Sunday, June 9, 2013


I finally saw a copy of the DSM-5 today.  It was sitting on a table at a course on the DSM put on by the Minnesota Psychiatric Society.  The DSM-5 portion of the course was about 3 1/4 hours of lectures (98 information dense PowerPoint slides) by Jon Grant, MD.    Dr. Grant explained that he was in a unique position to provide the information because he and Donald Black, MD had been asked by the American Psychiatric Association (APA) to write the DSM-5 Guidebook.  In this unique position they were privy to all of the notes, minutes, e-mails and documents of the DSM Work Groups.  In the intro it was noted that Dr. Grant had written over 150 papers and 5 books.  He was probably one of the best lecturers I have ever seen with a knack to keep the audience engaged in some very dry material.  There were times that he seemed to be riffing like a stand up comedian.  The content was equally good.  I thought I would summarize a few of the high points that I think are relevant to this blog.

The first section was an overview of the history.  The original DSM was published in 1952, but before that there were several efforts to classify mental disorders dating back to ancient times.  Some of the systems persisted for hundreds of years.  He credited Jean-Etienne Esquirol (1772-1840) as one of the innovators of modern classification.  The philosophical approaches to the subsequent DSMs were reviewed and they generally correlate with the theories of the day.

The development of DSM-5 began in 1999.  The original goals included the definition of mental illness, dimensional criteria, addressing mental illness across the lifespan, and to possibly address how mental disorders were affected by various contexts such as sex and culture.  Darrel Regier, MD was recruited from the NIMH to coordinate the development of DSM-5 in the year 2000.  Between 2003 and 2008 there were 13 international conferences where the researchers wrote about specific diagnostic issues and developed a research agenda.  This produced over 100 scientific papers that were compiled for use as reference volumes.  As far as I can tell the people on the ground on this issue was the DSM Task Force and the Work Groups.  The Task Force addressed conceptual issues like spectrum disorders, the interface with general medicine, functional impairment, measurement and assessment, gender and culture and developmental issues.  The Work Groups met weekly or in some cases twice a week by conference call and twice a year in person.  The work groups had several goals including revising the diagnostic criteria according to a  review of the research, expert consensus and "targeted research analyses".  No cost estimate of this multi-year infrastructure was given.

Like any volume of this nature the originators had some guiding principles including a focus on utility to clinicians, maintaining historical continuity with previous editions, and the changes needed to be guided by the research evidence. The most interesting political aspect of this process was the elimination of people closely involved in the development of DSM-IV in order to encourage "out of the box" thinking.  This was a conscious decision and I have not seen it disclosed by some of the professional critics out there.

Final approval of the DSM occurred after feedback was received through the DSM-5 web site.  There were thousands of comments from individuals, clinicians and advocacy organizations.  Field trial data was analyzed and discussed.  A scientific committee reviewed the actual data behind the diagnostic revisions and confirmed it.  Hundreds of expert reviewers considered the risks in revising the diagnoses.  The APA Assembly voted to approve in November 2012.

Some of the criticisms of the DSM-5 were discussed in about 4 slides.  Dr. Grant was aware of all of the major criticisms and I have reviewed most of them here on this blog such as the issue of diagnostic proliferation.  Dr. Grant's lecture contained this graphic for comparison:

Rather than repeat what I have already said, it should be apparent to anyone who knows about this process that it was open, transparent and involved a massive effort of the part of the psychiatrists and psychologists involved.  It should also be apparent that the DSM process was clinically focused and that safeguards were in place to consider the risk of diagnostic changes.  I have not seen any of that discussed in the press and don't expect it to be.  For all of you DSM-5 conspiracy theorists, more than enough people involved without a sworn oath to assure that no secret would ever be kept.

What about the final product?  The DSM-5 ends up including 19 major diagnostic classes.  Some of the highlights include moving some disorders around.  Obsessive-compulsive disorder and Post Traumatic Stress Disorder were moved out of the Anxiety Disorders section to their own separate categories.  Bipolar and Depressive Disorders each have their own diagnostic class instead of both being placed in a Mood Disorders class.  Adjustment Disorders have been moved into the Trauma and Stress Related Disorders class and there are two new subtypes.  As previously noted here, all of the Schizophrenia subtypes have been eliminated.  The Multiaxial System of diagnosis has been scrapped.  One of the changes impacting the practice of addiction psychiatry is the elimination of the categories of Substance Abuse and Substance Dependence and collapsing them into a Substance Use Disorder.  Panic attacks can now be used as a symptom of another disorder without having to specify that the person has panic disorder and that is a pattern I have observed over the course of my career.  The controversial Personality Disorders section is unchanged but there is a hybrid diagnostic system that includes dimensional symptoms, the details of which (I think) are in the Appendix.  Mapped onto all of the diagnostic classification and criteria changes are a number of subtypes and specifiers as well as a number of ways to specify diagnostic certainty.  As with previous editions since DSM-III there is a mental disorder definition that indicates that behavior or criteria are not enough.  There must be functional impairment or distress.  The definition specifies that socially deviant behavior or conflicts between the individual and society do not constitute a mental illness unless that was the actual source of the conflict.

