# Presentation: 257202

## Research Planning for Future Psychiatric Classifications

***Research Planning for Future Psychiatric Classifications***
**Darrel A. Regier, M.D., M.P.H.**
**Executive Director,**
**American Psychiatric Institute**
**For Research and Education; and**
**Director, Division of Research,**
**American Psychiatric Association;**
**Vice-chair, DSM-V Task Force**
**The 99****th**** Meeting of the **
**National Advisory Council on Drug Abuse**
**Wednesday, May 14, 2008**

## Overview

- Darrel A. Regier, M.D., M.P.H.; Review of conference series output and research implications
- David J. Kupfer, M.D.; Update status of task force activities
- Charles O’Brien, M.D., Ph.D.; Update on work group activities

## High rates of comorbidity
High use of –NOS category
Treatment non-specificity
Inability to find a laboratory markers/ tests
DSM is starting to hinder research progress

**High use of –NOS category**
**Treatment non-specificity**
**Inability to find a laboratory markers/ tests**
**DSM is starting to hinder research progress**

- Perceived Shortcomings in DSM-IV

## New Developments

**Move toward an “Etiologically Based” Classification**** **
**Are there data in these areas that can be helpful in developing/changing/refining diagnoses?**
**cognitive or behavioral**** ****science**** **
**family studies**** and ****molecular genetics**** **
**neuroscience**
**Requires a Paradigm Shift**
**Neo-Kraepelinian to ??**

## Incorporate research into the revision and evolution of the classification 
Move beyond a process of clinical consensus and build diagnoses on a foundation of empirical findings from scientific disciplines
Seek multidisciplinary, international scientific participation in the task of planning the DSM-V revision

**Move beyond a process of clinical consensus and build diagnoses on a foundation of ****empirical**** findings from scientific disciplines**
**Seek multidisciplinary, international scientific participation in the task of planning the DSM-V revision**

- Strategies for Improving DSM

## Planning for DSM-V

- 1999-2002 – three initial work conferences and six “white papers”
- Identification of “gaps”

## APIRE obtains $1.1M NIH conference grant for DSM/ICD dx research planning
13 Conferences over 5 years
APIRE commissions 3 additional White Papers:
Infant/Young Child, Sex/Gender, Geriatric Mental Health

**13 Conferences over 5 years**
**APIRE commissions 3 additional White Papers:**
**Infant/Young Child, Sex/Gender, Geriatric Mental Health**

- 2003

## Aims of Research Review                           Work Groups and Conferences

**To stimulate the ****empirical research**** necessary to allow informed decision making regarding crucial diagnostic deficiencies identified in the current nosology **

- Aims of Research Review                           Work Groups and Conferences

## Slide 10

## Conference Output

- Initial publication of papers in relevant peer-reviewed journals, e.g., Journal of Personality Disorders, Addiction, Journal of Geriatric Psychiatry and Neurology, Psychosomatic Medicine, Schizophrenia Bulletin, International Journal of Methods in Psychiatric Research
- American Psychiatric Publishing Inc. (APPI) publishing monograph proceedings of all conferences
- Special sessions at international forums

## Conference Output 

- 13 Conferences (2004-07)
- 5 internationally-held
- 4 monographs published
- Diagnostic Issues in Substance Use Disorders
- Diagnostic Issues in Dementia
- Dimensional Models of Personality Disorders
- Dimensional Approaches in Diagnostic Classification
- 4 monographs in press
- 4 monographs in preparation
- 83 journal articles published

## Sept. 2006,        Vol 101, Supp 1.

***Sept. 2006,        Vol 101, Supp 1.***

## Diagnostic Issues in                        Substance Use Disorders 

***Rockville, MD***
***February 16, 2005***

## Substance Use Disorders Conference Representatives

- SUD conference representative at each conference, except Autism and Pervasive Developmental Disorders
- Examination of impact of co-occurrence of SUDs with each specific diagnostic topic
- Emphasized importance of SUD in conceptualizing diagnoses and etiologies

## Substance Use Disorders Conference Representatives

| Deborah Hasin | Dimensional Models of Personality Disorders |
| --- | --- |
| Edward Nunes | Stress-induced and Fear Circuitry Disorders |
| John Saunders | Diagnostic Issues in Dementia |
| Bruce Rounsaville | Deconstructing Psychosis |
| Marc Potenza | Obsessive-Compulsive Behavior Spectrum Disorders |
| Kathleen Bucholz, John Helzer, Michael Gossop, Bridget Grant | Dimensional Approaches in Psychiatric Classification:  A Critical Appraisal |
| Deborah Hasin  | Somatoform Disorders |
| Guilherme Borges, Wilson Compton | Externalizing Disorders of Childhood |
| Bridget Grant | Comorbidity of Depressive and Generalized Anxiety Disorders |
| John Saunders | Public Health Implications of Psychiatric Illness |

## Research Implications

- Dimensional vs. categorical classification
- Facilitating etiology research
- Retaining face validity
- Implications for genotyping
- Issues of nomenclature
- Non-substance use addictions, or behavioral compulsions
- “addiction” versus “dependence”

