1. Abolish the multiaxial system?
                   [In 2004, the APA Assembly voted [81 to 49] for abolishing the Multiaxial system unless there were studies that showed that patients had benefited. There is some controversy as to whether DSM’s multiaxial system is the dx or just a way of listing one’s findings. DSM text isn’t clear on this. Furthermore, DSM allows a non-axial system (DSM-IV-TR, page 37)]

2. Adopt spectrum perspectives? The following is a list of some, not all proposed spectra. No agreement by the Task Force yet on any of this.  For example, not all agree with the move of pathological gambling from impulse disorders to addiction spectrum. Some would combine bipolar and schizophrenia.  Some would combine addiction and impulse dyscontrol.

• Obsessive-compulsive spectrum.  Would include:

                             ---- OCD
                             ---- Tic disorders
                             ---- Stereotypic movement disorders
                             ---- Body dysmorphic disorder
                             ---- Trichotillomania
                             ---- Obsessive-compulsive personality disorder
                             ---- Gen Medical conditions with obsessive-compulsive features
                             ---- Substance-induced with obsessive-compulsive features

• Depression-GAD spectrum. Would include

                             ---- Non-bipolar depressive disorders
                             ---- GAD and anxiety disorder NOS
                             ---- Adjustment disorders [except those with "conduct disorder"]
                             ---- Premenstrual dysphoric disorder
                             ---- Bereavement
                             ---- Gen Medical conditions with anxiety or depressive features
                             ---- Substance-related disorders with anxiety or depressive features

• Bipolar spectrum. Would include:

                             ---- Bipolar disorders
                             ---- Borderline disorder
                             ---- Substance-related disorder with bipolar features
                             ---- Gen Medical conditions with bipolar features

• Fear circuitry and stress related. Would include:

                             ---- Panic disorders
                             ---- Phobias
                             ---- Separation anxiety disorder
                             ---- Stress disorders
                             ---- Avoidant disorder
                             ---- Dissociative disorders
                             ---- Substance-related disorders with panic, dissociative or phobic features
                             ---- Gen Medical conditions with panic dissociative or phobic features

• Schizophrenia spectrum. Would include:

                             ---- All psychotic disorders [but not mood or other disorders “with psychotic features”]
                             ---- Schizotypal disorder

• Autism spectrum. Would include:

                             ---- Pervasive developmental disorders

• Addiction spectrum. Would include:

                             ---- Substance-related abuse and dependent disorders
                             ---- Pathological gambling

• Externalization spectrum. Would include:

                             ---- ADHD & disruptive disorders
                             ---- Impulse control disorder [sans pathological gambling and trichotillomania]                            
                             ---- Antisocial disorder

3. Adopt dimensional approach? Is "dimension" the best word?  Some would prefer "sign and symptom" to reach the same goal of deconstructing psychopathology. Some dimensions:
                  

• For schizophrenia:

                             ---- As to pathology
                             ---- As to function
                             ---- As to associated features such as risk factors, more specifically as to suicide
                             ---- As to treatment targets
                             ---- As to signs such as
                                      -- Psychosis
                                      -- Deficit signs [avolition and so forth]
                                      -- Cognitive signs
                                      -- Dysphoric signs
                                      -- More speculative: prefrontal cortex gray matter thickness

• For mood disorders:

---- As to mania, e.g., using a scale of 0 to 5.
---- As to depression, using a scale of 0 to 5.
Could this two dimensional approach be used in place of the present MDD and bipolar disorders?

• For sleep disorders:

                             ---- Insomnia be given a dimensional approach that includes hyperarousal, abuse of alcohol/sedatives, poor sleep hygiene.
 
          D. For personality disorders, many scales proposed, including the following five part one:
                             ---- Extraversion v. introversion
                             ---- Antagonism v. compliance
                             ---- Constraint v. impulsivity
                             ---- Emotional dysregulation v. emotional stability
                             ---- Unconventionality v. closedness to experience

• Would it be useful to have a suicidal dimension? This would be applicable to all DSM disorders.  Would be independent of impairment.

                               
4. Give “trauma” the statue of a broad conceptualization with many manifestations, e.g., like the substance-related disorders?  Or like DSM-I’s “Reactions”?

