hacia el dsm-5 - renato alarcón

Hacia el DSMHacia el DSM--5: 5: Controversias, Logros y Controversias, Logros y

PerspectivasPerspectivas

Renato D. AlarcRenato D. Alarcóón, MD, MPHn, MD, MPHTitular de la CTitular de la Cáátedra Honorio Delgado, UPCH, tedra Honorio Delgado, UPCH, Lima, PerLima, Perúú; Profesor de Psiquiatr; Profesor de Psiquiatríía, Mayo a, Mayo Clinic College of Medicine, Rochester, MN, Clinic College of Medicine, Rochester, MN,

Estados UnidosEstados Unidos

Estructura de la PresentaciEstructura de la Presentacióónn

�� Breve historia y debates contemporBreve historia y debates contemporááneos en neos en torno al Diagntorno al Diagnóóstico Psiquistico Psiquiáátrico trico

�� Programa de Trabajo para la elaboraciPrograma de Trabajo para la elaboracióón del n del DSMDSM--55

�� CaracterCaracteríísticas principales del nuevo modelosticas principales del nuevo modelo�� Debates y controversias en Grupos de Trabajo y Debates y controversias en Grupos de Trabajo y a nivel pa nivel púúblicoblico

�� Propuestas recientes y Perspectivas futurasPropuestas recientes y Perspectivas futuras�� Reflexiones finalesReflexiones finales

Psychiatric diagnosis in the Psychiatric diagnosis in the labyrinths of the labyrinths of the ““Global VillageGlobal Village””

Psychiatric

Dx

WPA

WHO

Ntl/Reg

Glossaries

APANIMH

El diagnEl diagnóóstico en Psiquiatrstico en Psiquiatríía: La odisea a: La odisea de un nuevo lenguaje para la de un nuevo lenguaje para la ““aldea aldea

globalglobal””

�� La globalizaciLa globalizacióón y su impacton y su impacto�� Abordajes contemporAbordajes contemporááneosneos–– Conflictos de escuelaConflictos de escuela–– Dx categDx categóórico vs. dimensionalrico vs. dimensional–– Perspectiva axialPerspectiva axial–– ParticipaciParticipacióón internacionaln internacional

El diagnóstico psiquiátrico en la escena internacional contemporánea

�� ÉÉnfasis en los nfasis en los ““dominios de dominios de informaciinformacióónn”” (ejes)(ejes)

�� Normas Internacionales de EvaluaciNormas Internacionales de Evaluacióón n DiagnDiagnóóstica (AMP)stica (AMP)

�� FormulaciFormulacióón personalizada o idiogrn personalizada o idiográáficafica�� Esfuerzos de conciliaciEsfuerzos de conciliacióón y presentacin y presentacióón n de investigaciones (APA, OMS, AMP)de investigaciones (APA, OMS, AMP)

Debates contemporDebates contemporááneos en neos en torno al diagntorno al diagnóóstico psiquistico psiquiáátricotrico

�� TerminologTerminologííaa�� Base(s) cientBase(s) cientíífica(s)fica(s)�� Aspectos polAspectos polííticosticos�� Niveles de aplicabilidad prNiveles de aplicabilidad práácticactica�� Escenarios clEscenarios clíínicosnicos�� Adaptabilidad culturalAdaptabilidad cultural

ÁÁreasreas--problema en el Diagnproblema en el Diagnóósticosticopsiquipsiquiáátrico: Limitaciones del DSM IV trico: Limitaciones del DSM IV TRTR

�� Criterios descriptivos debidos a informaciCriterios descriptivos debidos a informacióón limitada n limitada sobre etiologsobre etiologíía y patofisiologa y patofisiologíía de los trastornos a de los trastornos mentalesmentales

�� Sistemas basados en Sistemas basados en ““consenso de expertosconsenso de expertos””-- Criterios Criterios son mezcla de rasgos y sson mezcla de rasgos y sííntomasntomas

�� RelaciRelacióón poco clara entre validez, severidad, n poco clara entre validez, severidad, discapacidad y aspectos cuantitativos del discapacidad y aspectos cuantitativos del diagndiagnóóstico/stico/““Puntos de cortePuntos de corte””

�� Altos niveles de comorbilidad y excesivo nAltos niveles de comorbilidad y excesivo núúmero de mero de diagndiagnóósticos sticos ““no especificados de otra manerano especificados de otra manera”” (NOS)(NOS)

�� Carencia de signos patognomCarencia de signos patognomóónicos, marcadores nicos, marcadores biolbiolóógicos o tratamientos especgicos o tratamientos especííficos (con polifarmacia ficos (con polifarmacia resultante) resultante)

�� Debilidad de componentes socioDebilidad de componentes socio--culturalesculturales

