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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