The Draft DSM-V - Few Surprises

This just in: The American Psychiatric Association’s DSM-V Task Force has just published a rough draft of its proposed changes to the DSM, psychiatry’s diagnostic bible. The document is available for viewing and comment on the APA’s website.

The new version of the DSM, scheduled for publication in 2013, would supersede the current DSM-IV, in effect since 1994. (There is the DSM-IV-TR of 2000, which involved only minor technical adjustments.) The DSM-IV - and before that the DSM-III-R of 1987 - represented incremental changes to the groundbreaking DSM-III of 1980. The proposals for the DSM-V would go a lot farther, but can hardly be regarded as revolutionary.

Essentially, the new DSM would build on our current system of classifying mental illness according to clusters of symptoms rather than underlying causes. In essence, the people who did the original legwork on depression, bipolar, anxiety, schizophrenia, and the like got a lot of it right on the first go. On the other hand, the brain science that promises to turn all our current assumptions upside-down is not there yet.

Thus, the DSM-V will be a conservative document. The DSM-VI, assuming the DSM is still around in say 2025, will be a whole new ball game.

Following are some quick impressions:

Personality disorders. Only in the field of personality disorders did the DSM-V Task Force essentially rip everything up and start all over. The Task Force had telegraphed its punches in earlier discussion papers, noting the extreme confusion and overlap that exists in the current DSM.

What we will see is a “hybrid” system that preserves the old “categorical” approach but introduces a “dimensional” perspective. Thus, “borderline personality disorder” will survive as “borderline type” (and be included with other “types”), but clinicians will also be able to make alternative diagnoses based on personality “levels” (involving “self” and “interpersonal”) and “trait domains” (such as “emotional negativity”).

Mood disorders. Same-old, same-old. The symptom lists for depressive and manic episodes remain intact. So do the bounds of bipolar (no bipolar III or IV to add to bipolar II). What’s new is a widened definition to “mixed” episodes to embrace both depression and bipolar II (rather than the current version which only applies to bipolar I); mixed anxiety depression; a widened definition of dysthymia to emphasize its chronic nature and to include major depression, presumably to differentiate chronic from recurrent depression.

Schizophrenia and psychosis. Some retooling of the definition of schizophrenia, elimination of the various categories of schizophrenia, no new definition of schizoaffective. What’s new is “psychosis risk syndrome,” which would encourage clinicians to seek out tell-tale signs and engage in early treatment, before it is too late.

Anxiety. Major change: OCD be included in another category of disorders.

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There is a lot more to the DSM-V proposals than I outlined here. This is just a quick first pass. A lot more to come, lots more ...

Further reading

Last October, I did a five-part series on the development of the ground-breaking DSM-III of 1980 and the issues involved, plus my unexpected dinner with its prime mover, Robert Spitzer:

• Spitzer and the DSM - Part V
• Spitzer and the DSM - Part IV
• Robert Spitzer and the DSM - Part III
• Robert Spitzer and the DSM - Part II
• Robert Spitzer and the DSM - Part I