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They were char ged with recommending chairs for the 13 diagnostic work groups and additional task force members with a disciplinary range of expertise who would oversee the development of | [
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] | 402 |
An tional vetting process was init iated by the APA Board of Trus tees to disclose sources of income and thus avoid conflicts of interest by task force and work group members | [
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The full disclosure of all income and research grants from commercial sources including the maceutical industry in the previous 3 years the imposition of an income cap from all mercial sources and the publication of disclosu res on a Web site set a new standard for theIntroduction 7 field | [
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] | 404 |
Thereafter the task force of 28 memb ers was approved in 2007 and appointments of more than 130 work group members were approved in 2008 | [
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More than 400 additional work group advisors with no voting authority were also approved to participate in the cess | [
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A clear concept of the next evolutionary stage for the classification of mental disorders was central to the efforts of the task force an d the work groups | [
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] | 407 |
This vision emerged as the task force and work groups recounted the history of classification its current strengths and limitations and strategic directio ns for its revision | [
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] | 408 |
An intensive cess involved conducting liter ature reviews and secondary an alyses publishing research reports in scientific journals developing dr aft diagnostic criteria posting preliminary drafts on the Web site for public comme nt presenting preliminary findings at fessional meetings performing field tr ials and revising criteria and text Proposals for Revisions Proposals for the revision of diagnostic criteria were develo ped by members of the work groups on the basis of ra tionale scope of change expected impact on clinical agement and public health strength of the su pporting research evidence overall clarity and clinical utility | [
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Proposals encompassed chan ges to diagnostic the addition of new disorders subtypes an d and the deleti on of existing disorders In the proposals for revisions strengths and weaknesses in the current criteria and sology were first identified | [
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Novel scientific findings over the previous two decades were considered leading to the creation of a resear ch plan to assess potential changes through literature reviews and se condary data analyses | [
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Four princi ples guided the draft is primarily intended to be a manual to be used by clinicians and revisions must be feasible for routine clinical recommendations for revisions should be guided by research where possible co ntinuity should be maintained with previous editions of and no a priori constraints should be placed on the degree of change between and Building on the initial lite rature reviews work groups identified key issues within their diagnostic areas | [
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] | 412 |
Work groups also examined broa der methodological concerns such as the presence of contra dictory findings within the development of a fined definition of mental issues relevant to all and the revision of disorders categorized in as otherwise specified Inclusion of a proposal for revision in Section II was informed by consideration of its advantages and disadvantages for public health and clinical ut ility the strength of the evidence and the magnitude of the change | [
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] | 413 |
New diagnoses and d isorder subtypes and specifiers were ject to additional stipulations such as demons tration of reliability e the degree to which two clinicians could independently arrive at the same diagnosis for a given | [
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] | 415 |
Placement of conditions in for Further in Section III was contingent on the amount of empirical evidence generated on the diagnosis diagnostic reliability or ity presence of clear clinical need an d potential benefit in advancing research Field Trials The use of field trials to empirically demonstrat e reliability was a noteworthy improvement troduced in | [
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The design and implemen tation strategy of the Field Trials resent several changes over approaches used for and particularly in obtaining data on the precision of kappa reliabil ity estimates statistical measure that assesses level of agreement between raters that corrects for chance agreement due to prevalence in the context of clinical settings with high leve ls of diagnostic comorbidity | [
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For field trials were extended by using two distinctive one in large diverse settings and the other in routine clinical practice s | [
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] | 418 |
The former capitalized on the need for large sample sizes to test hypotheses on reliability and clinical utility of a range of diagnoses in a8 Introduction variety of patient the latter su pplied valuable information about how proposed revisions performed in everyday clinical settings among a diverse sample of DSM users | [
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It is anticipated that future clinical and basic research studies will focus on the validity of the vised categorical diagnostic criteria and the underlying dimensional features of these ders those now being explored by th e NIMH Research Domain Criteria The field trials were cond ucted at 11 North American sites and assessed the reliability feasibility and clinical utility of select revisions with priority given to those that represented the greatest degree of change from or those potentially having the greatest public health impact | [
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] | 420 |
The fu ll clinical patient populations coming to each site were screened for diagnoses or qu alifying symptoms likely to predict several cific disorders of interest | [
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Stratified sample s of four to seven specific disorders plus a stratum containing a representative sample of all other diagnoses were id entified for each site Patients consented to the study and were randomly assigned for a clinical interview by a nician blind to the diagnosis followed by a se cond interview with a clinician blind to previous diagnoses | [
