Current Activities: Report of the DSM-V Task Force (November 2008)

DSM-V Task Force and Work group Update
APA Division of Research Report to the APA Board of Trustees
Submitted by: David J. Kupfer, M.D. and Darrel A. Regier, M.D., M.P.H.
November 17, 2008 

Current Status and Activities of the DSM-V Task Force, Study Groups, and Work Groups 

The sixth meeting of the DSM-V Task Force was held October 26-27, 2008.  The four DSM-V Task Force Study Groups on cross-cutting issues (Lifespan Developmental Issues, Diagnostic Spectra, Gender and Cross-Cultural Expression, and Psychiatric/General Medical Interface) have met face to face in their respective groups and brought their recommendations back to the full task force for discussion during each of the task force meetings.  Each study group has held approximately 15 conference calls since their formation, in April 2007.  A fifth study group, charged with working to implement measures of impairment across diagnoses, has been formed, and held its first in-person meeting October 7-8, 2008. 

Each study group is addressing specific research questions and hypotheses, based on their review of existing literature, findings from the DSM research planning conferences, and relevant work from Research Agenda white papers.  Plans for secondary data analysis to address these questions have been developed, and are beginning to be conducted.  These activities are being used to inform the diagnostic work groups on strategies for incorporating cross-cutting themes into their work processes.  The study groups have invited members of DSM-V work groups with expertise in certain topics to join them on conference calls and the writing of research proposals.  The study groups will continue their work throughout the life of the task force.  A summary of their activities to date is located in Appendix A. 

An additional group, focused on the development of diagnostic instruments to be created in conjunction with development of the DSM-V, is currently being formed.   

Each DSM-V work group has now had two to four 2-day face-to-face meetings.  The following meetings have been convened since the last report to the BOT:

  • October 6-7, 2008: Anxiety, Obsessive Compulsive Spectrum, Posttraumatic, and Dissociative;
  • October 7-8, 2008: Impairment Study group
  • October 26-27, 2008: DSM-V Task Force

The following meetings have been scheduled to take place later this year and in 2009: 

  • December 16-17, 2008: Anxiety, Obsessive Compulsive Spectrum, Posttraumatic, and Dissociative; Mood; Personality and Personality Disorders; and Psychotic Disorders 
  • February 24-25, 2009: Mood; Sleep-Wake; Somatic Distress; and Substance-Related Disorders
  • March 17-18, 2009: Anxiety, Obsessive Compulsive Spectrum, Posttraumatic, and Dissociative Disorders; Childhood & Adolescent; Eating; and Neurocognitive Disorders
  • April 21-22, 2009: Neurodevelopmental; ADHD and Disruptive Behaviors; Personality and Personality Disorders; and Psychotic Disorders
  • October 6-7, 2009: ADHD and Disruptive Behaviors; Childhood & Adolescent; Mood; and Somatic Distress Disorders
  • October 19-20, 2009: Anxiety, Obsessive Compulsive Spectrum, Posttraumatic, and Dissociative Disorders; Neurodevelopmental; Neurocognitive; and Psychotic Disorders
  • November 16-17, 2009: Eating; Sleep-Wake; Substance-Related; and Personality and Personality Disorders 

BOT Appointed Committee to Review Advisor Nominations

The BOT appointed committee to review and appoint advisors to the DSM-V Task Force, Study groups, and Work groups (Advisor Committee) has appointed more than 50 advisors. Approximately 40 additional nominees are currently under review. 

Media Issues

APA’s confidentiality policy regarding the work of DSM-V members has recently been given attention, via editorial pieces in newsletters and on Internet “blogs”.  In addition to a response to one critique of these policies that was published in the July 18, 2008, edition of Psychiatric News, by Drs. Nada Stotland, James Scully, David Kupfer, and Darrel Regier, public versions of each DSM-V report to the APA BOT Trustees will now be posted on the psych.org Web site.  The September report is posted here.  Summaries of the DSM-V Work Group activities, authored by the chairs of each work group, are also posted here (see Appendix B for a compilation of these summaries).   

Diversity, Conceptual, and Philosophical Issues 

To ensure that those involved in the revision process represent diverse perspectives, disciplines, and areas of expertise, the task force and work groups represent a variety of clinical and scientific disciplines, patient and family groups, women, and minority/underrepresented groups (see Appendix F for a breakdown of current representation).   Efforts have also been made for each work group to have at least one international member.  As noted above, the task force study group on gender and cross-Cultural issues will continue its work throughout the DSM-V process. In addition, a large number of advisors involved in the revision process will increase the level of diversity involved in the revision process. 

Conceptual and philosophical issues related to diagnosis and classification are being addressed at several levels.  The task force has been addressing such issues from its onset, particularly through the Spectra Study Group, which is addressing such issues as organizing principles for the DSM-V, and prioritization of specific types of validators. The Developmental Study Group is evaluating alternative conceptualizations to address lifespan issues across disorders.  The Gender and Cross-Cultural Study Group is considering issues of criteria changes on the basis of sex and cultural differences.  All work groups are addressing the feasibility of incorporating dimensional assessments of psychopathology.  As the work groups continue their literature reviews and secondary data analyses, procedures for issues such as developing a threshold for making changes to criteria are being developed.  Several work group and task force members with a special interest in these issues continue to push this process forward by addressing possible alternative overarching “meta-structures” for the future manual.  A number of the workgroups have discussed these proposals.  Potential strategies for incorporating these issues in the DSM-V in a clinically useful way were reviewed during the October task force meeting.    

Research Activities 

As noted above, the work groups are now actively developing literature reviews and secondary data analysis plans.  To date, 23 data analysis proposals and 43 literature review proposals have been received.  The Research Group has its own limited-access page on SharePoint.  In addition, documents have been posted on SharePoint that can be accessed by all work group members, e.g., data analysis proposal forms, literature review tracking forms, advisor nomination forms, and a statement on how the Research Group can assist the work groups in achieving their research goals. 

Integration with ICD-11 

The APA continues to participate with the World Health Organization in a “DSM/ICD Harmonization Coordination Group.”  The aim of this group is to facilitate the highest possible extent of uniformity and harmonization between ICD-11 mental and behavioral disorders and DSM-V.  The functions of the group are:  

  • To identify effective mechanisms to share information on developmental processes of the two diagnostic systems.
  • To find strategies to narrow the differences between the two diagnostic systems.
  • To coordinate efforts towards harmonization of the two diagnostic systems by making specific recommendations to the respective decision making bodies.
  • To provide a forum in which difficult issues around harmonization can be discussed and common approaches identified. 

