No great production is possible without the work of a lot of people behind the scenes. The same can be said about that world-famous tome of psychiatric diagnosis—APA’s Diagnostic and Statistical Manual of Mental Disorders (DSM)—which was published for the first time back in 1952. Each volume now requires years of research and the input of hundreds of psychiatric investigators from around the United States and in every subspecialty.

And now the groundwork is being laid for the next edition—volume V—which is not expected to make its debut for another eight to 10 years at least. The groundwork essentially constitutes the building of a research agenda by APA’s Office of Research and APA’s Committee on Psychiatric Diagnosis and Assessment (CPDA), with the cooperation of the National Institutes of Health (NIH) and some other organizations.

Or as Darrel Regier, M.D., director of APA’s Office of Research, explained it to Psychiatric News, "At the present time we are taking an historic step to plan a research agenda that addresses known weaknesses of the current classification and potential scientific advances that will provide a much-improved data base at the time DSM-V development begins. . . .By focusing more research on the validity of psychiatric diagnosis over a seven- to eight-year period, the NIH and other research funding institutions can greatly improve the clinical utility of their research investments. By facilitating more intensive work on psychopathology research prior to consideration of changes in actual diagnostic criteria, the CPDA and the Office of Research will be investing some of the funds from DSM-IV in a research and development effort that is appropriate for continually updating the DSM for research and clinical practice. On the advice of the APA Council on Research, the APA Board of Trustees has enthusiastically supported this collaborative effort with NIH and international organizations such as the World Health Organization and the World Psychiatric Association."

The first discussions regarding DSM-V began some months ago when APA Medical Director Steven Mirin, M.D., got together with Steven Hyman, M.D., director of the National Institute of Mental Health (NIMH) in Bethesda, Md., and David Kupfer, M.D., of the Western Psychiatric Institute and Clinic in Pittsburgh and chair of the APA Committee on Psychiatric Diagnosis and Assessment. The three concurred that it was important for APA and NIMH to work together on the next volume and to focus on an agenda that would advance a scientific basis for psychiatric classification.

APA and NIMH then cosponsored a research planning conference for the volume in September 1999. As an outgrowth of this conference, work groups were formed to concentrate on five general areas deemed critical to improving DSM. They were developmental diagnoses, gaps in the current diagnostic system, disability and impairment, neuroscience, and nomenclature. The APA Council on Research, which includes the Committee on Psychiatric Diagnosis and Assessment, was also notified that groundwork for DSM-V was getting under way and enthusiastically endorsed the activity.

In July Hyman and Kupfer met with Regier, who had recently joined APA as director of the Office of Research, as well as with the heads of the five work groups for DSM-V. They were Dennis Charney, M.D., and Daniel Pine, M.D., of NIMH; Michael First, M.D., of the New York State Psychiatric Institute in New York City; Anthony Lehman, M.D., of the University of Maryland in Baltimore; and Bruce Rounsaville, M.D., of VA Connecticut Healthcare in West Haven, Conn. Another work group on cross-cultural issues was also formed after this date. And then last month, Regier, Hyman, and work group heads also met with other work group members to further refine their strategies for setting a research agenda for DSM-V.

What do these strategies consist of? First off, identifying problem areas in DSM-IV that should be rectified or at least improved in DSM-V.

One of the problem areas, for instance, is personality disorders. There is a more urgent need for changes in this domain of the DSM than any other, First asserted. "Most clinicians and researchers find the current DSM method of classifying personality disorders to be unsatisfactory," First said. "Most patients with personality disorders either do not fit into any of the existing categories or else qualify for four or five different personality disorder diagnoses."

The simple fact is, such disorders are not well understood. Do they have a biological basis or not? It’s not clear, Hyman said. He said that he suspects that some may not.

Still another area of difficulty is diagnostic criteria. The researchers involved with laying the groundwork for DSM-V want to make the criteria more applicable across cultures and across gender than they are currently and also to make them work in nonpsychiatric settings as well as psychiatric ones, Rounsaville said.

In addition to identifying specific areas of DSM-IV that need fixing, the work groups are also starting to focus on some research questions that need to be answered if psychiatric diagnosis is to become even more scientifically based. For instance, in the area of disability and impairment, why do some people with a lot of symptoms still manage to function, whereas others with few symptoms become dysfunctional? And if someone is distressed but not dysfunctional, does he or she have a psychiatric disorder?

What’s more, it has been known for some years that most childhood psychiatric disorders are developmental, Pine pointed out, but still unknown are how symptoms change over time and when symptoms actually become a disorder.

Certainly basic science is having some impact on psychiatric diagnosis, Charney said. For instance, he pointed out, a genetic marker for major depression has been identified. Yet so much more needs to be learned, he stressed, if psychiatric diagnosis is going to become more scientific. For instance, what is the biology of cognition? Of various emotions? Of social interactions? And what is the biochemistry of impulsivity, of gambling?

As one of the work group members pointed out to the others, they should consider an "uncoupling" of their dual goals—producing a good diagnostic manual for clinicians, but also obtaining more research results that would buttress psychiatric diagnoses. And the reason became clear at the conference: Even if the research questions of interest can be answered, the answers may not be obtained in time for incorporation into DSM-V. For instance, Charney explained, researchers can probably get an answer to the question of whether early-onset depression is the same as late-onset depression much quicker than to the other research questions he raised. And while Hyman concurred with First that there is urgency about improving the DSM section on personality disorders, "we are not going to fully understand personality disorders for a long time," he observed.

Nonetheless, Regier, Kupfer, Hyman, and the others who are involved in setting a research agenda for DSM-V remain bullish about the great enterprise they are launching. Or as Hyman enthusiastically reminded his colleagues, "We want creativity and intellectual boldness," not a finished product. It is time for those involved "to think about some different things," to worry about the scientific validity of psychiatric diagnoses, to contemplate how they might incorporate discoveries in genetics or in imaging into the diagnosis of various disorders.

Even though the science of psychiatry is young, he admitted, "what we are looking for ultimately is a framework that will really inform DSM-V."