DSM-5: Creation and Purpose

DSM-5 Creation

• The creation of the DSM-5 took 12 years.
• Hundreds of people were involved in the process.
• New features such as dimensional measures were created in order to enhance the usefulness of the DSM-5.
• The goal was to enhance the use of DSM-5 as a clinical guide and a tool for research.
• The DSM-5 aims to provide clinicians, patients, families, and researchers with descriptions of mental disorders.
• Diagnostic criteria are operationalized and supplemented with dimensional severity measures.
• The DSM-5 includes information on risk factors, culture, sex, and gender-related issues pertaining to diagnosis.
• Clinical training and experience are essential for accurate DSM diagnosis.
• The diagnostic criteria identifies symptoms, signs, affects, behaviors, cognitive functions, and personality traits.
• Physical signs, symptom combinations, and durations are defined in diagnostic criteria and require clinical expertise
• Differentiation between normal variation and responses to stress can be achieved through examination of symptoms.
• It is recommended to conduct a review of mental systems using the DSM-5 Level 1 Cross-Cutting Symptom Measure.
• The use of DSM criteria helps create a common language for clinicians.
• Officially recognized disorders are in Section II, but their classification is subject to change based on research advances.

Development of DSM-5-TR

• The first edition of the Diagnostic and Statistical Manual of Mental Disorders was published in 1952 by the APA
• The first DSM contained a glossary of descriptions of diagnostic categories.
• "Reaction" reflected Adolf Meyer's psychobiological view of mental disorders as reactions to psychological, social, and biological factors.
• The second edition, DSM-II, based its classification on the mental disorders section of the eighth revision of the International Classification of Diseases (ICD-8).
• DSM-II and the ICD-8 went into effect in 1968.
• DSM-III development was coordinated with ICD-9, published in 1975 and implemented in 1978.
• DSM-III, published in 1980 under Robert L. Spitzer, introduced explicit diagnostic criteria
• DSM-III took a descriptive approach that attempted to be neutral with respect to theories of etiology of mental disorders.
• The APA appointed a Workgroup to Revise DSM-III, leading to DSM-III-R in 1987, to amend inconsistencies
• DSM-IV was published in 1994, and it involved over 1,000 people and many professional organizations over 6 years.
• Developers of DSM-IV and ICD-10 worked to increase congruence, and ICD-10 was published in 1992.
• More information can be found on the APA website at https://www.psychiatry.org/psychiatrists/practice/dsm/history-of-the-dsm.

DSM-5 Revision Process

• In 1999, the APA initiated an evaluation of DSM strengths and weaknesses
• WHO, the World Psychiatric Association, and the NIMH were involved in the evaluation.
• The proceedings were published in the 2002 monograph A Research Agenda for DSM-V.
• From 2003 to 2008, the APA and WHO led thirteen DSM-5 research planning conferences, supported by the NIMH, NIDA, and NIAAA.
• The conferences involved 400 participants from 39 countries to review literature in specific diagnostic areas.
• The goal was to prepare revisions for both DSM-5 and ICD-11.
• Reports from these conferences became the basis for future reviews by the DSM-5 Task Force.
• David J. Kupfer, M.D., was named Chair, and Darrel A. Regier, M.D., M.P.H., was named Vice-Chair of the DSM-5 Task Force in 2006.
• Kupfer and Regier were charged with recommending chairs for the 13 diagnostic work groups.
• Task force members were selected with a multidisciplinary expertise.
• The APA Board of Trustees initiated a vetting process to disclose income sources
• Conflicts of interest were avoided among task force and work group members.
• A new disclosure standard was set by disclosing all income and research grants from commercial sources, including the pharmaceutical industry
• There was a cap on income from commercial sources, and disclosures were published on a website.
• The task force of 28 members was approved in 2007, and over 130 work group member appointments were approved in 2008.
• Over 400 additional work group advisors were approved to participate without voting authority.
• The task force and work groups focused on the next evolution of mental disorder classification.
• The DSM-IV’s history, strengths, limitations, and strategic directions for its revision were recounted to visualize this evolution.
• A literature review, secondary analyses, scientific journal publication, writing, website posting, professional meeting presentations, field testing, and criteria/text revision were involved in an intensive, 6-year process.
• Overall, DSM-5 development and testing involved many health professional and educational groups.
• Physicians, psychologists, social workers, epidemiologists, and neuroscientists participated.
• Mental disorder patients and their families, consumer organizations, and advocacy groups in DSM-5 revision by feedback were involved