Outreach and Dissemination Activities 

To further enhance global outreach, a symposium, titled: “Conceptual Considerations for Revising DSM and ICD Disorders” took place Sunday, September 21, 2008, at the World Psychiatric Association’s 14th World Congress in Prague.  The session was chaired by Darrel Regier, with speakers highlighting globally-relevant outcomes from key areas of the DSM-V Research Planning conferences.  Over 200 people were in attendance.  Another WPA symposium, chaired by Dr. Norman Sartorius, with participation by David Kupfer, entitled: “Preparations for DSM-V/ICD-11” also took place. 

The DSM-V will be the focus of the 99th Annual Meeting of the American Psychopathological Association (APPA), to be held in New York City on March 5-7, 2008.  Sixteen speakers will be speaking in five topic sessions and two award lectures.  The topics are: 

  • Diagnostic Spectra: Assessing the Validity of Disorder Groupings
  • Integrating Dimensional Concepts into a Categorical System
  • Assessing Functional Impairment for Clinical Significance and Disability
  • Identifying Important Culture- and Gender-Related Expressions of Disorders
  • Incorporating Developmental Variations of Disorder Expression Across the Lifespan

This meeting will be chaired by Dr. Regier, who is the current president of the APPA. 

The 2009 APA Annual Meeting will have several opportunities for members and other interested persons to hear the latest news in the development of DSM-V. The planned DSM-V track will begin with the annual DSM-V Forum, which provides an overview of activities over the past year, as well as a preview of upcoming Annual Meeting sessions.  There will be four symposia related to DSM-V.  Two symposia will cover the final two conferences in the APA/NIH/WHO conference series, “Public Health Aspects of Psychiatric Classification” and “Autism and Other Pervasive Developmental Disorders.”  Another symposium will summarize the APPA meeting, and cover the five cross-cutting DSM-V topics listed above.  Finally, a symposium on Gender Identity Disorder will bring together transgender advocates and DSM-V group members to give a status report on work group activities and discuss issues around this controversial diagnosis, including whether it should be listed in DSM-V at all. 

Members of the DSM-V Task Force and Work Groups continue to make presentations at meetings, such as the AACAP Annual Meeting and the WPA World Congress.  Dr. Daniel Pine chaired a full-day town hall meeting October 30, 2008, at the AACAP Annual Meeting to present developments in DSM-V developmental issues.  Drs. Swedo, Castellanos, and Regier also presented.   Also, on October 31, 2008, at the AACAP meeting, Dr. Heino Meyer-Bahlburg chaired a symposium on GID, at which Dr. Kenneth  Zucker presented.  

Appendix A:
DSM-V Cross-Cutting Study Group Summary
of November, 2008

Summary of DSM-V Task Force Study Group Interactions:  October, 2008 

During the April 2007 Task Force meeting, each Task Force member was assigned to one of four study groups to examine issues that cut across the full range of disorders, and to develop examples for incorporating these issues into the new classification in a clinically useful way. Group topics are: 1) Lifespan Developmental Approach; 2) Diagnostic Spectra; 3) Psychiatric/General Medical Interface; and 4) Gender and Cross-Cultural Expression. Since this meeting, each study group has met several times via face-to-face meetings and conference calls.   

Since the last report, some changes have been made to the study group structure, to better incorporate the evolving work of the DSM-V revision.  This includes naming new chairs, expanding membership of the groups to include relevant diagnostic work group members, nominating advisors, and in one case, shifting a group’s focus.   A new study group has been formed to address Functional Impairment, Distress, and Disability issues in diagnosis.  The group held its first meeting on October 7-8, 2008. 

1) Lifespan Development Study Group:  

This group is examining issues such as: age of onset, how symptoms and diagnoses change across the lifespan; and how disorders evolve into new disorders over time.  The Lifespan Developmental Study Group has shifted its focus to the adult/geriatric ages.  Issues of childhood, adolescence and the transition to adulthood will continue to be addressed by the Child and Adolescent Disorders work group.  This work group and the Lifespan Study Group have already collaborated on the development of a document addressing developmental issues and diagnosis in adults and the elderly, based on concepts developed earlier for children and adolescents.  

The DSM-V Lifespan Developmental Issues Work Group with an emphasis on aging has begun to address the valuable opportunity to incorporate important aging information into the DSM-V regarding how the clinical expression and diagnosis of mental disorders varies across the lifespan into later life.  We seek to survey the evidence that may lead to DSM-V text revisions, such as “age-related manifestations” specified in the text, or “age-related subtypes” incorporated into diagnostic criteria depending on the level of evidence regarding age effects on the expression of a given disorder.   For all disorders we seek to increase the content in the DSM text that is devoted to lifespan issues and their effect on clinical expression.    

The study group will address the following areas that are relevant to diagnostic accuracy in the older adult as follows:

  1. True age-related differences, i.e., symptoms of disorders do vary by age
  2. Reduced detection of symptoms but greater functional impact, i.e., there is a higher threshold for symptom reporting and detection but potentially a lower threshold for functional impairment for a given level of symptom severity
  3. Variation through time of onset, i.e., late-onset illnesses may have unique symptom expression
  4. Subthreshold presentations, i.e., clinically significant disorders may result in impairment but be subthreshold in terms of diagnostic criteria.  Together the four issues above significantly affect the identification and treatment of mental disorder in the latter half of life, where we have both a demographic imperative to intervene as well as a growing literature base to guide us.

