DSM stands for Diagnostic and Statistical Manual of Mental Disorders. DSM is published by the American Psychiatric Association (APA) and contains descriptions, symptoms, and other criteria for diagnosing mental disorders. These criteria for diagnosis provide a common language among clinicians – professionals who treat patients with mental disorders.  By clearly defining the criteria for a mental disorder, DSM helps to ensure that a diagnosis is both accurate and consistent; for example, that a diagnosis of schizophrenia is consistent from one clinician to another, and means the same thing to both of these clinicians, whether they reside in the U.S. or other international settings. It is important to understand that appropriately using the diagnostic criteria found in DSM requires clinical training and a thorough evaluation and examination of an individual patient.

Another important role of DSM is to establish criteria for diagnosis that can be used in research on psychiatric disorders. Only by having consistent (reliable) diagnoses can researchers compare different treatments for similar patients, determine the risk factors and causes for specific disorders, and determine their incidence and prevalence rates.  DSM disorders are also used as the basis for treatment indications by the FDA or and for clinical Practice Guidelines.  DSM diagnoses are linked to the diagnostic codes listed in the International Classification of Diseases used by clinicians to report diagnoses to insurers for reimbursement, and to public health authorities for causes of illness and death.

 No information about treatment is included in DSM.  While determining an accurate diagnosis is a first step for the clinician in defining a treatment plan for a patient, DSM contains no recommendations on what that course of treatment should be. That said, DSM is certainly important to those who provide treatment to patients with mental illness, because accurate diagnosis leads to appropriate treatment.   

 DSM has been periodically reviewed and significantly revised since the publication of DSM-I in 1952. Particularly over the past two decades, there has been a wealth of new information in neurology, genetics and the behavioral sciences that dramatically expands our understanding of mental illness. Researchers have generated a wealth of knowledge about the prevalence of mental disorders, how the brain functions, the physiology of the brain and the lifelong influences of genes and environment on a person’s health and behavior.  Moreover, the introduction of scientific technologies, ranging from brain imaging techniques to sophisticated new methods for mathematically analyzing research data, have given us new tools to better understand these illnesses.

The current process for revising DSM has been guided by four principles.  First, the highest priority is clinical utility – that is, making sure the manual is useful to those who diagnose and treat patients with mental illness, and to the patients being treated.  Second, all recommendations should be guided by research evidence. Third, whenever possible, DSM-5 should maintain continuity with previous editions. And fourth, no a priori restraints should be placed on the level of change permitted between DSM-IV and DSM-5.  The third and fourth principles may seem contradictory, but both principles are necessary – those charged with revising the manual must carefully consider the impact that any changes would have on clinical practice, disorder prevalence and other important factors, while at the same time, considering the diagnostic advances that would be made through implementation of new scientific knowledge and clinical understanding. 

In revising DSM, work groups (made up of global experts in various areas of diagnosis) have looked at what elements of the current edition (DSM-IV) are working well, what elements do not meet the needs of clinicians and how best to correct those concerns.  For example, the work groups are determining how to better assess the severity of symptoms and how to handle psychiatric disorders that often occur together in the same patient (called co-occurring disorders), such as anxiety and depression. They are focusing on reducing diagnoses currently called “Not Otherwise Specified” in DSM-IV and on improving diagnostic criteria that are not precise.  The work groups are also aiming to better specify “treatment targets” for clinicians – helping them identify those symptoms that should be addressed in treatment and for which improvement may be possible.

Additionally, the DSM-5 Task Force has focused on how to include assessment of common symptoms that are not addressed within the diagnostic criteria for a specific illness (for example, symptoms of insomnia that may be experienced by a patient with schizophrenia). One way of addressing these issues is through cross-cutting dimensional assessments.

One of the challenges in accurately diagnosing mental disorders is to evaluate the range of symptoms and other factors that appear in a single patient.  In the earlier versions of DSM, as with the current DSM-IV, disorders were described and arranged by category, with a specific list of symptoms for each mental illness. In this categorical system, a person either had a symptom or they didn’t, and having a certain number of symptoms was required to receive a diagnosis.  If this number was not met, the disorder could not be diagnosed. 

While these specific criteria for disorders were a vast improvement over the previous diagnostic guidelines available to diagnose patients with mental disorders, there are real-world problems with this system of diagnosis. The categorical syndromes do not always fit with the reality of the range of symptoms that individuals’ experience.  For example, individuals with Schizophrenia often have other symptoms that do not match the criteria for diagnosing Schizophrenia – Insomnia, for example, or symptoms of depression and anxiety. Also, because the criteria for diagnosis are “yes/no” (i.e., does the individual have this disorder or not?), in most cases there is no method in DSM-IV to account for the severity of the disorder, and thus no specified way to determine if the patient is improving with treatment.

