This is a presentation I'd done during my Psychiatry residency. I evaluated the Preamble of the DSM5, evaluating how and why the new manual was conceived, the process of creation and review and the rationale behind these changes. I also evaluated the reasons why DSM5 has come in for such attack, and did a critique of the very obvious shortcomings in the execution and implementation of the stated aims.

1. DSM5
Preamble & Critique
Dr (Maj) Ashutosh Ratnam

2. Overview
• The Felt Need for DSM5
• Revision Process
– Work groups
– Proposals for Revisions
– Field Trials
– Reviews
• Cultural Issues
• The Multiaxial System
• Definition of a Mental
Disorder
• Organisational Structure
– Dimensional Diagnosis
– Developmental / Lifespan
Approach

3. Definition – Preamble
• “an introductory statement; especially the
introductory part of a constitution or statute that
usually states the reasons for and intent of the law”
Merriam-Webster
• “an introduction to a document, speech, or report
explaining its purpose”
• Macmillan English Dictionary for Advanced Learners

4. The Felt Need for DSM5
• “…past science was not mature enough to yield fully
validated diagnoses – i.e. to provide consistent, strong
and objective scientific validators of indl DSM
disorders”
• “Speculative results do not belong in an official
nosology, but DSM must evolve in the context of other
clinical research initiatives”
• “The boundaries between many disorder ‘categories’
are more fluid over the life course than DSM-IV
recognized”
• “Many symptoms assigned to a single disorder may
occur, at varying levels of severity, in many other
disorders”

5. The Revision Process
•American Psychiatric
Association
•WHO Division of Mental
Health
•World Psychiatric
Association
•National Institute of Mental
Health
•“Stimulate research that would enrich the empirical database
before the start of the DSM-V revision process”
•“Devise a research and analytic agenda that would facilitate the
integration of findings from research and experience in animal
studies, genetics, neuroscience, epidemiology, clinical research, and
crosscultural clinical services”

6. “It can be concluded that the field of psychiatry
has thus far failed to identify a single
neurobiological phenotypic marker or gene that
is useful in making a diagnosis of a major
psychiatric disorder or for predicting response
to psychopharmacologic treatment”
“Such an accomplishment would help move the
specialty into the mainstream of modern
medicine, where etiology and pathophysiology
have replaced descriptive symptomatology as
the fundamental basis for making diagnostic
distinctions”

8. The Revision Process
•American Psychiatric
Association
•WHO Division of Mental
Health
•National Institute of
Mental Health
•National Institute on Drug
Abuse
•National Institute on
Alcoholism & Alcohol Abuse
Preparing for Revisions
to
•DSM5
•ICD-11

9. David Kupfer, MD
•Thomas Detre Professor of Psychiatry
•Professor of Neuroscience and Clinical
and Translational Science
University of Pittsburgh School of
Medicine
Darrel Regier, MD
•Senior Scientist, Center for the Study of
Traumatic Stress
Department of Psychiatry
Uniformed Services University

10. Diagnostic Working Groups
• ADHD and Disruptive
Behavior Disorders
• Anxiety, Obsessive-
Compulsive Spectrum,
Posttraumatic, and
Dissociative Disorders
• Childhood and Adolescent
Disorders
• Eating Disorders
• Mood Disorders
• Neurocognitive Disorders
• Neurodevelopmental
Disorders
• Personality and Personality
Disorders
• Psychotic Disorders
• Sexual and Gender Identity
Disorders
• Sleep-Wake Disorders
• Somatic Symptoms Disorders
• Substance-Related Disorders

11. Working Groups
1. Revisions must be feasible for routine clinical practice
2. Recommendations for revision should be guided by
research evidence
3. When possible, continuity should be maintained with
previous DSM editions
4. No a priori constraints should be placed on the degree of
change from DSM-IV to DSM5
• Change Diagnostic Criteria
• Add new disorders, subtypes & specifiers
• Delete Existing Disorders

