The American bible of psychiatric classification—APA’s DSM-IV—is, as American youngsters would put it, "morphing" into a somewhat more advanced form. It is called the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision 2000, or DSM-IV-TR for short.

However, one should not consider this latest makeover a true revision of DSM-IV, said Harold Pincus, M.D., the executive vice chair of the department of psychiatry at the University of Pittsburgh and cochair of the work group to revise the text of DSM-IV.

"That would give absolutely the wrong message. . . . It is not like this is an evolution, something qualitatively different. The most important material stays exactly the same. The only things that have changed substantially are the text accompanying the diagnoses and some parts of the introduction and appendices."

Michael First, M.D., a research psychiatrist with the New York State Psychiatric Institute in New York City and cochair and editor of DSM-IV-TR, essentially concurs: The only major difference between DSM-IV and DSM-IV-TR is in the text, not in the classification of psychiatric disorders or in the diagnostic criteria for each of these disorders. However, some codes for psychiatric disorders also have been changed, he pointed out. The codes that were used in DSM-IV were taken from the International Classification of Disease, 9th Edition, Clinical Modification (ICD-9-CM). The ICD is used by the federal government. An ICD committee has since changed a few codes for mental illness. Thus, DSM-IV-TR reflects these news codes.

The text changes needed to be made now since the next edition of DSM will not be published before 2005 or 2006 at the earliest, said First. That puts more than a decade between it and the release of DSM-IV, which was published in 1994. Thus, there was concern that the text in DSM-IV would become seriously outdated before DSM-V makes its debut.

Work was begun on DSM-IV-TR about three years ago. First and Pincus started by asking psychiatrists and psychologists who had worked on DSM-IV whether they wanted to tackle a text revision for DSM-IV. Many did, but some did not, so new recruits were lined up as well, resulting in the ultimate involvement of about 100 authorities.

Out of these 100 experts, committees were formed, and each committee was given the job of reviewing the latest medical literature in a particular diagnostic area to determine whether the text relevant to those disorders should be updated. Their results led to a number of text changes in DSM-IV.

For example, the text on schizophrenia was rewritten and expanded because of a recent explosion of knowledge about this illness. The "Associated Features" section includes additional information about risk factors for suicidal and violent behavior and comorbidity with other mental disorders. The "Associated Laboratory Findings" section includes separate discussions of structural and functional neuroimaging, neuropsychological deficits, and neurophysiological abnormalities.

Some text changes also have been made regarding autistic disorder. The "Diagnostic Features" section highlights difficulties in the pragmatic aspects of language, which are especially important in higher-functioning individuals. In addition, better examples of restricted, repetitive, and stereotyped patterns of behavior, interests, and activities have been added. The text reflects evidence that in up to a fifth of cases, parents retrospectively report relatively normal development for the first or second years of life.

Text alterations likewise accompany attention-deficit/hyperactivity disorder, many highlighting differences among the subtypes. For example, individuals with the "predominantly inattentive and combined types" tend to have academic deficits and school-related problems, whereas those with the "predominantly hyperactive-
impulsive type" tend to experience more peer rejection and accidental injuries.

Still other text modifications can be found pertaining to alcohol-related disorders, catatonic features, conduct disorder, delirium, mood disorders, paraphilias, and tic disorders, among others.

In areas where no text alterations were made, First emphasizes, much work was still done. "Very often somebody spent hours reviewing the literature and determined that the text was up to date. So even in the areas without changes, the reader of the revised text can be assured that all the information in it is current."

First and Pincus agree that the DSM-IV-TR should prove particularly valuable for medical students and residents who are just starting to learn about psychopathology.

"I think the main reason to buy the book," said First, "is that it differs from a regular textbook in that we had a huge number of experts from all areas reviewing material. You see, even after we had people prepare and review the text and make proposals, it got sent out to a group of distinguished advisers for review. So the amount of input that went into this was much, much more than for a regular textbook. DSM-IV-TR is really a very good summary of our state of knowledge with respect to psychiatric diagnosis."