Hacia el DSM-5:

Controversias, Logros y
Perspectivas

Renato D. Alarcón, MD, MPH

Titular de la Cátedra Honorio Delgado, UPCH,
Lima, Perú; Profesor de Psiquiatría, Mayo
Clinic College of Medicine, Rochester, MN,
Estados Unidos
Estructura de la Presentación

Breve historia y debates contemporáneos en
torno al Diagnóstico Psiquiátrico

Programa de Trabajo para la elaboración del
DSM-5

Características principales del nuevo modelo

Debates y controversias en Grupos de Trabajo y
a nivel público

Propuestas recientes y Perspectivas futuras

Reflexiones finales
 Psychiatric diagnosis in the
labyrinths of the “Global Village”

NIMH
WHO APA

Psychiatric
Dx

Ntl/Reg
Glossaries WPA
El diagnóstico en Psiquiatría: La odisea
de un nuevo lenguaje para la “aldea
global”

Laglobalización y su impacto

Abordajes contemporáneos
– Conflictos de escuela
– Dx categórico vs. dimensional
– Perspectiva axial
– Participación internacional
 El diagnóstico psiquiátrico en la
escena internacional contemporánea

Énfasisen los “dominios de

información” (ejes)

Normas Internacionales de Evaluación
Diagnóstica (AMP)

Formulación personalizada o idiográfica

Esfuerzos de conciliación y presentación
de investigaciones (APA, OMS, AMP)
 Debates contemporáneos en
torno al diagnóstico psiquiátrico

Terminología

Base(s) científica(s)

Aspectos políticos

Niveles de aplicabilidad práctica

Escenarios clínicos

Adaptabilidad cultural
 Áreas-problema en el Diagnóstico
psiquiátrico: Limitaciones del DSM IV TR

Criterios descriptivos debidos a información limitada
sobre etiología y patofisiología de los trastornos
mentales

Sistemas basados en “consenso de expertos”- Criterios
son mezcla de rasgos y síntomas

Relación poco clara entre validez, severidad,
discapacidad y aspectos cuantitativos del
diagnóstico/“Puntos de corte”

Altos niveles de comorbilidad y excesivo número de
diagnósticos “no especificados de otra manera” (NOS)

Carencia de signos patognomónicos, marcadores
biológicos o tratamientos específicos (con polifarmacia
resultante)

Debilidad de componentes socio-culturales
 Áreas-problema en el Diagnóstico
Psiquiátrico: Limitaciones del DSM IV
TR

El enfoque multiaxal no capta todos los componentes

esenciales de las categorías diagnósticas

Edad y variantes del desarrollo son ignoradas

Heterogeneidad entre pacientes con el mismo
diagnóstico

El curso clínico puede ser/parecer pre-determinado y
artificial

Criterios de respuesta clínica ausentes o poco útiles

El diagnóstico diferencial puede ser dificil y confuso
 DSM-V: INITIAL WORK GROUPS (2002)

NOMENCLATURE NEUROSCIENCE

PSYCHIATRIC
DIAGNOSIS

GAPS/Ax. II DEVELOPMENTAL
ISSUES

CULTURAL
DISABILITIES
ISSUES
En ruta al DSM-V: Programa de
Trabajo de la APA (I)

1999-2002: “Papeles de Trabajo” y publicación
de Una Agenda de Investigación para la DSM-V
(2003: adición de secciones sobre Género y
Orientación Sexual)

2002-2007: Doce conferencias internacionales
(sobre entidades clínicas específicas,
investigación, tratamiento, e Implicaciónes en
Salud Pública,) auspiciadas por APA, NIMH,
WHO, y WPA.
 Hacia el DSM-5: Programa de
Trabajo de la APA (II)

2006: Nombramiento del Comité del DSM-5 y del Grupo
de Investigación.

2007: Creación de 12 (más 2) Grupos de Trabajo and
cuatro (más 2) Grupos de Estudio.

2008: Anuncio oficial de la membresia del Comité y de
los Grupos: 163, 124 de los E.E.U.U., 103 psiquiatras, 47
psicólogos, 18 epidemiólogos, 30 % mujeres, 18 % no
“Caucásicos” y 24 consultores internacionales

2009-2012: Revisiones de la literatura, Análisis de
bancos de datos, Informes de los Grupos, Pruebas de
campo.