ÁÁreasreas--problema en el Diagnproblema en el Diagnóóstico stico PsiquiPsiquiáátrico: Limitaciones del DSM IV trico: Limitaciones del DSM IV

TRTR

�� El enfoque multiaxal no capta todos los componentes El enfoque multiaxal no capta todos los componentes esenciales de las categoresenciales de las categoríías diagnas diagnóósticassticas

�� Edad y variantes del desarrollo son ignoradasEdad y variantes del desarrollo son ignoradas�� Heterogeneidad entre pacientes con el mismo Heterogeneidad entre pacientes con el mismo diagndiagnóósticostico

�� El curso clEl curso clíínico puede ser/parecer prenico puede ser/parecer pre--determinado y determinado y artificialartificial

�� Criterios de respuesta clCriterios de respuesta clíínica ausentes o poco nica ausentes o poco úútilestiles�� El diagnEl diagnóóstico diferencial puede ser dificil y confusostico diferencial puede ser dificil y confuso

PSYCHIATRIC

DIAGNOSIS

NOMENCLATURE NEUROSCIENCE

GAPS/Ax. II DEVELOPMENTAL

ISSUES

DISABILITIESCULTURAL

ISSUES

DSM-V: INITIAL WORK GROUPS (2002)

En ruta al DSMEn ruta al DSM--V: Programa de V: Programa de Trabajo de la APA (I)Trabajo de la APA (I)

�� 19991999--2002: 2002: ““Papeles de TrabajoPapeles de Trabajo”” y publicaciy publicacióón n de de Una Agenda de InvestigaciUna Agenda de Investigacióón para la DSMn para la DSM--V V (2003: adici(2003: adicióón de secciones sobre Gn de secciones sobre Géénero y nero y OrientaciOrientacióón Sexual)n Sexual)

�� 20022002--2007:2007: Doce conferencias internacionales Doce conferencias internacionales (sobre entidades cl(sobre entidades clíínicas especnicas especííficas, ficas, investigaciinvestigacióón, tratamiento, e Implicacin, tratamiento, e Implicacióónes en nes en Salud PSalud Púública,) auspiciadas por APA, NIMH, blica,) auspiciadas por APA, NIMH, WHO, y WPA.WHO, y WPA.

Hacia el DSMHacia el DSM--5: Programa de 5: Programa de Trabajo de la APA (II)Trabajo de la APA (II)

�� 2006: Nombramiento del Comit2006: Nombramiento del Comitéé del DSMdel DSM--5 y del Grupo 5 y del Grupo de Investigacide Investigacióón.n.

�� 2007: Creaci2007: Creacióón de 12 (mn de 12 (máás 2) Grupos de Trabajo and s 2) Grupos de Trabajo and cuatro (mcuatro (máás 2) Grupos de Estudio.s 2) Grupos de Estudio.

�� 2008: Anuncio oficial de la membresia del Comit2008: Anuncio oficial de la membresia del Comitéé y de y de los Grupos: 163, 124 de los E.E.U.U., 103 psiquiatras, 47 los Grupos: 163, 124 de los E.E.U.U., 103 psiquiatras, 47 psicpsicóólogos, 18 epidemilogos, 18 epidemióólogos, 30 % mujeres, 18 % no logos, 30 % mujeres, 18 % no ““CaucCaucáásicossicos”” y 24 consultores internacionalesy 24 consultores internacionales

�� 20092009--2012: Revisiones de la literatura, An2012: Revisiones de la literatura, Anáálisis de lisis de bancos de datos, Informes de los Grupos, Pruebas de bancos de datos, Informes de los Grupos, Pruebas de campo.campo.

�� 2013: Publicaci2013: Publicacióón del DSMn del DSM--55

Principios Generales en el Principios Generales en el desarrollo del DSMdesarrollo del DSM--55

�� Recomendaciones deberRecomendaciones deberáán basarse en evidencias de n basarse en evidencias de investigaciinvestigacióónn

�� Mantenimiento de continuidad con ediciones previas del Mantenimiento de continuidad con ediciones previas del DSMDSM

�� No hay restricciones No hay restricciones a prioria priori en el nivel de cambios entre en el nivel de cambios entre DSMDSM--IV y DSMIV y DSM--5 5

�� ConsideraciConsideracióón cuidadosa de temas de aplicacin cuidadosa de temas de aplicacióón global n global (cross(cross--cutting)cutting) en el desarrollo de nuevos criterios en el desarrollo de nuevos criterios (operacionalizaci(operacionalizacióón y aplicaciones intern y aplicaciones inter--culturales)culturales)

�� Documento que permita y favorezca avances en Documento que permita y favorezca avances en investigaciinvestigacióónn

En ruta al DSMEn ruta al DSM--5: Los 14 5: Los 14 Grupos de Trabajo Grupos de Trabajo

�� Trastornos de Ansiedad, Trastornos de Ansiedad, Espectro OEspectro O--C y TEPT C y TEPT