## Slide 18

## On the Road to DSM-V and ICD-11

***On the Road to DSM-V and ICD-11***
**David J. Kupfer, M.D.**
**University of Pittsburgh Medical Center**
**Western Psychiatric Institute and Clinic**
**The 99th Meeting of the National Advisory Council           on Drug Abuse**
**Wednesday, May 14, 2008**

## Revision Principles

- The highest priority in modifying DSM-V should be optimizing clinical utility
- Recommendations should be guided by research evidence
- Continuity with previous editions should be maintained
- Unlike in DSM-IV, there will be no *a priori* constraints on the degree of change between DSM-IV and DSM-V

## Revision Principles 2

- Development – across the life span
- Dimensional concepts – measurement of distress, disability and severity
- Incorporation of new knowledge – risk factors, prodromes, prevention
- Living document

## Toward DSM-V and ICD-11

**The object is:  *****“to facilitate the highest possible extent of uniformity and harmonization between ICD-11 mental and behavioral disorders and DSM-V disorders and their definitions”***

## Initial List of Tasks and Activities

**Harmonize the ****timeline**** of both revision processes**
**Considering ****severity**** as a separate dimension**
**Considering ****disability/impairment****/functioning as a separate dimension**
**Review and identification of ****broad/super-ordinate**** categories of diagnosis**

## DSM-V 

**                               ****Task Force**
**Workgroup chairs**
**Health professionals from stakeholder groups**

**                               ****Workgroups**
**Members work in specific diagnostic areas**
**Advisors for workgroups**

**http://www.dsm5.org**

## Broadly based Task Force (TF) to oversee Workgroup chairs and committees for every diagnostic area
TF and Workgroups will assess the readiness               of individual disorders to incorporate biological measures and dimensional approaches
TF will work closely to utilize the recommenda-tions derived from the 13 research conferences
TF will coordinate closely its efforts with the WHO / ICD developments
Study Groups

**TF and Workgroups will assess the readiness               of individual disorders to incorporate biological measures and dimensional approaches**
**TF will work closely to utilize the recommenda-tions derived from the 13 research conferences**
**TF will coordinate closely its efforts with the WHO / ICD developments**
**Study Groups**

- Overall DSM-V Task Force

## Cross-Cutting Study Groups

- Diagnostic Spectra
- Life Span Developmental Approach Study Group
- Gender and Cross-Cultural Study Group
- Psychiatric/General Medical Interface Study Group

## Possible Validators for Diagnostic Groupings

- Neural substrates
- Familiality
- Genetic risk factors
- Specific environmental risk factors
- Biomarkers

## Possible Validators for Diagnostic Groupings

- Temperamental antecedents
- Symptom similarity
- Abnormality of cognitive or emotional processing
- Course of illness
- High rates of comorbidity
- Treatment response

## DSM-V Timeline

**1999-2002 **
**Research**
** ****Agenda **
**For DSM-V**

**2003-2008 **
**APA/WHO/NIH **
**Research Conferences**

**2004**
**Prelude Page**
**Launched**

**2007- 2011**
**DSM-V Workgroups**

**2014**
**ICD-11**

**2012**
**DSM-V**

**2007**
**Infant,**
**Gender,**
**Geriatric**

## Slide 30

## DSM-V Substance Use Disorders Current Status

***DSM-V Substance Use Disorders Current Status***
**Charles P. O’Brien, M.D., Ph.D.**
**University of Pennsylvania**
**Philadelphia VA Medical Center**
**The 99th Meeting of the National Advisory Council           on Drug Abuse**
**Wednesday, May 14, 2008**

## SUD Work Group

**T. Crowley, Co-chair**
**M. Auriacombe****	****	****D. Hasin**
**G. Borges****	****	****W. Ling**
**K. Bucholz****	****	****S. Manson**
**A. Budney****	****	****T. McLellan**
**W. Compton*****	****	****H. Moss***
**B. Grant****	****	****N. Petry****	**
**	****	****	****M. Schuckit**
**Plus large cast of advisers**
*** DSM-V Task Force Member Liaisons to SUD Work Group**

**SUD Work Group**

## Deliberative Process

**	****Frequent teleconferences **
**	****Present findings to large work group at ****	****meetings and conference calls**
**Review DSM IV**
**	****Where can it be improved?**
**	****What are the opportunities to move beyond ****	****behavioral criteria and use ****	****biomarkers?**
**	**

**Deliberative Process**

## Issues currently under active discussion   and research

**	****Gambling**
**	****Computer games, etc.  List of candidates still under discussion**
**Chair:  N. Petry**
**Collaborating with Impulse control disorders group**
**	**

**Issues currently under active discussion   and research**

## Issues

**	****Chair:  Alan Budney**
**Dimensions v. Categories, experimental criteria applied to large databases, need for “abuse” category**
**	****Chair:  Howard Moss**
**Bio-markers**
**	****Chair:  Deborah Hasin**
**Terminology**
**	****Dependence v. Addiction**
**	****Should criteria be substance specific?**
**Whole work group is addressing these issues**
**	**

**Issues**

## Possible field trials

**	****SUD and OCD**
**	****SUD and Compulsive Gambling**
**Reanalysis of large databases**
**	****NESARC**
**	****Cross cultural data**
**Bio-markers**
**	****Brain imaging comparisons, e.g. gambling and SUD**
**	**
**	**

**Possible field trials**