Zarate CINP 2002

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Research Planning for Future Psychiatric
Classifications Darrel A. Regier, M.D.,
M.P.H. Executive Director, American Psychiatric
Institute For Research and Education
and Director, Division of Research, American
Psychiatric Association Vice-chair, DSM-V Task
Force The 99th Meeting of the National Advisory
Council on Drug Abuse Wednesday, May 14, 2008
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Overview

• Darrel A. Regier, M.D., M.P.H. Review of
  conference series output and research
  implications
• David J. Kupfer, M.D. Update status of task
  force activities
• Charles OBrien, M.D., Ph.D. Update on work
  group activities

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Perceived Shortcomings in DSM-IV

• High rates of comorbidity
• High use of NOS category
• Treatment non-specificity
• Inability to find a laboratory markers/ tests
• DSM is starting to hinder research progress

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New Developments

• Pressures to improve validity
• Move toward an Etiologically Based
  Classification
• Are there data in these areas that can be helpful
  in developing/changing/refining diagnoses?
• cognitive or behavioral science
• family studies and molecular genetics
• neuroscience
• Requires a Paradigm Shift
• Neo-Kraepelinian to ??

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Strategies for Improving DSM

• Incorporate research into the revision and
  evolution of the classification
• Move beyond a process of clinical consensus and
  build diagnoses on a foundation of empirical
  findings from scientific disciplines
• Seek multidisciplinary, international scientific
  participation in the task of planning the DSM-V
  revision

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Planning for DSM-V

• 1999-2002 three initial work conferences and
  six white papers
• Identification of gaps

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2003

• APIRE obtains 1.1M NIH conference grant for
  DSM/ICD dx research planning
• 13 Conferences over 5 years
• APIRE commissions 3 additional White Papers
• Infant/Young Child, Sex/Gender, Geriatric Mental
  Health

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Aims of Research Review
Work Groups and Conferences

• To promote international collaboration among
  members of the scientific community in order to
  increase the likelihood of developing a future
  unified DSM/ICD
• To stimulate the empirical research necessary to
  allow informed decision making regarding crucial
  diagnostic deficiencies identified in the current
  nosology

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Conference Output

• Initial publication of papers in relevant
  peer-reviewed journals, e.g., Journal of
  Personality Disorders, Addiction, Journal of
  Geriatric Psychiatry and Neurology, Psychosomatic
  Medicine, Schizophrenia Bulletin, International
  Journal of Methods in Psychiatric Research
• American Psychiatric Publishing Inc. (APPI)
  publishing monograph proceedings of all
  conferences
• Special sessions at international forums

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Conference Output

• 13 Conferences (2004-07)
• 5 internationally-held
• 4 monographs published
• Diagnostic Issues in Substance Use Disorders
• Diagnostic Issues in Dementia
• Dimensional Models of Personality Disorders
• Dimensional Approaches in Diagnostic
  Classification
• 4 monographs in press
• 4 monographs in preparation
• 83 journal articles published

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Sept. 2006, Vol 101, Supp 1.
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Diagnostic Issues in
Substance Use Disorders Rockville, MD February
16, 2005
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Substance Use Disorders Conference
Representatives

• SUD conference representative at each conference,
  except Autism and Pervasive Developmental
  Disorders
• Examination of impact of co-occurrence of SUDs
  with each specific diagnostic topic
• Emphasized importance of SUD in conceptualizing
  diagnoses and etiologies

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Substance Use Disorders Conference
Representatives
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Research Implications

• Dimensional vs. categorical classification
• Facilitating etiology research
• Retaining face validity
• Implications for genotyping
• Issues of nomenclature
• Non-substance use addictions, or behavioral
  compulsions
• addiction versus dependence

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On the Road to DSM-V and ICD-11 David J.
Kupfer, M.D. University of Pittsburgh Medical
Center Western Psychiatric Institute and
Clinic The 99th Meeting of the National Advisory
Council on Drug Abuse Wednesday, May
14, 2008
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Revision Principles