�� TDATDA--H y Trastornos de H y Trastornos de Conducta DisruptivaConducta Disruptiva

�� Trastornos de Infancia y Trastornos de Infancia y AdolescenciaAdolescencia

�� Trastornos del Trastornos del NeurodesarrolloNeurodesarrollo

�� Trastornos NeurocognitivosTrastornos Neurocognitivos�� Trastornos alimentariosTrastornos alimentarios�� Trastornos del AnimoTrastornos del Animo

�� Personalidad y Trastornos de Personalidad y Trastornos de PersonalidadPersonalidad

�� Trastornos PsicTrastornos Psicóóticosticos�� Trastornos de Genero e Trastornos de Genero e Identidad SexualIdentidad Sexual

�� Trastornos de Sueno y VigiliaTrastornos de Sueno y Vigilia�� Trastornos DisociativosTrastornos Disociativos�� Trastornos SomatomorfosTrastornos Somatomorfos�� Trastornos de Abuso de Trastornos de Abuso de SustanciasSustancias

En ruta al DSMEn ruta al DSM--5: Los seis 5: Los seis Grupos de EstudioGrupos de Estudio

�� Aspectos del Ciclo Vital y del Desarrollo.Aspectos del Ciclo Vital y del Desarrollo.�� Espectros diagnEspectros diagnóósticos.sticos.�� InterrelaciInterrelacióón Psiquiatrn Psiquiatríía/Medicina a/Medicina General.General.

�� Temas de GTemas de Géénero y Aspectos nero y Aspectos TransculturalesTransculturales

�� EvaluaciEvaluacióón de Discapacidadesn de Discapacidades�� Instrumentos diagnInstrumentos diagnóósticos y de sticos y de medicimedicióón cuantitativan cuantitativa

Algunos temas controversiales Algunos temas controversiales de caracter general (I)de caracter general (I)

�� DefiniciDefinicióón de Trastorno Mentaln de Trastorno Mental�� ¿¿SobrevivirSobreviviráá el enfoque multiaxial?el enfoque multiaxial?�� ConsolidaciConsolidacióón de entidades nosoln de entidades nosolóógicasgicas�� EvaluaciEvaluacióón de factores de riesgo y de n de factores de riesgo y de protecciproteccióónn

�� IncorporaciIncorporacióón de la experiencia subjetiva del n de la experiencia subjetiva del pacientepaciente

�� AdmisiAdmisióón de insuficiente informacin de insuficiente informacióón n neurobiolneurobiolóógicagica

Algunos temas controversiales Algunos temas controversiales de caracter general (II)de caracter general (II)

�� Cambios de nombres, eliminaciCambios de nombres, eliminacióón de algunos n de algunos trastornos y creacitrastornos y creacióón de otrosn de otros

�� ¿¿Diferentes versiones de la prDiferentes versiones de la prááctica clctica clíínica y nica y la investigacila investigacióón? n? –– Propuesta del INSM Propuesta del INSM

�� Un Manual mUn Manual máás s ““amigableamigable””�� Impacto de los factores culturales en la Impacto de los factores culturales en la causalidad y la expresicausalidad y la expresióón de los sn de los sííntomas. ntomas.

�� ¿¿MMáás alls alláá del del ““diagndiagnóóstico basado en la stico basado en la evidenciaevidencia””??

Algunos ejemplos de temas Algunos ejemplos de temas discutidos por Grupos de Trabajodiscutidos por Grupos de Trabajo

Trastornos del Trastornos del ÁÁnimonimo

�� RemociRemocióón del Tr. Bipolar I, n del Tr. Bipolar I, Episodio MixtoEpisodio Mixto

�� AdiciAdicióón de Depresin de Depresióón Ansiosan Ansiosa�� InclusiInclusióón de Tr. Disfn de Tr. Disfóórico rico PremenstrualPremenstrual

�� Cambios en Tr. CiclotCambios en Tr. Ciclotíímicomico�� CreaciCreacióón de Tr. de n de Tr. de DisregulaciDisregulacióón Temperamental n Temperamental con Disforiacon Disforia

�� SuicidioSuicidio

Trastornos de Trastornos de PersonalidadPersonalidad

�� AplicaciAplicacióón del modelo n del modelo dimensionaldimensional

�� Niveles de funcionamiento y Niveles de funcionamiento y secuencia diagnsecuencia diagnóósticastica

�� UtilizaciUtilizacióón y agrupacin y agrupacióón de n de RasgosRasgos

�� UbicaciUbicacióón del Trastorno n del Trastorno EsquizotEsquizotíípicopico

�� ExclusiExclusióón de tipos Narcisista, n de tipos Narcisista, HistriHistrióónico, Esquizoide, nico, Esquizoide, Paranoide y DependienteParanoide y Dependiente