Revision Proposals

• Members of the work groups developed proposals for the DSM-IV diagnostic criteria revision.
• Rationale, scope of change, impact on clinical management, public health, research evidence, and clinical utility were used for creation
• Proposals included changes to diagnostic criteria, new disorders/subtypes/specifiers, and existing disorder deletions.
• Strengths and weaknesses were first identified in the current criteria and nosology
• The previous two decades' novel scientific findings were considered
• A research plan was created to assess potential changes through literature reviews and secondary data analyses.
• The four guiding principles for draft revisions stated:
• DSM-5 should be a clinician's manual, with feasible revisions for routine clinical practice.
• Revisions must be based on research evidence.
• DSM should maintain continuity with previous editions where possible.
• There should be no a priori limits on the degree of change between DSM-IV and DSM-5.
• Work groups identified key issues within their diagnostic areas
• Broader methodological concerns like contradictory findings and the need for a refined definition of mental disorder were examined
• Cross-cutting issues were considered.
• Advantages and disadvantages were used when evaluating proposals to include in Section II
• Additional stipulations were used for new diagnoses, subtypes, and specifiers
• One additional stipulation was demonstration of reliability, the degree to which two clinicians could independently arrive at the diagnosis.
• Low clinical utility and weak validity resulted in disorders considered for deletion.
• A proposed condition's placement in Section III depended on a number of factors
• Empirical evidence was needed for the diagnosis as were the presence of clinical need was a potential benefit in advancing research.

DSM-5 Field Trials

• The use of field trials demonstrated reliability and was a noteworthy improvement introduced in DSM-III.
• The DSM-5 field trials had several design/implementation strategy changes from DSM-III and DSM-IV approaches.
• Data was obtained relating to the precision of kappa reliability estimates.
• The estimates are a statistical measure that assesses level of agreement between raters.
• Kappa reliability estimates correct for chance agreement due to prevalence rates.
• Field trials extended by using two designs.
• The first was in a large, diverse medical-academic setting.
• The second was in routine clinical practices.
• The medical-academic setting capitalized on the need for large sample sizes.
• Hypotheses on the reliability and clinical utility of a range of diagnoses were tested in a variety of patient populations.
• The design supplied valuable information about proposed revisions in everyday clinical settings among DSM users.
• Medical-academic field trials were from December 2010 to October 2011 in 11 North American medical-academic sites.
• Select revisions had their reliability, feasibility, and clinical utility were assessed, with priority given to those changes.
• The changes represented the greatest degree of change or have the greatest potential impact on public health.
• All clinical patient populations coming to each site were screened for DSM-IV diagnoses.
• Symptoms were analysed that were likely to predict several specific DSM-5 disorders of interest.
• Stratified samples of four to seven specific disorders, plus a stratum containing all other diagnoses were identified for each site.
• Patients were randomly assigned for a clinical interview by a blind clinician followed by a second interview within 2 weeks
• Other clinicians, blind to the diagnoses, did the second interview
• Patients completed a computer-assisted inventory of cross-cutting symptoms in more than a dozen psychological domains
• Inventories were scored by a computer and results were provided to clinicians before the clinical interview.
• Clinicians determined a patient's diagnoses, score their severity, and upload the data .
• This determined the degree to which independent clinicians could agree on a diagnosis (using the intraclass kappa statistic)
• Agreement was also measured via clinician-administered ratings of cross-cutting and diagnosis-specific symptom severity.
• The self-reported symptoms, personality traits, disability, and diagnostic severity were administered and analyzed.
• Prevalence rates of DSM-IV and DSM-5 were able to be assessed in respective clinical populations.
• The routine clinical practice field trials involved recruitment of individual psychiatrists/mental health clinicians in October 2011–March 2012.
• A volunteer sample was recruited; it included psychiatrists, psychologists, licensed clinical social workers, and nurses.
• Proposed DSM-5 diagnoses and dimensional measures were exposed to a wide range of clinicians and assessed their feasibility and clinical utility.

Public and Professional Review

• In 2010, the APA launched a website for public and professional input into DSM-5.
• Draft diagnostic criteria and organizational changes were posted on www.dsm5.org for feedback.
• 8,000 submissions were reviewed by 13 work groups, and members integrated questions and comments into discussions.
• A second posting occurred in 2011 following revisions to the criteria and proposed chapter organization.
• The work groups considered feedback from web postings and the DSM-5 Field Trials when drafting proposed final criteria.
• Proposed final criteria were posted on the website in 2012 for a third and final time.
• Three iterations of external review led to more than 13,000 individually signed comments
• The work groups reviewed website comments
• The task force addressed concerns of DSM users, patients, and advocacy groups, and ensured clinical utility remained high.