5. Add greater cultural sensitivity?

6. Add greater gender sensitivity? Allow for different criteria for females and males?

7. Add greater ethnic sensitivity?

8. Add age sensitivity to the diagnosing of the elderly, including identifying specific brain structure abnormalities, biomarkers, and contributing psychosocial and environmental factors of mental illnesses in the elderly?

9. Add relational disorders beyond present V codes.  There are some proposed classifications for:
                   --- Parent-child disorder
                   --- Adult-child and parent disorder
                   --- Marital conflict disorder
          Another approach is to have four components to each important relationships:
                   --- Recognition
                   --- Motivation
                   --- Approach
                   --- Bonding

10  Children and adolescent:

• Drop: “first evidence in childhood” from criteria sets?
• Replace name “Mental Retardation” with “Intellectual Deficiency”?
• Remove the category Oppositional Deviant Disorder.
• Remove the category Conduct Disorder
• Develop criteria for pediatric bipolar disorders? [Assembly passed motion in 2004 asking that this be done.]

1] If so, change criteria to allow for episodes that are too rapid to be detected using adult techniques?
2] If so, change criteria to allow “extreme irritability” to substitute for “elation”?  

• Markedly enhance the recognition of disorders in infancy and early childhood? For that age group, recognize PTSD, mood disorders, anxiety disorders, night-waking dysomnia, sleep-onset dysomnia, overeating disorders, overfeeding disorders, early childhood behavioral disorders, and earlier dx of autism.
• Add fetal alcohol syndrome/spectrum. [In May, 2005, an Assembly motion (initiated by Susan Rich, M.D.) was passed asked that fetal alcohol syndrome be added.]
• Add Severe Mood Dysregulation? Chronic mood signs and chronic agitation with no distinct manic episode  

11. Cognitive Disorders:
          A. Add newly minted neurological disorders, e.g., fronto-temporal dementia and Lewy body dementia, that is, pull them out of “General Medical Disorders.”
          B. Add Adult ADHD, not necessarily under “Cognitive Disorder?” What age should be used for onset?  [In 2003, the Assembly passed a motion that criteria be developed for Adult ADHD.]
          C. Add Mild Cognitive Disorder? Add it with two subtypes, amnestic and non-amnestic?
          D. Have DSM-V define dementia? Require two or more cognitive areas of decline for at least one year?
          E. Abolish early and late onset subtypes?
         

12. Substance-related disorders:
          A. Replace “Dependence” with “Addictions”?

          B. Add 5 subtypes to alcoholism?
                   --- Young adult subtype
                   --- Young antisocial subtype
                   --- Functional subtype
                   --- Intermediate family subtype
                   --- Chronic severe subtype?

          Or add the following subtypes:

• continuous vs. binge use
• familial vs. non-familial
• affiliative vs. schizoid
• primary vs. secondary
• milieu-limited vs. male-limited
• early onset vs. late onset

C. Conceptualize Pathological Gambling as part of Dependence/Addiction?

D. ICD-10 has fewer symptoms to meet the diagnoses of withdrawal, Should DSM-V follow ICD-10?
         
          E. Should cannabis withdrawal be added to DSM-V?

• Rather than generic criteria for “abuse” and “dependence,” should each substance have its own criteria set?
• Abolish “abuse” and “dependence” distinction and replace with “alcohol-use disorder,” with gradations [close to a dimensional approach].

 
13. Psychotic disorders:
          A. Replace “Schizophrenia” with another term, e.g., “Integration Disorder”?
          B. Replace term “positive” with term “psychotic” or “florid”?
          C. Replace term “negative” with term “deficit”?
D. Remove 6 month requirement?
E. Give greater prominence in defining schizophrenia to:
          --- Cognitive deficiencies?
          --- Anosognosia?
          --- Neophobia?
         