OnOn--line Public Response to line Public Response to DSMDSM--5 Initial Proposals5 Initial Proposals

�� More than 50,000 hits in two weeksMore than 50,000 hits in two weeks

�� More than 2000 general commentsMore than 2000 general comments

�� Close to 7000 comments on specific Close to 7000 comments on specific disorders (mainly Cognitive, disorders (mainly Cognitive, Developmental, Childhood and Developmental, Childhood and Adolescence disorders)Adolescence disorders)

Public Survey on DSMPublic Survey on DSM--5 Initial 5 Initial Proposals (APA 2010 Meeting)Proposals (APA 2010 Meeting)

DisorderDisorder

Opinions About InclusionOpinions About Inclusion

New New DisDis--orderorder

SpecSpec--ifierifier

SubSub--sumedsumed

Further Further ResearchResearch/ Appendix/ Appendix

Not Not acceptaccept--ableable

OtherOther

GA and Worry Disorder GA and Worry Disorder 10%10% 30%30%

Public Survey on DSMPublic Survey on DSM--5 Initial 5 Initial Proposals (APA Meeting 2010)Proposals (APA Meeting 2010)

Disorder Disorder


New New DisDis--order order


SubSub--sumedsumed



OtherOther


Mixed Anxiety & Depression Mixed Anxiety & Depression (Anxious Depression)(Anxious Depression)

40%40% 20%20%


Disorder Disorder




SubSub--sumedsumed



OtherOther



40%40% 20%20%

Complicated GriefComplicated Grief 30%30% 30%30%


Disorder Disorder




SubSub--sumedsumed



OtherOther



40%40% 20%20%


Developmental Traumatic Developmental Traumatic Disorder Disorder 18%18% 27%27% 36%36%


Disorder Disorder




SubSub--sumedsumed



OtherOther



40%40% 20%20%



Premenstrual Dysphoric Premenstrual Dysphoric Disorder Disorder 50%50% 17%17% 33%33%


Disorder Disorder




SubSub--sumedsumed



OtherOther



40%40% 20%20%




Parental Alienation Disorder Parental Alienation Disorder 8%8% 38%38% 31%31%


Disorder Disorder




SubSub--sumedsumed



OtherOther



40%40% 20%20%




Parental Alienation Disorder Parental Alienation Disorder 8%8% 38%38% 31%31%

Temper Dysregulation Temper Dysregulation DysphoriaDysphoria 33%33% 22%22% 17%17% 56%56%


Disorder Disorder




SubSub--sumedsumed



OtherOther

Sensory Processing Disorder Sensory Processing Disorder (Children without autism)(Children without autism) 27%27% 37%37% 36%36%


Disorder Disorder




SubSub--sumedsumed



OtherOther


Schizoaffective Disorder Schizoaffective Disorder 47%47% 20%20%


Disorder Disorder




SubSub--sumedsumed



OtherOther



Attenuated Psychotic Attenuated Psychotic Disorder Disorder 33%33% 17%17% 17%17% 33%33%


Disorder Disorder




SubSub--sumedsumed



OtherOther




Hypersexual Disorder (Not Hypersexual Disorder (Not Addiction)Addiction) 29%29% 43%43% 28%28%


Disorder Disorder




SubSub--sumedsumed



OtherOther





Paraphilic Coercive Disorder Paraphilic Coercive Disorder (Rapists)(Rapists) 27%27% 33%33% 40%40%


Disorder Disorder




SubSub--sumedsumed



OtherOther






Internet AddictionInternet Addiction 27%27% 13%13% 40%40%


Disorder Disorder




SubSub--sumedsumed



OtherOther







Fetal Alcohol SyndromeFetal Alcohol Syndrome 44%44% 19%19% 6%6%


Disorder Disorder




SubSub--sumedsumed



OtherOther







Fetal Alcohol SyndromeFetal Alcohol Syndrome 44%44% 19%19% 6%6%

Binge Eating Disorder Binge Eating Disorder 33%33% 27%27% 33%33%


OTHER QUESTIONSOTHER QUESTIONSOPINIONSOPINIONS

Agree Agree StronglyStrongly AgreeAgree DisagreeDisagree Disagree Disagree

StronglyStrongly

Is the label Is the label ““Drug and Alcohol Use Drug and Alcohol Use DisorderDisorder”” acceptable?acceptable? 63%63% 25%25% 10%10% 2%2%




StronglyStrongly


Shall Shall ““Gambling DisorderGambling Disorder”” be moved be moved to Addiction Disorders?to Addiction Disorders? 33%33% 7%7% 40%40% 20%20%




StronglyStrongly



Is Is ““Autism Spectrum DisorderAutism Spectrum Disorder””acceptable?acceptable? 56%56% 19%19% 13%13% 13%13%




StronglyStrongly




Should Should ““Fetal Alcohol SyndromeFetal Alcohol Syndrome”” be be considered a Developmental considered a Developmental Neurocognitive Disorder?Neurocognitive Disorder?