The DSM-5 Work Groups are now considering an additional way to help the clinician capture the symptoms and severity of mental illnesses, by using dimensional assessments.  These would allow clinicians to systematically evaluate patients on the full range of symptoms they may be experiencing. For instance, information about depressed mood, anxiety level, sleep quality and substance use would be important for clinicians to know regardless of the patient’s diagnosis. Dimensional assessments would allow clinicians to rate both the presence and the severity of the symptoms, such as “very severe,” “severe,” “moderate” or “mild”.  This rating could also be done to track a patient’s progress on treatment, allowing a way to note improvements even if the symptoms don’t disappear entirely.  It would encourage mental health professionals to document all of a patient’s symptoms and not just those that were tied to their primary diagnosis. 

The current task of the DSM-5 Work Groups is to examine the available scientific evidence and determine what the appropriate dimensional assessments would be for the specific illnesses they are reviewing, and to provide clinicians with specific guidance on how to apply them.   

The proposed framework for DSM-5 re-orders the current manual’s 16 chapters based on underlying vulnerabilities as well as symptom characteristics. The chapters are arranged by general categories such as neurodevelopmental, emotional and somatic to reflect the potential commonalities in etiology within larger disorder groups. Such changes are aimed at facilitating more comprehensive diagnosis and treatment approaches and encourage research across diagnostic criteria..

A Diagnostic Spectra Study Group was charged with examining the ways in which disorders in DSM-5 might be organized and whether advances in neuroscience, brain imaging and genetics suggested a framework that would arrange disorders by more than common symptoms. Discussions took place with officials from the National Institute of Mental Health, followed by a presentation to the DSM-5 Task Force.   

What steps has the APA taken to ensure that the process for developing DSM-5 is open and inclusive?

DSM-5: The Future Manual outlines the extensive process in which the APA is engaging to ensure that the development of DSM-5 is the most open and inclusive in the history of the manual.  More than 500 of the world’s most renowned clinicians and researchers have been involved in working together to provide a solid scientific basis for the proposed changes to DSM. The initial planning process took place over nine years and involved a National Institutes of Health-funded conference series in concert with the World Health Organization, where global experts in various aspects of mental illness conducted literature reviews, conferred at meetings around the world and created papers highlighting “the state of the science” in specific areas of mental health.  Summaries of each meeting are posted on the DSM-5 website, and full monographs of the proceedings are available through American Psychiatric Publishing at www.appi.org.

The activities of the 13 DSM-5 Work Groups are summarized in regular reports on the DSM-5 website, and members routinely make presentations at scientific conferences open to all attendees. As of mid-2010, presentations (with question-and-answer opportunity) had been made at hundreds of national and international conferences and in grand rounds at leading university medical centers. The APA holds a number of sessions on the DSM-5 revision process at every Annual Meeting.

Additionally, members and advisors of the work groups, study groups and task force are writing and submitting a number of scientific papers to peer-reviewed publications articulating the issues around potential diagnostic changes of DSM for a number of psychiatric disorders. From 2005 to 2009, more than 200 papers were published, with many more in press (a complete citation list can be found here).

In addition to the 162 members of the work groups and task force tasked with analyzing the data and recommending any diagnostic changes to DSM, each work group enlists the input of advisors who have expertise in research and clinical practice of specific psychiatric disorders. To date, an additional 300+ advisors have been engaged to work with the work group members, and many more will be engaged during the revision process.

Suggestions and ideas for members of the work groups were also solicited through the DSM-5 website. The proposed draft revisions to DSM-5 are posted on the website, and anyone can provide feedback to the work groups during periods of public comment.

Finally, members of the DSM-5 Task Force have given numerous media interviews to help explain the process of development to mental health professionals, consumers, family members and members of the public, and they will continue to do so through the development process.

The APA is strongly committed to a transparent process of development for DSM, and to an unbiased, evidence-based DSM, free from any conflicts of interest. To ensure an unbiased DSM-5, the APA’s Board of Trustees required that all task force and work group members abide by a set of guiding principles and disclosure policies.

Every work group and task force member has disclosed their relationships with commercial entities that have an interest in psychiatric diagnoses and treatments.  This includes income, honoraria, ownership interests, and direct research grants from industry.  Additionally, the APA sharply limits both work group and task force members’ income and ownership interests (such as stock) from industry sources; this limit does not include unrestricted research grants paid through the member’s institution.

Disclosure was required for the period of time three years prior to each person’s nomination to the task force or work group, and is being updated annually during the duration of work on DSM-5.  This information is available for each task force and work group member.  The APA is providing active oversight of these disclosure policies.   

