DSM-V

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Upcoming Changes in DSM-V : 

Upcoming Changes in DSM-V A Critical Review Dr. Atiqul Haq Mazumder Post Graduate Student Department of Psychiatry BSMMU, Dhaka

Before the DSM: Classification in the Ancient World : 

Before the DSM: Classification in the Ancient World The first recorded depiction of mental illness. Description of the syndrome senile dementia Sumerian & Egyptian reference “Melancholia” & “Hysteria” mental illness in the Ebers Papyrus 3000 B.C 2600 B.C

Before the DSM: Classification in the Ancient World : 

Before the DSM: Classification in the Ancient World The oldest known attempt to systematically classify presentations in mental illness. Ayur-Veda: System of medicine in ancient India Disorders were grouped based on 7 kinds of demonic possession * Sources: First, Frances, & Pincus, 2004 1400 B.C

Before the DSM: Classification in the Ancient World : 

HIPPOCRATES First to place psychiatric conditions within the secular and naturalistic domain of medicine. He identified 6 conditions: Before the DSM: Classification in the Ancient World 460-377 B.C. (1) Phrenitis (2) Mania (3) Scythian disease Provided what amounted to a 2nd diagnostic axis (4) Epilepsy (5) Hysteria (6) Melancholia

Before the DSM: Classification in the Ancient World : 

* Sources: First et al., 2004 Before the DSM: Classification in the Ancient World He noted 4 temperaments: (1) Choleric (2) Melancholic Similar to “personality traits” (3) Sanguine (4) Phlegmatic

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Over the next 10 centuries, Hippocrates’ list of 6 conditions was extended & further differentiated. Two approaches: Hippocratic observation and empiricism Platonic rationalistic search for universal causes - vs. - Culminated in classification proposed by Paul of Aegina (624-700 AD) Before the DSM: Classification Until the 15th Century

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Sydenham (“father of modern medical thinking”) rejected the notion that a single dysfunction was the root of all problems. Instead, he hypothesized that each disease had an individual existence with a uniform presentation in different individuals. * Sources: First et al., 2004 Before the DSM: Classification Until the 15th Century 15th Century Sydenham

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He proposed that diseases should be observed & classified in the same way that botany was beginning to classify plants (i.e. system proposed by Boissier de Sauvages in which he classified 2,400 species of diseases) * Sources: First et al., 2004 Before the DSM: Classification Until the 15th Century

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Before the DSM: Classification in the 18th & 19th Centuries Movement towards a more simplified system A less systematic, more clinical approach to classification emerged Boissier nosology was seen as complex & impractical Practical “rule of thumb” lists focusing on relevant clinical types Key Individuals: Philippe Pinel, Jean-Dominque Esquirol 18th Century

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Before the DSM: Classification in the 18th & 19th Centuries Movement towards organic etiologies Key Individuals: Benedict Morel, Paul Broca, & William Griersinger 18th & 19th Century

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Before the DSM: Classification in the 18th & 19th Centuries * Sources: First et al., 2004; Gaines, 1992; Malik & Beutler, 2002 Initial attempts at formal psychiatric classification “Idiocy and Insanity”- Label given to individuals who were considered by health professionals to have mental illnesses. “Normals” - Identified all other individuals 5 additional categories 1840-US Census 1880- Govt. Re-Classified System

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German clinical/experimental psychiatrist Synthesized classification approaches from late 19th century Compiled disorders in Compendium der Psychiatrie (1883): 9 editions in 40 yrs. Studied with Wundt: Conducted pharmacological experiments Before the DSM: Classification in the 18th & 19th Centuries 1856-1926 EMIL KRAEPELIN

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The structure of his classification system formed the basis for current psychiatric nosologies such as the DSM In his books, he argued that psychiatry was a branch of medical science & should be investigated by observation/experimentation He believed that all mental illness had an organic cause * Sources: Alic, 2001; First et al., 2004; Müller, Fletcher, & Steinberg, 2006 Before the DSM: Classification in the 18th & 19th Centuries

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Swiss neuropathologist, psychiatrist, & professor 1892 - Emigrated to the United States Largely responsible for the introduction & dissemination of Kraepelin’s classification in the US. Before the DSM: Classification in the 18th & 19th Centuries ADOLF MEYER 1866-1950

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Embraced Kraeplin’s emphasis on prognosis for its applicability to treatment; however, he had scientific concerns regarding the: Generalizability from large groups of cases to the individual. Establishment of disease entities in the absence of empirical support Before the DSM: Classification in the 18th & 19th Centuries

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* Sources: First et al., 2004 He eventually proposed his own classification system Based on the notion of reaction types Disorders viewed as pathological reactions of the individual to environmental stressors. Before the DSM: Classification in the 18th & 19th Centuries

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Other influences on classification: Bleuler: Combined Kraepelin & Meyerian approaches Freud: Classified neurosis (anxiety, depressive, hysterical, obsessive-compulsive) Health Records: Asylums began developing their own classification systems intended primarily for the purpose of keeping statistics on their patients. Before the DSM: Classification in the 18th & 19th Centuries