• The highest priority in modifying DSM-V should be
  optimizing clinical utility
• Recommendations should be guided by research
  evidence
• Continuity with previous editions should be
  maintained
• Unlike in DSM-IV, there will be no a priori
  constraints on the degree of change between
  DSM-IV and DSM-V

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Revision Principles 2

• Development across the life span
• Dimensional concepts measurement of distress,
  disability and severity
• Incorporation of new knowledge risk factors,
  prodromes, prevention
• Living document

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Toward DSM-V and ICD-11

• The object is to facilitate the highest
  possible extent of uniformity and harmonization
  between ICD-11 mental and behavioral disorders
  and DSM-V disorders and their definitions

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Initial List of Tasks and Activities

• Harmonize the timeline of both revision processes
• Considering severity as a separate dimension
• Considering disability/impairment/functioning as
  a separate dimension
• Review and identification of broad/super-ordinate
  categories of diagnosis

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DSM-V

• Task Force
• Workgroup chairs
• Health professionals from stakeholder groups

• Workgroups
• Members work in specific diagnostic areas
• Advisors for workgroups

http//www.dsm5.org
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Overall DSM-V Task Force

• Broadly based Task Force (TF) to oversee
  Workgroup chairs and committees for every
  diagnostic area
• TF and Workgroups will assess the readiness
  of individual disorders to incorporate
  biological measures and dimensional approaches
• TF will work closely to utilize the
  recommenda-tions derived from the 13 research
  conferences
• TF will coordinate closely its efforts with the
  WHO / ICD developments
• Study Groups

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Cross-Cutting Study Groups

• Diagnostic Spectra
• Life Span Developmental Approach Study Group
• Gender and Cross-Cultural Study Group
• Psychiatric/General Medical Interface Study Group

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Possible Validators for Diagnostic Groupings

• Neural substrates
• Familiality
• Genetic risk factors
• Specific environmental risk factors
• Biomarkers

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Possible Validators for Diagnostic Groupings

• Temperamental antecedents
• Symptom similarity
• Abnormality of cognitive or emotional processing
• Course of illness
• High rates of comorbidity
• Treatment response

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DSM-V Timeline
2003-2008 APA/WHO/NIH Research Conferences
1999-2002 Research Agenda For DSM-V
2007- 2011 DSM-V Workgroups
2012 DSM-V
2007 Infant, Gender, Geriatric
2004 Prelude Page Launched
2014 ICD-11
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DSM-V Substance Use Disorders Current
Status Charles P. OBrien, M.D.,
Ph.D. University of Pennsylvania Philadelphia VA
Medical Center The 99th Meeting of the National
Advisory Council on Drug
Abuse Wednesday, May 14, 2008
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SUD Work Group
C. OBrien, Chair T. Crowley, Co-chair M.
Auriacombe D. Hasin G. Borges W. Ling K.
Bucholz S. Manson A. Budney T. McLellan W.
Compton H. Moss B. Grant N. Petry M.
Schuckit Plus large cast of advisers DSM-V Task
Force Member Liaisons to SUD Work Group
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Deliberative Process
Work group divided into small sub-committees
Frequent teleconferences Present findings to
large work group at meetings and conference
calls Review DSM IV Where can it be
improved? What are the opportunities to move
beyond behavioral criteria and use biomarkers?
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Issues currently under active discussion and
research
Non-substance addictions Gambling Computer
games, etc. List of candidates still under
discussion Chair N. Petry Collaborating with
Impulse control disorders group
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Issues
Cannabis withdrawal Chair Alan
Budney Dimensions v. Categories, experimental
criteria applied to large databases, need for
abuse category Chair Howard
Moss Bio-markers Chair Deborah
Hasin Terminology Dependence v.
Addiction Should criteria be substance
specific? Whole work group is addressing these
issues
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Possible field trials
Co-morbidity in treatment programs SUD and
OCD SUD and Compulsive Gambling Reanalysis of
large databases NESARC Cross cultural
data Bio-markers Brain imaging comparisons, e.g.
gambling and SUD