2) Diagnostic Spectra Study Group:

The Spectra Group is looking at the concept of “spectrum” as a group of disorders related by etiology/pathophysiology rather than solely by symptom similarity and syndromic relationships.  The spectrum validators developed by this group are being actively used by the diagnostic work groups in their literature reviews.  This study group is following the progress of these reviews.  The validators are: 

  1. Shared neural substrates (e.g., evidence that OCD spectrum involves frontal-striatal circuits; fear-based anxiety disorders involve amygdala circuits)
  2. Familiality (a level of evidence that does not parse genes and environment and that may include relationship issues)
  3. Shared genetic risk factors
  4. Shared specific environmental risk factors
  5. Shared biomarkers
  6. Shared temperamental antecedents
  7. Symptom similarity (to be used with caution, lest we end up with syndromes)
  8. Shared abnormalities of cognitive or emotional processing (e.g., working memory deficits that characterize schizotypy)
  9. Course of illness
  10. High rates of comorbidity
  11. Shared treatment response (to be used cautiously) 

3) Gender and Cross-Cultural Study Group:   

The Gender and Cross-Cultural Study Group has been working on a number of different tasks.  First, we have been assembling teams to work on literature reviews that are germane to the various work groups but focus on either gender differences and issues or race/ethnic differences and issues.  Each team associated with a work group has several to many members that will enable a thorough or timely review of the relevant topic.  After groups are assembled, they are asked to submit a literature review form and once approved, the review can commence.  It is our hope that these reviews will provide us with the empirical research on possible race/gender/ethnic differences for the various disorders and will point out additional issues regarding race/gender/ethnicity and psychiatric illness.  This will be helpful for those who are working on the text as well as for individuals that are planning field trials and secondary data analyses. 

The group has also been working on secondary data analyses along the lines we previously mentioned and have looked at possible measures of illness severity and functional impairment among individuals with major depressive disorder.  We hypothesized that differences in these domains may indicate that some subgroups may not be diagnosed until their illness is of greater severity and hence we may miss the less severely afflicted group.  To date, we have looked at gender groups, racial and ethnic groups in the CPES (NCS-R, NLAAS, NSAL), NESARC, and a Canadian national survey and have not found evidence suggesting that the groups are skewed on severity or functional impairment.  We have begun to look at item response by gender/race/ethnicity of these several data sets to tell us whether the items are relevant to these different subgroups.  

The group also has a subgroup that will be working on the cultural formulation.  We are in discussions about what relevant covariates and questions can be recommended to the various work groups who will be conducting field trials that would help collect uniform data about race/ethnicity and gender.  Finally, we are discussing how we can best communicate with the respective work groups about study group activities that are relevant to the work group and vice versa.   

4) Psychiatric and General Medical Interface Study Group:  

This study group is looking at links between the central nervous system and other organ systems, and between mental disorders and general medical conditions (e.g., disorders due to a general medical condition, somatic presentations of mental disorders).  This study group’s primary purpose is to oversee the development of a version of DSMV that will serve the needs of general medical practitioners. One of the study group’s previous areas of concentration, disability and functional impairment, will now be taken over by the new study group mentioned above.  This study group met most recently on October 22, 2008, after a hiatus of several months.

Appendix B:
DSM-V Work Group Summaries
of November, 2008 

ADHD and Disruptive Behavior Disorders Work Group
F. Xavier Castellanos, M.D. 

With regard to Disruptive Behavior Disorders (DBD), the work group identified six main issues: 

  1. Child-onset versus adolescent-onset subtypes of Conduct Disorder (CD);
  2. The life-course continuity from Oppositional Defiant Disorder (ODD) to CD to Antisocial Personality Disorder (ASPD);
  3. The use of psychopathic or callous-unemotional traits to designate subtypes of antisocial disorders in adults and children;
  4. Female-specific diagnostic protocols for CD;
  5. Early substance use as part of the CD criteria; and
  6. The co-occurrence of mood symptoms and DBD and how to incorporate irritability into the nosology.   

The next major focus has been on ADHD. The work group identified research questions relating to three broad areas: 

  1. Coverage, exclusions, and age of onset;
  2. Adjusting criteria for key patient characteristics, especially age; and
  3. Accounting for severity, heterogeneity, and subtypes.   

The work group condensed these two memos into single-page announcements that were submitted for publication in the Journal of the American Academy of Child and Adolescent Psychiatry, Journal of Child Psychology & Psychiatry, European Child & Adolescent Psychiatry, Journal of Abnormal Child Psychology, Journal of Clinical Child and Adolescent Psychology, and Child and Adolescent Mental Health Journal among others.   

The work group is currently revising a letter to be sent to targeted colleagues inviting them to assist in secondary analyses that would target Inattentive type of ADHD.   

Next, the group plans to address the issue of callous unemotional traits as a specifier for CD, ASPD, and possibly ODD. This will also be based on secondary data analyses that are being conducted and/or coordinated.  The Journal of Abnormal Psychology has commissioned a special issue containing nine articles that will focus on ODD and CD. Leaders in the field have signed on to submit manuscripts by April 30, 2009; these will undergo peer review and editorial oversight. These papers will provide comprehensive reviews of the pertinent literatures and provide an important foundation for proposed revisions.   

The work group has commissioned and received an article on adult ADHD. A review of the literature on ODD has also been commissioned. Other reviews of the literature on age of onset of ADHD and on the interface between ADHD and autism are currently being prepared.  Finally, the group has established a sub-work group focusing on the overlap between mood and disruptive behavior symptoms which includes members from the Childhood and Adolescent Disorders Work Group.

Anxiety, Obsessive-Compulsive Spectrum, Post-Traumatic, and Dissociative Disorders Work Group
Katharine Phillips, M.D.

Work Group Structure

The Anxiety, Obsessive Compulsive (OC) Spectrum, Post-Traumatic, and Dissociative Disorders Workgroup has three subworkgroups: 1) Anxiety, 2) Trauma/Dissociation, and 3) the Obsessive Compulsive Spectrum.

Liaisons to Other Work Groups and Study Groups

This work group has liaisons to many other work groups, including: Childhood Disorders, Mood Disorders, Psychosis, Personality and Personality Disorders, Neurocognitive Disorders, Sleep/Wake Disorders, Somatic Distress Disorders, and Substance-Related Disorders. The work group also has liaisons to the Lifespan/Developmental, Diagnostic Spectra, Gender/Cross-Cultural, and Functioning Study Groups.

Advisors 

Advisors have been nominated for all sub-work groups. Additional advisors will likely be nominated. Some advisors have participated on conference calls, and many are co-authoring literature reviews. 

