Proposals for DSM-V Need High Evidence Threshold: Diagnostic Research Conferences Planned

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MIAMI -- Psychiatrists still have plenty of time to participate in helping to formulate the next major edition of the Diagnostic and Statistical Manual of Mental Disorders, according to a presentation at the annual conference of the Anxiety Disorders Association of America.

The anticipated publication date is 2012, but the revision process is already underway for the DSM-V. So far, nine wide-ranging issues are addressed in published "white papers." In addition, the American Psychiatric Association and the National Institute of Mental Health will sponsor 10 diagnostic research conferences, which are intended to stimulate research early enough in the process to be included in the DSM-V.

"We could have had 1,000 conferences. But for financial reasons, we know we can only have 10. so we choose areas with a lot of research," said Dr, Michael B. First of Columbia University, New York.

Formation of DSM-V workgroups will be next. Participating in a workgroup is one of the major ways psychiatrists can take an active role in the update process.

Another means of involvement is a new Web site, www.dsmv.org. "One of the things we realize is that there are all sorts of rumors going around about DSM-V. We are really attempting to keep the people interested in DSM-V aware of what is going on," said Dr. First, who is also director of the DSM-V Prelude Web Based Project and editor of the DSM-IV Text Revision (DSM-IV-TR).

Major changes that are expected include:

* Posttraumatic stress disorder (PTSD) and obsessive-compulsive disorder (OCD) may be removed from the anxiety disorders grouping.

* New diseases proposed for inclusion in the DSM-V require evidence of clinical utility.

* More international participation is planned, in the hopes of reducing some differences between U.S. and international classifications.

* Extra research criteria will be added. Some critics claim the DSM's clinical diagnostic criteria are too limiting and inhibit the scope of research.

The proposal to remove PTSD from the anxiety grouping raises the question of where to put it, Dr. First said. DSM editors will reconsider a DSM-IV proposal to create a category called Stress-Induced and Fear Circuitry Disorders. Such a grouping might also include acute stress disorder, adjustment disorders, and "disorder of extreme stress not otherwise specified." This last group could include some patients exposed to extreme stress who do not currently meet the criteria for any DSM-IV categories.

The diagnostic criterion for PTSD may change, Dr. First said. The question is whether the condition should be defined by the nature of the stressor or by the phenomenology of reexperiencing the trauma. Another goal will be to simplify the current 19 criteria for the disorder--for both practical and legal reasons.

"We are trying to stop the floodgates of new lawsuits, with everyone claiming they suffer from PTSD."

Removal of OCD from the anxiety grouping is another consideration. "The chance that anxiety and OCD have the same etiology is close to zero. People with OCD are generally anxious, but other than that it does not make much sense," Dr. First said. OCD may end up in a new category called Obsessive-Compulsive Spectrum Disorders, one that might also include tics. trichotillomania, body dysmorphic disorder, and hypochondria.

More than 100 new disease proposals were pitched for the DSM-IV, which Dr. First said was "hard to believe. …