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Patients first filled out a inventory of symptoms in more than a dozen psychological domains | [
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] | 423 |
These inventories were scored by a central server and results were provided to clinicians before they conducted a typical clinical interview no structured | [
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] | 424 |
Clinicians were required to score the presence of qualifying criteria on a diagnostic checklist de termine diagnoses score the severity of the diagnosis and submit all data to the central server | [
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] | 425 |
This study design allowed the calculation of the degree to wh ich two independent clinicians could agree on a diagnosis ing the intraclass kappa and the agreement of a single patient or two different cians on two separate ratings of symptoms pers onality traits disability and diagnostic severity meas ures intraclass correlation along with information on the precision of these estimates of reliabilit y | [
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It was also possible to assess the prevalence rates of both and conditions in the respective clinical populations The routine clinical practice field trials in volved recruitment of individual psychiatrists and other mental health clinicians | [
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] | 427 |
A volunteer sample was recruited that included alist and specialty psychiatrists psychologists licensed clinical social workers counselors marriage and family therapists and advanced practice psychiatric mental health nurses The field trials provided exposure of the proposed diagnoses and dimensional sures to a wide range of clinicians to assess their feasibility and clinical utility Public and Professional Review In 2010 the APA launched a unique Web site to facilitate public and professional input into | [
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] | 428 |
All draft diagnostic criteria and prop osed changes in organization were posted on www dsm5 org for a co mment period | [
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After revisions to the initial draft criteria and proposed chapter organization a second posting occurred in 2011 | [
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] | 431 |
Wo rk groups considered feedback from both Web postings and the results of th e Field Trials when drafting proposed final criteria which were posted on the Web si te for a third and final time in 2012 | [
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] | 432 |
These three iterations of external review produced more than 13 000 individually signed ments on the Web site that were received and reviewed by the work groups plus thousands of organized petition signers for and against so me proposed revisions all of which allowed the task force to actively address concerns of DSM users as well as patients and advocacy groups and ensure that clinical utility remained a high priority Expert Review The members of the 13 work groups representi ng expertise in their respective areas laborated with advisors and reviewers unde r the overall direction of the TaskIntroduction 9 Force to draft the diagnostic criteria and ac companying text | [
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] | 433 |
This effort was supported by a team of APA Division of Research staff an d developed through a network of text dinators from each work group | [
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The preparation of the text was coordinated by the text editor working in close collaboration with th e work groups and under the direction of the task force chairs | [
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The Scientific Review Comm ittee was established to provide a entific peer review process that was external to that of the work groups | [
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The SRC chair and six committee members were charged with reviewing the degree to which the proposed changes from could be supported with scientific evidence | [
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] | 437 |
Each proposal for diagnostic revi sion required a memorandum of evidence for change pared by the work group and accompanied by a summary of supportive data organized around validators for the proposed diagnostic criteria e antecedent validators such as familial aggregation concurrent validators such as biological markers and prospective validators such as response to treatment or course of | [
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] | 438 |
The submissions were viewed by the SRC and scored according to the strength of the supportive scientific data Other justifications for change such as those arising from clinical experience or need or from a conceptual reframing of diagnostic ca tegories were generall y seen as outside the purview of the SRC | [
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] | 439 |
The scores wh ich varied substantially across the different proposals and an accompanying brief commen tary were then returned to the APA Board of Trustees and the work groups for consideration and response The Clinical and Public Health Committee composed of a chair and six members was appointed to consider additi onal clinical utility public health and ical clarification issues for criteria that ha d not yet accumulated the type or level of dence deemed sufficient for change by the SRC | [
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] | 440 |
This review process was particularly important for disorders with known deficiencies for whic h proposed remedies had neither been previously considered in the DSM revision process nor been subjected to replicated research studies | [
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] | 441 |
These selected d isorders were evaluated by four to five nal reviewers and the blinded results were reviewed by CPHC members who in turn made recommendations to the APA Boar d of Trustees and the work groups Forensic reviews by the members of the APA Council on Psychiatry and Law were ducted for disorders frequently appearing in forensic environments and ones with high potential for influencing civil and criminal judgments in courtroom settings | [
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] | 442 |