Conference Calls 

Work group conference calls have focused on “overarching” themes that are relevant to all of the sub-work groups, such as clinical utility, criteria for adding and deleting disorders, considerations for changing diagnostic criteria, and how to incorporate gender, developmental considerations, a cross-cultural perspective, and etiology/pathophysiology into DSM-V. The sub-work group calls have focused on issues relevant to the disorders and other topics covered by each sub-work group. Literature review proposals and literature reviews, advisors, secondary data analyses, available databases, and other issues are being addressed by the work group as a whole, as well as by the sub-work groups.    

Workgroup Meetings  

Since the last task force meeting, the work group met in October 2008. At that meeting, progress was made on the above issues. There were several content-focused presentations/discussions, including developmental considerations, dimensional issues, and how some of the disorders covered by our work group might be grouped in DSM-V.  

Literature Reviews 

Evidence-based literature reviews are being done, some in collaboration with other work groups and study groups. The reviews will provide a balanced review of the literature on key issues that are relevant to DSM-V. They will include a statement of the issues, significance of the issues, search methodology, results, and discussion and recommendations. Reviews are in progress on key issues for DSM-V in each of the following topic areas: 

  • Operationally defining the term: “mental disorder“
  • The nature and conceptualization of anxiety/anxiety disorders
  • Panic disorder
  • Agoraphobia
  • Social phobia
  • Generalized anxiety disorder, including overanxious disorder of childhood
  • Specific phobia
  • Adult separation anxiety disorder
  • Subthreshold anxiety
  • Obsessive compulsive spectrum
  • Relationship of OCD to anxiety disorders
  • OCD subtypes and dimensions
  • Hoarding
  • Tourette’s disorder/tics
  • Stereotypic movement disorder
  • Body dysmorphic disorder
  • Trichotillomania
  • PTSD
  • Developmental aspects of traumatic events and response
  • Acute reactions to stress
  • Dissociative disorders
  • Categorization of trauma/dissociation/adjustment disorders
  • Psychosis/insight across disorders
  • Developmental issues: in addition to a broader overview review, developmental issues will be covered in other reviews
  • Cross-cultural review focusing on broader issues for DSM-V using dissociative disorders as an example
  • Gender review of disorders covered by the work group

Funded Secondary Data Analyses 

Two funded projects (see below) are in progress. Additional, unfunded secondary data analyses are being conducted to address other key issues being considered by the work group. 

            1) The structure of mental disorders based on epidemiological data on lifetime, cross-sectional, and sequential comorbidity: Several authors have recently suggested structural models of selected mental disorders for DSM-V, based on epidemiologic data and higher-order factor analytic methods. This study is re-examining the assumptions, models, and findings of this line of research, examining the effects of using a considerably broader scope of diagnoses than originally covered in these modeling exercises, the stability/instability of these models in different age groups, and the value and limitations for specific diagnostic areas and anxiety disorders in particular.
            2) Obsessive-compulsive disorder comorbidity and familiality: This study is using comorbidity and familiality data to determine the extent to which anxiety disorders/traits and putative OC-spectrum conditions occur in OCD-affected probands and their first-degree relatives, compared with control probands and their first-degree relatives. This review will shed important light on the concept of the OC spectrum. 

Meetings with the Field 

Work group members have participated in a number of scientific and advocacy group meetings to discuss the DSM-V development process and issues being considered by the work group, including: annual meetings of the American College of Neuropsychopharmacology, the American Psychiatric Association, the Anxiety Disorders Association of American, the Obsessive Compulsive Foundation, and the upcoming meeting of the International Society for Traumatic Stress Studies.  These meetings involve discussion with attendees and have produced valuable input from the field.   

Childhood and Adolescent Disorders Work Group
Daniel Pine, M.D. 

Work performed by the Childhood and Adolescent Disorders Work Group has revolved around two central themes.  First, considerable time has been devoted to developing procedures that would enable greater emphasis on developmental themes throughout DSM-V than in DSM-IV.  Second, the work group has been engaged in preparing individual reviews in specific areas.   

Very early in the process of delineating work group goals, the need to formally establish coherent, clearly-defined structure was identified.  After this structure had been effectively established, the Child and Adolescent Disorders Work Group focused on considering potential procedures for increasing developmental focus in DSM-V, relative to DSM-IV.  These procedures led to proposals that were formally assessed by the work group, and incorporated into a document that was circulated to the entire DSM-V Task Force and each work group.  The document delineates three specific suggestions.  One of these focuses on enhanced text revisions to focus on specific aspects of age-related features.  A second extends the designation of age-related subtypes beyond conduct disorder, the only age-related subtype in DSM-IV.  The third proposal calls for a novel addition to DSM-V, emphasizing developmental manifestations of each mental disorder listed in DSM-V.  Through meetings with various other work groups, the Child and Adolescent Disorders Work Group is attempting to implement these proposals.   

Work group deliberations also focused on finalizing literature reviews.  Two types of literature reviews have been prepared.  One set of these considers novel additions to DSM-V.  The second set considers revisions to existing disorders.  Efforts have involved interactions with the Mood Disorders, Anxiety Disorders, Disruptive Behavior Disorders, and Neurodevelopmental Disorders Work Groups. 

Eating Disorders Work Group
B. Timothy Walsh, M.D. 

Introduction

Beginning with DSM-IIIR, there has been a section in DSM devoted to eating disorders. In DSM-IV, criteria are provided for two disorders: Anorexia Nervosa and Bulimia Nervosa. A residual category, Eating Disorder Not Otherwise Specified (EDNOS) is provided for eating disorders not meeting criteria for one of these. In addition, appendix B of DSM-IV (Criteria Sets and Axes Provided for Further Study) provided provisional criteria for a specific form of EDNOS, Binge Eating Disorder.  

Charge to the Work Group

The work group was asked to review, critique, and suggest revisions to the existing diagnostic criteria for eating disorders, and for Feeding and Eating Disorders of Infancy or Early Childhood (Pica, Rumination Disorder, Feeding Disorder of Infancy or Early Childhood). In addition, the work group was asked to consider whether obesity should be considered for inclusion in DSM-V. 

Identification of Issues

In its first meetings, the work group considered commonly held views of the advantages and disadvantages of the current nomenclature for eating disorders. There was general agreement that the traditionally defined eating disorders, Anorexia Nervosa and Bulimia Nervosa, were clinically useful. The major problem with the existing criteria, widely discussed in the field, is the very high frequency of use of EDNOS in clinical settings. This issue overlaps with the important question of whether Binge Eating Disorder is a valid and useful diagnostic entity. In addition, other “atypical” variants of the recognized eating disorders have been suggested, such as Purging Disorder and Night Eating Syndrome. The designation of obesity as a mental disorder would be a major and controversial change. 

