DSM-V at a Glance

The Work in Progress.. Dr Subas Pradhan

The Shrink¶s Bible

Understanding 50 Years of Change
DSM-II: 182 disorders DSM-III: 265 disorders

134 pages 494 pages 567 pages 886 pages

DSM-III-R: 265 disorders

DSM-IV: 365 disorders

DSM-IV-TR: 365 disorders

943 pages

In 50 years: 800% increase in the number of diagnoses

Why change DSM-IV 
  

Clinical Utility Research Evidence Category Vs Dimensionality Reducing the junk i.e. 40% of all diagnosis are NOS category!

The Future of the DSM: Towards DSM -V
The begining:

http://www.dsm5.org/

DSM 5 in last decade.. 

2004-2007: ³The Future of Psychiatric Diagnosis: Refining the Research Agenda´ APA/NIH/WHO global research planning conferences. ³Phase 2: Refining the Research Agenda for DSM-5: NIH Conference Series´ April 2006: Drs. David Kupfer and Darrel Regier are appointed as chair and vice-chair, respectively, of the DSM-5 Task Force. July 2007: DSM-5 Work Group Chairs are appointed. Assembling of DSM-5 Work Groups begins. May 2008: DSM-5 Work Group members announced. APA Names DSM-5 Work Group Members.   

Phase 1 Field Trial ..2010 
 

January± May 2010: Site Recruitment for Field Trial Testing. February ± May 2010: Pilot Testing for DSM-5 Field Trials. May 2010 ± March 2011: DSM-5 Field Trials, Phase 1. The first phase of DSM-5 field trials will begin in May 2010 and is scheduled to run for 10 months. Initial text for DSM-5 & case studies will also be developed, which will be published after DSM-5¶s release in a series of case books. 



DSM 5 in 2011 
   

March ± April 2011: Revisions to Proposed Criteria. April ± May 2011: Review of Revised Criteria. May-July 2011: Online Posting of Revised Criteria till June 30 2011. August 2011 ± February 2012: DSM-5 Field Trials, Phase II. 



DSM 5 in 2012 

February ± August 2012: Prepare Final Draft Text. March 2012: Presentation of DSM-5 Structure to APA¶s Board of Trustees. August 2012: Final Review. September 2012: The National Center for Vital and Health Statistics¶ Annual ICD-10-CM Revision Conference. The final, approved overall structure of DSM5 will be complete in time for this conference so that organization of ICD-10CM can be aligned with DSM-5. September ± November 2012: Final Revisions to Draft Criteria. November 2012: APA Assembly Approval of DSM-5. December 2012: APA Board of Trustees Approval of DSM-5 and submission to APA¶s publishing division, American Psychiatric Publishing, Inc.      

May 2013: Publication of DSM-5. The release of DSM-5 will take place during the APA¶s 2013 Annual Meeting in San Francisco, CA.

Proposed Field Trials
Generalized Anxiety Disorder 
       

       

Minor Neurocognitive Disorder Major Neurocognitive Disorder Autism Spectrum Disorder Learning Disabilities Intellectual Disabilities ADHD (in children and adults) Callous/Unemotional Specifier for Conduct Disorder Oppositional Defiant Disorder (linked to Field Trial for Temper Dysregulation Disorder) Temper Dysregulation Disorder Non-Suicidal Self Injury Preschool PTSD Psychotic Risk Syndrome Schizoaffective Disorder Psychotic Disorder Major Depressive Disorder Anxious Depression Bipolar Disorder

Agoraphobia PTSD Obsessive-Compulsive Disorder Hoarding Nicotine (Tobacco Use Disorder) Alcohol Use Disorder Cannabis Use Disorder Opioid Use Disorder Complex Somatic Symptom Disorder Binge Eating Disorder Avoidant/Restrictive Food Intake Disorder Primary Insomnia Hypersexual Disorder

Proposed Draft Revisions to DSM Disorders and Criteria
‡ Structural, Cross-Cutting, and General Classification Issues for DSM-5 Adjustment Disorders Anxiety Disorders Delirium, Dementia, Amnestic, and Other Cognitive Disorders Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence Dissociative Disorders Eating Disorders Factitious Disorders Impulse-Control Disorders Not Elsewhere Classified Mental Disorders Due to a General Medical Condition Not Elsewhere Classified Mood Disorders Other Clinical Conditions That May Be a Focus of Clinical Attention Personality and Personality Disorders Schizophrenia and Other Psychotic Disorders Sexual and Gender Identity Disorders Sleep Disorders Somatoform Disorders Substance-Related Disorders

General format of DSM-5 website 
  

Proposed Revision Rationale Severity DSM IV

Structural, Cross-Cutting, and General Classification Issues for DSM-5   

Use of the multi-axial system to record diagnoses and clinical variables of interest (collapsing axis-I,II&III into one) Consideration of factors that cut across all diagnoses (e.g., gender and cultural issues) The use of dimensional measures to refine diagnostic assessment and treatment planning i.e. depression in many disorders

Adjustment Disorders  

The work group is recommending that this disorder be included in a grouping of Trauma and Stress-Related Disorders Specify if With PTSD-Like or ASD-Like symptoms: when the predominant manifestation is PTSD-like or ASD-like symptoms, but the PTSD/ASD stressor and/or symptom criteria are not met.

