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• DSM-V

DSM-V: The Future Manual

The process for revising the Diagnostic and Statistical Manual of Mental Disorders (DSM) began with a brief discussion between Steven Hyman, M.D., (then-director of the National Institute of Mental Health), Steven M. Mirin, M.D., (then-medical director of the American Psychiatric Association) and David J. Kupfer, M.D., (then-chair of the American Psychiatric Association Committee on Psychiatric Diagnosis and Assessment) at the National Institute of Mental Health (NIMH) in 1999. They believed it was important for the American Psychiatric Association (APA) and NIMH to work together on an agenda to expand the scientific basis for psychiatric diagnosis and classification.

The initial DSM-V Research Planning Conference in 1999 was under the joint sponsorship of the two organizations to set research priorities. Participants included experts in family and twin studies, molecular genetics, basic and clinical neuroscience, cognitive and behavioral science, development throughout the life-span, and disability. To encourage thinking beyond the current DSM-IV framework, many participants closely involved in the development of DSM-IV were not included at this conference. Through this process, participants recognized the need for a series of white papers that could guide future research and promote further discussion, covering over-arching topic areas that cut across many psychiatric disorders. Planning work groups were created, including developmental issues, gaps in the current system, disability and impairment, neuroscience, nomenclature, and cross-cultural issues.

In early 2000, Darrel A. Regier, M.D., M.P.H., was recruited from the NIMH to serve as the research director for the APA and to coordinate the development of DSM-V. Additional conferences to set the DSM-V research agenda were held later in July and October of 2000 to propose planning work group members and to hold the first face-to-face meetings. These groups, which included liaisons from the National Institutes of Health (NIH) and the international psychiatric community, developed the series of white papers, published in A Research Agenda for DSM-V (2002, American Psychiatric Association). A second series of cross-cutting white papers entitled, Age and Gender Considerations in Psychiatric Diagnosis, was subsequently commissioned and published by APA in 2007.

Leaders from the APA, the World Health Organization (WHO) and World Psychiatric Association (WPA) determined that additional information and research planning was needed related to specific diagnostic areas. Hence, in 2002, the American Psychiatric Institute for Research and Education (APIRE), with Executive Director Darrel A. Regier, M.D., M.P.H., as the Principal Investigator, applied for a grant from the NIMH to implement a series of research planning conferences that would focus on the research evidence for revisions of specific diagnostic areas. A $1.1 million cooperative agreement grant was approved with support provided by NIMH, the National Institute on Drug Abuse (NIDA), and the National Institute on Alcoholism and Alcohol Abuse (NIAAA).

Under the guidance of a steering committee comprised of representatives from APIRE, the three NIH institutes, and the WHO, 13 conferences were held from 2004 to 2008, with expertise that spanned the globe – each conference had co-chairs from both the U.S. and another nation, and approximately half of the participants were from outside the U.S. In each conference, participants wrote papers addressing specific diagnostic questions, based on a review of the literature, and from these papers and the conference proceedings, a research agenda was developed on the topic. The results of seven of these conferences have been published to date in peer-reviewed journals or American Psychiatric Publishing, Inc. (APPI) monographs, with the remainder of the publications anticipated in 2008. Findings from all 13 conferences are immediately available to serve as a substantial contribution to the research base for the DSM-V Task Force and Work Groups, and for the WHO as it develops revisions of the International Classification of Diseases.

In 2006, APA President Dr. Steven Sharfstein announced Dr. Kupfer as chair and Dr. Regier as vice chair of the task force to oversee the development of DSM-V. They, along with other leaders at the APA, nominated additional members to the task force, which includes the chairs of the diagnostic work groups that will review the research and literature base to form the content for DSM-V. These task force nominees were reviewed for potential conflicts of interest, approved by the APA Board of Trustees, and announced in 2007. In turn, the work group chairs, together with the task force chair and vice-chair, recommended to the successive APA Presidents, Drs. Pedro Ruiz and Carolyn Robinowitz, nominees widely viewed to be the leading experts in their field, who were then formally nominated as members of the work groups. All work group members were also reviewed for potential conflicts of interest, approved by the APA Board and were announced in 2008.

The work groups began meeting in late 2007. While the 13 work groups reflect the diagnostic categories of psychiatric disorders in the previous edition DSM-IV, it is expected that those categories will evolve to better reflect new scientific understanding. With the understanding that some continuity from DSM-IV to DSM-V is desirable to maintain order in the practice of psychiatry and continuity in research studies, there has been no pre-set limitation on the nature and degree of change that work groups can recommend for DSM-V.

Each work group meets regularly, in person and on conference calls. They begin by reviewing DSM-IV’s strengths and problems, from which research questions and hypotheses are first developed and then investigated through literature reviews and analyses of existing data. They will also develop research plans, which can be further tested in DSM-V field trials involving direct data collection. In order to invite comments from the wider research, clinical, and consumer communities, the APA launched a DSM-V Prelude Web site in 2004, where these groups could submit questions, comments, and research findings to be distributed to the relevant work groups.

Based on this comprehensive review of scientific advancements, targeted research analyses, and clinical expertise, the work groups will develop draft DSM-V diagnostic criteria. A period of comment will follow, and the work groups will review submitted questions, comments, and concerns. The diagnostic criteria will be revised and the final draft of DSM-V will be submitted to the APA’s Council on Research, Assembly, and Board of Trustees for their review and approval. A release of the final, approved DSM-V is expected in May 2012.