DSM-5 revised in response to comments; clinicians prepare to field-test
■ Thousands responded to the first-ever call for public input on the new version of the psychiatric manual, scheduled for publication in 2013.
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The fifth edition of the Diagnostic and Statistical Manual of Disorders is ready to be field-tested after an unprecedented call for public comment that drew about 8,600 responses from health professionals, patients, professional societies and researchers during a 2½ month period.
The DSM-5 is undergoing revisions because of those comments, with changes made to entries including those covering eating disorders and sexual disorders. One particularly contentious issue was left untouched: the grouping of the current four classifications of autism spectrum disorders into one.
The American Psychiatric Assn., which publishes the DSM, did not make public the comments it received. However, there has been plenty of discussion elsewhere, both online and in physicians' offices, that captured the intense debate that surrounds any revision of the DSM -- debate that is far from over, although the opportunity for comment directly to the publisher has ended.
For primary care doctors, who often are on the front lines of diagnosing mental illnesses, the DSM-5 has to be practical, said Lori Heim, MD, president of the American Academy of Family Physicians.
Darrel Regier, MD, MPH, vice chair of the DSM-5 task force, said a DSM-IV geared toward nonpsychiatrists was not well-used because it still was too complex. He said there will be a version of the DSM-5 for psychiatrists and one for nonpsychiatrists.
"What we're trying to do is make DSM useful for primary care physicians, as well as for specialists," Dr. Regier said. He noted that a study group was created to focus on the interface of psychiatry and general medicine.
Latest changes to DSM-5
The reason for accepting online comments was to offer the public an opportunity to provide feedback on a process that has long been reserved for expert panels within the APA. When DSM-IV was published in 1994, the association did not have the Internet capabilities to take feedback online, Dr. Regier said. Instead, there was a form at the back of the draft on which people could write comments to mail to the APA.
Dr. Regier said the APA estimated that 500,000 people came to its DSM-5 website during the comment period. Some comments registered concerns about behaviors that were defined as mental disorders. Others were concerned about insurance coverage for treatment of a nonspecified diagnosis.
"We were interested in what these criteria changes would actually mean" to the public, Dr. Regier said.
Based on comments, and experts' review of them, some changes already have been made:
- Removing the diagnostic requirement for anorexia nervosa that patients have a body weight less than 85% of that expected. In its place, the phrase "markedly low weight" was added.
- Expanding mechanisms of compensatory behavior for bulimia nervosa to include medication, excessive exercise and fasting.
- Revising sexual and gender identity disorders. For all paraphilia disorders, two specifiers were added -- "in remission" and "in controlled environment."
- Amending hypersexual disorder to specify that diagnosis applies only to patients who are at least 18 years old.
- Removing the qualification that the patient must be male to be diagnosed with transvestic disorder.
Work groups formed to study and classify mental disorders reviewed comments to determine whether changes should be made. For example, strong suggestions from commenters led to the replacement of a specific number with a general guideline for body weight and anorexia nervosa, Dr. Regier said.
Still more controversy
More changes to DSM-5 are expected as it gets field-tested by clinicians on its way to a 2013 release.
How DSM-5 handles autism and related conditions remains in dispute. The largest number of comments received on any specific category were about neurodevelopmental disorders.
In DSM-IV, autism is split into four categories: autistic disorder, Asperger's syndrome, childhood disintegrative disorder and pervasive developmental disorder not otherwise specified.
DSM-5 proposes the four categories be grouped together under "autism spectrum disorder." The APA's DSM-5 website explains: "A single spectrum disorder is a better reflection of the state of knowledge about pathology and clinical presentation."
Chicago pediatric neuropsychologist Scott Hunter, PhD, has heard concerns about the proposed changes from parents of the autistic children he treats -- particularly parents of children with Asperger's syndrome.
"This is on their radar. ... I think they're really struggling with understanding [how their] child, who doesn't have a classic presentation of autism, would still [be considered to have] autism spectrum disorder" under DSM-5, said Hunter, associate professor of psychiatry and pediatrics at the University of Chicago. He also is director of pediatric neuropsychology at the University of Chicago Medical Center.
There are also questions about whether experts decreased the required number of binging and purging episodes for a bulimia diagnosis too steeply in DSM-5, said Douglas Bunnell, PhD, past president of the National Eating Disorders Assn. He is the vice president and director of nonresidential clinical services for the Renfrew Centers. The women's mental health facilities treat eating disorders and other issues and have locations throughout the U.S.
The criteria dropped from at least two binging and purging episodes a week for three months in DSM-IV to once a week for the same duration in DSM-5.
During field trials -- which are expected to continue through February 2011 -- clinicians will assess the feasibility, clinical utility, reliability and, where possible, the validity of the draft criteria and the dimensional measures proposed for DSM-5.
"We hope that our criteria will help facilitate communication between general medicine physicians and psychiatrists, and also help them to diagnose and monitor treatment response," Dr. Regier said.