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DSM-5 Moves Closer to 'Living Document'

— APA works to fulfill promises for psychiatry's 'bible'

Last Updated May 8, 2018
MedpageToday

NEW YORK CITY -- Five years after releasing the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5) -- which came with promises of a faster and more dynamic process for revisions -- the APA is now working in earnest to make good on that promise, a presentation here indicated.

Earlier DSM editions were released on a cycle of roughly 12-20 years and, until well into the era of DSM-IV, the manual existed only as a fat printed book. With the launch of DSM-5 in 2013, APA leaders called it a "living document" that would live primarily online and thus be amenable to more frequent updates.

The APA isn't quite there yet, but officials were optimistic that it would soon be reality.

"We are moving very rapidly to the point when the canonical version of the DSM we'll all need to consult is not the version that sits on our bookshelves or our desks today, but the online version which is where the changes will appear, and have begun appearing already," commented Paul S. Appelbaum, MD, of Columbia University here and chair of the DSM steering committee, at the .

In August 2015, was made, involving 15 disorder classifications, and are under consideration.

Speaking on the fifth anniversary of the release of DSM-5, steering committee members including Appelbaum (a past APA president) discussed how exactly the APA is re-examining the DSM and its revision process to accommodate "incremental changes" to the text's content.

A working group was assembled in 2013-2014 to identify a strategy for amending the text. The group has evolved to include a steering committee, 11 work groups, and five review committees, comprising experts in the field.

The speakers outlined the types of key changes that could reasonably be made to the DSM-5 content. These include:

  • Changing an existing criteria
  • Adding a new diagnostic category or specifier to an existing category
  • Deleting an existing diagnostic category
  • Finding an error in the DSM-5
  • Changing the text

The need for a balanced approach was stressed, with a focus on not changing so much so quickly that practice becomes confused, but instead judiciously identifying when changes are necessary.

Researchers, clinicians, and members of the public -- with an emphasis on professionals -- are invited to submit proposals for change via

The process for change will be rigorous, officials said. Proposals will be subject to initial review by the steering committee. If a suggestion makes it past this point it will be sent for consideration by experts from the following five fields:

  • Neurodevelopmental disorders
  • Serious mental illness: psychotic/neurodegenerative disorders
  • Internalizing disorders: depression/anxiety
  • Externalizing and personality disorders
  • Body disorders: eating disorders/sexual dysfunction

This is followed by re-review by the steering committee after which the proposal is published online and opened for public comment. The steering committee then review the public comment before moving the proposal to the board of trustees for final implementation approval.

Audience questions included an inquiry about the possibility for even more visibility, suggesting a Wikipedia-style open forum set-up with rapid public involvement as the first step. Speakers responded heedfully. "We're trying to balance openness which is a good thing, and input from the field which is essential, with not overwhelming people and stirring the field up with proposals that are unlikely ever to move forward," replied Kenneth Seedman Kendlar, MD, of Virginia Commonwealth University in Richmond.

Speakers warned that although now more transparent, this is "not a simple process," and emphasis was placed on possessing robust datasets and empirical evidence to substantiate major claims, such as those involving diagnostic categories.

Appelbaum discussed an expedited review process for more minor changes, which could be fast-tracked through the review board. Also, for smaller changes such as descriptive changes in the text, "commonsense evidence" would be acceptable, commented Ellen Leibenluft, MD, of the National Institute of Mental Health in Bethesda, Md.

Asked about estimates for the time to implication for submissions, speakers were reluctant to be specific but one said, "We're talking 6 months to a year, not 5 years."

Appelbaum offered a simple formula for those presenting proposals for change: "The magnitude of the change should be related to the magnitude of the data that you present." He sharply condemned armchair theorizing, stating that proposals that may be "conceptually compelling, with no data, will not be taken seriously."

The best proposals the committee has received so far, said Appelbaum, have been from individuals who have come together as a collective and "pooled data" to achieve a "consensus view," expanding this focus on "following the science."

The biggest tripping point to avoid? "We are inherently suspicious of proposals that only cite only your own research. If there is no other research group that has replicated your results ... expect us to be skeptical."