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Committee on Statistics of the American Medico-Psychological (became the American Psychiatric Association [APA] in 1921) was founded by a group of medical doctors. Before the DSM: Classification in the 18th & 19th Centuries Late 19th Century

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* Sources: First et al., 2004; Houts, 2000; Malik & Beutler; Mendelson, 2003 Before the DSM: Classification in the 18th & 19th Centuries Late 19th Century Concern that the lack of a uniform classification system would inhibit science by preventing accurate comparisons among patient groups

Before the DSM: Classification in the 20th Century : 

APA develops a diagnostic system listing 59 mental disorders APA makes revision to classification By the 1940’s and following WWII, military clinicians found little practical use for the APA’s diagnostic system 1917 1934 1940s Before the DSM: Classification in the 20th Century

Before the DSM: Classification in the 20th Century : 

In response, General William Menninger chaired the committee for the writing of a new classification system, Medical 203 Did not receive widespread attention-Used by a few clinicians APA did not officially support the document 1943 Before the DSM: Classification in the 20th Century

Before the DSM: Classification in the 20th Century : 

* Sources: Gaines, 1992; Houts, 2000; Widiger, 2004; Wilson & Skodol, 1994 6th edition of the International Classification of Diseases (ICD-6) Propelled the APA Committee on Nomenclature to develop an alternative to the ICD-6 for use in the US 1948 Before the DSM: Classification in the 20th Century

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The Creation & Emergence of the DSM APA Committee on Nomenclature produced 1st draft of the Diagnostic & Statistical Manual of Mental Disorders (DSM) First edition of the DSM (DSM-I) was published 1950 1952

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The Creation & Emergence of the DSM Heavily reflected psychodynamic thought 106 diagnoses - Characterized primarily as reactions to psychological, social, and biological factors * Sources: Gaines, 1992; Houts, 2000, 2002; Kutchins & Kirk, 1995; Malik & Beutler, 2002; Mayes & Horwitz, 2005; Rentoul, 1995; Widiger, 2004; Wilson & Skodol, 1994 Ironically, despite the lack of initial attention paid to Medical 203, the DSM-I was heavily influenced by the document Many of the passages were virtually identical to Medical 203

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Rationale for DSM-II Beginning Revisions: DSM-II The first official changes were made to DSM 1968 Continued to reflect the influence of psychoanalysis & Medical 203 Published Edition DSM and DSM-II were strikingly similar to one another Symptoms conceptualized as reflecting underlying, internal conflicts To conform to the system used in the ICD

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Beginning Revisions: DSM-II Meyer & Menninger significantly shaped the creation of both editions * Sources: Gaines, 1992; Houts, 2002; Kutchins & Kirk, 1995; Malik & Beutler, 2002; Mayes & Horwitz, 2005 In response to critics: removed “reaction”/“reactive” Changes Number of diagnoses: from 106 to 182 Influences Views of dominant 20th century psychiatrists & psychoanalysts

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The third edition of the DSM (DSM-III) is published 1980 Published Edition In response to critics: attempts at a “data-driven” DSM Changes Number of diagnoses: from 182 to 265 diagnoses Reflected a shift from a theoretical paradigm to a “medical model” To retain conformity with the newest ICD The Beginning of the DSM Controversies: DSM-III Rationale for DSM-III Multi axial system - Focused on symptoms rather than causes

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* Sources: Gaines, 1992; Houts, 2000; Kutchins & Kirk, 1995; Mayes & Horwitz, 2005; Rogler, 1997; Widiger, 2004 Influences 1970’s: Ongoing struggle for power within the professional field The Beginning of the DSM Controversies: DSM-III Psychiatrists wanted the profession to be more scientifically-oriented Increased power of neo-Kraeplinian, research-oriented psychiatrists who felt the psychodynamic orientation to be unscientific

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Professional & Political Controversies: DSM-III Task Force: Chose professionals primarily committed to medically-oriented research - Mostly white male senior psychiatrists ROBERT SPITZER: Chair of DSM -III Task Force Intended to delete neurosis: felt had no empirical basis “Neurosis” Controversy Due to opposition from psychodynamic psychiatrists, APA Board of Trustees threatened not to publish DSM-III unless neurosis was included Task force reinserted “neurosis” back before final draft was published

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Professional & Political Controversies: DSM-III Homosexuality as a Mental Illness As chairman, Spitzer was influential in the decision to retain a diagnosis for homosexuals experiencing distress over their sexual orientation * Sources: Houts, 2000; Kutchins & Kirk, 1995; Mayes & Horwitz, 2005; Rogler, 1997 After protests, homosexuality was removed by vote (1974, 7th printing of DSM-II) Thus, the diagnosis of ego-dystonic homosexuality appeared in DSM-III