12. Field Trials
1. Medical/Academic
Settings
Large sample sizes required to test
diagnostic hypotheses on
•reliability
•clinical utility
2. Routine Clinical
Practice (RCPs)
Tested how proposed revisions
performed in everyday clinical
settings when used by a range of
clinicians
(General + speciality psychiatrists,
Psychologists, Counselors, Therapists,
Nurses)

13. Field Trials – Medical/Academic
• New York State Psychiatric
Institute, Columbia
University Medical Center,
New York
• Baystate Medical Center,
Springfield, Mass
• Children's Hospital, Aurora,
Colo
• Lucile Packard Children's
Hospital, Stanford University
in Stanford, Calif.
• Department of Veterans
Affairs, Dallas
• University of California, Los
Angeles
• University of Texas Health
Science Center, San Antonio
• University of Pennsylvania,
Philadelphia;
• Mayo Clinic, Rochester, Minn
• Centre for Addiction and
Mental Health, Toronto
• The Menninger Clinic, Baylor
College of Medicine, and the
DeBakey VA Medical Center
in Houston.

14. Consenting
Patient
Screened for
DSM-IV
Diagnoses
Likely to predict specific
DSM5 disorders of
interest
Stratified Sampling of
patients for
4-7 specific disorders
Patients fill CAI
of Cross-Cutting
Symptoms
Scored
Results
Provided to
interviewers
CLINICAL
INTERVIEW
# 1
CLINICAL
INTERVIEW
# 2
Calculation
of Kappa
Statistic
CLINICAL INTERVIEW
•Presence of qualifying
criteria on CAI of DSM5
checklist
•Determine Diagnosis
•Score Severity of
Diagnosis

15. Public/Professional Review
• All draft criteria & proposed changes posted to
www.dsm5.org for 02 mth comment period (2010)
– 8000 submissions systematically reviewed by work
groups
– Comments integrated into discussions for revisions and
field trial plans
• After revisions + proposed chapter organisation
– Second posting in 2011
– Third posting 2012

16. WORK GROUPS
SCIENTIFIC REVIEW
COMMITTEE
Review
recommended
revisions based on
strength of
supporting scientific
data
CLINICAL & PUBLIC
HEALTH COMMITTEE
Regarding criteria
deemed inadequate
by SRC
•Consider additional
clinical utility
•Public health issues
•Logical clarification
APA Council on
Psychiatry and Law
DSM5 TASK FORCE
APA Board of Trustees
APA Assembly’s Committee on DSM5

17. Dimensional Approach to Diagnosis
• Previous DSMs considered each diagnosis separate
from health and other diagnoses
– Failed to capture widespread sharing of symptoms and
risk factors across many disorders
– Focused on excluding false positive results
• Diagnostic spectra study group examined if
scientific validators could inform possible new
groupings of related disorders
– Within existing categorical framework
– Used to suggest grouping of disorders, e.g. internalising
v/s externalising

18. Dimensional Approach to Diagnosis
• Shared Neural
substrates
• Family traits
• Genetic Risk Factors
• Specific Environmental
Risk Factors
• Biomarkers
• Temperamental
antecedents
• Abnormalities of
emotional or cognitive
processing
• Symptom Similarity
• Course of Illness
• High co-morbidity
• Shared treatment
response

19. Developmental/Lifespan Considerations
• DSM5 organisation
– Begins with diagnoses thought to reflect developmental
processes manifesting early in life
• Neurodevelopmental, Schizophrenia Spectrum
– Followed by diagnoses manifesting in adolescence / young
adulthood
• BPAD, Depressive & Anxiety Disorders
– Ends with diagnoses relevant to adulthood & later life
• Neurocognitive
• Grouping of disorders after Neurodevelopmental into
– Internalising
– Externalising
– Neurocognitive
– Other Disorders

20. Developmental/Lifespan Considerations
• Encourage study of underlying pathophysiological
processes giving rise to diagnostic comorbidity &
symptom heterogeneity
• Facilitate identification of potential diagnoses by
non-mental health professionals
• Guide clinicians to explain to patients why over a
lifespan they recd
– multiple diagnoses
– additional / altered diagnoses