The overall impression at the end of these lectures was that this was a massive 18 year effort by the APA and hundreds and possibly thousands of volunteer psychiatrists and psychologists.  None of those volunteers has a financial stake in the final product.  Many of the criticisms were addressed in the process and many of the critics have a financial stake in the DSM-5 criticism industry.  The criticisms of the DSM-5 seem trivial compared with the process and built in safeguards.  The DSM-5 was also designed to be updated online instead of waiting for another massive effort to start to make modifications, hence this is not DSM-5 but DSM-5.0.

If Dr. Grant is lecturing in your area and you are a psychiatrist or a psychiatrist in training, these lectures are well worth attending.  If you have a chance to look at his Guidebook, I think that it will be a very interesting read.

George Dawson, MD, DFAPA

Supplementary 1:  The DSM-5 Guidebook by Donald W. Black, MD and Jon E. Grant, MD came out in March 2014.  Table 1.  (p.  xxiii) lists the total diagnoses is DSM-5 as 157 excluding "other specified and unspecified disorders". 


  1. I would certainly agree that there's been a massive process, but I'm not sure if that process has translated into much progress. I certainly appreciate the changes to autism and PTSD when it comes to child psychiatry, but diagnoses that were way too heterogeneous were unchanged (MDD) or made even broader (GAD).

    There's no denying the political nature of the process. At the APA, a Canadian expert in hebephilia was incensed that the diagnosis was not differentiated from pedophilia in DSM-5, despite the research evidence differentiating the two. When it comes to DMDD, Ellen Liebenluft, the person perhaps most responsible for that diagnosis coming about, said back in October that she's "about 65% pro-DMDD".

    So no matter how long or rigorous the process, how much DSM-5 will actually improve things for clinicians or patients remains to be seen.

    1. I think there are politics and then there are politics. Science as a necessary process can be quite political. There are rather famous political disagreements in all areas of math and science. Some scientists have made a career out of disagreement with a major figure. So the politics of the process don't bother me at all, I expect it. I think the format of the DSM-5 will make it easier to assess and drop what is not clinically useful in a much more timely manner without having to wait for the verdict on "Criteria Sets and Axes Provided for Further Study" in another 20 years.

      The problem I have with the political issue is that the detractors seem to frame this as an issue that only affects psychiatry and not the rest of medicine when that is not remotely true.

  2. George,

    You've certainly been following this closer than most folks I know. Can you comment on (or, have you already commented on) pharmaceutical industry involvement in the DSM-5? Was it attempted, did it happen, etc.?

    Thanks and take care,

    1. There was no direct pharmaceutical industry involvement. There was the usual bean counting to demonstrate the degree of an appearance of conflict of interest. That bean counting showed that 72% of the task force and work group members had no relationship with the pharma industry in 2011. Of the remaining fraction 12% received grant support, 10% were paid consultants, and 7% received honoraria.

      But I don't even consider this to be an issue. The detractors and deniers of psychiatry always march out this issue and to me it is meaningless and let me illustrate why. I probably spent 10 or 15 years working on Pharmacy and Therapeutics (P&T) Committees for large health care corporations. The structure of these committees was generally about 90% physicians and 10% PharmDs. In the beginning there was the implicit agreement that everyone was trying to save money for the company of which all of us were employees. P&T Committees generally do that in two ways - forcing the prescription of generic drugs or signing large deals with manufacturers distributors as in "we will give you a deal on this drug if you eliminate competing compounds from a class and use our other drug(s) exclusively. Health care organizations, the middlemen, and the manufacturers are all making money on those deals and it is a direct elimination of competition in order to make that money. The other issue with PBMs is that even if a doctor wanted to get their favorite drug on a formulary it would be impossible. They would have to be able to convince the other 20 members on scientific merit and the administrators in the room that it made better business sense. Despite the deck being stacked in their favor, they wanted me to sign what was basically a loyalty pledge. That was an insult and the day I quit.

      The whole notion that somebody who is being paid by the pharmaceutical industry will influence a process that is much more complicated than a P & T Committee and has clear fidelity markers is absurd to me, but then again so is much of the criticism levelled at the DSM process. The idea that the appearance of conflict of interest in psychiatry means more than actual conflict of interest outside of psychiatry with billions of dollars in play is even more absurd, but it is all part of the criticize and deny psychiatry industry.

  3. Thanks, George. I hadn't actually heard any rumors or accusations. I suppose it was just my cynical nature coming forth.

    Keep on keeping on. I'm enjoying your posts and have been trying to read more regularly lately. I'm a bit busy w/ my bees, but I'll keep visiting real-psychiatry here.