Advice To DSM V. . .Change Deadlines And Text, Keep Criteria Stable

August 26, 2009

There is no magic moment when it becomes clear that the world needs a new edition of the DSM. With just one exception, the publication dates of all previous DSM’s were determined by the appearance of new revisions of the International Classification of Diseases (ICD). Thus, DSM-I appeared in conjunction with ICD-6 in 1952; DSM-II with ICD-8 in 1968; DSM-III with ICD-9 in 1980; and DSM-IV with ICD-10 in 1994. The lone exception was DSM-IIII-R, which appeared in 1987-out of cycle only because it was originally meant to be no more than a minor revision. The official publication date for DSM-V is May 2012. That date was picked to be consistent with an earlier, no longer correct, expectation that ICD-11 would be published in that same year.

There is no magic moment when it becomes clear that the world needs a new edition of the DSM. With just one exception, the publication dates of all previous DSM’s were determined by the appearance of new revisions of the International Classification of Diseases (ICD). Thus, DSM-I appeared in conjunction with ICD-6 in 1952; DSM-II with ICD-8 in 1968; DSM-III with ICD-9 in 1980; and DSM-IV with ICD-10 in 1994. The lone exception was DSM-IIII-R, which appeared in 1987-out of cycle only because it was originally meant to be no more than a minor revision. The official publication date for DSM-V is May 2012. That date was picked to be consistent with an earlier, no longer correct, expectation that ICD-11 would be published in that same year.

It now seems obvious that this looming deadline is neither necessary nor feasible, and that a later or a flexible deadline should instead be substituted.   

Why is 2012 no longer a necessary deadline? It recently became known that delays in the preparation of the ICD-11 will postpone its publication at least until 2014. Under normal circumstances, it would make sense to continue the tradition of publishing DSM-V and ICD-11 simultaneously, whenever ICD-11 is ready-probably in 2014. But there is also a problem with a 2014 deadline caused by a coding change that will go into effect before then. ICD-9-CM is now the official method of diagnostic coding used to specify all medical encounters in the United States. It will be replaced in October 2013 by a completely revamped ICD-10-CM.  Publishing DSM-V much before October 2013 would result in great confusion and force a choice between 2 equally undesirable options: publish DSM-V in 2012 with the current ICD-9-CM codes, which would be usable only for 18 months; or else, publish DSM-V with the new ICD-10-CM codes even though DSM users would still have to use the ICD-9-CM codes for the next 18 months. Only by delaying publication of DSM-V until just before October 2013 would this problem  be solved.

Why is 2012 no longer a feasible deadline?

It seems obvious that extra time is needed to ensure that DSM-V will not cause serious unintended consequences. The fatal flaw in the current work on DSM-V is its intention to conduct field trials without having first posted for review the specific wordings of the options being considered. This is a clear case of putting the cart before the horse.

By far the most important step in the development of any DSM is the creation and posting of the first draft-presenting all the criteria sets in a systematic form. The first draft is crucial because only the Task Force working as a whole can discipline and reconcile the often inconsistent outputs produced by the different Workgroups. It is a very reliable rule of thumb that Workgroups are always more willing to make changes than is desirable. Experts in any given area tend to have their pet ideas and to worry more about missed cases than about creating potential false positives. By ruthlessly applying the necessary rule of empirical documentation, the Task Force must provide a useful check on Workgroup enthusiasm.

Once a complete first draft of DSM-V is posted, it will require several months to allow the field at large the opportunity for a searching critique of the explicit wordings of all DSM-V suggestions. It will then take several more months for the Workgroups to digest and incorporate the comments from the field into revised criteria sets. Finally, it will take the Task Force at least 1 or 2 more months to reconcile the inconsistencies in the Workgroup revisions.

No field testing of the criteria set for any disorder should ever begin until it has been thoroughly reviewed by the field and by the entire Task Force. Field testing is itself a laborious and time consuming process. First, the methodology should be posted, reviewed, and then revised based on suggestions received. Next, sites must be recruited. The obvious time-saving temptation is to use samples of convenience, but these will almost certainly not generalize well to the actual environments in which DSM-V will be used. Human subjects approval by various Institutional Review Boards will almost certainly cause long and unpredictable delays. Raters and administrative staff must be trained; data management systems installed; patients recruited; data cleaned and analyzed; results posted, reviewed, interpreted, and incorporated into the evolving drafts of DSM-V. Then the revised drafts must be reviewed a final time by the field and by the Task Force.

Finally comes the very time consuming task of writing the text and having it reviewed. Then DSM-V must be approved through the APA’s governance structure. All this takes time-and the schedule is far from predictable.

The secrecy surrounding DSM-V prevents us from knowing the precise state of its current development or from understanding the rationale for beginning field trials now. However, it is a fair guess that the reason no first draft of DSM-V has yet been posted is that the criteria sets are still far from being presentable to the field, even though field trials are meant to begin now. We can only assume that the crucial step of vetting criteria sets before doing field trials is being skipped to allow the Task Force to save time in order meet the arbitrary and now clearly very inconvenient publication deadline of May 2012. 