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Political & Economic Controversies: DSM-III Late 1960’s: Standard practice of medical insurance companies to request a DSM diagnosis before reimbursement will be made Landmark case (1980): U.S. Court of Appeals ruled against Blue Shield for refusal to pay clinical psychologists unless billed through a physician. Blue Shield reps pleaded with Spitzer to standardize DSM-III so insurers could separate “legitimate” mental illnesses from non-psychiatric problems * Sources: Albee & Joffee, 2004; Gaines, 1992; Houts, 2000; Mayes & Horwitz, 2005; Rogler, 1997; Zur & Nordmarker, 2006 Managed Healthcare

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Political & Economic Controversies: DSM-III Only after a 10 yr. political campaign of vets & a few psychiatrists did war-related stress reactions become recognized in the DSM-III. Managed Healthcare & PTSD Vietnam War: Vets often denied psychological services because insurers would not reimburse for problems that did not have a DSM diagnosis * Sources: Albee & Joffee, 2004; Gaines, 1992; Houts, 2000; Mayes & Horwitz, 2005; Rogler, 1997; Zur & Nordmarker, 2006 Despite claims that DSM-III was data-driven, empirical literature was not the primary point of contention in deciding the fate of PTSD . . .

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The third edition-revised of the DSM (DSM-III) is published 1987 Published Edition To increase reliability & validity More Revisions: DSM-III-R Robert Spizter & task force begin working on revisions 1983 While revisions were intended to be few, several diagnostic categories were renamed/reorganized, & significant changes made to diagnostic criteria. Rationale for DSM-III

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* Sources: Gaines, 1995; Houts, 2002; Kutchins & Kirk, 1995; Malik & Beutler, 2002; Rentoul, 1995; Widiger, 2004 In response to critics: renamed & re-organized Changes Number of diagnoses: from 265 to 292 diagnoses Influences Robert Spitzer & DSM task force More Revisions: DSM-III-R External pressure from various sources

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Sleep Disorders (listed in the appendix of DSM-III ): Promoted to mental disorders in DSM-III-R based on a vote not results from new research Despite force’s insistence of a scientific basis, they were placed in a new appendix, “Proposed Diagnostic Categories in Need of Further Study” More Controversies: DSM-III-R Lack of Empirical Data 27 new diagnoses: Drastic increase in # of diagnoses b/t DSM III & DSM-III-R was much larger than could be explained by research literature

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* Sources: Gaines, 1995; Houts, 2002; Kutchins & Kirk, 1995; Spitzer, 1981 as cited by Rogler, 1997 Spitzer admits that homosexuality was not included or removed from DSM-III-R on empirical grounds, but became an issue based on inherent heterosexual biases More Controversies: DSM-III-R Resulted in removal of paraphilic rapism, self-defeating personality disorder, & premenstrual dysphoric disorder Political & Social Pressures Confrontations with feminists Removal of “ego dystonic homosexuality”

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The fourth edition of the DSM (DSM-IV) is published 1994 Published Edition Changes Number of diagnoses: from 292 to 365 diagnoses A Major Change: DSM-IV Work on DSM-IV began a year after DSM-III-R 1988 Detailed system of diagnostic criteria, change to Axis IV To retain conformity with ICD-10 Rationale for DSM-IV

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* Sources: Frances & Egger, 1997; Houts, 2002; Kutchins & Kirk, 1995; Malik & Beutler, 2002; Widiger, 2004 A Major Change: DSM-IV Effort to include women, minorities, psychologists & social workers Appointed Allen Frances as the new chairman Established a task force of several hundred mental health professionals Sought to adhere to a more rigid empirical approach Stated primary objective of the was to move beyond expert consensus In response to critics significant changes to the revision process itself

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Influences Motivating Change: DSM-IV & DSM IV-TR While APA stated that new diagnoses had to meet rigorous scientific tests for inclusion in DSM-IV, most were carried over from earlier editions APA admitted that most of them did not meet the new standards A few years after publication, announcement to revise the text was made 2000 Fourth edition-revised of the DSM (DSM-IV-TR) is published Currently translated in 22 languages

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Influences Motivating Change: DSM-IV & DSM IV-TR * Sources: Houts, 2002; Kutchins & Kirk, 1995 Published Edition Changes Number of diagnoses: 365(no diagnoses added) The 50-page increase from the DSM-IV reflected an effort to include the growth that occurred in research knowledge Cultural, ethnic, & age group variation sand new lab and physical findings were Added In response to critics

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Understanding 50 Years of Change DSM-II: 182 disorders DSM-IV: 365 disorders 494 pages 134 pages 567 pages DSM-III: 265 disorders DSM-III-R: 265 disorders DSM-IV-TR: 365 disorders 886 pages 943 pages In 50 years: 800% increase in the number of diagnoses

Slide 43: 