21. Cultural Issues
• Judgment of given behaviour being abnormal and requiring
clinical attention depends on cultural norms
• Awareness of culture may correct mistaken interpretations
of psychopathology
• Culture may contribute to vulnerability and suffering
• Culture may provide coping strategies to enhance resilience
& suggest help seeking /health care options of various
types
– Alternative & complementary health systems
• Influence acceptance or rejection of diagnosis and
adherence to treatment
• Affect conduct of clinical encounter
– Accuracy & acceptance of diagnosis, treatment decisions

22. Cultural Issues
• Culture Bound Syndrome replaced by
1. Cultural Syndrome
2. Cultural Idiom of Distress
3. Cultural explanation or perceived cause

23. The Multiaxial System
• DSM5 moved to a non-axial documentation of diagnosis
– Separate notations for important psychosocial & contextual
factors (earlier Axis IV) and disability (earlier Axis V)
• Consistent with DSM-IV stance that the multiaxial system DOES
NOT imply that
– There are fundamental differences in the conceptualisation of
Axix I, II or III disorders
– That mental disorders are unrelated to physical/biological factors
– That general medical conditions are unrelated to behavioural /
psychosocial factors or processes
• Consistent with WHO and ICD guidance to consider indl’s
functional status distinct from diagnostic/symptomatic status

24. Defining a Mental Disorder
• A mental disorder is a syndrome characterised by
clinically significant disturbance in an indl’s
– Cognition
– Emotional regulation
– Behaviour
• that reflects a dysfunction in the psychological,
biological or developmental processes underlying
mental functioning .
• Mental disorders are usually associated with significant
distress or disability in social, occupational or other
important activities
• An expectable or culturally approved response to a
common stressor or loss (e.g. the death of a loved one)
is NOT a mental disorder

25. Summary
• Efficient administrative machinery
• Open process of review
• Emphasis on empirical validation
• Rigorous Field Trial Framework

26. DSM5
Critique

27. Definition – Critique
• “a careful written examination of a subject that
includes the writer’s opinions”
Macmillan’s Dictionary
• “a report of something such as a political situation
or system, or a person's work or ideas, that
examines it and provides a judgment, especially a
negative one”
Cambridge English Dictionary

28. DSM5 Timeline
2009 2010 2011 2012 2013 2014
Phase 2 Sched End,
Phase 1 actually ends
Feb 12
Phase 2
sched Start
Sep 11
Phase 1
actually
starts
June 2010
Academic
Insitutue
Phase 1
scheduled
start
June 2009
Scheduled Phase 1
Scheduled Phase 2
Actual Phase 1

29. Failed Deadlines
• Clinician Field trial
– Aug 10 – scheduled to be trained by then
– Dec 11 – training actually completed (14mths late)
– Nov 10 – patients scheduled to be enrolled
– Feb 11 – scheduled to finish trial 1
• “RCP field trials continued until after enrollment
ended in February 2012. Work groups were
provided with results from both field trials and
updated their draft criteria as needed”

30. Kappa Statistic Discrepancies

32. Distortion of Kappa Values
• According to the authors, of the 23 disorders
– 14 had “very good” or “good” reliability
– 6 had questionable, but 'acceptable' levels
– 03 had “unacceptable” rates
• Only 5 of the 23 DSM 5 diagnoses that achieved kappa
levels of agreement between 0.60–0.79 would have
been considered 'good' in the past
• 9 DSM 5 disorders in the kappa range of 0.40–0.59
previously would have been considered poor
(DSM 5 calls these 'good')
• 3 diagnoses that were below <0.20 (which is barely
better than chance) are found unacceptable

33. Questionable Quality of Field Trials
•Major Depressive Disorder
•Generalized Anxiety Disorder
•GAD - DSM 5 definition was so very poorly done
•DSM 5 had made no changes from the MDD definition
•reliability has been repeatedly studied
•always achieved rates twice as high
•? Incompetence in how the DSM 5 field trials were conducted
•Throws in doubt all of the other results