If anything like proper care is taken to accomplish the steps listed above in their proper order, DSM-V cannot possibly be ready for publication by May 2012. Even if all the previous problems in the DSM-V methodology were immediately corrected and every future step of the revision were done with perfect efficiency, the publication date would likely have to be delayed at least until close to October 2013-far more convenient because DSM-V can then be coordinated with the introduction of the new ICD-10-cm codes. Of course, it is possible that the careful preparation of DSM-V may take even longer.

Why not do the obviously right thing and substitute a postponed or flexible date of publication to ensure there is adequate time to avoid the many sticky problems a rushed DSM-V is likely to cause? Publishing profits are the only possible driver of a fixed and implacable 2012 publication deadline, and this is obviously not acceptable.

The DSM-V Task Force and Workgroup members are dedicated people doing their best under very difficult circumstances. They should be given sufficient time to ensure that DSM-V will be a worthwhile contribution and not the cause of enduring problems for the field and for our patients.

Keep criteria sets stable

Criteria sets should not be changed except for very good reasons and when there is exceptionally strong supporting evidence. The most important criteria sets have a long track record with substantially constant wording ever since the publication of DSM-III in 1980. They have survived the test of time and have become familiar to generations of clinicians and educators. Any arbitrary changes will be needlessly disruptive.

Especially problematic is the impact of changed criteria sets on research. All the widely used interview instruments have for decades been keyed to the existing DSM criteria items. Changed wording would be enormously disruptive to the conduct of future research and to the interpretation of the existing clinical and epidemiologic literature, which would no longer be consistent with new findings based on the changed diagnostic definitions. The research community will be justifiably upset by a DSM-V that liberally alters criteria sets when there is no clear reason to do so.

The forensic applications of the DSM system can be extremely sensitive to even slight changes in the criteria sets. I have discussed previously how a seemingly trivial “or” for “and” wording change in the DSM-IV paraphilia section had a very unfortunate impact on the civil commitment of rapists.1 It must be anticipated that the legal system will parse DSM-V wording changes much more precisely and idiosyncratically than can ever occur to work group members. Experts in forensic psychiatry will therefore also be very concerned about any changes in DSM-V and should be recruited to vet the wording of every option with a fine tooth comb.

Problems can result even from improvements in the wording of criteria sets. For example, the better written and more easily remembered DSM-IV criteria set for ADHD may have resulted in its overuse-especially by primary care doctors and the general public.

However perilous it is to change existing criteria sets, the risks are much greater still whenever the system adds totally new diagnoses that are at best lightly tested. The potential for false positive epidemics and forensic conundrums are much harder to predict for anything novel. New disorders are best kept in the appendix until they have achieved wide acceptance in the field. The DSM system should always follow, not lead, research and practice. It can never be paradigm shifting on its own weight.

The final caution, if one were needed, is that it is surprisingly difficult to write clean, foolproof criteria items. I know this from frustrating personal experience. Despite many years of effort and practice, I never mastered this highly technical writing skill. Until the actual DSM-V options are publicly posted, it is impossible to judge whether they will meet the necessary standards of precision, clarity, and consistency. However, the obscure writing style displayed in the available conceptual papers about DSM-V do not inspire confidence in this regard.2,3 Moreover, it is troubling that no one working on DSM-V has had any extensive experience in writing diagnostic criteria.

Areas for Innovation

DSM-V should update and greatly improve the tired, old text of DSM-IV-TR. Most in need of exhaustive revision are the text sections on biolological factors, epidemiology, and the developmental, cultural, and gender contributions to diagnosis. But all of the DSM-IV-TR text should be up for grabs. Its current formulaic style fails to convey any of the vividness of actual clinical practice. There could be less rote repetition of the wording of items in the criteria sets and much more illustration with rich clinical examples.

The DSM-V task force has suggested another possible innovation: the reorganization of the grouping of disorders. Obsessive-compulsive disorder might be pulled from the anxiety disorders and placed as the lead of its own section with accompanying spectrum disorders (eg, Tic Disorders, Body Dysmorphic Disorder). The section on Disorders First Diagnosed in Infancy, Childhood or Adolescence might be eliminated altogether (or stripped down) and its component disorders given their own sections or sorted with their closest counterparts in other sections (eg, Separation Anxiety Disorder with the Anxiety Disorders).

I am neutral on these suggested reorganizations-plausible arguments can be made either way. But the point here is that such restructuring is much less risky than changing criteria sets. Similarly, the suggestion to add dimensional ratings to DSM-V has its pluses and minuses, but is more likely to be neglected by clinicians than to cause any serious harm.

Undoubtedly, the most valuable innovation possible for DSM-V would be an integration with ICD11, but this important topic requires another column.

References:

References


1.

First M, Frances A. Issues for DSM-V. Unintended consequences of small changes: the case of paraphilias.

Am J Psychiatry.

2008.165:1240-1241.

2.

Kupfer DJ, Regier DA, Kuhl EA. On the road to

DSM-V

and ICD-11.

Eur Arch Psychiatry Clin Neuroscience.

2008;258(suppl 5):2-6.

3.

Regier DA, Narrow WE, Kuhl EA, Kupfer DJ .The conceptual development of

DSM-V. Am J Psychiatry.

2009;166:645-650.