Expert Review and Final Approval

• The 13 work groups collaborated with advisors and reviewers under the DSM-5 Task Force to draft diagnostic criteria and text.
• The APA Division of Research staff supported the DSM-5 Task Force
• Text coordinators from each work group were developed through a network.
• The text editor coordinated the preparation of the text
• A scientific peer review process was provided by the Scientific Review Committee (SRC), separate from the work groups.
• The SRC chair, vice-chair, and six committee members reviewed the degree to which proposed DSM-IV changes had scientific evidence.
• Each diagnostic revision proposal required a memorandum of evidence and a summary of supportive data.
• Validators were organized around the proposed diagnostic criteria, including antecedent, concurrent, and prospective validators.
• The SRC reviewed submissions
• Other justifications for change including clinical experience or conceptual revisions were seen as outside the purview of the SRC.
• APA Board of Trustees and work groups considered the reviewers' scores
• Clinical and Public Health Committee (CPHC) consisted of a chair, vice-chair, and six members.
• Their goal was to consider clinical utility, public health, and logical clarification issues for criteria that lacked sufficient evidence.
• This review process was important for DSM-IV disorders with known deficiencies which proposed remedies had not previously considered.
• Four to five external reviewers evaluated the selected disorders
• The blinded results were reviewed by CPHC members which made recommendations to the APA Board of Trustees.
• The APA Council on Psychiatry and Law performed forensic reviews of diagnostic criteria and text.
• Work groups added forensic experts to complement the Council on Psychiatry and Law's expertise
• The task force then sent a recommendation to the APA Assembly’s Committee on DSM-5 to consider clinical utility and feasibility.
• The Assembly is a deliberative body of the APA.
• The group represented the district branches and wider membership;it was composed of psychiatrists across the United States.
• Geographic area, practice size, and interest-based diversity were represented.
• The Committee on DSM-5 was composed of Assembly leaders.
• Executive “summit committee” sessions consolidated input from review;these included Assembly committee chairs, task force chairs, a forensic advisor, and a statistical advisor.
• Each disorder was reviewed by the Assembly and APA Board of Trustees executive committees
• The Assembly voted in November 2012 to recommend the Board approve DSM-5
• The APA Board of Trustees approved publication in December 2012.

Revisions to DSM-5

• Digital publishing allows for more efficient dissemination of changes.
• APA has adopted an iterative improvement model for DSM
• Revisions can be pegged to specific scientific advances.
• The DSM Steering Committee appointed in Spring 2014 oversaw it as Vice Chairs.
• A web portal was created for continuous proposals to be submitted
• Proposed changes can include adding new disorders, deleting or modifying criteria sets, and changing text.
• Submissions must be accompanied by supporting information reasons for change and validity/reliability data.
• Approaches to validating diagnostic criteria have included antecedent, concurrent, and predictive validators.
• New criteria that improve some classes of validators are adopted for current disorders.
• If the new disorders are valid by some of these validators with mental disorder and demonstrate clinical utility they will also be added.
• The Steering Committee initially reviews all proposals
• The Committee looks to see that the evidence is to meet the criteria for approval
• The proposal is sent to one of the five standing Review Committees (the DSM Work Groups).
• The Review Committee reviews the evidence, requests more data as needed, and returns the proposal with recommendations.
• If the Steering Committee agrees that sufficient evidence support the proposal, the proposal is posted online for public comment.
• The final version makes adjustments based on the comments and is sent to the APA Assembly and Board of Trustees for approval.
• https://psychiatryonline.org gets updates (the online version)
• DSM-5-TR includes changes approved since DSM-5 publication in 2013.

DSM-5 Text Revision

• The APA began working on DSM-5-TR in 2019.
• Michael B. First, M.D., and Philip Wang, M.D., Dr.P.H., were Revision Subcommittee Co-Chairs.
• Wilson M. Compton, M.D., and Daniel S. Pine, M.D., were Revision Subcommittee Vice Chairs.
• The effort involved over 200 experts(primarily the people that were involved in DSM-5’s development).
• The experts reviewed the past 10 years of literature and reviewed existing text for outdated material.
• Reviews were made to any possible compromise on the content’s objectivity.
• The process mirrored DSM-5 with experts in 20 Disorder review groups headed by a section editor.
• 4 cross-cutting review groups (Culture, Sex and Gender, Suicide, and Forensic) reviewed all chapters.
• A work group on Ethnoracial Equity and Inclusion reviewed the textto ensure that attention to race was sufficient
• Conceptual changes to the criteria sets were not included in the scope of text revisions.
• Review of the text led to some necessary clarifications to diagnostic criteria.
• APA Assembly and Board of Trustees reviewed and approved proposals

Changes in DSM-5 Organizational Structure

• DSM is a medical classification of disorders that increases comprehensibility and utility.
• Disorder classification provides a high-level organization for the manual.