2013: Publicación del DSM-5
 Principios Generales en el
desarrollo del DSM-5

Recomendaciones deberán basarse en evidencias de
investigación

Mantenimiento de continuidad con ediciones previas del
DSM

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

Consideración cuidadosa de temas de aplicación global
(cross-cutting) en el desarrollo de nuevos criterios
(operacionalización y aplicaciones inter-culturales)

Documento que permita y favorezca avances en
investigación
 En ruta al DSM-5: Los 14
Grupos de Trabajo

Trastornos de Ansiedad,
Personalidad y Trastornos de
Espectro O-C y TEPT Personalidad

TDA-H y Trastornos de
Trastornos Psicóticos
Conducta Disruptiva

Trastornos de Genero e

Trastornos de Infancia y Identidad Sexual
Adolescencia

Trastornos de Sueno y Vigilia

Trastornos del

Trastornos Disociativos
Neurodesarrollo

Trastornos Somatomorfos

Trastornos Neurocognitivos

Trastornos de Abuso de

Trastornos alimentarios
Sustancias

Trastornos del Animo
En ruta al DSM-5: Los seis
Grupos de Estudio

Aspectos del Ciclo Vital y del Desarrollo.

Espectros diagnósticos.

Interrelación Psiquiatría/Medicina
General.

Temas de Género y Aspectos
Transculturales

Evaluación de Discapacidades

Instrumentos diagnósticos y de
medición cuantitativa
Algunos temas controversiales
de caracter general (I)

Definición de Trastorno Mental

¿Sobrevivirá el enfoque multiaxial?

Consolidación de entidades nosológicas

Evaluación de factores de riesgo y de
protección

Incorporación de la experiencia subjetiva del
paciente

Admisión de insuficiente información
neurobiológica
Algunos temas controversiales
de caracter general (II)

Cambios de nombres, eliminación de algunos
trastornos y creación de otros

¿Diferentes versiones de la práctica clínica y
la investigación? – Propuesta del INSM

Un Manual más “amigable”

Impacto de los factores culturales en la
causalidad y la expresión de los síntomas.

¿Más allá del “diagnóstico basado en la
evidencia”?
 Algunos ejemplos de temas
discutidos por Grupos de Trabajo
Trastornos del
Ánimo

Remoción del Tr. Bipolar I,
Episodio Mixto

Adición de Depresión Ansiosa

Inclusión de Tr. Disfórico
Premenstrual

Cambios en Tr. Ciclotímico

Creación de Tr. de
Disregulación Temperamental
con Disforia

Suicidio
Trastornos de
Personalidad

Aplicación del modelo
dimensional

Niveles de funcionamiento y
secuencia diagnóstica

Utilización y agrupación de
Rasgos

Ubicación del Trastorno
Esquizotípico

Exclusión de tipos Narcisista,
Histriónico, Esquizoide,
Paranoide y Dependiente
 On-line Public Response to
DSM-5 Initial Proposals

More than 50,000 hits in two weeks

More than 2000 general comments

Closeto 7000 comments on specific

disorders (mainly Cognitive,
Developmental, Childhood and
Adolescence disorders)
Public Survey on DSM-5 Initial
Proposals (APA 2010 Meeting)
Opinions About Inclusion

Disorder New Further Not

Spec- Sub-
Dis- Research accept- Other
ifier sumed
order / Appendix able
GA and Worry Disorder 10% 30%
Public Survey on DSM-5 Initial
Proposals (APA Meeting 2010)
Opinions About Inclusion

Disorder New Further Not

Spec- Sub-
Dis- Research accept- Other
ifier sumed
order / Appendix able
GA and Worry Disorder 10% 30%
Mixed Anxiety & Depression
40% 20%
(Anxious Depression)
Public Survey on DSM-5 Initial
Proposals (APA Meeting 2010)
Opinions About Inclusion

Disorder New Further Not

Spec- Sub-
Dis- Research accept- Other
ifier sumed
order / Appendix able
GA and Worry Disorder 10% 30%
Mixed Anxiety & Depression
40% 20%
(Anxious Depression)
Complicated Grief 30% 30%
Public Survey on DSM-5 Initial
Proposals (APA Meeting 2010)
Opinions About Inclusion