Work groups also added forensic experts as advisors in pertinent areas to complement expertise vided by the Council on Psychiatry and Law The work groups themselves were charged with the responsib ility to review the entire search literature surrounding a diagnostic area including old revised and new diagnostic teria in an intensive re view process to assess the pros and cons of making either small iterative changes or major conceptual changes to address the inevitable reification that occurs with diagnostic conceptual approaches that pe rsist over several decades | [
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] | 443 |
Such changes cluded the merger of previously separate diagno stic areas into more dimensional spectra such as that which occurred with autism spectrum disorder substance use disorders sexual functions and somatic symptom and related di sorders | [
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These types of changes po sed particular challenges to the SRC and CPHC review cesses which were not constructed to evaluate the validity of diagnostic criteria However the Task Force which had re viewed proposed changes and had bility for reviewing the text describing each disorder contemporaneously with the work groups during this period was in a unique positio n to render an informed judgment on the entific merits of such revisions | [
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] | 446 |
Furthermore ma ny of these major changes were subject to field trial testing although comprehensive testing of all proposed changes could not be dated by such testing because of time limitations and availa bility of resources A final recommendation from the task forc e was then provided to the APA Board of Trustees and the APA Committee on to consider some of the clinical utility and feasibility features of the propos ed revisions | [
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The assembly is a deliberative10 Introduction body of the APA representing the district branches and wider membership that is posed of psychiatrists from throughout the United States who provide geographic tice size and diversity | [
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] | 448 |
The Committee on is a committee made up of a diverse group of assembly leaders Following all of the preceding review steps an executive session was held to consolidate input from review and assembly committee chairs task force chairs a forensic advisor and a statistical ad visor for a preliminary review of each der by the assembly and APA Board of Trus tees executive committees | [
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] | 449 |
This preceded a preliminary review by the full APA Board of Trustees | [
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The assembly voted in November 2012 to recommend that the bo ard approve the publication of and the APA Board of Trustees approved its publication in December 2012 | [
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] | 451 |
The ma ny experts re viewers and advisors who contributed to this pr ocess are listed in the Appendix Organizational Structure The individual disorder definitions that cons titute the operationali zed sets of diagnostic criteria provide the core of for clinic al and research purpos es | [
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These criteria have been subjected to scientific re view albeit to varying degrees and many disorders have dergone field testing for interrater reliability | [
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In contrast the classification of disorders way in which disorders are grou ped which provides a organization for the has not generally been thought of as scientif ically significant despite the fact that ments had to be made when disorders were initially divided into chapters for DSM is a medical classification of disorders and as such serves as a historically mined cognitive schema imposed on clinical an d scientific informatio n to increase its prehensibility and utility | [
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] | 454 |
Not surprisingly as th e foundational science that ultimately led to has approached a in ag e challenges have begun to emerge for nicians and scientists alike that are inherent in the DSM structure rather than in the scription of any single disorder | [
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] | 455 |
These challenges include high rates of comorbidity within and across DSM chapters an exce ssive use of and need to rely on otherwise criteria and a growing inability to integrate DSM disorders with the results of netic studies and other scientific findings As the APA and the WHO began to plan their respective revisions of the DSM and the International Classification of Disorders both cons idered the possibility of improving clinical utility g by helping to explain a pparent and facilitating scientific investigation by rethinking the organizational structures of both publications in a linear system designated by alphanume ric codes that sequence chap ters according to some tional and relational structure | [
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] | 456 |
It was critical to both th e Task Force and the WHO International Advisory Group on the revision of the Section on Mental and ioral Disorders that the revisions to the or ganization enhance clinical utility and remain within the bounds of scientific information | [
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] | 457 |
Although the need for reform seemed apparent it was import ant to respect the state of the science as well as the lenge that overly rapid change would pose for the clinical and research communities | [
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] | 458 |
In that spirit revision of the organization was approached as a conservative evolutionary agnostic reform that would be guided by emer ging scientific evidence on the relationships between disorder groups | [
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] | 459 |
By reordering and regrouping the existing disorders the vised structure is meant to stim ulate new clinical perspectives and to encourage ers to identify the psychological and physiologi cal factors that are not bound by strict categorical designations The use of DSM criteria has the clear virtue of creating a common language for munication between clinicians about the diagno sis of disorders | [
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] | 460 |
The official criteria and disorders that were determined to have accepted clinical applicability are located in tion II of the manual | [
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] | 461 |
However it should be noted that these diagnostic criteria and theirIntroduction 11 relationships within the classification are ba sed on current research and may need to be modified as new evidence is gathered by fu ture research both within and across the mains of proposed disorders for Further Study described in Section III are those for which we determined that the scient ific evidence is not yet available to support widespread clinical use | [
