Magazine article Clinical Psychiatry News

Should Fetal Alcohol Spectrum Disorder Be Included in DSM-V?

Magazine article Clinical Psychiatry News

Should Fetal Alcohol Spectrum Disorder Be Included in DSM-V?

Article excerpt

SAN DIEGO -- Work on the fifth edition of American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders is well underway, and at least one psychiatrist thinks that alcohol-related neurobehavioral syndrome should be included.

Fetal alcohol spectrum disorder "has never been part of our taxonomy, and yet many psychiatrists wind up seeing these patients," said Dr. Howard B. Moss, associate director for clinical and translational research at the National Institute on Alcohol Abuse and Alcoholism, Bethesda, Md., and a member of the DSM-V Task Force. "It would be helpful to have in the DSM so psychiatrists can bill for services as well as provide some sort of diagnosis for these patients."

At the annual scientific conference of the Research Society on Alcoholism, Dr. Moss discussed the perceived shortcomings of the APA's current classification system, the DSM-IV, which was first published in 1994 and was updated in 2000.

First, he said, the DSM-IV tends to emphasize reliability over validity. "This is particularly problematic when you talk about the construction of psychiatric syndromes: whether or not the disorders as described in the DSM-IV represent conditions that clinicians actually see in their office, or whether they represent idealized conditions that really don't fit any given patient when you see them in real life," Dr. Moss said.

Issues surrounding severity, disability, and quantitative scaling of mental disorders "are pretty much absent," he added. "The thought is, through enhancing one's capacity to measure severity, disability, and quantitative aspects of the phenotype of interest in the DSM-V, you will be able to improve the quality of the diagnosis and perhaps increase its validity."

The DSM-IV is also characterized by high rates of psychiatric comorbidity, he said, noting that some patients seen in clinical practice might meet diagnostic criteria for five or more mental disorders simultaneously. This suggests that "perhaps we're not doing a great job in terms of accurately describing the nature of the syndromes that are physically present."

The extensive use of "not otherwise specified" criteria (NOS) in the DSM-IV is another concern. "NOS means that a patient sitting across from you has something that looks like a disorder that's in the DSM, but does not really meet any of the criteria specific for that disorder," Dr. Moss said. "There's also treatment nonspecificity, and there has been a concern about a lack of biomarkers available for these criteria. Several individuals have stated that the DSM-IV hinders progress in [mental health care] because of its lack of validity."

The DSM-V Task Force, launched in 2006, is chaired by David J. Kupfer, professor and chairman of the department of psychiatry at the University of Pittsburgh Medical Center. The vice chair is Dr. Darrel A. Regier, who directs the APA's division of research and is executive director of the American Psychiatric Institute for Research and Education. They oversee 13 work groups composed of more than 120 researchers and clinicians, including a work group on substance-related disorders (

Each work group is permitted to seek input from outside advisers to help identify specific issues in specific areas, but those advisers undergo a strict vetting process, Dr. Moss said, "such that individuals who have what is deemed as a conflict of interest due to their receipt of research grant dollars or consulting dollars from the pharmaceutical industry are eliminated from being able to participate. …

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