Anxiety Disorders 
 

OCD as another diagnostic category Remove Agoraphobia without panic disorders Disorders Not Currently Listed in DSM-IV
± ± ± ± ± Substance-Induced (indicate substance) Tic Disorder Tic Disorder Due to a General Medical Condition Hoarding Disorder Olfactory Reference Syndrome Skin Picking Disorder

Conditions Proposed by Outside Sources 
    

     

Apathy Syndrome Body Integrity Identity Disorder Complicated Grief Disorder Developmental Trauma Disorder Disorders of Extreme Stress Not Otherwise Specified (DESNOS) Fetal Alcohol Syndrome Internet Addiction Male-to-Eunuch Gender Identity Disorder Melancholia Parental Alienation Disorder Seasonal Affective Disorder Sensory Processing Disorder

Delirium, Dementia, Amnestic, and Other Cognitive Disorders
Removing the term ³Dementia´ and adding ³Major Neurocognitive Disorders´, 2) Adding a category of ³Minor Neurocognitive Disorders´, 3) Categorizing behavioral disturbances, particularly the syndromes of psychosis and depression, associated with Neurocognitive Disorders, and 4) Selecting specific domains as well as measures of severity of cognitive functional impairment 1)

Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence 

New name for category, autism spectrum disorder, which includes

Asperger¶s disorder,autistic disorderchildhood disintegrative disorder, Pervasive Developmental Disorder 

Mental retardation (Renamed Intellectual Disability) 

Code no longer based on IQ level

Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence 

*Childhood Disorders Proposed for Possible Reclassification in Another Diagnostic Category
± ± ± ± Pica Rumination Disorder Feeding Disorder of Infancy or Early Childhood Separation Anxiety Disorder *Childhood Disorders Proposed for Possible Removal from DSM (No DSM-5 Criteria Proposed)
‡ ‡ ‡ ‡ Expressive Language Disorder Mixed Receptive-Expressive Language Disorder Communication Disorder Not Otherwise Specified Rett's Disorder

Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence 

Childhood Disorders Proposed to be Divided into New Childhood Disorders
± Reactive Attachment Disorder of Infancy or Early Childhood Childhood Disorders Proposed to be Subsumed Under Other Diagnoses (No DSM-5 Criteria Proposed) ± Disorder of Written Expression ± Learning Disorder Not Otherwise Specified ± Childhood Disintegrative Disorder ± Asperger's Disorder ± Pervasive Developmental Disorder Not Otherwise Specified

Childhood Disorders Not Currently Listed in DSM-IV
‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ ‡ Posttraumatic Stress Disorder in Preschool Children Temper Dysregulation Disorder with Dysphoria Callous and Unemotional Specifier for Conduct Disorder Learning Disabilities Non-Suicidal Self Injury Non-Suicidal Self Injury Not Otherwise Specified Language Impairment Late Language Emergence Specific Language Impairment Social Communication Disorder Voice Disorder

Factitious Disorder  

The work group has proposed that this diagnosis be reclassified from Facitious Disorders to Somatic Symptom Disorders Proposed Subtype: 

Factitious Disorder imposed on another (previously, factitious disorder by proxy)

Substance-Related Disorders 

Work group¶s proposals is the recommendation that the diagnostic category include both substance use disorders and non-substance addictions Gambling disorder has been moved into this category and there are other addiction-like behavioral disorders such as ³Internet addiction´ Pathological gambling: The work group has proposed that this diagnosis be reclassified from Impulse-Control Disorders Not Elsewhere Classified to Substance-Related Disorders which will be renamed as Addiction and Related Disorders.  

Mood Disorders 

Mood Disorders Being Recommended for Removal or Reclassification-Mixed Episode Mood Disorders Not Currently Listed in DSM-IV  

Mixed Anxiety Depression ± Mixed Features Specifier  Premenstrual Dysphoric Disorder 

Mood Disorders Proposed for Possible Removal from DSM (No DSM-5 Criteria Proposed) Bipolar I Disorder - Most Recent Episode Mixed

Major Depressive Episode  

The exclusion of symptoms judged better accounted for by Bereavement is removed because evidence does not support separation of loss of loved one from other stressors "Do not include symptoms due to... moodincongruent delusions or hallucinations" is eliminated because meaning and purpose are unclear.

Dysthymic Disorder  

The work group is proposing that this disorder be renamed Chronic Depressive Disorder, and will not require the exclusion of a Major Depressive Episode. The category of major depression with chronic specifier to be combined with dysthymic disorder under the term ³chronic depressive disorder´.