The work group also noted concerns about the specifics of the current criteria, for example, whether amenorrhea should be required for the diagnosis of Anorexia Nervosa, whether an average frequency of binge eating and the use of inappropriate compensatory behaviors of twice per week for three months should be required for Bulimia Nervosa, and whether the wording of several criteria reflects the range of phenomena seen across cultures and among younger patients. 

Finally, there is uncertainty about the utility and validity of the current criteria provided to categorize feeding disorders of infancy and early childhood. 

Approach

The members of the work group are conducting 11 focused literature reviews on the areas noted above; all reviews are in draft form, and several are nearly final. The target date for their completion, and for preliminary suggestions regarding options for change, is January 2009. These will be published so that they may be critically reviewed, examined in clinical settings, and revised accordingly during 2009 and 2010.  

The work group’s efforts are substantially aided by an R13 grant from NIMH, which will support two meetings of investigators with data sets relevant to the diagnosis of eating disorders. The first of these took place in September 2008, and focused on three topics: (1) Are there empirical data to support grouping all clinically significant eating disorders into several broad categories? (2) Are there empirical data to clarify the composition of the EDNOS category and possibly support additional specific eating disorders, such as Purging Disorder? (3) What empirical data support the clinical validity of Binge Eating Disorder? The next R13 meeting will occur in early 2009. Preliminary topics to be addressed at that meeting will include a review of empirical data regarding feeding disorders of infancy and early childhood, the clinical validity of “binge eating”, and the influence of culture on the clinical presentation of eating disorders.  The work group is consulting with other work groups reviewing topics of potential diagnostic overlap. 

Finally, the work group is actively reaching out to clinicians and investigators to solicit their thoughts and suggestions. For example, most members of the work group will attend the next meeting of the Academy for Eating Disorders in Spring 2009 and have proposed a workshop session to present current thinking and obtain feedback. Information about the work group and its plans has been distributed to the Academy’s newsletter and to all members of the Eating Disorders Research Society via e-mail.

Mood Disorders Work Group
Jan Fawcett, M.D. 

The Mood Disorders Work Group has created three sub-work groups, focused on Major Depressive Disorder (MDD), Bipolar Disorder, and Suicide.  The groups began by discussing needed changes to DSM-IV criteria, and then assessing evidence for them via literature reviews and secondary data analyses.    

The group and its subgroups are increasingly working with advisors and members from other work groups to assess comorbidity of mood disorders with other disorders.  Some overarching issues, such as operationally defining the term “psychosis” and examining the role of anxiety in mood disorders, have been discussed, with input from liaisons from appropriate work groups.  Other issues, including revising the definition of mixed states and how these present in both bipolar and unipolar disorder, addressing psychotic states within affective disorders, and melancholia are also being addressed.  Secondary analysis of symptom severity and impairment in mood disorders, is currently being performed via a twin-study data re-analysis. 

Sub-work groups are being formed to conduct research in the areas of pre-menstrual dysphoric disorder (PMDD) and seasonal affective disorder (SAD).  Advisors to these sub-work groups will provide evidence concerning the criteria and disposition of these conditions, whether they should be classified as subtypes or dimensional constructs, and how they relate to the spectrum of bipolar disorders.

Anxious depression is being examined to determine whether it is best classified as a separate category, a separate severity dimension, or as a specifier. Comorbid anxiety appears to predict a more severe course, longer depressive episodes, poorer treatment outcome, and a greater risk of suicide and suicidal behavior across both unipolar and bipolar mood disorders. 

Another subgroup has been working with the task force study group on gender and cross-cultural issues regarding possible differences in depression symptoms and functional impairment across gender and ethnic groups. 

The suicide sub-work group has focused on the possibility of a suicide risk dimension that might be applied across diagnoses, as after reviewing various diagnoses, differential risk factors across diagnoses do not appear to have significant differences. The group hopes, despite the known lack of ability to predict suicide in individual patients, to incorporate the state of knowledge concerning chronic and acute suicide risk factors to assist clinicians in making the best possible determination of suicide risk factors present in a patient.  A major area of interest has been the suicide sub-work group’s discussion of non-suicidal self injury, a behavior which seems to span across a number of diagnoses and to sometimes occur without a specific diagnosis.

Neurocognitive Disorders Work Group
Dilip Jeste, M.D. 

1)         Although our work group is now called “Neurocognitive Disorders,” this is not official terminology for the DSM-V or the ICD-11.  Such name changes, along with their implications, will need to be considered for these publications.  Currently, the DSM-IV-TR chapter is entitled, “Delirium, Dementia, and Amnestic and Other Cognitive Disorders” and the ICD-10 heading is “Organic, including Symptomatic Mental Disorders”.

2)         The disorders examined by this group will be those that are ‘acquired’ - i.e., there is evidence of decline from a previous level of neurocognitive function (reported by patient, significant other, evidence from longitudinal data, or based on cross-sectional assessment of prior function).  Developmental neurocognitive disorders will be covered by a separate work group.  Cognitive dysfunction is a feature of a number of mental disorders (e.g., schizophrenia, depression, OCD, etc.), but is not the most prominent or the defining feature, and is not ‘necessary’ for these diagnoses.

3)         For our deliberations, we have broadly divided the neurocognitive disorders into Delirium (with alteration in consciousness) and disorders with unimpaired level of consciousness.  The disorders in the second group have seen notable scientific progress during the past 15 years, with implications for revisions in DSM-V. 

4)         The work group is considering the roles of both functional and neurocognitive impairments in the disorders without altered level of consciousness.  This may be a basis for defining and distinguishing two broad categories of minor neurocognitive disorder (often called Mild Cognitive Impairment or MCI) and major neurocognitive disorder or Dementia.   

Issues Being Discussed 

1)         Should the severity of impairment for diagnosing and differentiating minor from major neurocognitive disorders be based on neuropsychological tests and/or functional impairment?

2)         Which neurocognitive domains should be included for this purpose (e.g., Memory – verbal/non-verbal, Attention/working memory, Language, etc.), and what tests would be optimal for assessing them?