14. Mood Disorders:
          A. Add Premenstrual Dysphoric Disorders?
          B. Add Minor Depressive Disorder?
          C. Add Recurrent Brief Depressive Disorder?
          D. Add bipolar II mixed state?
          E. Add a category less extensive of mixed signs than “Bipolar I Disorder, Mixed type, e.g., dysphoric mania that requires only two signs of mania and two signs of depression?
          F. Place people with recurring depressive disorders with bipolar even though no manic/hypomanic hx?
          G. Add a specifier for suicide risk, e.g., acute, chronic, low, or undeterminable suicide risk?
          H. Change hypomania required criteria from a mood one to a hyperactive one?
          I. Are MDD/Dysthymia over diagnosed?
                   “Yes” view claims: Has led to treating normal emotional states as illness, risking inappropriate management, and generalizing everyone to have had a psychiatric illness.
                   “No” claims: Concept has saved lives, avoided disability, reduced stigma, removed hurdles to treatment, improved physical health outcomes, reduced substance-related disorders, and widened public understanding of the benefits of treatment.

• Combine MDD and dysthymia and no longer require the double depression diagnosing.
• Dimensional approach of scale of 0 to 5 of depression and 0 to 5 of mania [from Gary Sacks]. Using these two scales would apparently solve the mixed disorder problems as well as put depression and mania in the same family regardless of the presence of mania.

15. Conceptualize post-partum illnesses more broadly than DSM-IV-TR does:
          DSM-IV-TR conceptualizes post-partum psychiatric psychopathology as featuring mood or psychotic features. Since anxiety disorders are also very common, why not open up the conceptualization to any disorder apparently related to the post-partum period.

16. Remove the time limit as to onset of post-partum disorders. The four weeks is arbitrary. Why not leave it to the clinical judgment of the practitioner as to whether the psychopathology is related to the post-partum.
           
17. Anxiety Disorders:
          A. Add Mixed Anxiety-Depressive Disorder? Or add an anxiety specifier to depressive disorders?  Or use term cothymia? Reasons to add this alternative to DSM-V include:
                   1] Consistent with genetic studies
                   2] Consistent with family studies
                   3] Consistent with epidemiological studies that suggest cothymia is more common than GAD or MDD
                   4] Consistent with fact that neurobiological studies cannot seem to separate GAD and MDD
                   5] Treatments overlap
          Against:
                   1] Anxiety and depression are different emotions
                   2] To add cothymia would create a hierarchy in association with reference to mood and anxiety disorders. Better to avoid hierarchies and continue with co-morbidity approach.
                   3] There are many disorders in DSM-IV-TR that are comorbid with other disorders. Combining the many possibilities makes an already cumbersome dx system even more cumbersome.
                   4] The two have been separated in the psychiatric classification systems for over a century, and we don’t need this unnecessary disconnect from the past.
                    

• Move OCD out of anxiety disorder grouping? [See OCD Spectrum Disorders supra.]
• Should there be a “Fear and Stress Circuitry Disorder” section that includes PTSD, ASD and panic disorder?
• Should PTSD be characterized as a memory problem, memories that have become indelible or else cannot be retrieved?
• Should we list, in DSM-V, the more common phobias, e.g., “claustrophobia,” “gephyrophobia”

                   
18. Somatic Disorders [“somatic” preferred to “somatoform”]:
          A] Remove Undifferentiated Somatoform Disorder?
          B] Place Pain Disorder on Axis III?
          C] Rename Pain Disorder “Essential Pain Disorder” or “Idiopathic Pain Disorder” and remove “psychological factors” from diagnostic criteria wording?
          D] Remove the Somatoform Disorders [except Body Dysmorphic Disorder] and add the following modifiers to any of the other DSM Disorders, including Psychological Factors Affecting Physical Disorders:
                   1] Hypochondriasis
                   2] Disease Phobia
                   3] Illness Denial
                   4] Persistent Somatization
                   5] Conversion Symptoms
                   6] Demoralization
                   7] Irritable Mood
          E] Place body dysphoric disorder within OCD?
         
19. Factitious Disorders:
          Add Factitious Disorder by Proxy?

20. Dissociative Disorders:
          Add Dissociative Trance Disorder?

21. Sexual and Gender Identity Disorders:
          A. Remove Gender Identity Disorder?
          B. Remove Gender Identity Disorder as a psychiatric disorder, and include transsexual operation and medical care for people with gender variance in ICD-9-CM’s plastic surgery section.

