NEW ORLEANS -- More than 10 years after the American Psychiatric Association (APA) began developing the fifth edition of its Diagnostic and Statistical Manual of Mental Diseases (DSM), the process is now moving smartly toward its planned 2013 conclusion, leaders of the effort said here.
After receiving more than 8,600 comments on a first draft of the DSM-5 after it was in February, field trials of revised definitions and some entirely new diagnoses are set to begin in July, said David Kupfer, MD, of the University of Pittsburgh, chairman of the DSM-5 task force.
Often called the "bible" of the psychiatric profession, the DSM was last fully updated in 1994. More than a dozen symposia and presentations at the APA's annual meeting here focused on the progress to date.
The upcoming field trials of the proposed DSM-5 revisions -- the association has abandoned Roman numerals for Arabic -- will take place both in large academic centers and in small, routine-practice settings, according to Darrel Regier, MD, MPH, the APA's director of research. All of the field trials will be testing the feasibility, clinical utility, and sensitivity to change in the revisions.
Some of the trials will involve as many as 300 patients and will also look at the reliability of the proposed diagnostic protocols -- that is, whether retesting of patients using the same criteria will produce the same diagnostic results.
The larger trials will focus on disorders in which the proposed new diagnostic criteria have the greatest potential to change clinical practice, Regier said.
Among them:
- Collapsing four separate autism-related disorders in the current edition of the DSM into just one, Autism Spectrum Disorder
- New eating disorder categories, including binge eating as separate from bulimia
- So-called temper dysregulation disorder with dysphoria, expected to dramatically reduce the number of children diagnosed with bipolar disorder
- New scales for assessing suicide risk in adults and adolescents
Although the trials will mainly involve psychiatrists and allied professionals such as clinical psychologists, primary care physicians will also be included in at least some of the large trials, Kupfer said.
Also to be tested are so-called dimensional assessments, an innovation in DSM-5.
Up to this point, the DSM has focused on providing labels for groups of patients, but had no formal way of noting disorder severity or tracking changes over time. The 13 DSM-5 work groups have been charged with developing quantitative measures as part of the symptom assessment process for each disorder category.
The idea, said Jay Burke, MD, MPH, of Harvard University, is to "provide additional information to clinicians" beyond the simple categorization of symptoms.
Dimensional assessments may cover not only severity of symptoms, but also other factors not necessary to diagnosis but important in prognosis, treatment planning, and measuring outcomes.
These could be ideal for evaluating functional impairments, which are being deemphasized in DSM-5 as diagnostic criteria per se.
These were included in the last edition of the DSM. The intent was to justify medicopsychiatric treatment of conditions that, without a finding of objectively negative impacts, might be considered merely extreme expressions of normal behaviors and emotions.
This was "useful in theory, but not reliable in practice," said Jane Paulsen, PhD, of the University of Iowa. "It was too complicated and subject to differing interpretations."
Another difficulty has been that a requirement of impairment as part of diagnosis precludes treating patients before they become impaired.
The field trials are to be completed in time for results to be available by next April, Kupfer said. The results will likely trigger additional revisions, some of which will need testing in a second round of field trials in 2011.
Final language is to be drafted in 2012, to be approved by the APA's governing bodies late that year. The official DSM-5 is to be unveiled at the group's annual meeting in 2013.
The current meeting here "is very important for the DSM process," Kupfer said at a press conference.
He said the direct, face-to-face feedback with meeting attendees here was an important complement to the online comments, suggestions, and criticisms of the proposed revisions.
Most people at the meeting are practicing clinicians, Kupfer noted, calling them "the ultimate consumers" of the final DSM-5 product, whose input is essential to creation of the revised diagnostic manual.
At least one potential revision emerged at a symposium here that included a report on new criteria for attention deficit-hyperactivity disorder (ADHD).
The proposed changes, described by work group co-chair Xavier Castellanos, MD, of New York University, included an attention-deficit symptom of difficulty with "lengthy readings."
During the question-and-answer period, Thomas E. Brown, PhD, of Yale University and also in private practice, commented that many children have no trouble reading books they choose for themselves, mentioning the Harry Potter series as an example.
What they have trouble with is long readings assigned to them in school, Brown said. He suggested revising the language to stipulate difficulty with "lengthy assigned readings."
"I like it. We'll take it to the work group," Castellanos responded.
But, highlighting the contentiousness of the DSM-5 revisions, another questioner followed Brown to the microphone to say his experience was exactly the opposite -- that his ADHD patients often focused better with assignments and deadlines than when left on their own.