3)         Could the necessary neurocognitive impairment be in only one, as opposed to multiple, domains for diagnosing minor or major neurocognitive disorders, and must it involve memory? 

4)         How should the cut-offs to be used for minor versus major neurocognitive disturbance be developed and operationalized? 

5)         How can functional impairment be reliably measured to make a diagnosis of Neurocognitive Disorder, and to differentiate minor versus major Disorder?  

6)         What other specifiers should be used to better define the clinical condition in a given patient – e.g., course (transient, remitting, persistent but stable, persistent and worsening, persistent with fluctuations), age of onset (<65, ≥65), associated behavioral disturbances (e.g., psychosis, depression, agitation), etc.?

7)       What should be the role of biomarkers such as genetics, neuroimaging, and neurochemistry in the diagnosis of these disorders?

8)       What criteria should be used for specifying etiology of neurocognitive disorders – e.g., Alzheimer disease, vascular neurocognitive disorder, Frontotemporal degeneration, Lewy Body disease, etc.? 

Plans for Further Work 

1)         Literature reviews
2)         Assessing secondary data analysis results, including existing longitudinal data sets.
3)         Preparing draft criteria that can then lead to field tests or additional data analysis to support revision options.
4)         Field testing of neurocognitive and functional measures.

Neurodevelopmental Disorders Work Group
Susan Swedo, M.D. 

The Neurodevelopmental Disorders (ND) work group’s discussions have focused on three areas: 

  1. Possible modification of ADHD criteria to allow for co-morbidity of autism and ADHD (currently excluded). The ADHD & Disruptive Behavior Disorders Work Group has agreed to consider this possibility.
  2. Discussion of the validity of Rett’s disorder as a separate disorder and inclusion of a new modifier within the Autism Spectrum Disorders (ASD), which might include genetic and medical disorders and other biologically-definable conditions.
  3. How to address Pervasive Developmental Disorders – Not Otherwise Specified (PDD-NOS).  The individuals currently diagnosed with PDD-NOS may still be described in DSM-V, but the work group will discuss whether they can redefine ASD in such a way that the PDD-NOS diagnosis isn’t necessary, as this diagnosis currently captures a very heterogeneous group of individuals.   

The ND Work Group will be seeking additional feedback from advisors and other experts prior to “finalizing” any recommendations.   

Questions still under active discussion for ASD include:

  1. How to describe the “spectrum” of disorders now known as ASD (e.g., how many domains will define the disorder);
  2. What is the specificity of repetitive behaviors in ASD and how might they be better defined;
  3. Whether Childhood Disintegrative Disorder (CDD) is a unique and separate disorder, and if so, what are its defining characteristics; 
  4. Whether autism is a life-long diagnosis or whether it is possible to recover/remit to the point where the diagnosis is no longer applicable; 
  5. Whether Asperger’s disorder is the same as “high-functioning autism”;
  6. How the DSM-V can alert clinicians to common medical comorbidities (including genetic disorders, epilepsy/EEG abnormalities and sleep, or GI problems) and potential biomarkers;
  7. How to include consideration of severity and impairment in diagnosis (currently defined as “qualitative impairments”) and how to integrate these with the overall structure of DSM-V; and 
  8. How/where to discuss cultural influences on diagnosis (e.g., Korean use of reactive attachment disorder rather than ASD to avoid family stigmatization).  

The following issues are being evaluated by subcommittees of the ND work group:  core criteria and domains; CDD and regression; genetics and biomarkers; Asperger’s disorder; and the Gender, Lifespan and Cultural Study Groups.  Secondary data analyses are underway to address each of these areas.  

The Neurodevelopmental Work Group is also charged with examining definitions of intellectual disabilities and learning disabilities.  Two subcommittees are addressing these issues – Intellectual Disabilities (ID) and Learning Disabilities (LD). Advisors have been chosen for these subcommittees and new definitions of the LDs and IDs are being examined by a multi-disciplinary, internationally representative committee.

Personality and Personality Disorders Work Group
Andrew E. Skodol, M.D. 

The Personality and Personality Disorders Work Group has initiated 17 literature reviews relevant to possible revisions in DSM-V.  Overarching topics include a definition and diagnostic criteria for personality disorders, levels of severity of personality psychopathology, the clinical utility of an empirically-based model of personality traits, the conceptualization and assessment of functioning, a tripartite model of mental disorders, criteria for change in DSM-V, and gender and personality disorders.  In addition, reviews are being conducted on the validity of each of the 10 DSM-IV personality disorder categories.  Also under consideration are reviews on resiliency of personality, dimensional representations of personality disorder categories, and the impact of personality and personality disorders on the course of Axis I disorders. 

The work group has examined alternative models of personality and personality disorder classification and assessment.  Assessments of personality disorders, as well as non-diagnostic personality characteristics in all patients, are being examined.  An improved method for noting such personality characteristics could have significant clinical utility (e.g., bulimia nervosa with clinically significant impulsivity or sensation seeking).  Complementary dimensional and categorical assessment methods are being considered. 

The next steps for the work group are to complete the literature reviews (target date: December 2008), perform secondary data re-analyses (target date: June 2009), and conduct field trials (target date: December 2009).  These activities will refine a generic definition of personality disorder for patients with personality disorders at differing levels of severity; identify personality traits that most adequately describe and discriminate between revised personality disorders and have maximal clinical utility; and determine age, gender, and ethnic effects on generic personality disorder criteria, personality functioning, personality trait domains, and personality prototypes. 
 
Psychotic Disorders Work Group
William T. Carpenter, Jr., M.D. 