Depressive Disorder Not Otherwise Specified 

Depressive Conditions Not Elsewhere Classified (Depressive CNEC) 


Depressive CNEC with insufficient information to make a specific diagnosis. Subsyndromal Depressive CNEC 
 

Prodromal depression. Subsyndromal depression that meets duration criteria but not symptom count criteria for Major Depressive Episode (MDE.) Mixed Subsyndromal Anxiety-Depressive Disorder. Major Depressive Episode (MDE) superimposed on a psychotic disorder. Recurrent Brief Depressive Disorder. 

Other Depressive CNEC 


Schizophrenia and Other Psychotic Disorders 

Schizophrenia and Other Psychotic Disorders Not Currently Listed in DSM-IV  Attenuated Psychotic Symptoms Syndrome ± Catatonia Specifier 

Removing all sub-typing of schizophrenia! 

As it¶s rarely used diagnostically (<5%), with the exception of paranoid schizophrenia (5075%) and, to a lesser extent, undifferentiated schizophrenia

Personality and Personality Disorders 

Significant reformulation of the approach to the assessment and diagnosis of personality psychopathology 

Definition: Personality disorders represent the failure to develop a sense of selfidentity and the capacity for interpersonal functioning that are adaptive in the context of the individual¶s cultural norms and expectations.

Personality and Personality Disorders
Work Group recommends 5 specific personality disorder types (Reduced from 10 in DSM IV to 5)
± Antisocial/Psychopathic Type  Avoidant Type  Borderline Type  Obsessive-Compulsive Type  Schizotypal Type

Personality Traits 

The Work Group recommends that patients be rated on 6 broad, higher order personality trait domains each comprised of several lower order, more specific trait facets.
Trait Domains: 
     

Negative Emotionality Introversion Antagonism Disinhibition Compulsivity Schizotypy

Domains and Facets 

Negative Emotionality: Experiences a wide range of negative emotions (e.g., anxiety, depression, guilt/ shame, worry, etc.), and the behavioral and interpersonal manifestations of those experiences 

Trait facets: Emotional lability, anxiousness, submissiveness, separation insecurity, pessimism, low self-esteem, guilt/ shame, self-harm, depressivity, suspiciousness 

Introversion: Withdrawal from other people, ranging from intimate relationships to the world at large; restricted affective experience and expression; limited hedonic capacity 

Trait facets: Social withdrawal, social detachment, restricted affectivity, anhedonia, intimacy avoidance 

Antagonism: Exhibits diverse manifestations of antipathy toward others, and a correspondingly exaggerated sense of self-importance 

Trait facets: Callousness, manipulativeness, narcissism, histrionism, hostility, aggression, oppositionality, deceitfulness

Domains and Facets contd. 

Disinhibition: Diverse manifestations of being present- (vs. future- or past-) oriented, so that behavior is driven by current internal and external stimuli, rather than by past learning and consideration of future consequences 

Trait facets: Impulsivity, distractibility, recklessness, irresponsibility 

Compulsivity: The tendency to think and act according to a narrowly defined and unchanging ideal, and the expectation that this ideal should be adhered to by everyone 

Trait facets: Perfectionism, perseveration, rigidity, orderliness, risk aversion 

Schizotypy: Exhibits a range of odd or unusual behaviors and cognitions, including both process (e.g., perception) and content (e.g., beliefs) 

Trait facets: Unusual perceptions, unusual beliefs, eccentricity, cognitive dysregulation, dissociation proneness

Substance-Related Disorders 

Work group¶s proposals is the recommendation that the diagnostic category include both substance use disorders and non-substance addictions Gambling disorder has been moved into this category and there are other addiction-like behavioral disorders such as ³Internet addiction´ Pathological gambling: The work group has proposed that this diagnosis be reclassified from Impulse-Control Disorders Not Elsewhere Classified to Substance-Related Disorders which will be renamed as Addiction and Related Disorders.  

Sleep Disorders 

Proposed Sleep Disorders Not Currently Listed in DSM-IV 


Kleine Levin Syndrome Obstructive Sleep Apnea Hypopnea Syndrome (previously Breathing Related Sleep Disorder) Primary Central Sleep Apnea (previously Breathing Related Sleep Disorder) Primary Alveolar Hypoventilation (previously Breathing Related Sleep Disorder) Rapid Eye Movement Behavior Disorder Restless Legs Syndrome Circadian Rhythm Sleep Disorder - Advanced Sleep Phase Type Disorder of Arousal Circadiam Rhythm Sleep Disorder - Free-Running Type Circadiam Rhythm Sleep Disorder - Irregular Sleep-Wake Type   

  

 

Criticisms of the DSM
The DSM More of a Political (and economic) Art Than a Science

Pharmaceutical companies have played a big part in maintaining a ´medical modelµ classification system With profits to gain, pharmaceutical companies have readily funded research ?The writers of DSM have also benefited from the DSM·s medical model

More Criticisms of the DSM
The DSM Pathologizes ´Normalµ Behaviors