Physicians and researchers charged with updating the Diagnostic and Statistical Manual of Mental Disorders expect significant changes for the next edition, to debut in about 3 years.
The proposed revisions will affect not only the DSM-V's specific disorder criteria, but also the clinical approach to diagnosis. Plans call for a greater emphasis on the disability and functioning associated with psychiatric illness, experts said in interviews at the annual meeting of the American Psychopathological Association.
One possible change would be to separate symptoms from functioning entirely, as in the World Health Organization's International Classification of Functioning, Disability, and Health.
Such a separation would place more emphasis on the patient's level of functioning and disability, said Dr. David J. Kupfer, chair of the DSM-V Task Force and chair of the department of psychiatry at the University of Pittsburgh. It also would get away from the tricky issue of determining which of several comorbid conditions is most responsible for creating disability, Dr. Kupfer said.
In the current DSM, Axis V is a kind of global assessment of function that involves a combination of symptoms and functional impairment. It is the only dimensional measure in the DSM-IV, according to Dr. Darrel A. Regier, director of the division of research at the American Psychiatric Association and vice chair of the DSM-V Task Force. But it also creates some confusion by linking symptoms and functioning, he said.
By separating symptoms, impairment, and distress, the process would potentially be “cleaner” and more clinically useful, Dr. Kupfer said. It also would make the process of assessing a patient's level of functioning a standard part of any psychiatric diagnosis, he said.
Members of the DSM-V Task Force are also considering a dimensional, rather than solely categorical, approach to diagnosing mood disorders.
These new approaches are designed to address some of the manual's limitations in guiding management of complex patients with comorbid conditions, as well as making the document easier to use and more clinically relevant.
“The current DSM has resulted in a lot of people not meeting criteria, and yet needing care,” Dr. Regier said.
The current DSM edition fails to account for the significant amount of not otherwise specified (NOS) diagnoses, patients who are subthreshold but have significant impairment, and the significant comorbidities of many psychiatric patients, he said.
In an effort to address this, Dr. Regier and other members of the DSM-V Task Force are looking at including more dimensional measures, but they want to use measures of symptoms that will cut across more than one diagnosis. For example, it would be helpful clinically if physicians could have measures of anxiety, mood, and cognitive impairment when diagnosing psychosis, he said.
“We really need to have a diagnostic system that describes people as they are,” Dr. Regier said.
That information could then be used to generate clinical trials, as well as genetic and pathophysiology studies, that would yield more precise treatments for patients, he said.
Another change under consideration by the DSM-V Task Force is whether to add dimensional approaches to the diagnostic manual, said Dr. Ellen Frank, a professor of psychiatry and psychology at the University of Pittsburgh and a member of the DSM-V Mood Disorders Work Group.
Under the dimensional approach, clinicians might be less concerned with whether all of the symptoms occur at the same time. Instead, they would be looking for a greater number of symptoms that might have occurred at various times in the patient's lifetime.
The final version of the DSM-V is expected to be published in May 2012, though work began in 1999. Currently, the DSM-V Task Force is drafting revisions and developing new dimensional measures, Dr. Regier said. The next step will be to field test those proposed changes starting in June 2009 and continuing until June 2010.
“We've got to get into the field with real patients and see how this is going to work,” Dr. Regier said.
Another new feature of the DSM-V is that it will be a living document: The task force will be able to make changes periodically before issuing the next formal edition. A process for updating the criteria and associated features will be established in between releasing formal editions of the DSM, Dr. Regier said, in much the same way that treatment guidelines are periodically revised.
DSM-V may separate symptoms from functioning, Dr. David J. Kupfer said. Karen Meyers