Key issues presently under consideration by the work group are:

  1. Will the disorders assigned to the work group be kept as categories in DSM-V?  
  2. What might a psychotic disorder grouping look like in DSM-V?   For example, evidence is being reviewed to determine the relationship of schizophrenia to other disorders with psychotic symptoms, and to disorders that share other features (such as familiality).  These disorders, not currently classified as psychotic disorders in DSM-IV, include schizotypal personality disorder and bipolar disorder.
  3. How should the prodromal phase or early detection syndrome be handled in DSM-V?
  4. Which diagnostic criteria are problematic and how can these problems be addressed?  For example, the A criterion for schizoaffective disorder has low reliability.  The diagnostic criteria for this disorder might be improved with dimensional assessments.  The work group is also considering a separate category for catatonia with a subheading for associated condition, i.e., associated with schizophrenia, or mood disorder, or delirium, or general medical condition.  Under this scenario, the term psychomotor would anchor the criterion for schizophrenia and the term catatonia would be removed.
  5. Are the traditional subtypes useful for clinical or research purposes?  Might dimensional assessments be more valuable?  
  6. How can dimensional assessments be combined with categorical classification?  Questions include:  Will dimensions be functional or psychopathological?  Which dimensions that are relevant to the assessment of psychotic disorders cut across other disorders, and which are specific to this diagnostic cluster?  Dimensions that are based on psychopathology include such domains as reality distortion, disorganization of thought, negative symptoms, cognition impairment, depression, mania, obsessive symptoms, psychomotor, and suicidality.

Sexual and Gender Identity Disorders Work Group
Kenneth J. Zucker, Ph.D.

This work group functions primarily as three overarching sub-work groups: Sexual Dysfunctions, Paraphilias, and Gender Identity Disorders.  

Members of the work group have been performing diagnostic literature reviews. The Sexual Dysfunctions Sub-Work Group is reviewing the literature on eight core diagnoses; the Paraphilias sub-work group is reviewing the literature on nine core diagnoses; the Gender Identity Disorders (GID) Sub-Work Group is reviewing the diagnostic literature on one diagnosis (partitioned by childhood, adolescence, and adulthood). The GID Sub-Work Group is also working on a conceptual literature review evaluating the rationale for GID as a psychiatric diagnosis.  The Paraphilias Sub-Work Group has completed literature reviews on Pedophilia, Transvestic Fetishism, Fetishism, and Paraphilias NOS. The Sexual Dysfunctions Sub-Work Group has completed literature reviews on Premature Ejaculation and Male Orgasmic Disorder. Other review papers are anticipated for completion by the end of the 2008 calendar year. 

The Paraphilias Sub-Work Group has developed and is considering a proposal that might serve as an overarching framework to better distinguish the concepts of paraphilic behaviors and paraphilic disorders. 

In addition to preliminary discussion of the completed reviews, the Sexual Dysfunctions Sub-Work Group has been attending to the basis of reform of specific diagnostic criteria, with an emphasis on greater descriptive precision (e.g., duration criteria), the merit of current subtyping, relational parameters as a proposed specifier, and limitations of current data sets (e.g., largely constricted to adults with a heterosexual sexual orientation). 

Apart from the literature reviews, the Gender Identity Disorders Sub-Work Group has addressed feedback from interested advocacy groups and other stakeholders. It has developed a formal survey seeking input from various organizations that advocate for and represent transgender adults. Surveys were sent to more than 60 organizations, with a closing date for response in October 2008. 

The work group is planning for its next face-to-face meeting in which the literature reviews will be appraised, proposed changes to diagnostic criteria reviewed, and secondary data analyses and field trials planned.   

Members of the work group will begin presentations at various professional meetings, starting in October 2008 (American Academy of Child and Adolescent Psychiatry), followed by presentations at the Society for Sex Therapy and Research (April 2009), the American Psychiatric Association Annual Meeting (May 2009), World Professional Association for Transgendered Health (June 2009), and the International Academy of Sex Research (August 2009).

Sleep-Wake Disorders Work Group
Charles F. Reynolds III, M.D. 

Our Sleep/Wake Disorders Work Group is reviewing each of the approximately 25-30 DSM-IV sleep and circadian rhythm disorders (text and criteria), conducting focused literature reviews, and working with advisors who have specific expertise for a given disorder (and who have been, in most cases, among the primary contributors to the peer-reviewed literature for each disorder).  We expect to complete our initial review of all disorders by December 2008.  We have recently begun updating text to reflect scientific advances in related basic science, epidemiology, imaging, genetics, and interventions research.  Throughout, we have tried to integrate into our conversations important aspects of diagnostic spectra and developmental perspectives.  We also continue to benefit from input from liaisons from other work groups. 

The work group’s plan for 2009 is to continue the process of updating text, continuing to call upon advisors who are already active collaborators in this process.  We expect this process to lead to an update of diagnostic criteria and to specification of scientifically appropriate and clinically useful dimensional measures of nocturnal sleep quality and of daytime alertness/impairment.  (We expect to prepare a memorandum to other workgroup chairs on this topic.) 

We have identified a small number of clinically useful and scientifically valid measures of sleep quality and daytime alertness/impairment.  We are working with Patient Reported Outcomes Measurement Information Systems (PROMIS) investigators who have used Item Response Theory to identify a small number of informative and practicable items that convey accurately the severity, impairment, and distress occasioned by disturbed sleep and wakefulness.  We think of these measures as a “sleep thermometer,” that is, highly sensitive to sleep/wake “fever” (read: “disturbance”), but non-specific as to etiology.  An analysis of PROMIS measures shows potential usefulness in creation of dimensional measures.  Further pilot testing is needed, however, especially in persons with mental disorders.  (We intend to convey this in our memorandum on sleep disturbance to other work group chairs.)  Of existing dimensional measures, the Pittsburgh Sleep Quality Index has been the most widely used and cited over the past two decades. (It should perhaps have been named the “Pittsburgh Sleep Wake Quality Index” or the “Pittsburgh Sleep Wake Disturbance Index” to convey more accurately its content.)  While its performance characteristics are well known, including sensitivity to change in sleep-wake disturbance during treatment of sleep and mental disorders, its “utility” may be limited by the number of items (21).  Useful PROMIS items, as of this writing, total about 15 and probably can be reduced further. 