22.  Eating disorders:
          A. Add Binge-Eating Disorder?
B. Add Obesity?
          C. Add Wannarexia?

23. Sleep disorders:
          A. Add all the sleep disorders listed as sleep disorders in ICD-9-CM?
          B. Replace “Insomnia related to . . .” with “comorbid insomnia”?
          C. How do we deal with sleep disorder phenotypes that can be produced by genetic variants? Is it time to introduce gene markers into DSM-V?
          D. Pull out prior NOS categories and give them their own category?
          E. Are any disorders specific to the menstrual cyclic?

24. Impulse-Control Disorders Not Classified Elsewhere:
          A. Add compulsive shopping disorder?
          B. Add compulsive internet use disorder?
          C. Add compulsive sexual behavior disorder?
          D. Add compulsive hoarding disorder?
          E. Add more general “Self-defeating Impulse Control Disorder" and avoid the breakdown of "shopping disorders" and other self-injurious behaviors, leaving this entity more general?
          F. Break this grouping into:
                   1] Self-soothing: trichotillomania, skin picking, and self-injurious behavior.    
                   2] Reward seeking: pathological gambling, kleptomania, pyromania.
                   3] Anger dyscontrol: intermittent explosive disorder?

25. Adjustment Disorders:
          Add criteria sets for these disorders?

26. Personality Disorders:
          A. Replace with dimensional approach? [See 3, supra.]
          B. Remove word “personality” from the titles, e.g., “Histrionic Disorder," rather than “Histrionic Personality Disorder”? [Washington Psychiatric Society and Maryland Psychiatric Society passed motion to do so, 2002.]
          C. Replace “Obsessive-Compulsive personality disorder" with “Anankastic disorder”?
          D. Replace “Borderline” with another term, e.g., "emotional dysregulation disorder" or "regulation disorder"?
          E. Move schizotypal to the schizophrenia spectrum, move borderline to the bipolar spectrum, move avoidant to anxiety spectrum?
          F. Abolish avoidant disorder as it is redundant with social phobia?
          G. Add Depressive Personality Disorder
          H. Add Passive-Aggressive Disorder [Negativistic Disorder]?
          I.  Add Self-Defeating category?
          J.  Add Sadistic category?
          K. Add Querulous category?
          L. Add Stress-induced personality disorder?

27. Psychological Factors Affecting Medical Conditions:
          See “Somatic Disorders” supra.

28. V-Codes: [see Relational disorders, 9 supra]

29. Axis V:
          A. Only measure function? Axis V measures function, symptom severity, and dangerness. Some would like to see two separate scales, distress and dysfunction/impairment.

          B. Could dysfunctional be divided into?

                   1] Cognitive
                   2] Emotional
                   3] Physical
                   4] Relational
                   5] Volitional
         
30. Should DSM never use “due to,” only “associated with”?

31, Return to word “organic”?

32. Should there be functional impairment be required for every disorder?

33. Should there be an additional Experimental Diagnostic Criteria for Research? Three forms suggested by Hyman are:
A] dimensional;
B] clinically significant symptom clusters for which there are compelling hypotheses about the underlying neural circuits;
C] abandoning the fine-scale splitting of disorders to lead larger spectrum disorders, the constituents of which are presumed to share  pathophysiological features.

34. Definition of “mental disorders.”
A. DSM-IV-TR:
In DSM-IV, each of the mental disorders is conceptualized as a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. In addition, this syndrome or pattern must not be merely an expectable and culturally sanctioned response to a particular event, for example, the death of a loved one. Whatever its original causes, it must currently be considered a manifestation of a behavioral, psychological, or biological dysfunction in the individual. Neither deviant behavior (e.g., political, religious, or sexual) nor conflicts that are primarily between the individual and society are mental disorders unless the deviance or conflicts is a symptom of a dysfunction in the individual, as described above.”

B. Wakefield’s proposal has been the most discussed over the past 15 years: “mental illness = “harmful mental dysfunction.”

• [RP: "Mental Illness = An illness with behavioral, emotional, cognitive, or conative manifestations." (Conation = drives, wishes, and craving)

Should leave “illness” for medicine to define.] 

35. Who is DSM for? Everyone? Only clinicians? Only mental health professionals? Only physicians? Only psychiatrists?
 
36. To make suggestions.
To make suggestions to the DSM-V task force, go to website, WWW.DSM5.org, and submit your suggestion.