44%44% 20%20% 5%5% 6%6%




StronglyStrongly




Should Should ““Fetal Alcohol SyndromeFetal Alcohol Syndrome”” be be considered a Developmental considered a Developmental Neurocognitive Disorder?Neurocognitive Disorder?

44%44% 20%20% 5%5% 6%6%

Is a distinction between Is a distinction between ““MajorMajor”” and and ““MinorMinor”” Cognitive Disorder Cognitive Disorder acceptable?acceptable?

47%47% 13%13%




StronglyStrongly

Should Personality Disorders be Should Personality Disorders be integrated into Axis I?integrated into Axis I? 27%27% 33%33%




StronglyStrongly


Is the use of Personality Disorder Is the use of Personality Disorder labels derogatory?labels derogatory? 14%14% 14%14% 57%57% 14%14%




StronglyStrongly


Is the use of Personality Disorder Is the use of Personality Disorder labels derogatory?labels derogatory? 14%14% 14%14% 57%57% 14%14%

Should the label Schizophrenia Should the label Schizophrenia remain?remain? 69%69% 10%10% 10%10% 6%6%

MetaMeta--structure proposals for structure proposals for DSMDSM--5 and ICD5 and ICD--11, Chapter V11, Chapter V

�� To serve as a chapter organization for To serve as a chapter organization for DSMDSM--5, and as linear structure for ICD5, and as linear structure for ICD--1111

�� May influence the text of DSMMay influence the text of DSM--5 but is 5 but is neutral re: individual disordersneutral re: individual disorders’’ criteriacriteria

�� Meeting of WHO International Advisory Meeting of WHO International Advisory Group and APA, Geneva, June 21Group and APA, Geneva, June 21--22, 22, 20102010

�� Overall goal: Harmonization of the two Overall goal: Harmonization of the two classificationsclassifications


�� ICD volume stipulates no more than 10 large ICD volume stipulates no more than 10 large clusters (based on a decimal coding system)clusters (based on a decimal coding system)

�� The U.S. will have to adopt the structure of ICDThe U.S. will have to adopt the structure of ICD--10 CM in October 2013, and DSM10 CM in October 2013, and DSM--5 has to 5 has to comply with that structurecomply with that structure

�� DSMDSM--5 will then have a maximum of 10 5 will then have a maximum of 10 chapters, instead of DSMchapters, instead of DSM--IVIV’’s 16, and the 14 s 16, and the 14 current Work Groupscurrent Work Groups

�� Construction of Primary Care version of ICDConstruction of Primary Care version of ICD--11, 11, and NIMHand NIMH’’s Research Domain Diagnostic Criteria s Research Domain Diagnostic Criteria (RDoC)(RDoC)


�� DSMDSM--55’’s initial clustering was based on etiology, s initial clustering was based on etiology, pathophysiology or neuropathology pathophysiology or neuropathology

�� Neurobiological validators were discarded Neurobiological validators were discarded ““because because knowledge was so scantknowledge was so scant””, so diagnosis , so diagnosis ““must rely more must rely more strongly on clinical featuresstrongly on clinical features””

�� Goal of the structure: Goal of the structure: ““To organize, as best we can, To organize, as best we can, without sacrificing clinical utility, according to our most without sacrificing clinical utility, according to our most compelling and best replicated scientific hypotheses with compelling and best replicated scientific hypotheses with a view to facilitating the science that will cut across the a view to facilitating the science that will cut across the disease boundaries that were constructed for DSMdisease boundaries that were constructed for DSM--III III and in many cases have become reifiedand in many cases have become reified””

�� Proposal of two alternative versions of the MetaProposal of two alternative versions of the Meta--structurestructure


VERSION 1VERSION 1�� PDs distributed (dispersed) across the PDs distributed (dispersed) across the classification structure rather than clustered, classification structure rather than clustered, based on: based on: –– Clinical similarities with disorders from other chapters Clinical similarities with disorders from other chapters (i.e. Schizotypal PD and Schizophrenia)(i.e. Schizotypal PD and Schizophrenia)

–– Desirability of investigating shared etiology, Desirability of investigating shared etiology, pathophysiology and clinical featurespathophysiology and clinical features

** ADHD is placed in F6, Impulse Control ** ADHD is placed in F6, Impulse Control Disorders Disorders


VERSION 2VERSION 2�� Personality Disorders are clustered in F8, based Personality Disorders are clustered in F8, based on:on:–– Frequent comorbidities with other PDsFrequent comorbidities with other PDs–– Use of dimensional approach from normal variations Use of dimensional approach from normal variations to shared domains of dysfunction to shared domains of dysfunction