Understanding 50 Years of Change * Sources: Houts, 2000, 2002; Kutchins & Kirk, 1995; Zur & Nordmarker, 2006 The large increase in diagnoses (particularly in the last 30 years) and poor reliability & validity of DSM-based research has attracted much criticism Argued that the increase in scientific knowledge cannot explain expansion Criticism

Slide 44: 

Understanding 50 Years of Change * Sources: Houts, 2000, 2002; Kutchins & Kirk, 1995; Zur & Nordmarker, 2006 Included only in Appendix of DSM-IV Use of cultural content not mandated or required for hospital or clinic accreditation Demonstrated competence in cultural case formulation not required for professional certification of psychiatrists and other mental health clinicians Limitations of Cultural Content of DSM-IV

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The Future of the DSM: Towards DSM -V 1999-2005 : Development of DSM-V Preplanning White Papers 2002 : Publication of “A Research Agenda for DSM-V” 2004-5 : Publication of additional DSM-V Preplanning White Papers DSM-V Timeline:

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The Future of the DSM: Towards DSM -V DSM-V Timeline:

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The Future of the DSM: Towards DSM -V 2004-2007 : Review data from 10 APA/NIH-sponsored conferences on “The Future of Psychiatric Diagnosis: Refining the Research Agenda” 2007* : Appointment of DSM-V Workgroups 2011* : Publication of DSM-V * These dates are tentative; although these events will not occur any earlier, they could occur later DSM-V Timeline: DSM-V Timeline:

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1999-2002 Research Agenda For DSM-V 2003-2008 APA/WHO/NIH Research Conferences 2004 Prelude Page Launched 2007- 2011 DSM-V Workgroups 2014 ICD-11 2012 DSM-V 2007 Infant, Gender, Geriatric DSM -V Timeline

Slide 49: 

DSM -V Taskforce David J. Kupfer, M.D. Darrel A. Regier, M.D., M.P.H. William T. Carpenter, Jr., M.D. Francisco Xavier Castellanos, M.D. Wilson M. Compton, M.D., M.P.E. Joel E. Dimsdale, M.D. Javier Escobar, M.D., M.Sc. Jan Fawcett, M.D. Steven E. Hyman, M.D. Dilip Jeste, M.D. Helena C. Kraemer, Ph.D. Daniel T. Mamah, M.D., M.P.E. James McNulty, A.B., Sc.B. Howard B. Moss, M.D. William E. Narrow, M.D., M.P.H. Charles O’Brien, M.D., Ph.D. Roger Peele, M.D., D.L.F.A.P.A. Katharine A. Phillips, M.D. Daniel Pine, M.D. Charles F. Reynolds, III, M.D. Maritza Rubio-Stipec, Sc.D. Andrew E. Skodol, II, M.D. Susan Swedo, M.D. B. Timothy Walsh, M.D. Philip Wang, M.D., Dr.P.H. William M. Womack, M.D Kimberly A. Yonkers, M.D Kenneth J. Zucker, Ph.D. http://www.psych.org/MainMenu/Research/DSMIV/DSMV/MeettheTaskForce.aspx?mode=1

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DSM -V Workgroups http://www.psych.org/MainMenu/Research/DSMIV/DSMV/WorkGroups.aspx On May 1, 2008, the American Psychiatric Association (APA) announced the members of the work groups composed of more than 120 world-renowned scientific researchers and clinicians with expertise in neuroscience, biology, genetics, statistics, epidemiology, public health, nursing, pediatrics and social work.

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DSM -V Current Activities: Report of the DSM-V Work Groups (April 2009) Report of the DSM-V ADHD and Disruptive Behavior Disorders Work Group Report of the DSM-V Childhood and Adolescent Disorders Work Group Report of the DSM-V Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Work Group Report of the DSM-V Eating Disorders Work Group Report of the DSM-V Mood Disorders Work Group Report of the DSM-V Neurocognitive Disorders Work Group Report of the DSM-V Neurodevelopmental Disorders Work Group Report of the DSM-V Personality and Personality Disorders Work Group Report of the DSM-V Psychotic Disorders Work Group Report of the DSM-V Sexual and Gender Identity Disorders Work Group Report of the DSM-V Substance-Related Disorders Work Group Report of the DSM-V Somatic Distress Disorders Work Group Report of the DSM-V Sleep-Wake Disorders Work Group http://www.psych.org/MainMenu/Research/DSMIV/DSMV/DSMRevisionActivities/DSM-V-Work-Group-Reports.aspx

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DSM -V Report of the DSM-V ADHD and Disruptive Behavior Disorders Work Group Whether to differentiate ADD from ADHD Alternatively, there could be a single disorder of ADHD comprising the popular conceptions of ADD and ADHD More recent data provide support for a three-dimension factor structure for adults with ADHD that includes impulsivity/impulsive decision-making. DSM-IV-TR A criteria yield two dimensions (inattention and hyperactivity/impulsivity) for children. Job Bank/Careers http://www.psych.org/MainMenu/Research/DSMIV/DSMV/DSMRevisionActivities/DSM-V-Work-Group-Reports.aspx

