American Psychiatric Association explains DSM-5BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f3591 (Published 06 June 2013) Cite this as: BMJ 2013;346:f3591
Revision of the American Psychiatric Association (APA) Diagnostic and Statistical Manual of Mental Disorders, the first since 1994, has spanned more than a decade. The process has served as a lightening rod, drawing criticism from within and outside of the psychiatric community. That criticism intensified in the weeks leading up to the official release of DSM-5, while the APA largely kept silent.
So it is perhaps understandable that the organization seemed a bit defensive at the news conference that unveiled the DSM-5 on 18 May in San Francisco at the start of their 166th annual meeting. Reporters could only submit questions in writing, they were not allowed to pose them directly or ask follow-ups. That tactic was not employed for the news conference on the meeting itself, which followed a few minutes later. The APA clearly was intent on controlling the forum and its message.
“The DSM-5 is an investment into the future of mental health, one that will allow for more precise identification of mental disorders,” claimed APA president Dilip V Jeste, a professor of psychiatry and neuroscience at the University of California, San Diego. An early public draft of the document generated more than 15 000 comments that helped “refine the criteria and strengthen the manual” in its final language.
“The manual is first and foremost a guidebook for clinicians,” though it is used by many others, said David Kupfer. The University of Pittsburgh psychiatrist led the 31 person task force that revised the DSM. “We paid a lot of attention to provide this common language, which is important to understand and communicate about mental disorders” for clinicians, patients, and the general public.
Special attention was given “to better characterize and more precisely define symptoms,” he said. Although the definitions of some disorders saw minimal changes, “others were combined because we recognized the overlap between certain categories that suggested they were part of a spectrum rather than distinct conditions.”
The manual contains some “fundamental differences” from earlier iterations of the DSM that “reflect what we’ve learnt over the past two decades about the connections among disorders.” Additionally, “Disorders are framed in the context of age, gender, and cultural expectations . . . along developmental lifespan metrics within each chapter,” Kupfer said.
Among the substantial changes was creation of the category of autism spectrum disorder. It integrates the previously separate categories of autism, Asperger disorder, childhood disintegrative disorder, and basic developmental disorder not otherwise specified.
A growing body of research makes clear that hyperactivity disorder, often referred to as ADHD, is not restricted to young people, but can continue into and throughout adulthood. Kupfer said the revised, expanded definition assures that those who need care can receive it.
“We are very concerned that grief and sadness is sometimes mischaracterized as a disorder,” he said. The revised definition “makes it clear that grief and bereavement is part of the normal range of behavior.” But at the same time, it cautions that such behavior can turn into depression, which may need to be treated.
The new category of mild neurocognitive disorder serves as an opportunity for early detection and the development of an effective treatment plan “before deficits become more pronounced and progress to dementia,” he said.
Moving definitions of substance use and abuse into the context of a continuum improves language, helps to delineate more appropriate interventions, and provides a better organizational structure to integrate future basic research findings on the biology of cravings and addiction.
Kupfer shared the desire for more and better biomarkers related to mental health disorders. He lamented that the field had not progressed as rapidly as many had hoped when the process of revising the DSM was begun. But that was no reason for delay. “Patients can’t be kept waiting, and we can’t be kept waiting, for the prospect of such breakthroughs. We need the DSM-5 now to incorporate the clinical experience and the clinical research of the last twenty years.”
Dealing with controversies
Debate over revising the DSM “wasn’t always pretty,” acknowledged incoming APA president Jeffrey A Lieberman, director of the New York State Psychiatric Institute. He described the process as one that “entailed tremendous rigor, scholarship, integrity, and transparency . . . it represents the gold standard in psychiatric diagnosis such as it is today . . . but it must be applied judiciously” to achieve optimal benefit for people.
Although sympathetic to the desire for greater use of hard measures such as laboratory tests and imaging to help define disorders, Lieberman argued, “We can’t create new knowledge. The DSM reflects the state of our scientific knowledge. It can try to provide a way to translate scientific knowledge into clinical practice.“
Some critics have mischaracterized the DSM, said Darrel A Regier, director of the APA research division. “It is important to recognize that the DSM is not practice guidelines, it focuses on diagnosis.” There is an entirely separate process to develop recommendations for treatment and practice guidelines.
Thomas Insel, director of the National Institute of Mental Health (NIMH), wrote a blog entry earlier in the month that many interpreted as dismissive and critical of the DSM-5. The director and APA subsequently issued a joint statement that sought to smooth over the perception of disagreement.
Lieberman said Insel was frustrated that the field has not moved farther in terms of understanding the basic biology of mental health and disease. He drew a comparison with the progress that has been made in understanding the biology of cancer. And he reiterated that the DSM cannot create science, it can only reflect the current state of knowledge.
Kupfer added, the DSM was never intended to be a primary research tool for basic science. “We are hoping that other frameworks will help facilitate the movement of basic science into ultimately important sets of dialogue with information that can be used in routine practice by clinicians. But we are not there yet.”
“We believe this manual will stimulate further research in a variety of interventions, including early interventions,” he said. “Many of these will not necessarily be pharmacologic interventions but behavior and cognitive interventions that may be very appropriate for these serious disorders.”
Some critics have called the DSM a cash cow for the APA, insinuating that revenue was a principal reason for the revision. A spokesman later told the BMJ that DSM sales average about $5m (£3.3m; €3.8m) a year, roughly 10% of the annual budget. However, the association absorbed all of the decades-long costs associated with producing the revision, an estimated $20-25m. “If the manual were a money-making endeavor APA would have published DSM-5 much sooner rather than waiting nearly 20 years.”
A new section III was added to the DSM-5 to provide tools for clinicians to involve patients in their own care to a much greater degree. These include self-assessment tools, guidance for parents and guardians in assisting younger patients in making self-assessment, and materials to help clinicians become more culturally competent on issues of race, ethnicity, culture, age, and other traits that might affect a patient’s mental health.
An electronic version of the DSM-5 will become available later in the summer. It will be searchable, have links to source references, and will allow for easier updating to better reflect emerging research findings and understandings of particular diseases. Lieberman said they are in the process of establishing a mechanism to update content as needed.
Cite this as: BMJ 2013;346:f3591
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.