�� Two alternative placements for ADHD: Two alternative placements for ADHD: Developmental Disorders (F1)Developmental Disorders (F1) because of age of because of age of onset and delays in cerebral cortex maturation; onset and delays in cerebral cortex maturation; and and Impulse Control Disorders (F6),Impulse Control Disorders (F6), based on based on cognitive and behavioral deficits and high cognitive and behavioral deficits and high frequency of comorbiditiesfrequency of comorbidities


OTHER POINTS OF DEBATEOTHER POINTS OF DEBATE

�� Externalizing Disorders instead of Impulse Control Externalizing Disorders instead of Impulse Control Disorders and to include Substance Use DisordersDisorders and to include Substance Use Disorders

�� SubstanceSubstance--related Disorders subsuming them with related Disorders subsuming them with Antisocial and Impulse Control Disorders as three Antisocial and Impulse Control Disorders as three clusters within a large grouping (based on symptoms, clusters within a large grouping (based on symptoms, comorbidity and likely neural circuitry)comorbidity and likely neural circuitry)

�� Placement of GAD with Major Depression based on: Placement of GAD with Major Depression based on: –– Shared genetic risksShared genetic risks–– High rates of comorbidityHigh rates of comorbidity–– Implications for primary care Implications for primary care

Draft MetaDraft Meta--structure for DSMstructure for DSM--5 5

DSMDSM--5 Category5 Category DSMDSM--5 5 SubcategorySubcategory

DSMDSM--5 Proposed 5 Proposed DisordersDisorders

FF--0 0 Neurodevelopmental Neurodevelopmental Disorders Disorders

General General Neurodevelopmental Neurodevelopmental Cognitive Disorders Cognitive Disorders

Intellectual Disability Intellectual Disability Intllectual or Global Intllectual or Global Developmental DelayDevelopmental Delay

Learning DisordersLearning Disorders Learning Disability, Learning Disability, Unspecified TypeUnspecified TypeLD, Dyslexia TypeLD, Dyslexia TypeLD, Dyscalculia TypeLD, Dyscalculia Type

Autism Spectrum Autism Spectrum DisordersDisorders

Autism Spectrum Autism Spectrum Disorders (Fragile X, Rett, Disorders (Fragile X, Rett, ??Asperger, etc.)??Asperger, etc.)




FF--0 0 Neurodevelopmental Neurodevelopmental Disorders Disorders

Attention Attention Deficit/Hyperactivity Deficit/Hyperactivity Disorder Disorder

ADHD *SpecifyADHD *SpecifyCombined PresentationCombined PresentationPredominantly HyperactivePredominantly HyperactivePredominantly InattentivePredominantly InattentiveInattentive/RestrictiveInattentive/Restrictive

Communication Communication DisordersDisorders

ChildChild--onset Fluency onset Fluency Disorder (Stuttering) Disorder (Stuttering) Late language emergenceLate language emergenceLanguage Impairment (LI)Language Impairment (LI)LI, specificLI, specificLI, Social Communication LI, Social Communication DisorderDisorder

Draft MetaDraft Meta--structure for DSMstructure for DSM--5 5 DSMDSM--5 Category5 Category DSMDSM--5 5

SubcategorySubcategoryDSMDSM--5 Proposed 5 Proposed DisordersDisorders

FF--1 Schizophrenia 1 Schizophrenia Spectrum and Spectrum and Psychotic Disorders Psychotic Disorders

Schizophrenia Schizophrenia SpectrumSpectrum

Schizophrenia Schizophrenia Schizophreniform Disorder Schizophreniform Disorder Schizoaffective DisorderSchizoaffective DisorderPersonality Disorder, Personality Disorder, Schizotypal Schizotypal

Other Psychotic Other Psychotic DisordersDisorders

Delusional DisorderDelusional DisorderBrief Psychotic DisorderBrief Psychotic DisorderAttenuated psychotic sx Attenuated psychotic sx syndromesyndromePsychotic Disorder due to Psychotic Disorder due to general medical condition (w/ general medical condition (w/ delusions, hallucinations)delusions, hallucinations)ETOH or DrugETOH or Drug--induced induced psychoses (w/ delusions, psychoses (w/ delusions, hallucinations)hallucinations)

Draft MetaDraft Meta--structure for DSMstructure for DSM--5 5 DSMDSM--5 Category5 Category DSMDSM--5 5

SubcategorySubcategoryDSMDSM--5 Proposed 5 Proposed DisordersDisorders

FF--2 Mood Disorders2 Mood Disorders Bipolar and Related Bipolar and Related Disorders Disorders

Bipolar I Disorder Bipolar I Disorder ––Most Most Recent Episode Recent Episode …….. .. Bipolar II DisorderBipolar II DisorderBipolar Disorder Not Bipolar Disorder Not Elsewhere Classified Elsewhere Classified (subsyndromal subtypes)(subsyndromal subtypes)Cyclothymic Disorder Cyclothymic Disorder