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DSM -V Report of the DSM-V ADHD and Disruptive Behavior Disorders Work Group Inclusion of a section on: “Developmental or Age Related Manifestations” of other DSM syndromes There is strong support to eliminate the hierarchical exclusion that “the symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder.” symptoms would be present for at least 6 months, as opposed to 12 months Job Bank/Careers http://www.psych.org/MainMenu/Research/DSMIV/DSMV/DSMRevisionActivities/DSM-V-Work-Group-Reports.aspx

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DSM -V Report of the DSM-V Childhood and Adolescent Disorders Work Group DSM-V should involve a new entity, labeled non-suicidal self injury (NSSI). Possible modifications to various mood disorder syndromes: Pediatric bipolar disorder, Severe irritability, Pediatric Major Depressive Disorder. Possible modifications to various trauma-related syndromes: Preschool post-traumatic stress disorder (PTSD, Child and Adolescent PTSD, Developmental Trauma Disorder Job Bank/Careers http://www.psych.org/MainMenu/Research/DSMIV/DSMV/DSMRevisionActivities/DSM-V-Work-Group-Reports.aspx

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DSM -V Report of the DSM-V Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Work Group Anxiety Sub-work group : Use of panic attacks as a dimension or specifier for any DSM-V disorder for which they are relevant Changes to the wording of panic attack criteria, inclusion of respiratory subtype of panic attack Review of criteria for agoraphobia and its relationship to panic disorder Naming of the disorder :“social anxiety disorder” vs. “social phobia” Job Bank/Careers http://www.psych.org/MainMenu/Research/DSMIV/DSMV/DSMRevisionActivities/DSM-V-Work-Group-Reports.aspx

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DSM -V Report of the DSM-V Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Work Group Review of usefulness of the current “generalized” and “nongeneralized” distinction Whether the DSM-IV subtypes of animal phobia, environmental, blood/injury/injection, situational, and other are supported by external validators Review of link between generalized anxiety disorder and what used to be diagnosed as “overanxious disorder” in children Job Bank/Careers http://www.psych.org/MainMenu/Research/DSMIV/DSMV/DSMRevisionActivities/DSM-V-Work-Group-Reports.aspx

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DSM -V Report of the DSM-V Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Work Group Obsessive-Compulsive Spectrum Sub-work group: Obsessive-compulsive spectrum disorders might be subclassified as A. Cognitive (e.g., BDD), and B. Motoric (e.g., trichotillomania) Hoarding may be a symptom dimension of OCD, it may also merit classification as a separate disorder Whether to add additional subtypes or specifiers of OCD such as early-onset OCD or tic-related OCD Whether Tourette’s disorder is substantially distinct from other chronic motor or vocal tic disorders Job Bank/Careers http://www.psych.org/MainMenu/Research/DSMIV/DSMV/DSMRevisionActivities/DSM-V-Work-Group-Reports.aspx

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DSM -V Report of the DSM-V Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Work Group Whether trichotillomania should have subtypes and Whether trichotillomania deserves an alternate or additional name (e.g., hair-pulling disorder) Whether to remove OCD from the anxiety section and classify it, along with OC spectrum disorders or to broaden the current section on anxiety disorders so it is termed “anxiety and obsessive-compulsive spectrum disorders” Job Bank/Careers http://www.psych.org/MainMenu/Research/DSMIV/DSMV/DSMRevisionActivities/DSM-V-Work-Group-Reports.aspx

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DSM -V Report of the DSM-V Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Work Group Posttraumatic and Dissociative Disorders Sub-work group: Whether to include Disorders of Extreme Stress Not Otherwise Specified (DESNOS), Developmental Trauma Disorder Where conversion disorder should be classified (with dissociative disorders versus somatic disorders) How to formulate developmentally sensitive criteria for PTSD http://www.psych.org/MainMenu/Research/DSMIV/DSMV/DSMRevisionActivities/DSM-V-Work-Group-Reports.aspx

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DSM -V Report of the DSM-V Eating Disorders Work Group Whether to include additional categories in Eating Disorder, such as Binge Eating Disorder, Purging Disorder and Night Eating Syndrome. http://www.psych.org/MainMenu/Research/DSMIV/DSMV/DSMRevisionActivities/DSM-V-Work-Group-Reports.aspx

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DSM -V Report of the DSM-V Mood Disorders Work Group The major depression (MDD) sub-workgroup: Whether to add hopelessness and irritability with major symptoms of MDD Whether SADS is better considered a diagnostic category or a specifier The Bipolar sub-workgroup: A mixed episode specifier requiring 2-3 symptoms of either major depression or mania is being considered The PMDD sub-workgroup: Whether to remove PMDD as a diagnosis http://www.psych.org/MainMenu/Research/DSMIV/DSMV/DSMRevisionActivities/DSM-V-Work-Group-Reports.aspx