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] | 462 |
These diagnostic crit eria are included to highlight the evolution and direction of scientific advances in these areas to stimulate further research With any ongoing review proces s especially one of this co mplexity different viewpoints emerge and an effort was made to consider various viewpoints and when warranted commodate them | [
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] | 463 |
For example personality diso rders are included in both Sections II and III | [
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] | 464 |
Section II represents an update of the te xt associated with the same criteria found in whereas Section III includes the proposed research model for personality order diagnosis and conceptualization developed by the Personality and Personality Disorders Work Group | [
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] | 465 |
As this field evolves it is hoped that both versions will serve ical practice and research initiatives Harmonization With The groups tasked with revising the DSM and ICD systems shared the overarching goal of harmonizing the two classifications as much as possible for the following The existence of two major classifications of mental disorders hinders the collection and use of national health statistics the design of clinical trials aimed at developing new treatments and the consideration of global ap plicability of the results by international regulatory agencies More broadly the existence of two classificat ions complicates attempts to replicate entific results across national boundaries Even when the intention was to identify identical patient populations and diagnoses did not always agree Early in the course of the revisions it be came apparent that a shared organizational structure would help harmonize the classificatio ns | [
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In fact the use of a shared framework helped to integrate the work of DSM and ICD work groups and to focus on scientific sues | [
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The organization and the proposed linear structure of the have been endorsed by the leadership of the NIMH Resear ch Domain Criteria project as sistent with the initial overa ll structure of that project Of course principled disagreements on th e classification of psychopathology and on specific criteria for certain disorders were expected given the current state of scientific knowledge | [
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] | 468 |
However most of the salient differences betw een the DSM and the ICD fications do not reflect real sc ientific differences but rather represent historical of independent committee processes To the surprise of participants in both revi sion processes large sections of the content fell relatively easily into place reflecting real strengths in some areas of th e scientific erature such as epidem iology analyses of comorbidity twin studies and certain other netically informed designs | [
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] | 469 |
When disparities emerged they almost always reflected the need to make a judgment about where to plac e a disorder in the face of more often ata | [
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Thus for example on the ba sis of patterns of symptoms morbidity and shared risk factors attentio disorder was placed with neurodevelopmental disorders but the same data also supported strong guments to place ADHD within disruptive and conduct disorders These issues were settled with the preponderance of evidence notably validators proved by the Task | [
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] | 471 |
The work gr oups recognize however that future coveries might change the placement as well as the contours of individual disorders and furthermore that the simple and linear organi zation that best supports clinical practice12 Introduction may not fully capture the complexity and hete rogeneity of mental di sorders | [
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] | 472 |
The revised organization is coordinated with the mental and behavioral disorders chapter of which will utilize an expanded coding system | [
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] | 473 |
ever the official coding system in use in the Un ited States at the time of publication of this manual is that of the International Classificatio n of Diseases Ninth Revi sion Clinical tion U S adaptation of | [
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] | 474 |
International Classificat ion of Diseases Tenth Revision Clinical Modification adapted from IC is scheduled for mentation in the United States in October 2014 | [
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However given that adoption of the coding system will remain at the time of the releas e it will be necessary to use the codes | [
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] | 477 |
more given that organizational stru cture reflects the an ticipated structure of the eventual co des will follow the sequential order of diagnoses in the chapter structure more closely | [
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] | 478 |
At present both the and the codes have been indicated for each disorder | [
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] | 479 |
These codes will not be in sequential order throughout the manual because they were assigned to complement earlier organizational structures Dimensional Approach to Diagnosis Structural problems rooted in the basic de sign of the previous DSM classification structed of a large number of narrow diagnostic categories have emerged in both clinical practice and research | [
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] | 480 |
Relevant evidence come s from diverse sources including studies of comorbidity and the substantia l need for not otherwise specified diagnoses which sent the majority of diagnoses in areas such as eating disorders personality disorders and autism spectrum disorder | [
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] | 481 |
Stud ies of both genetic and environmental risk factors whether based on twin designs familial transmission or molecular analyses also raise concerns about the categorical structure of the DSM system | [
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] | 482 |
Because the previous DSM approach considered each diagnosis as categorically sepa rate from health and from other diagnoses it did not capture the widespread sharing of symptoms and risk factors across many orders that is apparent in studies of comorb idity | [
