By John Gever, Senior Editor, MedPage Today
Published: May 19, 2009
SAN FRANCISCO, May 19 — Some familiar disorders may be dropped and diagnostic criteria for others are in line for substantial revision in the forthcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V).Schizoaffective disorder and gender identity disorder are among those that may be on the chopping block, according to members of the working groups leading the revision who spoke here at the American Psychiatric Association annual meeting.
Perhaps more significantly, they said, DSM-V is likely to include dimensional assessments in addition to the familiar symptom checklists from past versions of the “psychiatrist’s bible.”
Since it was first published in 1952, the DSM has provided the definitive word on what is and is not mental illness, with enormous influence within medicine and on the world beyond.
The elimination of homosexuality as a mental illness in the third DSM edition issued in the 1970s, for example, is now widely viewed as a watershed development in changing society’s view from outright hostility to varying degrees of acceptance.
DSM-V is on track to be published in 2012, capping 13 years of literature reviews, commissioned research, and intensive discussions among more than 160 mental health professionals.
“Most of us involved would like a couple more years, but we know that’s not going to happen,” said David Kupfer, M.D., of the University of Pittsburgh, chairman of the task force overseeing the revision.
The 13 working groups in charge of DSM’s major subsections must still reach decisions on proposed language defining conditions and disorders. Field tests of revised diagnostic criteria are scheduled to begin this summer, with results ready for analysis in mid-2010, Dr. Kupfer said.
After further tweaking, the draft manual must be approved by the task force and ratified by the APA’s Council on Research, the Assembly, and the Board of Trustees.
Changes could be sweeping
No limits have been placed on the extent of the overhaul, explained William Narrow, M.D., the APA’s research director for DSM-V. Before the process that resulted in DSM-IV was launched, the APA had stipulated that changes be incremental.
Leaders of several work groups who spoke at a forum on Monday reported that the freedom granted this time around could indeed lead to substantial and even drastic revisions.
For example, William Carpenter, M.D., of the University of Maryland and chair of the work group on psychosis, said his team had considered moving bipolar illness into the category of psychosis rather than its current classification as a mood disorder.
But he acknowledged that such a move would face strong opposition and was unlikely. “It would happen over a number of dead bodies,” he quipped.
On the other hand, he said, “we hope to get rid of schizoaffective disorder.”
Schizoaffective disorder on the chopping block
The addition of dimensional assessments — on such features as depression, anxiety, cognitive impairment, and reality distortion, which can appear in conjunction with a wide range of psychiatric and somatic conditions — makes it possible to jettison the familiar and widely-used diagnosis, Dr. Carpenter suggested.
Patients who have previously been diagnosed with schizoaffective disorders could instead be said to have schizophrenia with a strong mood dimension.
Dr. Carpenter said his group was also likely to remove catatonia as a component of schizophrenia.
And the group was leaning heavily toward proposing a new risk syndrome for individuals — especially young people — that research has suggested are strongly predisposed to schizophrenia and other psychotic conditions.
He acknowledged, though, that there was danger in creating such a classification. It could stigmatize people diagnosed as at-risk but who don’t show overt pathology. “There are questions about how to distinguish them from the non-ill population,” Dr. Carpenter said.
He said he expected these proposals to be controversial, but when the question-and-answer period began, none of the approximately 300 people in attendance spoke against them.
“I’ll report to our work group that we had enthusiastic endorsement,” he joked.
In a similar vein, Katharine Phillips, M.D., of Brown University and Butler Hospital in Providence, R.I. — head of the anxiety conditions group — said hoarding may be added to the family of obsessive-compulsive illnesses as a separate disorder.
Genetics not ready for prime time
At the forum, and at a press briefing earlier on Monday, questions were raised about whether diagnostic criteria in DSM-V would include findings from genetic tests or neuroimaging as well as clinical presentations.
Dr. Phillips said that was not on the table, at least in her sphere. “I think at this point, it’s not clear to our work group that there are enough replicable, sensitive, specific findings from neurobiology that would allow [us] to incorporate the findings directly into diagnostic criteria,” she said.
Dr. Carpenter agreed, saying it was very unclear what to make of the gene discoveries related to schizophrenia for diagnostic purposes.
On the other hand, said Dr. Phillips, such data could inform thinking about the broad groupings of mental disorders.
Gender identity gets attention
One DSM issue that is drawing close attention from outside the psychiatric community is what to do with gender identity disorder.
The condition — in which people, often during childhood, realize that their biological gender does not match what their minds tell them — is now included in DSM-IV as a sexual dysfunction alongside pedophilia and sexual sadism.
Not surprisingly, transgender individuals and the groups representing them are lobbying hard to have gender identity disorder dropped from DSM-V.
A four-member group has been charged with developing recommendations and two of its members appeared at a separate forum here.
As described by its chairwoman, Peggy Cohen-Kettinis, Ph.D., of VU University in Amsterdam, the group is facing three main options: keep gender identity disorder approximately as it is, jettison it entirely, or change the name and diagnostic criteria.
Dr. Cohen-Kettinis said the group was nearing a decision, but both she and fellow group member Jack Drescher, M.D., a New York-based psychiatrist and prolific author on sexuality and gender, were noncommittal on which way the group was leaning.
A number of speakers at the forum represented the transgender community and most pleaded for option two.
Rebecca Allison, M.D., a Phoenix-based cardiologist and transsexual, said the ideal would be to drop the condition from DSM but keep it in the International Classification of Diseases system as a medical condition, with a name like “gender variance.”
Such a move would make it more likely that insurance companies would cover transgender transition services such as hormonal treatments and surgery, she and other speakers said.
Last year, the American Medical Association approved a resolution calling for full insurance coverage of transition services for transgender individuals — in part because of the efforts of Dr. Allison, who chairs the AMA committee on lesbian, gay, bisexual, and transgender issues.
“In a perfect world, psychiatrists could treat patients with gender variance, but not for gender variance,” she said.
Dr. Drescher argued that having gender identity disorder included in the manual’s earlier editions served a useful purpose.
In the 1970s, when it was first added, most psychiatrists considered it a neurosis or even psychosis, he said — suggesting a need for treatment and not with transition services.
He suggested that its separate identity in DSM-III and DSM-IV helped pave the way for its recognition as a physical problem rather than a psychiatric pathology.
Dr. Narrow, the research director for the DSM revision, said the process gave nearly unlimited latitude to work groups to determine diagnostic criteria that would be tested in field trials.
But he said that a recommendation to drop a disorder from DSM-V entirely would be reviewed closely at the task-force level.