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DSM -V Report of the DSM-V Neurocognitive Disorders Work Group The disorders in this group will be those that are “acquired”, not “developmental” Both Minor and Major Neurocognitive Disorders may be further subclassified according to etiology – e.g., Alzheimer disease Use of specifiers like Course (transient, remitting, persistent but stable, persistent and worsening, persistent with fluctuations), Age of onset (<65, ≥65), Associated behavioral symptoms (e.g., agitation, wandering) http://www.psych.org/MainMenu/Research/DSMIV/DSMV/DSMRevisionActivities/DSM-V-Work-Group-Reports.aspx

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DSM -V Report of the DSM-V Neurocognitive Disorders Work Group Should there a code for the level of certainty of diagnosis of a neurocognitive disorder (e.g., possible, probably, likely)? What should be the role of biomarkers such as genetics, neuroimaging, and neurochemistry in the diagnosis of these disorders? Should specific behavioral syndromes such as psychosis of AD or depression of AD be included as sub-codes under neurocognitive disorders or under psychotic disorders? http://www.psych.org/MainMenu/Research/DSMIV/DSMV/DSMRevisionActivities/DSM-V-Work-Group-Reports.aspx

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DSM -V Report of the DSM-V Neurodevelopmental Disorders Work Group Whether to replace “Pervasive Developmental Disorder (PDD)” with “Autism Spectrum Disorders” (ASD) Whether to replace “Mental retardation (MR)” with “Intellectual Disabilities” with diagnostic specifiers for 1) IQ and 2) Adaptive functioning http://www.psych.org/MainMenu/Research/DSMIV/DSMV/DSMRevisionActivities/DSM-V-Work-Group-Reports.aspx

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DSM -V Report of the DSM-V Personality and Personality Disorders Work Group 5 domains of personality assessment: an overall rating of personality (self and interpersonal) functioning ranging from normal to severely impaired 2) prototype descriptions of major personality (disorder) types http://www.psych.org/MainMenu/Research/DSMIV/DSMV/DSMRevisionActivities/DSM-V-Work-Group-Reports.aspx

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DSM -V Report of the DSM-V Personality and Personality Disorders Work Group 3) personality trait assessment, on which the prototypes are based, but which can also be used to describe major personality characteristics 4) generic criteria for personality disorder 5) measures of adaptive functioning http://www.psych.org/MainMenu/Research/DSMIV/DSMV/DSMRevisionActivities/DSM-V-Work-Group-Reports.aspx

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DSM -V Report of the DSM-V Psychotic Disorders Work Group Testing a dimensional approach for key aspects of psychopathology (e.g., reality distortion, disorganization, avolition, restricted affect, cognition impairment, depression and mania) Developing new criteria for schizoaffective disorder to improve reliability and face validity Whether the dimensional assessment of mood will justify a recommendation to drop schizoaffective disorder as a diagnostic category http://www.psych.org/MainMenu/Research/DSMIV/DSMV/DSMRevisionActivities/DSM-V-Work-Group-Reports.aspx

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DSM -V Report of the DSM-V Psychotic Disorders Work Group Adding a risk syndrome section to DSM-V and including risk for conversion to psychosis as a category Moving Catatonia into its own diagnostic class Dropping traditional schizophrenia subtypes http://www.psych.org/MainMenu/Research/DSMIV/DSMV/DSMRevisionActivities/DSM-V-Work-Group-Reports.aspx

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DSM -V Report of the DSM-V Sexual and Gender Identity Disorders Work Group Adding “Hyper sexuality” as a potential new diagnostic entity Gender Identity Disorders Sub-work group has addressed criticisms and feedback from interested activist groups http://www.psych.org/MainMenu/Research/DSMIV/DSMV/DSMRevisionActivities/DSM-V-Work-Group-Reports.aspx

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DSM -V Report of the DSM-V Sleep-Wake Disorders Work Group Primary insomnia: If quantitative diagnostic criteria are justified Circadian rhythm sleep disorder: Elevation of “advanced sleep phase syndrome” from its current NOS status Elevation of “Restless legs syndrome” from its current NOS status http://www.psych.org/MainMenu/Research/DSMIV/DSMV/DSMRevisionActivities/DSM-V-Work-Group-Reports.aspx

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DSM -V Report of the DSM-V Sleep-Wake Disorders Work Group Parasomnia disorders : Elevation of “REM sleep behavior disorder” from its current NOS status Inclusion of Confusional Arousal Disorder http://www.psych.org/MainMenu/Research/DSMIV/DSMV/DSMRevisionActivities/DSM-V-Work-Group-Reports.aspx

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DSM -V Report of the DSM-V Somatic Distress Disorders Work Group “Somatic Symptom Disorders” may replace the term “Somatoform Disorders.” Combination of somatization disorder, hypochondriasis, pain disorder and undifferentiated somatoform disorder into one overarching disorder (tentatively entitled, “complex somatic symptom disorder”) Elimination of criteria such as “medically unexplained symptoms” http://www.psych.org/MainMenu/Research/DSMIV/DSMV/DSMRevisionActivities/DSM-V-Work-Group-Reports.aspx