Distress Disorders Distress Disorders (primary negative (primary negative affect) affect)

MDD (Single, Recurrent)MDD (Single, Recurrent)Chronic MDDChronic MDDGA and Worry DisorderGA and Worry DisorderMixed Anxiety DepressionMixed Anxiety DepressionPMDDPMDDTDD with DysphoriaTDD with DysphoriaDepressive CNECDepressive CNEC

Draft MetaDraft Meta--structure for DSMstructure for DSM--55

�� FF--3 Anxiety and Stress Related Disorders3 Anxiety and Stress Related Disorders�� FF--4 Obsessive4 Obsessive--Compulsive Spectrum, Tics Compulsive Spectrum, Tics and Stereotypic Behavior Disordersand Stereotypic Behavior Disorders

�� FF--5 Somatic Disorders5 Somatic Disorders�� FF--6 Antisocial and Disruptive Behaviors6 Antisocial and Disruptive Behaviors�� FF--7 Substancr7 Substancr--Related, Gambling and Related, Gambling and Related DisordersRelated Disorders

�� FF--8 Neurocognitive Disorders8 Neurocognitive Disorders




FF--9 Other Disorders9 Other Disorders PD, Traits SpecifiedPD, Traits SpecifiedPD, Borderline TypePD, Borderline TypePD, OPD, O--C TypeC Type

Disorder of Infancy, Disorder of Infancy, Childhood, or Adolescence Childhood, or Adolescence NOSNOSCaffeineCaffeine--Induced Disorder Induced Disorder NOSNOSCatatonia due to GMC Catatonia due to GMC

NIMHNIMH’’s Proposal of Research s Proposal of Research Domain Criteria (RDoC)Domain Criteria (RDoC)

PREMISESPREMISES

�� Diagnostic categories based on clinical Diagnostic categories based on clinical consensus fail to align w/ findings from clinical consensus fail to align w/ findings from clinical neuroscience and geneticsneuroscience and genetics

�� Boundaries of the categories have not been Boundaries of the categories have not been predictive of treatment responsepredictive of treatment response

�� Categories based on signs and symptoms may Categories based on signs and symptoms may not capture fundamental underlying mechanisms not capture fundamental underlying mechanisms of dysfunction of dysfunction �� Slow development of new Slow development of new targeted treatmentstargeted treatments


ASSUMPTIONSASSUMPTIONS

�� Mental illnesses conceptualized as brain disorders Mental illnesses conceptualized as brain disorders (circuits)(circuits)

�� Neural circuits dysfunction can be identified with tools Neural circuits dysfunction can be identified with tools of Clinical Neuroscience (i.e.,electrophysiology, of Clinical Neuroscience (i.e.,electrophysiology, neuroimaging, quantitative connections)neuroimaging, quantitative connections)

�� Data from Genetics and Clinical Neuroscience will yield Data from Genetics and Clinical Neuroscience will yield ““biosignaturesbiosignatures”” that will augment clinical symptoms and that will augment clinical symptoms and signs for clinical managementsigns for clinical management

�� Examples of circuitryExamples of circuitry--behavior relationships: behavior relationships: fear/extinction, reward, executive functions, impulse fear/extinction, reward, executive functions, impulse control)control)


STEPSSTEPS

�� Launching of the RDoC Project (2009; Insel T., Launching of the RDoC Project (2009; Insel T., et al. et al. Am J PsychiatryAm J Psychiatry 2010; 176, 7: 7482010; 176, 7: 748--751)751)

�� Creation of a framework for research on Creation of a framework for research on pathophysiology (esp. Genomics and pathophysiology (esp. Genomics and Neuroscience)Neuroscience)

�� GoalsGoals–– Help identify new targets for treatment developmentHelp identify new targets for treatment development–– Detect subgroups for treatment selectionDetect subgroups for treatment selection–– Better match between research findings and clinical decisionBetter match between research findings and clinical decision--makingmaking


DEVELOPMENTSDEVELOPMENTS

�� Developmental Neuroscience: imaging genomics and early life Developmental Neuroscience: imaging genomics and early life programmingprogramming

�� Structural changes in the genome (copy number variations) Structural changes in the genome (copy number variations) associated with psychopathologyassociated with psychopathology

�� From measures of circuitry function upwards to clinically relevaFrom measures of circuitry function upwards to clinically relevant nt variation or downwards to genetic and molecular/cellular factorsvariation or downwards to genetic and molecular/cellular factorsthat influence such factorthat influence such factor

�� Matrix with rows (constructs of domains of function such as Matrix with rows (constructs of domains of function such as negative emotionality or cognition) and columns (different levelnegative emotionality or cognition) and columns (different levels of s of analysis: genetic, molecular, cellular, circuit level, individuaanalysis: genetic, molecular, cellular, circuit level, individual, family l, family environment and social context)environment and social context)

�� Samples of patients spanning multiple DSM diagnoses: independentSamples of patients spanning multiple DSM diagnoses: independentvariables might be specified from any level of analys; dependentvariables might be specified from any level of analys; dependentvariables chosen from one or more other columns.variables chosen from one or more other columns.

