Clinical Topics

As of 17May08


  1. Prior to the DSMs.

              APA was party to classification systems of psychiatric disorders almost from APA’s inception. Most of the APA’s contributions were within medical classifications. Terms were not defined in those classification systems. US Census Office used terms [1880]: mania, melancholia, monomania, general paralysis of the insane, dementia, dipsomania. In 1918, American Medico-Psychological Association [older name for APA] issued the “Statistical Manual for the Use of Institutions for the Insane,” with 22 categories.
              In 1890s, Emil Kraepelin organization of psychopathology including dementia praecox and manic-depression become foundations for future classification systems. 
              First international classification of disease effort was in 1893, and there has been a new edition about every decade [but less rapid in recent times]. ICD-10 was in 1993, but not adopted in US yet. ICD-11 may be ready in about 2013.

  1. DSM-I, 1952:

--  Described terms, for example, Schizophrenic Reactions was defined as: “It represents a group of psychotic disorders characterized by fundamental disturbances in reality relationships and concept formations, with affective, behavioral, and intellectual disturbances in varying degrees and mixtures. The disorders are marked by strong tendency to retreat from reality, by emotional disharmony, unpredictable disturbances in stream of thought, regressive behavior, and in some, a tendency to ‘deterioration.’” 
--   Had 94% changes in nomenclature from the prior system. Seventy terms used “Reaction,” e.g., Schizophrenic Reaction. This included reaction to internal conflict.
-- While the typical history of the DSMs indicates that DSM-I was psychoanalytic, actually, there was very little in the way of psychoanalytic content in DSM-I. “Unconscious” was mentioned a few times in describing psychoneurotic disorders, nothing more. 
--   Chair: George Raines
--  Process: Raines, Chair at Georgetown, after career in Navy psychiatry, wrote a document drawing on several classifications developed in the military in the 1940s, got improvements from the other six members of the Nomenclature and Statistics Committee, then distributed a draft to about 500 APA members, 10% of the membership, half of whom responded, and of that half, over 90% approved.  With comments in hand, a final draft was written that became DSM-I.

  1. DSM-II, 1968:

--   Described terms
--  94% changes in nomenclature from DSM-I.
     Goal of using terms that coincided with ICD-8's.
     Removed all “Reactions.”
-- Took an atheoretical position: “In the case of diagnostic categories about which there is current controversy concerning the disorder’s nature or cause, the Committee has attempted to select terms which it thought would least bind the judgment of the user. … Inevitably some users of the Manual will read into it some general view of the nature of mental disorders. The Committee can only aver that such interpretations are, in fact, unjustified.”
--  Chair: Ernest Gruenberg.
--  Process: The Nomenclature and Statistics Committee developed a draft, sent it to 120 psychiatrists for reactions, then rewrote and sent to APA, parts of which had to be rewritten at APA Headquarters. Forward to DSM-II states principles of facilitating communications and avoiding terms that imply causation, principles which subsequent DSMs would follow.

  1. Post-DSM-II, 1973, “Homosexuality” replaced with “Egodystonic Homosexuality.” This was an APA Board of Trustee decision. A membership-wide vote to overturn the Board’s decision failed.
  1. DSM-III, 1980:

--  Criteria sets,
--  Five axes,
--  Vast increase in background information about each disorder, adding:
              Diagnostic features
              Associated features
              Cultural and gender features
              Familiar patterns
              Differential Dx      
-- Decision trees,
--  Glossary,
--  Field trials,
--  93% changes in nomenclature.
--  Chair: Robert Spitzer
--  Process: Many work groups were established of which Spitzer was a member of each.  A draft edition was available to many and reactions were encouraged and addressed by the work groups. Many were invited to provide input; probably the total eventually exceeded a thousand APA members. Assembly demanded successfully to be part of the approval process.