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DSM -V Report of the DSM-V Substance-Related Disorders Work Group Development of a separate set of criteria for cannabis withdrawal Whether to include non-substance addictions (also referred to as “behavioral addictions” or “appetitive disorders”) within the chapter e.g. Internet Addiction, Video Game Addiction http://www.psych.org/MainMenu/Research/DSMIV/DSMV/DSMRevisionActivities/DSM-V-Work-Group-Reports.aspx

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The Future of the DSM: Towards DSM -V http://www.dsm5.org/suggestions.cfm DSM-V Links: To make suggestions/comments: List of Research Planning Activities: http://www.dsm5.org/planning.cfm To View Timeline: http://www.dsm5.org/timeline.cfm

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Criticisms of the DSM The DSM More of a Political (and economic) Art Than a Science Pharmaceutical companies have played a big part in maintaining a “medical model” classification system With profits to gain, pharmaceutical companies have readily funded research The writers of DSM have also benefited from the DSM’s medical model

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Criticisms of the DSM The DSM More of a Political (and economic) Art Than a Science Of 170 contributors (DSM-IV/DSM-IV-TR): 56% had 1 (or more) financial ties to the pharmaceutical industry Certain diagnoses have received more attention than others throughout different eras - frequent parallels to development of new medications 42% received funding for research from the same industry * Sources: Albee & Joffee, 2004; Cosgrove et al., 2006; Gaines, 1992; Mayes & Horowitz, 2005; Zur & Nordmarker, 2006

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The DSM Pathologizes “Normal” Behaviors Feeling jumpy & agitated from drinking too much coffee can now be diagnosed as “Caffeine Related Disorder” Healthy grieving may be diagnosed as “Complicated Grief Reaction” if it lasts longer than the time frame allotted by DSM More Criticisms of the DSM

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The DSM Pathologizes “Normal” Behaviors Smoking too much may lead to a diagnosis of “Nicotine Dependency Disorder,” a disorder now afflicting about 12.8% of the US adult population More Criticisms of the DSM

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The DSM Pathologizes Certain Groups Over Others Children, Ethnic Minorities, Geriatric Population, Women, and Sexual Minorities are at an increased risk for being unfairly diagnosed with mental illness * Sources: Albee & Joffee, 2004; Gaines, 1992; Grant & Stinson, 2004; Widiger, 2004; Zur & Nordmarker, 2006 More Criticisms of the DSM

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Thoughts Regarding the DSM-V “The present diagnostic system based on a descriptive approach was a great advance of previous systems which had a very low reliability. This improvement has facilitated research and clinical communication” (1999, p. 164) Frances [DSM-IV chair] & Egger [DSM Research Fellow] on DSM-IV

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“…as a text, [the DSM] is a simple collection of tales of suffering and complaint, a compilation of information (by its own admission) often transient and mutable quality” (Amundson, 1998, p. 3). Thoughts Regarding the DSM-V A Criticism From the Field “… For some of these, there is an issue of grandfathering...The onus is on the person who wants to change it to prove that we should do so” (from Time magazine’s “How we get labeled,” Cloud, 2003). A Comment from Michael First [DSM-IV editor & chair of DSM-V]

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Advice Regarding the DSM-V “DSM-IV and ICD-10 are very similar, but annoyingly different—and neither is clearly superior to the other. ICD-11 has been postponed until at least 2014.” Frances A.[DSM-IV chair] (Frances A. Advice To DSM V. . . change deadlines and text, keep criteria stable. Available athttp://www.psychiatrictimes.com/display/article/10168/1444633. Accessed August 31, 2009.).

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Advice Regarding the DSM-V “If, as seems necessary, the DSM-V publication date is postponed for a year or more, there will be sufficient time to join the systems in a nested alignment. This would be the most welcome and enduring legacy of both DSM-V and ICD-11” (Frances A. Advice To DSM V. . . change deadlines and text, keep criteria stable. Available athttp://www.psychiatrictimes.com/display/article/10168/1444633. Accessed August 31, 2009.). Frances A.[DSM-IV chair]

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Warning Regarding the DSM-V “I have little confidence that the DSM-V leadership will do the kind of careful risk-benefit analysis of each proposed change that is necessary to avoid damaging unintended consequences. My concerns arise from the following: Their ambition to achieve a paradigm shift when there is no scientific basis for one. Francs A. [DSM-IV chair] Regarding DSM-V leadership

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Warning Regarding the DSM-V Their failure to provide clear methodological guidelines on the level of empirical support required for changes. Their lack of openness to wide scrutiny and useful criticism. Francs A. [DSM-IV chair] Regarding DSM-V leadership

