements will include naming the workgroups on specific categories of disorders and their research-based recommendations on updating various disorders and definitions.

Owing to criticism over the perceived proliferation of diagnoses in the current edition of the DSM, David Kupfer, who is shepherding the DSM's revision, said in an interview: "One of the raps against psychiatry is that you and I are the only two people in the U.S. without a psychiatric diagnosis."

Proposed changes to DSM-IV diagnoses

There have been proposals to eliminate Asperger's syndrome as a separate disorder, and instead merge Asperger syndrome under Autism Spectrum disorders. Under the new classification, clinicians can rate the severity of clinical presentation of ASD as severe, moderate or mild.

There have been proposals for more stringent criteria for the diagnosis of bipolar disorder in children. with a new diagnosis temper dysregulation disorder with dysphoria proposed .

There have been proposals to include further and more accurate sub-typing for bipolar disorder (Akiskal and Ghaemi, 2006).

Major changes have been proposed in the assessment and diagnosis of personality disorder . These include a revamped definition of personality disorder and a dimensional rather than a categorical approach based on the severity of dysfunctional personality trait domains (negative emotionality, introversion, antagonism, disinhibition, compulsivity, and schizotypy). In addition, patients would be assessed on how much they match each of five prototypic personality disorder types: antisocial/psychopathic, avoidant, borderline, obsessive-compulsive, and schizotypalwith their criteria being derived directly from the dimensional personality trait domains. Some former personality disorders, like narcissistic personality disorder and histrionic personality disorder, will be submerged under facets of various personality type domains (in this case, the narcissism and histrionism facets of antagonism).

Proposed new DSM-V diagnoses

The proposed new DSM-V diagnoses include the following:

• Absexual
• Complex post-traumatic stress disorder
• Depressive personality disorder
• Negativistic (passive-aggressive) personality disorder
• Post-traumatic embitterment disorder
• Relational disorder
• Sluggish cognitive tempo

Criticism of DSM-V

Robert Spitzer, the head of the DSM-III task force, has publicly criticized the APA for mandating that DSM-V task force members sign a nondisclosure agreement, effectively conducting the whole process in secret: “When I first heard about this agreement, I just went bonkers. Transparency is necessary if the document is to have credibility, and, in time, you’re going to have people complaining all over the place that they didn’t have the opportunity to challenge anything.”

Although the APA has since instituted a disclosure policy for DSM-V task force members, many still believe the Association has not gone far enough in its efforts to be transparent and to protect against industry influence . In a recent Point/Counterpoint article, Lisa Cosgrove, PhD and Harold J. Bursztajn, MD noted that "the fact that 70% of the task force members have reported direct industry ties---an increase of almost 14% over the percentage of DSM-IV task force members who had industry ties---shows that disclosure policies alone, especially those that rely on an honor system, are not enough and that more specific safeguards are needed." David Kupfer, MD, chair of the DSM-V task force, and Darrel A. Regier, MD, MPH, Vice Chair of the task force, countered that "collaborative relationships among government, academia, and industry are vital to the current and future development of pharmacological treatments for mental disorders." They asserted that the development of DSM-V is the "most inclusive and transparent developmental process in the 60-year history of DSM." The developments to this new version can be viewed on [2]. In June 2009 Allen Frances, head of the DSM-IV task force, issued strongly-worded criticisms of the processes leading to DSM-V and the risk of "serious, subtle, (…) ubiquitous" and "dangerous" unintended consequences such as new "false 'epidemics'". He writes that "the work on DSM-V has displayed the most unhappy combination of soaring ambition and weak methodology" and is concerned about the task force's "inexplicably closed and secretive process.". His and Spitzer's concerns about the contract that the APA drew up for consultants to sign, agreeing not to discuss drafts of the fifth edition beyond the task force and committees, have also been aired and debated.

The appointment, in May 2008, of two of the taskforce members, Kenneth Zucker and Ray Blanchard, has led to an internet petition to remove them. According to MSNBC, "The petition accuses Zucker of having engaged in 'junk science' and promoting 'hurtful theories' during his career." According to The Gay City News, "Dr. Ray Blanchard, a psychiatry professor at the University of Toronto, is deemed offensive for his theories that some types of transsexuality are paraphilias, or sexual urges. In this model, transsexuality is not an essential aspect of the individual, but a misdirected sexual impulse." Blanchard responded, "Naturally, it's very disappointing to me there seems to be so much misinformation about me on the Internet. [They didn't distort] my views, they completely reversed my views." Zucker "rejects the junk-science charge, saying there 'has to be an empirical basis to modify anything' in the DSM. As for hurting people, 'in my own career, my primary motivation in working with children, adolescents and families is to help them with the distress and suffering they are experiencing, whatever the reasons they are having these struggles. I want to help people feel better about themselves, not hurt them.'"

Borderline personality disorder controversy

The Treatment and Research Advancements National Association for Personality Disorders (TARA-APD) campaigns to change the name and designation of borderline personality disorder in DSM-V. The paper How Advocacy is Bringing BPD into the Light reports that "the name BPD is confusing, imparts no relevant or descriptive information, and reinforces existing stigma...". There is also discussion about changing Borderline Personality Disorder, an Axis II diagnosis (personality disorders and mental retardation), to an Axis I diagnosis (clinical disorders).

External links

• DSM-V Prelude Project - DSM-V Prelude Review Project by American Psychiatric Association
• Topic Center: DSM-V