Future steps in the Future steps in the development of DSMdevelopment of DSM--55

�� Field Trials (FTs) Phase I (Pilot, July/August, Field Trials (FTs) Phase I (Pilot, July/August, 20102010--March/April 31, 2011) March/April 31, 2011) (Academic and large (Academic and large clinical settings)clinical settings)

�� Beginning of text drafting (December 2010Beginning of text drafting (December 2010--March 2011)March 2011)

�� Development of casebooks (July 2010Development of casebooks (July 2010--March March 2011)2011)

�� Ongoing consumer feedbackOngoing consumer feedback�� Revisions of criteria and measures (MarchRevisions of criteria and measures (March--April, April, 2011)2011)

Future steps in the Future steps in the development of DSMdevelopment of DSM--5 (II)5 (II)

�� Internal review of the revised draft criteria Internal review of the revised draft criteria based on Phase FT results (Maybased on Phase FT results (May--June 2011) June 2011) (To (To be posted on Web site)be posted on Web site)

�� Meeting DSMMeeting DSM--5/ICD5/ICD--11 Harmonization 11 Harmonization Committee (April 2011)Committee (April 2011)

�� Field Trials Phase II (December 2010Field Trials Phase II (December 2010--February February 2012) 2012) (Routine clinical practice settings)(Routine clinical practice settings)

�� DSMDSM--5 Interactive Workshops at APA and IPS 5 Interactive Workshops at APA and IPS Annual Meetings (May and October 2012)Annual Meetings (May and October 2012)

Future steps in the Future steps in the development of DSMdevelopment of DSM--5 (III)5 (III)�� Final draft text and criteria for review Final draft text and criteria for review (February(February--August 2012)August 2012)

�� Presentation of DSMPresentation of DSM--5 structure to APA5 structure to APA’’s s Board of Trustees (March 2012)Board of Trustees (March 2012)

�� Presentation of draft criteria to Assembly Presentation of draft criteria to Assembly and BoT for final review (August 2012)and BoT for final review (August 2012)

�� National Center for Vital and Health National Center for Vital and Health Statistics Annual ICDStatistics Annual ICD--1010--CM Revision CM Revision Conference (September 2012)Conference (September 2012)

Future steps in the Future steps in the development of DSMdevelopment of DSM--5 (IV)5 (IV)

�� Final revisions to draft criteria based on Final revisions to draft criteria based on feedback from APAfeedback from APA’’s Assembly and BoT s Assembly and BoT (September(September--November 2012)November 2012)

�� Assembly approval of DSMAssembly approval of DSM--5 text and criteria 5 text and criteria (November 2012)(November 2012)

�� BoT approval of DSMBoT approval of DSM--5 text and criteria 5 text and criteria (December 2012)(December 2012)

�� Submission of completed manuscript of DSMSubmission of completed manuscript of DSM--5 5 text and criteria to APPI (December 2012)text and criteria to APPI (December 2012)

�� Publication and distribution of DSMPublication and distribution of DSM--5 (May 5 (May 2013)2013)

Other recent developmentsOther recent developments

�� El debate en torno a ubicacion de los TPsEl debate en torno a ubicacion de los TPs�� Textos de Secciones y Subsecciones en el nuevo Textos de Secciones y Subsecciones en el nuevo ManualManual

�� Medidas o Medidas o ““puntos de cortepuntos de corte”” determinados por el determinados por el paciente (Escalas y otros instrumentos)paciente (Escalas y otros instrumentos)

�� Componentes CulturalesComponentes Culturales–– En la definicion de Trastorno MentalEn la definicion de Trastorno Mental–– Formulacion CulturalFormulacion Cultural–– ““Sindromes ligados a la culturaSindromes ligados a la cultura””

Reflexiones FinalesReflexiones Finales

�� Proceso laborioso y a veces tormentosoProceso laborioso y a veces tormentoso�� Significativo impacto de factores no Significativo impacto de factores no necesariamente clinicosnecesariamente clinicos

�� Fascinante mixtura de ciencia, politica, egos, Fascinante mixtura de ciencia, politica, egos, sesgos y culturassesgos y culturas

�� Persistencia de perspectivas diferentesPersistencia de perspectivas diferentes�� Debates mas alla del 2013Debates mas alla del 2013�� El Diagnostico en Psiquiatria como El Diagnostico en Psiquiatria como ““un mal un mal necesarionecesario””

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