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Warning Regarding the DSM-V Their inability to spot the obvious dangers in most of their current proposals. Their failure to set and meet clear timelines. The likelihood that time pressure will soon lead to an unconsidered rush of last-minute decisions.” Frances A. Advice To DSM V. . . change deadlines and text, keep criteria stable. Available at http://www.psychiatrictimes.com/display/article/10168/1444633. Accessed August 31, 2009. Francs A. [DSM-IV chair] Regarding DSM-V leadership

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Video Clip: DSM “DSM: Inventing Mental Illness” DSM Video Clip [ * From Citizens Commission on Human Rights, http://www.cchr.org/ video/psychiatry_pseudo-science/dsm_inventing_mental_illness.html * ]

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Albee, G. W. & Joffee, J. M. (2004). Mental illness is NOT “an illness like any other.” The Journal of Primary Prevention, 24(4), 419-437. Amundson, J. (1997). Tales of Suffering and Complaint - Asking DSM-IV to do more than it was Intended For. Journal of Systemic Therapy, 16(4) 1-11. Alic, M. (2001). Kraepelin, Emil (1856-1926). Gale Encyclopedia of Psychology (2nd ed.). Retrieved on March 17, 2008 from http://findarticles.com/p/articles/mi_g2699/is_0005/ai_2699000523. Cosgrove, Krimsky, Vijayaraghavan, Schneider (2006). Financial ties between DSM-IV panel members and the pharmaceutical industry. Psychotherapy & Psychosomatics, 75, 154- 160. First, M. B., Frances, A., & Pincus, H. A. (2004). Roots: A brief history of psychiatric classification. In DSM-IV-TR Guidebook (pp. 3-11). Washington, DC: American Psychiatric Press. Frances ,A. Advice To DSM V. . . change deadlines and text, keep criteria stable. Available athttp://www.psychiatrictimes.com/display/article/10168/1444633. Accessed August 31, 2009. Gaines, A. (1992). From DSM-III to DSM III-R; Voices of self, mastery and the other: A cultural constructivist reading of U.S. psychiatric classification. Social Science & Medicine, 35(1), 3-24. References:

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Grant, B. F. & Stintson, F. S. (2004). Nicotine dependence and psychiatric disorders in the United States. Archives of General Psychiatry, 61, 1107-1115 Houts, A. C. (2000). Fifty years of psychiatric nomenclature: Reflections on the 1943 War Department Technical Bulletin, Medical 203. Journal of Clinical Psychology, 56(7), 935-967. Houts, A. C. (2002). Discovery, invention, and the expansion of the modern diagnostic and statistical manuals of mental disorders. In L. E. Beutler and M. L. Malik (Eds.), Rethinking the DSM: A psychological perspective. (pp. 17-65). Washington, DC: American Psychological Association. Kutchins, H. & Kirk, S. A. (1995). DSM-IV: Does bigger mean better? Harvard Mental Health Letter, 11(11), 4-7. Malik, M. L. & Beutler, L. E. (2002). The emergence of dissatisfaction with the DSM. In L.E. Beutler & M. L. Malik (Eds.), Rethinking the DSM (pp. 3-16). Washington, DC: American Psychological Association. Mayes, R. & Horwitz, A. V. (2005). DSM-III and the revolution in the classification of mental illness. Journal of the History of the Behavioral Sciences, 41(3), 249-267. Mendelson, G. (2003). Homosexuality and psychiatric nosology. Australian and New Zealand Journal of Psychiatry, 37, 678-683. References:

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Müller, U., Fletcher, P. C., & Steinberg, H. (2006). The origin of pharmacopsychology: Emil Kraeplin’s experiments in Leipzig, Dorpat, and Heidelberg (1882-1892). Psychopharmacology, 184, 131-138. Rentoul, R. (1995). Psychiatric diagnosis, natural categories, and DSM-IV. Counseling Psychology, 8(1), 51-55. Rogler, L. H. (1997). Making sense of the historical changes in the Diagnostic and Statistical Manual of Mental Disorders: Five propositions. Journal of Health and Social Behavior, 38(1), 9-20. Widiger, T.A. (2004). Classification and diagnosis: Historical development and contemporary issues. In J. Maddux & B. Winstead (Eds.), Psychopathology: Foundations for a contemporary understanding (pp. 63-83). Lawrence Erlbaum Associates, Inc. Wilson, H. S. & Skodol, A. (1994). Special report: DSM-IV: Overview and examination of major changes. Archives of Psychiatric Nursing, 8(6), 340-347. Zur, O. & Nordmarker, N. (2006). DSM: Diagnosing for money and power. Zur Institute: Innovative Resources and Continuing Education, Retrieved March 17, 2006 from http://www.drzur.com/DSMcritique.html#summary. References:

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The future DSM-V should Presenter’s Suggestions Eliminate the vagueness to limit diagnosis to 1%-2% of the population Should be free from possible cultural biases Require field-testing of DSM-V categories in varied cultural contexts, including multi-cultural communities Revise DSM-V categories on the basis of multi-cultural field testing

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Thank You!

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