  1. DSM-IIIR, 1987,

--  Modifications of some criteria sets,
--  removed “Egodystonic Homosexuality,”
--  established a category of Disorders to Be Studied,
--  contained a symptom index,
--  had 45% changes in nomenclature.
--  Chair: Robert Spitzer
--  Process: Much like DSM-III.

  1. DSM-IV, 1994:

--  Modifications of some criteria sets,
--  removed “organic” as a concept and replaced with conditions related to “General Medical Conditions,”
--  removed Self-defeating and Sadistic Personality Disorder from Disorders to be Studied.
--  removed symptom index.
--  allowed non-Axial system  
--  48% changes in nomenclature.
--  Chair: Allan Frances,
     Co-Chair: Harold Pincus
     Editor: Michael First
--  Process:  Much like DSM-III with greater international involvement and more involvement of other mental health organizations.  Criteria for change included a] empirical justifications and b] the wish to coincide with ICD-10 [which was being developed concurrently].

  1. DSM-IV-TR, 2000, virtually no changes in criteria sets or nomenclature, but text was improved considerably.

     Chair: Michael First. Co-Chair: Harold Pincus.
     Process. With switch in Chair form Frances to First, used DSM-IV structure and Task Force members to rapidly make text accurate and current.  No massive involvement of APA membership was necessary.

  1. DSM-V, 2012.  Values outlined so far:

                   A. Recommendations should be guided by research evidence.
                   B. Continuity with previous editions should be maintained.
                   C. No a priori constraints on the degree of change between DSM-IV and DSM-V.
                   D. Cross-cutting issues should be addressed when looking at all criteria:
                             1. Developmental, prevention, dimensional, gender, and race/ethnicity
                             2. Cross-cultural applications
                             3. Operationalization of “clinical significant.”
                   E. A living document that can advance with the state of the research should be produced.
          Also implied values:
                   A. Epistemic freedom. While eventually the text must be approved by the APA’s governance that involves four layers, about 99% of DSM-V is likely to be developed independent of APA governance.
B. Peer review.
C. Transparency.
          APA Board of Trustees vetted membership of Task Force and Work Groups diligently, especially as to pharmaceutical company connections. Task Force membership includes one consumer representative. Structure is matrix of Disorder-specific Work Groups and four Study Groups whose mandate crosses all of the Work Groups. 
          DSM-V present time-table calls for a DSM-V draft be available for comment in 2009. The final draft is to go to the Assembly and subsequently the Board of Trustees in 2011. To be published in 2012.

          Charge to Work Groups. DSM-V Workgroup Guidelines—November 16, 2007

Following the October 29, 2007 meeting of the DSM-V Task Force, there was a request for a general outline of expected Workgroup activities, along with some prioritization for this work.  To that end, the following outline is offered as preliminary guidance:

  1. Recommend basic structural organization of DSM-V—see attached references.
  2. Recommend large disorder groupings—using developmental, latent trait, or spectrum criteria.
  3. Review current evidence for validity of individual disorder criteria in each group based on both DSM-IV and research conducted in the last 15 years relevant to the specific disorder.
  4. Assess impact of developmental, gender, cultural expression factors on criteria.
  5. Assess ability to separate functional disability from diagnostic criteria.
  6. Assess appropriate dimensional measures to establish diagnostic thresholds, and for severity and functional disability measurement.
  7. Conduct secondary data analyses
  8. Develop individual disorder diagnostic criteria based on literature reviews and secondary data analyses
  9. Test alternative versions of criteria and their feasibility in field trials
  10. Finalize diagnostic criteria
  11. Write DSM-V text describing how criteria should be applied and associated features
  12. Develop Case-book illustrating how diagnostic criteria can be applied in practice for selected individual disorders
  13. Recommend diagnostic assessment approaches/instruments for different levels of clinical practice and research
  14. Submit final drafts for publication

As noted above, the first responsibility of the Workgroups will be to make recommendations to the DSM-V Task Force for any major structural change in how diagnoses are grouped and presented. Initial consultations with Task Force and Workgroup members have identified a few key reference documents that are recommended (required!) reading for each participant in the DSM-V development process.