34. Hypervigilance
• Work group members sign confidentiality agreements to protect
DSM 5 'intellectual property‘
• APA rebuffs calls from 51 mental health associations for an open
and independent scientific review
• APA's legal office tries to stifle criticism and censor internet
derision
– threats of trademark litigation
• Original DSM 5 plan for field trials included no prior public viewing
of criteria sets and no period for public comment
– These are added only under heavy outside pressure
• DSM 5 publishes no aggregations of key areas of concern
identified during public reviews
– Doesn't respond publicly to them
– No indication that public input has had any impact whatever on DSM 5
• APA declares it will “post a complete set of DSM 5 reliability data
in time to allow comments during the final period of public
review”
– NOT DONE

36. CONCLUSIONS
• “Melancholia’s features cluster with greater consistency
than the broad heterogeneity of the disorders and
conditions included in major depression and bipolar
disorder
• The melancholia diagnosis has superior predictive
validity for prognosis and treatment, and it represents a
more homogeneous category for research study.
• We therefore advocate that melancholia be positioned
as a distinct, identifiable and specifically treatable
affective syndrome in the DSM-5 classification”

37. • “I believe you and your colleagues are
fundamentally correct
• But the inclusion of a biological measure would be
very hard to sell to the mood group
• The problem isn’t the test’s reliability, which I think
is better than anything else in psychiatry.
• Rather, it is that the D.S.T. will be the only biological
test for any diagnosis being considered”
Dr William Coryell, Member, APA Assembly’s Committee on DSM5

38. Overdiagnosis
• Binge Eating Disorder
• Disruptive Mood Dysregulation Disorder
• Removal of Bereavement Exclusion
• MDD K=0.32
• Fewer than one-third of antidepressant users have
consulted a mental health professional in the past year
• Four out of five prescriptions for psychotropic drugs are
written by practitioners who are not psychiatrists
(Psychiatric Services, 2009)
• 72% of psychotropic drugs are prescribed without
meeting a psychiatric diagnosis
• (Health Aff (Millwood). 2011 Aug;30(8):1434-42. doi: 10.1377/hlthaff.2010.1024. Proportion of antidepressants
prescribed without a psychiatric diagnosis is growing)

39. • Persons who had a bereavement related depressive syndrome at
baseline were no more likely over a 3-year follow-up period to have a
major depressive episode than those who had no lifetime history of
major depression at baseline.
• Subjects who had had an episode of major depression at baseline
were significantly more likely to have a recurrence of depression
during the 3-year followup than those without a history of depression
or those who had only had bereavement-related depression.
• Mojtabai R. Bereavement-related depressive episodes: characteristics, 3-year course, and implications for the DSM-5. Arch Gen Psychiatry 2011;68:920-8.
• The majority of bereaved and clinically depressed patients are seen
by primary care practitioners
• It is critical that such practitioners be skilled at distinguishing
between clinical depression, which requires treatment, and
uncomplicated grief, which is an entirely normal emotional response
to loss.

40. Why the rush?
• “The need to coordinate DSM-5 with ICD-10-CM coding,
which was scheduled to start Oct 2013”
• Health and Human Services (HHS) Secretary Kathleen G.
Sebelius has announced that the start date for ICD-10-CM
has been postponed. It is not yet clear for how long, but
most likely a year
ICD-10-CM Delay Removes Excuse For Rushing DSM-5 Into Premature Publication,
Psychiatric Times, February 22, 2012

42. Summary
• Poor Diagnostic Consistency
• Empirical Groundwork was incomplete
• Encourages overdiagnosis of mental illness
• Ignored the ONE objective scientific validator
available
• Rushed into implementation when time was
available for a completion of 2nd phase of trials
• Validity of Psychiatry as a science undermined
– Asperger’s removed completely

43. References
• DSM-5 : How Reliable Is Reliable Enough? Am J
Psychiatry 169:1, January 2012
• Grief, Depression, and the DSM-5 Richard A.
Friedman, M.D. N Engl J Med 366;20 May 17, 2012
• DSM-5, American Psychiatric Association
• A Research Agenda for DSM-V, APA
• Issues for DSM-5: Whither Melancholia? The Case
for Its Classification as a Distinct Mood Disorder,
Am J Psychiatry 167:7, July 2010