DSM-5 will capture the dynamic nature of mental illness


Much of the debate over the future edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has centered on what disorders will be added, modified or dropped. But lost in the discussion is a change that will align disorders along a developmental continuum—one that looks at them across the lifespan. This shift will provide clinicians with a critical perspective that until now has been missing.

Historically, disorders were classified in DSM by symptom manifestation and patient presentation. As a result, they generally were grouped by discreet stages of life, as if there were no connections or implications from one stage to another. In particular, the opening chapter of DSM-IV, “Disorders Usually First Diagnosed in Infancy, Childhood, Adolescence,” segregated such conditions as attention-deficit/hyperactivity disorder, pica, rumination and autism disorder from the rest of the manual. The implication was that disorders in the “child” chapter affect only children and disorders in the rest of the manual affect only adults.

The result has been problematic for both sides of the age spectrum. ADHD in an adult, for example, is more likely to be overlooked because that disorder is so linked to pediatric cases.  Similarly, although sleep disorders are most associated with adults, they can still affect children and adolescents. Yet they are less likely to even be assessed because the criteria and text do not address their appearance at that point of the lifespan.

By contrast, the DSM-5 framework will recognize age-related aspects of disorders by arranging diagnostic chapters and categories in a chronological fashion, with diagnoses most applicable to childhood listed first, followed by diagnoses more common to adolescence and the early 20s and ending with those most relevant to adulthood and later years. The same developmental pattern will be evident within each set of individual disorders, with conditions most frequently diagnosed in childhood listed first. Importantly, the DSM-IV chapter on infants, children and adolescents will be redistributed throughout the manual, to chapters on Neurodevelopmental Disorders; Elimination Disorders; Feeding and Eating Disorders; and Disruptive, Impulse Control, and Conduct Disorders.

DSM-5 will also include discussion of how specific features might manifest at different ages and over a lengthy period; this will underscore how a disorder may persist into later life and be impacted by the particular demands of those years. At the same time, diagnostic criteria for many disorders typically associated with adults will include specific reference to how symptoms may appear in children, such as irritability and failure to gain weight as part of a major depressive episode.

The need for these changes is obvious: The real world doesn’t work within distinct boundaries, and clinicians are not best able to understand potential connections, interrelations and ramifications when they only consider a single, narrow point in time. A young girl who lashes out with persistent and significant anger could presage a young adult with similarly explosive behavior, for example. Conversely, a middle-aged man’s extreme anxiety might reflect a difficult recent event, such as a divorce or layoff. But it also might be a problem that first manifested itself decades earlier, in panic attacks or a fear of leaving the house. In both cases, diagnosis as well as treatment will be more clinically useful if the factors involved are evaluated through a longitudinal lens.

This different perspective will especially benefit women, for whom mental disorders are often linked to specific ages or periods of life. We know that young women between 15 and 22 are much more likely to have negative body image than young men and to develop eating disorders, low self-esteem, depression, self-harm and,  in the most extreme cases, suicide. But what happens after 22?  Even with treatment, the risk of recurrent depression remains, and it often needs to be assessed in terms of the extra emotional and physical issues many women face throughout their lives—because of lower income, discrimination, sexual harassment and violence.

The next manual will capture the dynamic nature of mental illness. Rather than isolating childhood disorders or ignoring the developmental continuum that influences many disorders, its structure aggregates disorders based on similar pathology and emphasizes development across disorders. It is intended to capture impact at age of onset, variations within different phases of life and the natural course of core psychopathology.

Its approach across the lifespan is just one way that DSM-5 will help move the field forward and benefit patients.

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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