Organizing DSM-5: The new framework of mental disorders

It will not be an ordinary table of contents. But then, the DSM-5 will not be an ordinary book.

When the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders comes out in 2013, it will reflect the advances over the past two decades that have helped illuminate connections between the brain and behavior.

Functional MRI studies, for example, have provided insight into obsessive-compulsive disorder. Studies supporting a “schizophrenia spectrum” have shown how the full spectrum of disorders tend to aggregate in families, suggesting shared genetic risks. And still-emerging evidence suggests that there are neurological parallels between behavioral addictions such as pathological gambling and alcohol and substance addictions.

For those of us involved in the huge project leading to the DSM’s revision – the first full update by the American Psychiatric Association (APA) since 1994 – the question of the book’s internal structure presented an interesting challenge almost from the start. Our aim was to incorporate new scientific knowledge as well as the latest clinical observations in the most effective way, not only as both applied to specific diagnostic criteria, but to the book as a whole. The way we have addressed that challenge is immediately apparent as one looks at the manual’s table of contents.

The chapters listed there represent both the conceptual and the organizational framework of DSM-5.  Their order and their titles represent current thinking about how various conditions relate to each other, with the goal of facilitating more comprehensive diagnoses and research.

This new structure is based on current thinking about underlying vulnerabilities too, as well as the symptom characteristics and co-occurrence patterns of specific disorders. As proposed, the framework not only reorders or redefines individual chapters, but arranges them as five general categories to indicate the potential commonalities in etiology within larger disorder groups.

It’s a real departure from every previous manual, in which the sequence of chapters and the chapter titles themselves seem almost an afterthought. In the present edition,DSM-IV, the opening chapter on “disorders first diagnosed in infancy, childhood and adolescence” is immediately and somewhat illogically followed by a chapter on delirium, dementia and amnesia. From mental disorders triggered by general medical conditions, one jumps to substance-related disorders and so on. There’s nothing to suggest any connection between or among chapters that might have implications for diagnosis.

By contrast, DSM-5 will have a linear logic and an overarching cohesion that should move the field forward. The changes should assist researchers in their work and clinicians in their daily practice – not only psychiatrists and other mental health professionals, but primary care physicians and the medical specialists who commonly assess depression and other problems following events such as heart attacks, trauma or childbirth.

Above all, we hope the new DSM will help patients. Individuals who have been diagnosed with multiple disorders within and across disorder groups may see a particular benefit. It may be that they are actually dealing with a single disorder with a range of symptoms that present differently at different times.

Through June 15, the APA is requesting public feedback on the framework and changes proposed for some diagnostic criteria. This is the second comment period in 15 months, and it signals a transparency that I believe is unprecedented in psychiatry or the rest of medicine.  The first comment period last year elicited responses from more than 8,000 mental health professionals, consumer advocates, family members and patients. Each submission to the website was reviewed by the task force and work groups coordinating the revision, and many of these comments influenced some element of the manual’s future direction.

Some doctors have asked why my colleagues and I would spend time on so many thousands of emails. It’s for the same reason that we have involved hundreds of top researchers and clinicians from around the world in the DSM-5’s development. From the very start of our effort nearly 11 years ago, we wanted a depth of research, a breadth of expertise, and a range of diverse opinions and experiences to shape the final document.

Far from ordinary, the organizational framework is already one clear result of that commitment.

Dr. David Kupfer is chair of the DSM-5 Task Force and professor at the University of Pittsburgh School of Medicine in the Department of Psychiatry.

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  • Rob Lindeman

    “…DSM-5 will have a linear logic and an overarching cohesion that should move the field forward.”

    Isn’t this backwards? Shouldn’t the field move the texts forward? Diagnoses are not diseases, but yet the DSM gives names to phenomena, and they become diseases!

    Likewise, diagnoses disappear from the DSM and cease to be diseases (Homosexuality, in 1973)

  • Rob Lindeman

    “Through June 15, the APA is requesting public feedback on the framework and changes proposed for some diagnostic criteria”.

    [the following comment has been made by others in other forums]

    What other medical discipline solicits public comment regarding it’s diagnostic categories?

    • buzzkillersmith

      As a family doc, some of my best friends are shrinks, but you gotta face facts: Psychiatry= medicine+politics+voodoo.

      • doc99

        It’s been said that someone pursues a career in psychiatry to save money on therapy.

  • Carolyn Thomas

    I refer readers to the observations of Dr. Alan Frances, editor of the 4th edition of the DSM, who warned in a recent interview that the new DSM-5, with its emphasis on early intervention, would cause a “wholesale imperial medicalization of normality” and “a bonanza for the pharmaceutical industry,” for which patients would pay the “high price [of] adverse effects, dollars, and stigma”.

    The DSM-5, he observed, may well be “giving drugmakers a new target for their hard sell and doctors, most of whom see it as part of their job to write prescriptions, more reason to medicate”. Read the ‘Wired’ interview, “Inside The Battle To Define Mental Illness” at:

    • Rob Lindeman

      Thanks for the link, Carolyn!

      Here’s the money quote:

      “…[E]very fight over nomenclature threatens to undermine the legitimacy of the profession by revealing its dirty secret: that for all their confident pronouncements, psychiatrists can’t rigorously differentiate illness from everyday suffering.”

  • Marc Gorayeb, MD

    Is the DSM a medical tool or a socio-political tool? What relationship does it have to the thorny issue of insurance payments for psychological therapy? Can the document be trusted to provide physicians with medical information untainted by social pressures?

    • horseshrink

      This is why I prefer working with the sickest of the sick … e.g., those with “dementia praecox.” No ambiguity. Such patients fall comfortably within the heretically narrow range of valid phenomena recognized by the “Midwest Mafia” descriptive psychiatrists who shaped DSM III (the Robins/Goodwin/Guze crowd.) Despite the subsequently metastatic nature of DSM IV, the contemporaneous “Midwest Mafia” list had barely changed.

      I am grateful to an older generation of teachers/mentors who grew up with DSM. They have drilled into me the human nature of this tome … the human factors that shape it.

      And yes … part of the de facto function of DSM is to communicate with third party payers in an effort to trigger remuneration. Money, politics and clinical science make for uneasy bedfellows.

      However, DSM is also an earnest effort by psychiatry to communicate a current “state of the profession.” It is another milestone (for better and for worse) in my field’s efforts to classify human disease.

      “DSM 10″ may look much different from our existing concepts. Or DSM, as a construct, could become outmoded. Neurologists and surgeons don’t seem to require statistical manuals to define the illnesses they tend.

  • horseshrink

    I know of no other field in medicine that struggles so much with its nomenclature that it requires public input to proceed.

    Unfortunately, people mistake DSM with definitive knowledge, going so far as to call it the “Bible” of psychiatry.

    What would Goodwin and Guze (and Robins) say were they still alive? The forwards to “Psychiatric Diagnosis” remain etched in my mind.

  • D.S. Arrowsmith

    On a tangential matter, what about the title of this bible? The last time the DSM had any info on statistics was in the second edition of 1968. The editors of the fourth edition declared the term “mental disorders” inappropriate. How about calling it the Diagnostic Manual?

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