To date, there appears to be a preliminary, growing consensus on several potential recommendations to the DSM-V Task Force.  With emphasis on the words “preliminary” and “potential”, these are as follows:  

  1. DSM-IV “primary insomnia,” while not rare in epidemiologic studies, is not nearly as prevalent as insomnia comorbid with other mental or medical disorders.  Note: the work group recommends the term “comorbid” rather than “secondary to” in order to be consistent with the 2006 recommendations of an NIH consensus conference on insomnia, because “comorbid” carries fewer, unwarranted causal assumptions than “secondary to.”  Work group members are working with advisors on these issues. 
  2. DSM-IV “primary hypersomnia” lumps together a rather heterogeneous group  of disorders,  where little scientific progress has been made since DSM-IV.  Nonetheless, it should be possible to further clarify this heterogeneity in the text to make this area less confusing to clinicians.  In contrast, considerable progress has occurred in the field of narcolepsy cataplexy research that will mandate updating of text and possibly updating of diagnostic criteria as well.  Work group members are collaborating with advisors on these issues and tasks.  One issue under discussion is whether specific polysomnographic (psg) criteria should be integrated with clinical diagnostic criteria, or whether psg measures should simply be addressed in the text.  (DSM-IV did not allow the inclusion of quantitative psg criteria, but the science of sleep disorders makes the revisiting of this issue mandatory.)
  3. DSM-IV “breathing-related sleep disorder” text and criteria will require updating to reflect considerable scientific (basic, epidemiologic) and clinical progress in this area.  An important consideration is to have scientific accuracy while still retaining accessibility to the non-sleep expert in both specialty mental health and primary care medicine.  Work group members are working with advisors to address these issues and tasks.  As with narcolepsy cataplexy and other disorders of excessive sleepiness, the work group is discussing whether specific psg criteria should be integrated with clinical criteria or simply explicated in the text.
  4. DSM-IV “circadian rhythm sleep disorders” rely on the default “not otherwise specified” (NOS) to a greater extent than would now be warranted by scientific advances both basic (i.e., genetic) and clinical.  Thus, it seems likely that further differentiation of, for example, “advanced sleep phase syndrome” (rather than subsuming it under “NOS”) may be recommended.  Work group members are working with advisors on these issues and tasks as well.
  5. DSM-IV placed “restless legs syndrome” (RLS) under “dyssomnia not otherwise specified.”  However, in light of considerable scientific progress in basic (genetic) and clinical research (clinical phenotype and interventions), the work group is considering the evidence base for “elevating” RLS to its own specific diagnosis rather than subsuming it under a NOS grouping.  RLS provides a useful example of how progress in genetics, definition of clinical and physiological phenotype, and controlled interventions research may warrant greater diagnostic specificity in DSM-V and less reliance on “NOS”. Work group members are working with advisors on these issues and tasks.
  6. The work group continues to integrate discussion of the International Classification of Sleep Disorders-II (ICSD-II) into our conversation; we plan to incorporate links to ICSD-II in the text, that is, show how DSM-IV and ICSD-II map onto each other.  The same is true with respect to the ICD-9.  The process of mapping is helped by the fact that many of our work group members and advisors were active contributors to the ICSD-II.
  7. The work group continues to analyze how best to integrate categorical diagnostic and dimensional measures (e.g., severity, distress, impairment, and sensitivity to treatment associated changes).  A simple approach would be to juxtapose categorical and dimensional “boxes” above the text and then use the text to justify and explain the choice of each type of measure and explicate to the non-sleep expert how and when to use the categorical measures (categorical, polysomnographic, and dimensional). 

Somatic Distress Work Group
Joel Dimsdale, M.D. 

The Somatic Distress Work Group has focused on the following themes: 

  1. Identification of external advisors and establishing liaisons with other work groups. Because of the prominence of somatic distress disorders in non-psychiatric settings, our work group has sought advisors from additional fields of medicine such as primary care, pediatrics, and neurology. Because of potential overlap with other disorders, we have sought liaisons with other work groups in the areas of mood disorders, personality disorders, childhood/adolescent disorders, and anxiety disorders. We have also had interactions with some of the cross-cutting study groups, particularly the psychiatric general medical interface and the lifespan developmental groups. It is our intention to utilize these advisors and liaisons more heavily once our general rubric of disorders (see item #3 below) is more established.
  2. Development of data analysis proposals. One of the challenging issues in reviewing evidence on somatic distress is that somatic distress disorders are rarely considered by psychiatric epidemiology. As a result, the work group has proposed a number of small data analysis projects, with the goal of informing issues such as: the relationship between hypochondriasis and OCD; comorbidities in conversion disorder; the prevalence of somatoform disorders as determined from insurance claims; the relationship of pain disorders to global functioning and axis I disorders; reports from psychiatrists and primary care physicians regarding potential underuse of these diagnostic codes; and dimensional approaches as applied to somatic distress.
  3. Developing a draft schema for organizing somatic distress disorders. The group is considering a restructured diagnostic grouping for DSM-V under the general rubric of “Somatic Symptom Disorders.” The latter would include Psychological Factors Adversely Affecting General Medical Conditions, Complex Somatic Symptom Disorders (which groups together somatization disorder, undifferentiated somatoform disorder, hypochondriasis, pain disorder, and neurasthenia), Factitious Disorder, and Functional Neurologic Symptoms/Conversion Disorder. The group is also considering the utility of an Acute Somatic Symptom Disorder—either as part of the Somatic Symptom Disorder rubric or perhaps covered as a variant of Adjustment Disorders. Body Dysmorphic Disorder is being addressed primarily by another work group.

Substance-Related Disorders Work Group
Charles O’Brien, M.D., Ph.D. 

The work group has been systematically addressing areas of DSM-IV that have been the focus of concern and debate.  Great progress was achieved at the September face-to-face meeting at APA and continues to be made in bi-weekly conference calls.  Several sub-work groups have been formed and are having separate conference calls of their own. 

Some of the issues being considered are:  

  • Should the concepts of “Addiction” and “Addictive Disorders” be used in DSM-V?  What are the advantages and disadvantages of using such terms? 
  • Are the “Substance Use Disorders” and the so-called “Non-substance Addictions,” such as pathological gambling related, and if so, what are the nature and strength of the relationships?  Among the other widely suggested candidates for a possible “Non-substance addictions,” category (e.g., Internet gaming, eating, shopping, sexual activity), how strong is their research evidence base?
  • The problems of the substance abuse category have been pointed out in many studies and reviews, for example, its factor structure related to substance dependence, and the cross-cultural generalizability of several of its symptoms.  The work group is studying alternative ways to address the problems with this diagnosis, and develop a more cohesive structure for substance use disorders.   Several data analyses are being conducted to help in this endeavor.

In terms of diagnostic criteria, drug craving is being considered as a possible additional criterion.  Consideration is also being given to some drug-specific criteria to improve clinical and research utility.   Proposed criteria for cannabis withdrawal are being examined.

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