Revising the DSM

Lee Anna Clark, PhD, jumped at the chance to be involved in crafting the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5), due to be published in 2013.

"I saw this as a possible opportunity to see my research have real-world applications," says Clark, a University of Notre Dame psychology professor who is serving on working groups focusing on personality disorders and impairment assessment. Clark is one of several psychologists helping with the revision — the first since 1994.

Plenty has happened since then to warrant a revision, says Lynn F. Bufka, PhD, assistant executive director for practice research and policy in APA’s Practice Directorate.

"There’s been an awful lot of research that has gone on in the area of psychopathology, much of it done by APA members," says Bufka, pointing to advances in the field’s understanding of neuroscience and genetics as two examples. "It’s important to see if any of that research changes how we understand diagnosis."

The process of revising the DSM-IV began in 1999. Since then, the DSM-5 Task Force and more than a dozen work groups — many of which include psychologists — have been reviewing the current manual’s strengths and weaknesses, perusing the literature and analyzing data.

Changes ahead

In February, the task force released draft diagnostic criteria for public comment. The proposals include:

• Mood disorders. The draft proposes a new category called "temper dysregulation with dysphoria" intended to help clinicians distinguish between children with symptoms of severe mood dysregulation and those who have bipolar disorder or oppositional defiant disorder.

• Suicide. New suicide scales for adults and adolescents may help clinicians identify patients at greatest risk.

• Risk syndromes. The draft proposes a new diagnostic category called "risk syndromes," which may help clinicians identify earlier stages of such serious mental disorders as dementia and psychosis.

• Addiction. The draft proposes replacing the current categories of substance abuse and dependence with a new category called "addiction and related disorders." The draft also proposes a new category called "behavioral addictions," with gambling as its sole disorder.

• Eating disorders. The draft changes the criteria for diagnosing anorexia and bulimia. The proposed criteria for anorexia include a heightened focus on behavior, for example. While the DSM-IV’s diagnostic criteria include "refusal" and "fear of weight gain," the Eating Disorders Work Group points out that "refusal" is difficult to assess and that some people with anorexia deny fear of weight gain. In addition, the draft moves binge-eating disorder out of the Appendix and makes it its own freestanding diagnosis.

• Learning disorders. The proposed criteria include name changes for categories within the learning disorders section. The reading disorder and mathematics disorder categories become dyslexia and dyscalculia, bringing them into line with international usage. The draft also clarifies the diagnostic criteria. While the DSM-IV includes poor mathematics ability as a criterion, for example, the proposed version draws on emerging evidence to substitute poor basic numeracy skills. The draft also recommends the creation of a single diagnostic category — autism spectrum disorders — to replace current diagnoses of autistic disorder, Asperger’s disorder, childhood disintegrative disorder and pervasive developmental disorder.

The DSM-5 draft also proposes that "dimensional assessments" be added to diagnostic evaluations of mental disorders. These assessments would allow clinicians to evaluate the severity of symptoms and take into account symptoms that cut across multiple diagnoses.

"We know that anxiety is often associated with depression, for example, but the current DSM doesn’t have a good system for capturing symptoms that don’t fit neatly into a single diagnosis," says David Kupfer, MD, chair of the DSM-5 Task Force.

More than 8,000 clinicians, researchers and family and patient advocates commented on the draft criteria. The DSM-5 work groups are reviewing the comments and further refining the criteria.

Overall, APA’s Bufka predicts, the DSM-5 will not be a radically different manual. The revisions she expects are more of a "fine-tuning of things that were already there."

Now the revision team has launched field trials to test some of the proposed criteria in real-world settings. The trials will help ensure that the criteria are easy for clinicians to understand and that they accurately describe mental illness in ways that help clinicians make sound treatment decisions. The trials will also assess the criteria’s reliability and validity.

To gather data from the wide range of settings where the DSM is used, the revision group developed two study designs — one for use in academic and other large clinical settings and one for individual practitioners and smaller clinical practices. Eleven large medical centers are participating in the field trials, along with nearly 4,000 psychiatrists, psychologists and other mental health professionals in smaller practices.

"The two field trial designs will allow us to better understand how the proposed revisions affect clinicians’ practices and, most importantly, patient care," says Kupfer.

Implications for psychologists

How the DSM revision will affect psychologists depends not only on how different the DSM-5 is from the DSM-IV but how different it is from the World Health Organization’s International Classification of Diseases (ICD), says Bufka.

"The reality in this country is that increasingly our members are supposed to be reporting diagnoses by ICD codes for billing purposes," she says, adding that the ICD is itself in the process of revision. The ICD-9-CM, the version currently used in the United States, mirrors the DSM-IV in most codes.

"If the changes to the DSM aren’t huge and the ICD-10-CM syncs up, then there won’t be a huge amount of change for our members," says Bufka, explaining that many clinicians use billing software that automatically translates DSM codes into ICD codes. "If the two systems start to differ a fair amount, there’s going to need to be some mechanism for psychologists to learn the ICD."

Rebecca A. Clay is a writer in Washington, D.C.