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Public Comment Period Opens for First Set of New Proposals to Update DSM-5

Public Comment Period Opens for First Set of New Proposals to Update DSM-5

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ON DSM-5

The approach that has been used for revising the American Psychiatric Association’s DSM since its inception has been to overhaul the diagnostic classification in its entirety at fixed intervals. While revising the entire DSM in this way has some advantages, such as ensuring the uniformity and stability of the diagnostic definitions during the time interval during which the manual is in effect, a significant disadvantage is that it prevents the incorporation of new scientific knowledge into DSM as it emerges.

Advances in digital publishing that allow instantaneous dissemination of changes at minimal cost have paved the way towards the adoption of a continuous improvement model for DSM, in which revisions are pegged to specific scientific advances. Thus, rather than waiting until the next wholesale revision to implement a clinically useful change (such as incorporating a clinically validated biomarker into the definition of a disorder), such a change could be put into effect as soon as it has been determined that it is diagnostically advantageous to do so. Moreover, implementing a continuous data-driven approach has the added advantage of discouraging changes that are not well supported by empirical evidence.

A new DSM web portal (www.dsm5.org) was set up by the APA at the beginning of this year to field proposals for changes to DSM-5. Proposals must be accompanied by supportive information including the reasons for the change, and, depending on the nature of the proposal, data documenting improvements in validity across a range of validators, evidence of reliability and clinical utility, and a consideration of potential deleterious consequences associated with the proposed change. It is expected that most submissions will originate from interested persons who are external to the APA committee overseeing the DSM revision process (eg, psychiatric researchers, individual clinicians). This is in marked contrast to the way prior DSM revisions were done, during which proposals were drafted by DSM workgroup members who were also responsible for providing supportive literature reviews and data re-analyses.

The first set of proposed changes to DSM-5 since the web portal was opened for submissions are now being posted for public comment on the DSM-5 web site, with comments being accepted from November 22, 2017 until December 22, 2017.

This new continuous revision process is being overseen by a Steering Committee (analogous to the DSM Task Force). Five standing Review Committees, with about 6 members each, will work with the Steering Committee to consider the evidence in support of the proposed change. Proposals submitted to the DSM web portal will first be reviewed by the Steering Committee, which will refer the proposal to the appropriate review committee if it appears that the evidence for the proposal is substantially likely to meet the criteria for approval.

The Review Committee will then undertake whatever additional investigation might be needed, such as consultation with relevant experts. It will then forward the reviewed proposal back to the Steering Committee to decide whether the proposal is suitable to be posted for public comment.

If the Steering Committee determines that the proposal has met the criteria for approval, it will submit the proposal and a summary of the public comments for review by the Board of Trustees of the APA. Once approved, changes will be publicized by the APA and digital versions of the manual will be updated to reflect the change.

The DSM-5 web portal has identified 3 types of proposals that require substantial empirical support, each with explicit criteria regarding the type of evidence that is expected to be submitted. In general, proposals should include a thorough review of the relevant literature and the results of any secondary data analyses conducted by those making the proposal.

• Type 1 proposals involve changes to an existing diagnostic criteria set that purport to markedly improve the validity, reliability, or clinical utility of a criteria set, or to substantially reduce identified deleterious consequences

• Type 2 proposals involve the addition of a new diagnostic category, subtype, or specifier

• Type 3 proposals entail deleting an existing category or subtype or specifier

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