Development of Diagnostic and Statistical Manual (DSM)-V: An Alternative Perspective

Release of DSM-V is getting closer and the debate about this upcoming revision of Diagnostic and Statistical Manual of Mental Disorders (DSM) of American Psychiatric Association (APA) is escalating. No prior edition of DSM has attracted so much attention, especially even before its release. Comments and opinions, both in favor and against DSM-V, have been raised by clinicians, researchers, academicians, patient groups and civil society organizations. A similar, albeit at a much lower scale, discussion is focused around ICD-11, the upcoming revision of International Statistical Classification of Diseases and Related Health Conditions (ICD) of World Health Organization (WHO) [1]. DSM-V follows DSM-IV (and DSM-IV TR), that was released around two decades ago [2]. DSM-IV, in turn, had replaced DSM-III. DSM-IV carried forward the legacy of DSM-III as it described psychiatric disorders as diagnostic categories defined descriptively in terms of symptoms that have been observed to vary together in individuals, supplemented by optional severity dimensions and one cross-cutting dimension for assessment of functioning. This approach of DSM-IV has been criticized by researchers as well as clinicians [3]. Diagnostic criteria for various disorders, as specified in DSM-IV, were criticized in the years following its release [4]. This criticism grew louder over the years. High rates of diagnostic co-morbidity; lack of treatment specificity for the diagnostic categories; evidence that distinct syndromes share a genetic basis; and the high rates of individuals requiring the use of the diagnostically unspecific not otherwise specified (NOS) category have been cited in support of low validity of the classification given in DSM-IV [3]. A need to modify the existing diagnostic criteria has been expressed for various disorders [5]. DSM-IV, like its predecessors, has also been criticized for paying little attention to the explicit and implicit value commitments made by the classifications. Instead of careful inquiry and assessment of the principal values that drive the nosologic process, it aimed at incorporating more scientific diversity into the classification [6]. Additionally, it has been criticized for its limited cross-cultural applicability [7]. The case seems to be ripe for modifications in existing DSM-IV. However, the larger and more important debate is centered on how to bring in this change. Should the upcoming DSM-V use the existing blue print of DSM-IV and make necessary modifications? Or should it altogether follow a different approach to psychiatric diagnosis? One should not forget the numerous options that fall in between these two extreme options. DSM-V Research Agenda aims ‘to transcend the limitations of the current DSM paradigm and to encourage a research agenda that goes beyond our current ways of thinking…..’ Additionally, it specifies adopting an ‘etiologically and patho-physiologically based diagnostic system’ as an ultimate goal [8]. The task force on DSM-V mentions the approach to this new classificatory system a ‘paradigm shift’ from the one followed in DSM-IV. Structure for the diagnostic categories in upcoming DSM-V has also been changed. Introduction of long argued dimensional rating is another welcome change in upcoming DSM-V. This step is aimed at increasing the precision of psychiatric diagnosis by avoiding many theoretical presumptions about causal hypotheses as associated with DSM-IV (and also ICD-10). The intention of The American Psychiatric Association to change its revision model so that sections of the classification can be revised on an as-needed basis, driven by the presence of compelling empirical evidence indicating the need for change is also a welcome move [9]. An explicit effort has been made to avoid conflicts of interest and ensure transparency with the development of DSM-V. The official website of DSM-V has specified the criteria which all the members of the task force must meet and abide by. This includes the financial disclosures as well as relation with pharmaceutical industry. Decision for inclusion in latest draft diagnosis is based on findings from real life field testing. Additionally, the publications arising out of field trials conducted for DSM-V have been made available at the official website of DSM-V. Some changes have been proposed in almost all existing sections in DSM-IV. Some group of disorders such ‘Bipolar and Related Disorders’ contain updates in all individual disorders. Also, there are suggestions to include new disorders, such as Premenstrual Dysphoric Disorder, in DSM-V. Diagnosis specific severity measures have also been added for some of the disorders like Obsessive Compulsive Disorder. The process of development of DSM-V has involved a series of conferences, task force meetings, and field trials. Explicit effort has been made to keep the process objective and transparent. It remains to be seen what form DSM-V would finally take. There are concerns and apprehensions about the extent to which this upcoming revision would be able to address the limitations of the DSM-IV and contribute further to the psychiatric classification. However, the debate is likely to escalate further with publication of what would be the latest revision of DSM.

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