Since we began the DSM-V review process in 1999, the Research Agenda papers (2002, 2007), the NIH supported conferences on methods, dimensions, all the disorder-specific, and the public-health implications of diagnoses have made it clear for the past seven years that the field is ready for a major change—adding dimensions, adding a developmental perspective, and adding a gender/culture perspective are essential to consolidate what we know needs to be done with the diagnostic system.  Steve Hyman’s paper and his report from the WHO advisory meeting emphasized that we also need to look at the broad groupings of disorders as a major priority—using spectra, latent traits like externalizing/internalizing, and developmental principles including possible personality-temperament traits as organizing principles.

It is essential to have a focused discussion of our options on this organizational framework with the Task Force that is buttressed by input from the workgroups. The purpose of these reference documents is to provide a rapid orientation to those not involved in the full scope of the scientific reviews to date, and to stimulate additional thought about the most appropriate response to the emerging science base for supporting a significant organizational change in how mental disorders are described for clinical and research purposes.  We suggest that proposals for the overall structural approach of DSM-V be the highest priority for the Task Force and Workgroups during the next six months.

We will establish a discussion forum on the Task Force SharePoint website to facilitate input for this discussion.  Proposals should be comprehensive and cover the full range of mental disorders with very focused references-i.e., files for easy access.

We look forward to a stimulating synthetic discussion.

David Kupfer, M.D., Chair, DSM-V Task Force
Darrel Regier, M.D., M.P.H., Vice-Chair, DSM-V Task Force

10. DSM-V Task Force Members and Work Group Members


Chair: David Kupfer;
Co-Chair: Darrell Regier.
Other Members:
     William T. Carpenter, Jr. MD, Chairs Psychosis Work Group
     Wilson M. Comptom, MD, MPE,
     F. Xavier Castellanos, MD, Chairs Externalizing Disorders Work Group
     Joel E. Dimsdale, MD, Chairs Somatoform Disorders Work Group
     Javier I. Escobar, MD
     Jan Fawcett, MD, Chairs Mood Disorders Work Group
     Steven E. Hyman, MD, Chairs Spectrum Study Group and is liaison to World Health Organization
     Dilip V. Jester, MD, Chairs Cognitive Work Group
     Helena C. Kraemer, Ph.D.
     Jan Fawcett, MD, Chairs Mood Disorders Work Group
     Daniel T. Mamah, MD
     James P. McNulty, AB, ScB, Consumer Representative
     Howard B. Moss, MD
     William E. Narrow, MD, MPH
     Charles O'Brien, PhD Chairs Substance-Related Disorders Work Group
     Roger Peele, MD, Liaison to the Assembly
     Katharine Phillips, MD, Chairs Anxiety Disorders Work Group
     Charles F. Reynolds, MD, Chairs Sleep Disorders Work Group
     Norman Sartorius, MD, Ph.D., International Consultant.
     Maritza Rubio-Stipec, Sc.D. Statistics and Methods Director
     Andrew Skodol, MD, Chairs Personality Disorders Work Group
     Susan Swedo, MD, Chairs Development Disorders Work Group
     Timothy Walsh, MD, Chairs Eating Disorders Work Group
     Philip Wang, MD
     William Womack, MD, Liaison to the Board of Trustees
     Kimberly Yonkers, MD, Chairs Gender and Cross-Cultural Study Group
     Kenneth Zucker, MD, Chairs, Sexual and Gender Disorders  


ADHD and Disruptive Behavior Disorders:
F. Xavier Castellanos, M.D. (Chair)
Glorisa Canino, Ph.D.
Paul J. Frick, Ph.D.
TerrieMoffitt, Ph. D.
Joel T. Nigg, Ph.D.
Luis Augusto Rohde, M.D., Sc. D.
Rosemary Tannock, Ph. D.
Richard Todd, Ph. D., M.D.

Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders:
Katharine Phillips, M.D. (Chair)
Gavin Andrews, M.D.
Susan M. Bogels, Ph. D.
Michelle Craske, Ph. D.
Matthew J. Friedman, M.D., Ph. D.
Eric Hollander, M.D.
Roberto Lewis-Fernandez, M.D.
Scott L. Rauch, M.D.
Dan J. Stein, M.D., Ph. D.
RObert J. Ursano, M.D.
Hans Ulrich Wiitchen, Ph. D.

Disorders in Childhood and Adolescence Work Group:
Daniel Pine, M. D. (Chair)
E. Jane Costello, Ph. D.
Ronald E. Dahl, M.D.
Rachel Klein, Ph. D.
Regina Smith James, M.D.
James Leckman, M.D.
Ellen Leibenluft, M.D.
Judith Rapoport, M.D.
David Shaffer, M.D., FRCP
Eric Taylor, MB
Charles Zeanah, M.D.

Eating Disorders Work Group:
B. Timothy Walsh, M. D. (Chair)
Evelyn Attia, M.D.
Anne E. Becker, M.D., Ph. D., Sc. M.
Prof. Hans Wijbrand Hoek, M.D. Ph. D.
Richard E. Kriepe, M.D.
Marsha D. Marcus, Ph. D.
James E. Mitchell, M.D.
Ruth Striegel-Moore, Ph. D.
G. Terence Wilson, Ph. D.
Barbara E. Wolfe, Ph. D. APRN, FAAN
Stephen Wonderlich, Ph. D.

Mood Disorders:
Jan A. Fawcett, M.D. (Chair)
William Coryell, M.D.
J. Raymond DePaulo, M.D.
Ellen Frank, Ph. D.
Sir David Goldberg, M.D.
James Jackson, Ph.D.
Kenneth Kendler, M.D., Ph. D.
Mario Maj, M.D., Ph.D.
Husseini K. Manji, M.D.
Michael R. Phillips, M.D.
Trisha Suppes, M.D., Ph. D.
Carlos Zarate, M.D.

Neurocognitive Disorders Work Group:
Dilip V. Jeste, M.D. (Chair)
Deborah Blacker, M.D., Sc. D.
Dan Blazer, M.D.,Ph. D., M.P.H.
Warachal Faison, M.D.
Mary Ganguli, M.D., M.P.H.
Igor Grant, M.D., FRCP
Jane S. Paulsen, Ph. D.
Ronald Petersen, Ph. D., M.D.
Perminder Sachdev M.D., Ph. D., FRAZCP

Neurodevelopment Disorders:
Susan Swedo, M.D. (Chair)
Edwin H. Cook Jr., M.D.
Francesca G. Happe, Ph. D.
Walter E. Kaufmann, M.D.
Bryan H. King, M.D.
Catherine E. Lord, Ph. D.
Joseph Piven, M.D.
Sally J. Rogers, Ph. D.
Sarah J. Spence, M.D., Ph. D.
Poul Thorsen, M.D., Ph. D.
Fred Volkmar, M.D.
Amy Wetherby, Ph. D.
Harry H. Wright, M.D.

Personality and Personality Disorders:
Andrew E. Skodol, M.D.(Chair)
Renato D. Alarcon, M.D., M.P.H.
Carl C. Bell, M. D.
Donna S. Bender, Ph. D.
Lee Anna Clark, Ph. D.
Robert Krueger, Ph. D.
W. John Livesly, M.D., Ph.D.
Leslie Morey, Ph. D.
John M. Oldham, M.D.
Larry J. Siever, M.D.
Roel Verheul, Ph. D.

Psychotic Disorders:
William T. Carpenter, Jr., M.D. (Chair)
Deanna Barch, Ph. D.
Juan R. Bustillo, M.D.
Raquel E. Gur, M.D., Ph. D.
Stephan H. Heckers, M.D.
Michael Owen, Ph. D., M.D.
Susan K. Schultz, M.D.
Rajiv Tandon, M.D.
Ming T. Tsuang, M.D., Ph. D.
Jim van Os, M.D.

