Getting ready for DSM-5: Part 1

As clinicians, we want a nosological system that is easy to use, can guide treatment decisions, provides useful information about likely disease course and outcomes, and allows us to easily communicate about disease nature with patients, families, payers, and health care administrators. Additionally, although good validity and reliability are desirable for clinicians, adequate coverage of psychiatric disease—the listed conditions should be collectively exhaustive and mutually exclusive—is particularly valued. Finally, we want a diagnostic system that allows us to explain the reasoning behind psychiatric diagnoses and related treatment in lay terms to patients and their families.

DSM-5 development to date

DSM-5 development has been a collaborative effort led by the APA and involves the National Institute of Mental Health, the National Institute on Drug Abuse, the National Institute on Alcohol Abuse and Alcoholism, and the World Health Organization (WHO). Between 1999 and 2002, 3 work conferences resulted in a series of white papers that identified gaps and research needs.¹ Between 2003 and 2008, the American Psychiatric Institute for Research and Education, the National Institute of Health, and the WHO organized 13 international conferences to review a wide range of nosologic issues; the proceedings have been compiled into 13 monographs (11 published and 2 in press) and >125 scientific articles that serve as key reference sources for the DSM-5 process. For a continually updated list of these publications, see www.dsm5.org/Research.

In 2006, DSM-5 Task Force Chair David J. Kupfer, MD and Vice Chair Darrel A. Regier, MD, MPH were appointed and began selecting members of the DSM-5 Task Force, a process that was completed in 2007. Members of the 13 diagnostic area Work Groups (Table 2) were selected and the Work Groups were constituted in 2008. All 168 Task Force and Work Group members were vetted to ensure that they met standards of minimum conflict of interest and broad representation. Membership includes diverse professional representation from academia and mental health; 75% of members are from the United States. Six cross-cutting study groups have deliberated on a range of common issues, including:

• spectrum disorders
• lifespan and development
• gender and cross-cultural
• psychiatric/general medicine interface
• impairment and disability assessment
• diagnostic measurement and assessment.

Additionally, >300 external advisors with special expertise have participated in the process. Since 2008, each of the Work Groups has conducted extensive literature reviews of all assigned disorders, evaluated what works and what doesn’t work in DSM-IV-TR, assessed new research developments and clinical issues that have arisen since publication of DSM-IV-TR in 1994, and developed research plans to investigate critical issues utilizing systematic reviews and secondary data analyses. Based on these analyses, each Work Group proposed draft diagnostic criteria for its disorders, using a strict protocol for criteria revisions such as addition or deletion of disorders and changes to existing diagnostic criteria. These draft diagnostic criteria were first presented on www.dsm5.org in late 2009 through early 2010. Based on input from other Work Groups, the Task Force, several external groups, and the public, the Work Groups revised these criteria and prioritized necessary field trials to evaluate key recommendations. Phase I of the field trials began in 2010.¹² Results of these field trials are being compiled and analyzed.

The DSM-5 Work Groups have met via teleconference 1 to 2 times a month and in-person twice a year, with significant communication between meetings. Work Group chairs are members of the Task Force, which has equally frequent meetings. Reports of DSM-5 deliberations have been presented at hundreds of professional meetings and described in >200 scientific publications. Comprehensive information and ongoing updates on DSM-5 and a list of publications and meetings are provided at www.dsm5.org.

Public input has been sought and the Work Groups have received and processed >10,000 comments. In 2010, the APA Board of Trustees appointed a Scientific Review Committee to evaluate the scientific merit and clinical impact of the Work Group recommendations and comment on the strength of the evidence advanced in support of each proposed revision. In 2011, the Board of Trustees appointed a Clinical and Public Health Committee to evaluate the clinical utility and public health significance of the proposed revisions. The APA and WHO have shared information and assessments in an effort to harmonize diagnostic criteria between DSM-5 and ICD-11.