Regrouping Disorders

• Whether study of the DSM-5 diagnostic spectra to see if scientific validators could inform new groupings of related disorders within the existing categorical framework.
• Eleven such indicators were recommended by the study group for this purpose:
• neural substrates
• family traits
• genetic risk factors
• specific environmental risk factors
• biomarkers
• temperamental antecedents
• abnormalities of emotional or cognitive processing
• symptom similarity
• course of illness
• high comorbidity
• shared treatment response
• These indicators allowed the study group to be empirical guidelines.
• Inform decision-making by the DSM 5 work groups and the task force
• About how to cluster disorders to maximize their validity
• International journal Psychological Medicine published a series of papers;
• As a part of the ICD-11 developmental processes to document that such validators were most useful for suggesting grouping of disorders.
• Both the APA & WHO to improve clinical utility
• Improving clinical utility
• Helping to explain apparent comorbidity
• Facilitating scientific investigation
• Organization enhance clinical utility
• Remain within the bounds of well-replicated
• Structure with science

Conservatively Revise

• Conservatively revise the structure, By guiding how each disorder is grouped.
• Broad investigations across:
• Different categories
• Across individual chapters.

Harmonize

• To harmonize the classifications across scientific literature.
• Broad investigation across chapters and classifications.

DSM-5 Structure

• Organized along:
• Development
• Life Spans
• Improving Utility Focusing on the beginning:
• NEURO
• Psychotic Disorders Followed by :
• Diagnoses that manifest adolescence and young adulthood
• Ending with Diagnoses relevant to adulthood

Harmonization With ICD-11

• Task shared to make two classifications same.
• The existence of two issues of collection and stats
• Hinder design trials and treatments
• Lack application.
• Two broad classifications
• Attempt across boundaries.
• The prior IV and X didnt always Agree. All confine to largely harmonize.
• The harm of complete harmonization
• Differences were ahead
• Groups were just finished just in time to make guidelines Many group members were instructed So that it makes group similar unless the reason has them to differ.
• Reviewing differences were more or less similar with all the comparisons

Key Frameworks

• A mental disorder should have clinical utility*
• should help clinicians to determine
• prognosis
• treatment plans
• potential treatment outcomes Individuals symptoms demonstrate a clear need of what they are Limiting individuals can prevent from appropriate care access. Developed for clinical use This has high levels of legal judgement

Categorical and Dimensional Approaches to Diagnosis

• Substantial need to classify clinical presentations from DSM disorders
• Environmental factors have raised concerns and questions and twin designs
• A rigid system often does capture the scientific observations and clinical experience
• Boundaries between multiple disorder categories are fluid. -Essential features may occur, at varying severity, at many other disorders. -Dimensionally: Clinical presentations can be basis of quantification Phenomena is distributed continuously.

Increases Reliably: +Communicates the information

• Less useful than categorical symptoms Choice of dimensions does create limitations that is more accurate for classification There is a classification of mental disorders using categorical Also dimensional There is no assumption in each category that each is a discrete and completely entity Clinicians should also consider that Individuals sharing a diagnosis often more difficult Easy clinical use Encourages more specific attention Goes beyond

Cross-Cutting Symptom Measures

• Helps shift away boundaries of different categories
• Clinicians better come up with assessments and systems that are needed for more patients
• III which assist to improve major areas of psychiatric areas and potential subsydromal conditions
• Performance acts as general
• System for symptoms
• Is is required if in mind for care and guidelines and addressing heterogeneity
• Easy rated and online use!

Removal of the DSM-IV Multiaxial System

• Offers a more in depth approach to the diagnoses.
• Axes is more referenced to a different domain.
• The V scales shows the overall level.
• Replaced due to WHO.
• More use across assessment

Cultural and Social Structure

• Recognition amongst clinics and the community.
• Important areas of the culture
• Used in all assessment and is recommended
• The group and is now included to be one that is used

Cultural Norms

• Across the context
• Tolerance of symptoms do differ across different settings
• The levels differs from what is normal for a pathological standard
• Consider all context and support for a variety type care and acceptance.

Concepts of Distress

1. Idioms of distress

• Common ground and distress
• May use wide ranges
• Is common for all the groups

2. Explanation -Provides coherent concepts -May have features of healers if use 3.Syndromes -Symptoms within distress

• Illness

Impacts

• Race deeply affects mental health and society.
• Stereotyping and exclusion of any kinds
• Has structural levels.
• Personalized or microaggression due to racism
• Has overt racism ides but is mainly supported The system is bias It helps the clinician diagnose any assessments and biases.

Terminology

• The TR process:
• Has cultural impacts to discrimination that can be within disorder.
• Terminology for race and natural view
• The goal here is to not stereotype.
• Culture should not discriminate instead indicate a group of people and their societal preferences