Sexual and Gender Identity Disorders:
Kenneth J. Zucker, Ph. D. (Chair)
Irving M. Binik, Ph. D.
Ray Blanchard, Ph. D.
Peggy T. Cohen-Kettenis, Ph. D.
Jack Drescher, M.D.
Cynthia Graham, Ph. D.
Richard B. Krueger, M.D.
Niklas Langstrom, M.D., Ph. D.
Heino F. L. Meyer-Bahlburg, Dr.rer.nat.
Robert Taylor Segraves, M.D., Ph. D.

Sleep-Wake Disorders:
Charles F. Renolds III, M.D. (Chair)
Charles Morin, Ph. D.
Ruth M. O'hara, Ph. D.
Alan I. pack, Ph. D.
Kathy P. Packer, R.N., C.S., Ph. D.
Susan Redline, M.D., M.P.H.
Dieter Riemann, Ph. D.

Somatic Distress Disorders:
Joel E. Dimsdale, M.D. (Chair)
Arthur J. Barsky III, M.D.
Francis Creed, M.D.
Nancy Frasure-Smith, Ph. D.
Michael R. Irwin, M.D.
Francis J. Keefe, Ph. D.
Sing Lee, M.D.
James L. Levenson, M.D.
Michael Sharpe, M.D.
Lawson R. Wulsin, M.D.

Substance-Related Disorders:
Charles O'Brien, M.D., Ph. D. (Chair)
Marc Auriacombe, M.D.
Guilherme Borges, M.D., DrSc
Kathleen Bucholz, Ph. D.
Alan Budney, Ph. D.
Thomas Crowley, M.D.
Bridget Grant, Ph. D., Ph.D.
Deborah Hasin, Ph. D.
Walter Ling, M.D.
Spero M. Manson, Ph. D.
A. Thomas McLellan, Ph. D.
Nancy Petry, Ph. D.
Marc A. Schuckit, M.D.
Wim van den Brink, M.D.

Impact of the DSMs:

1. Access to care and treatment. DSMs “is the cornerstone in the edifice of mental health care” [Sadler, 2006].

2. Access to entitlements.  Defines the responsibilities of public agencies accountable for the psychiatrically ill. Reimbursements are administered on the basis of the DSM [in an overlap with ICDs]. Even the location within DSM can have an impact on access, e.g., the Axis II location, some claim, decreases access.

3. Approved treatments. A complaint:
Edward Shorter, medical historian: “the pipeline [of medication development] is empty at this moment [2004] despite spending billions of dollars on psychopharmacology,” a stall he traces largely to the effects of using DSM-III/IIIR/IV in defining disease indications for medication approval.  DSM disorders, he believes, have not provided specific treatment targets. [Assembly passed motion in 2006 saying that FDA should consider signs/symptoms for approval, not just dx categories].

4. Research [see #3 supra]

5. Education.  The teaching of psychopathology in the United States and many other countries follows the DSM.

6. Legal and criminal decisions. Despite disclaimer within the DSMs, the DSMs are often used to answer legal questions.

7. Society’s concept of mental illness, of normality. Some examples:
Conceptualizes homosexuality as normal.
--  1973, substituted “egodystonic homosexuality” for “homosexuality”
--  1987, DSM-IIIR, abolished “egodystonic homosexuality”

Many DSM terms have become part of the American discourse, for example, “ADHD” in a Google search found:
    --   “No child left behind” & “school” & “2006”:  9,640,000
    --    “ADHD” & “school” & “2006”: 9,170,000

8. Defines psychiatry. Defines the scope of professional skills of psychiatrists. [There is some discussion of the definition at the end of the DSM-V-Issues]






© 2005 Roger Peele, All Rights Reserved