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] | 484 |
Indeed the once plausible goal of identifying homogeneous populations for trea tment and research resu lted in narrow agnostic categories that did not capture clinical reality symptom heterogeneity within orders and significant sharing of symptoms across multiple disorders | [
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The historical aspiration of achieving diagnostic homogene ity by progressive subt yping within disorder categories no longer is like most common human ills mental disorders are erogeneous at many levels ranging fr om genetic risk factors to symptoms Related to recommendations about alteration s in the chapter structure of bers of the diagnostic spectra study group examined whether scientific validators could inform possible new groupings of related diso rders within the existing categorical work | [
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Eleven such indicators were recommended for this shared neural strates family traits genetic risk factors sp ecific environmen tal risk factors biomarkers temperamental antecedents abnormalities of emotional or cognitive processing symptom similarity course of illness high comorbidit y and shared treatmen t response | [
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] | 487 |
These cators served as empirical guidelines to info rm decision making by the work groups and the task force about how to cluster disorders to maximize their validity and clinical utility A series of papers was developed and published in a prominent international journal Medicine Vol 39 as part of both the and the mental processes to document that such valid ators were most useful for suggesting large groupings of disorders rather th an for individual disorder diagnostic criteria The regrouping of mental disorders in is intended to enable future research to 13 hance understanding of disease origins and pathophysiological commonalities between disorders and provide a base for future replication wherein data can be reanalyzed over time to continually assess validity | [
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Ongoing revisions of will make it a ument adaptable to future discoveries in neurobiology genetics and epidemiology On the basis of the published findings of this common and analysis it was demonstrated that clustering of diso rders according to what has been termed izing and externalizing factors represents an empirically supported framework | [
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Within both the internalizing group disorder s with prominent anxiety depressive and somatic and the externalizing group disorders with prominent impulsive disruptive conduct and substance use the sh aring of genetic and environmental risk factor s as shown by twin studies like ly explains much of the atic comorbidities seen in both clinical an d community samples | [
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] | 490 |
The adjacent placement of disorders characterized by de pressed mood anxiety and related logical and cognitive symptoms should aid in developing new diagnostic approaches cluding dimensional approaches while facilitati ng the identification of biological markers Similarly adjacencies of the group including disord ers exhibiting cial behaviors conduct disturbances addictio ns and disorders should courage advances in identifying diagnoses markers and underlying mechanisms Despite the problem posed by categorical diagnoses the Task Force recognized that it is premature scientifically to propose alternative definitions fo r most disorders | [
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] | 491 |
The organizational structure is meant to serve as a bridge to new diagnostic approaches out disrupting current clinical practice or research | [
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] | 492 |
With support from training materials the National Institutes of Health other funding agencies and scientific publications the more dimensional approach and organizational structure can cilitate research across current diagnostic ca tegories by encouraging broad investigations within the proposed chapters and across adja cent chapters | [
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Such a reformulation of search goals should also keep central to the development of dimensional approaches to diagnosis that will likely supplement or supersede current categorical approaches in coming years Developmental and Life span Considerations To improve clinical utility is organi zed on developmental and lifespan ations | [
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] | 494 |
It begins with diagnoses thought to reflect developmental processes that manifest early in life g neurodevelopmental and schizophrenia spectrum and other psychotic followed by diagnoses that more commonly manifest in adolescence and young adulthood g bipolar depressive and anxiety an d ends with ses relevant to adulthood and later life g neurocognitive disord | [
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] | 495 |
A similar approach has been taken where possible within each chapter | [
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This organizational structure tates the comprehensive use of lifespan informat ion as a way to assist in diagnostic sion making The proposed organization of chapters of after the neurodevelopmental ders is based on groups of internalizing onal and disorders externalizing disorders neurocognitive disorders and other disorders | [
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It is hoped that this organization will encourage furthe r study of underlying pathophysiological processes that give rise to diagnostic comorbidity and sy mptom heterogeneity | [
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] | 498 |
Furthermore by arranging disorder clusters to mirror clinical reality shou ld facilitate identifica tion of potential noses by health specialist s such as primary care physicians The organizational structure of alon g with ICD harmonization is designed to provide better and more flexible diagnostic concepts for the next epoch of research and to serve as a useful guide to clinicians in explai ning to patients why they might have received multiple diagnoses or why they might have re ceived additional or altered diagnoses over their lifespan 14 Introduction Cultural Issues Mental disorders are defined in relation to cultural social and familial norms and values Culture provides interpretive frameworks that shape the experience and expression of the symptoms signs and behaviors that are criter ia for diagnosis | [
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