The APA asked those involved in the DSM-5 process to sign a member acceptance form in order to protect the intellectual property and work product being developed. Participants in the DSM-5 development signed agreements designed to prevent them from creating competitive products for personal financial benefit from this collaborative effort involving the combined efforts of hundreds of participating clinicians and researchers.  A substantial amount of the publishing returns from DSM-5 products will be re-invested in future efforts to keep the diagnostic criteria current with advances in the scientific understanding of mental disorders.  Educational programs to assist clinicians to maintain their competency in diagnosis and the scientific basis for treatment will likewise be supported.  

It is important to note that the DSM Member Acceptance Forms are not intended to restrict the free discussion of ideas on the issues involved in revising DSM and developing new diagnostic criteria.  Nor have they done so in practice. In fact, task force and work group members have presented and participated in open discussions at psychiatric and other major medical meetings around the world. They have discussed issues they were addressing in their work groups. They have published articles on related-research in peer-reviewed journals and in trade publications (click here for a complete list of citations), and have given multiple interviews to medical and consumer media about the DSM-5 process (click here for a listing of previous and upcoming presentations).

Aided by technology, the development of DSM-5 has been the most open in the history of DSM. DSM-5 Work Groups have posted reports on their activities and discussions on our website.  The site, which has a section where interested parties can send the APA comments, helps facilitate the exchange of information from around the world.

The DSM-5 work groups began with a review of research, including monographs from a series of planning conferences in concert with the World Health Organization funded by the National Institutes of Health.

Several principles were established to guide the DSM-5 revision process: 

·         The highest priority is “clinical utility” – that is, making the manual useful to clinicians diagnosing and treating people with mental disorders.

·         Recommendations for revisions should be based on research evidence.

·         When possible, continuity with the previous edition, DSM-IV, should be maintained in order to limit disruption for clinicians and research.

·         There should be no pre-determined constraints on changes from DSM-IV in areas where the manual’s organization and criteria were problematic.

In addition the work groups were asked to:

·         clarify the boundaries between mental disorders to reduce confusion of disorders with each other and  to help guide effective treatment;

·         consider “cross-cutting” symptoms (symptoms that commonly occur across different diagnoses);

·         demonstrate the strength of research for the recommendations on as many evidence levels as possible; and

·         clarify the boundaries between specific mental disorders and normal psychological functioning.

Work groups have met frequently in person and via conference call since they were appointed in 2007. Each work group developed a research plan that included literature reviews and data analysis. This research guided recommendations for changes in DSM, following the principle that the amount of evidence required is related to the magnitude of the recommended change: i.e., the larger and more significant the recommended change, the stronger the research evidence should be. In general, a broad consensus of expert clinical opinion is expected for proposed changes in DSM-5. 

In addition to reviewing research, work groups consulted with advisors who were approved to provide specialized expertise and bring different viewpoints to the process. Work group members also presented results of their discussions at medical specialty meetings and brought feedback from those sessions back to the work group meetings. 

Each work group submitted a first draft of diagnostic criteria for DSM-5. The draft criteria were posted at www.DSM5.org for public review and comment during 2010. Comments provided through the website continue to be reviewed by the work groups and the draft criteria updated for field trials.

After each round of field trials, which are designed to see how some of the proposed diagnostic criteria work in real-world settings, changes may be made to the criteria based on the results. Revised criteria will be posted on the DSM-5 website for additional public comment.  Final criteria will be approved by the DSM-5 Task Force, with ultimate approval required by the APA Board of Trustees. Publication of DSM-5 is slated for May 2013.

Additional details on the decision-making process for DSM-5 may be found in "Guidelines for Making Changes to DSM-5."

With the interest in the revision of DSM, articles have appeared in the news media, speculating on the addition of potential new diagnoses. Most of this speculation has very little basis in fact.  The goal of DSM is to establish clear criteria for diagnosing mental disorders, not to create medical conditions out of the full range of human behavior and emotions. Any new or substantially modified diagnosis will come about only after a comprehensive review of the scientific literature, and full discussion by the work group members with input by the DSM-5 Task Force and Advisors.

DSM-5 is intended to be a manual for assessment and diagnosis of mental disorders and will not include information or guidelines for treatment for any disorder.  That said, determining an accurate diagnosis is the first step toward being able to appropriately treat any medical condition and mental disorders are no exception.  DSM-5 will also be helpful in measuring the effectiveness of treatment, as dimensional assessments will assist in assessing any changes in severity levels as a response to treatment.

Roman numerals have been attached to DSM since the second edition of the manual was published more than four decades ago. But in the 21^st century, when technology allows immediate electronic dissemination of information worldwide, Roman numerals are especially limiting. Research advances will continue to require text revisions to DSM, and a TR designation, as was done with DSM-IV-TR, can only be appended once. After DSM-5 is published in 2013, future changes prior to the manual’s next complete revision will be signified as DSM-5.1, DSM-5.2 and so on.