Disorder New Further Not

Spec- Sub-
Dis- Research accept- Other
ifier sumed
order / Appendix able
GA and Worry Disorder 10% 30%
Mixed Anxiety & Depression
40% 20%
(Anxious Depression)
Complicated Grief 30% 30%
Developmental Traumatic
18% 27% 36%
Disorder
Public Survey on DSM-5 Initial
Proposals (APA Meeting 2010)
Opinions About Inclusion

Disorder New Further Not

Spec- Sub-
Dis- Research accept- Other
ifier sumed
order / Appendix able
GA and Worry Disorder 10% 30%
Mixed Anxiety & Depression
40% 20%
(Anxious Depression)
Complicated Grief 30% 30%
Developmental Traumatic
18% 27% 36%
Disorder
Premenstrual Dysphoric
50% 17% 33%
Disorder
Public Survey on DSM-5 Initial
Proposals (APA Meeting 2010)
Opinions About Inclusion

Disorder New Further Not

Spec- Sub-
Dis- Research accept- Other
ifier sumed
order / Appendix able
GA and Worry Disorder 10% 30%
Mixed Anxiety & Depression
40% 20%
(Anxious Depression)
Complicated Grief 30% 30%
Developmental Traumatic
18% 27% 36%
Disorder
Premenstrual Dysphoric
50% 17% 33%
Disorder
Parental Alienation Disorder 8% 38% 31%
Public Survey on DSM-5 Initial
Proposals (APA Meeting 2010)
Opinions About Inclusion

Disorder New Further Not

Spec- Sub-
Dis- Research accept- Other
ifier sumed
order / Appendix able
GA and Worry Disorder 10% 30%
Mixed Anxiety & Depression
40% 20%
(Anxious Depression)
Complicated Grief 30% 30%
Developmental Traumatic
18% 27% 36%
Disorder
Premenstrual Dysphoric
50% 17% 33%
Disorder
Parental Alienation Disorder 8% 38% 31%
Temper Dysregulation
33% 22% 17% 56%
Dysphoria
Public Survey on DSM-5 Initial
Proposals (APA Meeting 2010)
Opinions About Inclusion

Disorder New Further Not

Spec- Sub-
Dis- Research accept- Other
ifier sumed
order / Appendix able
Sensory Processing Disorder
27% 37% 36%
(Children without autism)
Public Survey on DSM-5 Initial
Proposals (APA Meeting 2010)
Opinions About Inclusion

Disorder New Further Not

Spec- Sub-
Dis- Research accept- Other
ifier sumed
order / Appendix able

Sensory Processing Disorder

27% 37% 36%
(Children without autism)

Schizoaffective Disorder 47% 20%

Public Survey on DSM-5 Initial
Proposals (APA Meeting 2010)
Opinions About Inclusion

Disorder New Further Not

Spec- Sub-
Dis- Research accept- Other
ifier sumed
order / Appendix able

Sensory Processing Disorder

27% 37% 36%
(Children without autism)

Schizoaffective Disorder 47% 20%

Attenuated Psychotic
33% 17% 17% 33%
Disorder
Public Survey on DSM-5 Initial
Proposals (APA Meeting 2010)
Opinions About Inclusion

Disorder New Further Not

Spec- Sub-
Dis- Research accept- Other
ifier sumed
order / Appendix able

Sensory Processing Disorder

27% 37% 36%
(Children without autism)

Schizoaffective Disorder 47% 20%

Attenuated Psychotic
33% 17% 17% 33%
Disorder
Hypersexual Disorder (Not
29% 43% 28%
Addiction)
Public Survey on DSM-5 Initial
Proposals (APA Meeting 2010)
Opinions About Inclusion

Disorder New Further Not

Spec- Sub-
Dis- Research accept- Other
ifier sumed
order / Appendix able

Sensory Processing Disorder

27% 37% 36%
(Children without autism)

Schizoaffective Disorder 47% 20%

Attenuated Psychotic
33% 17% 17% 33%
Disorder
Hypersexual Disorder (Not
29% 43% 28%
Addiction)
Paraphilic Coercive Disorder
27% 33% 40%
(Rapists)
Public Survey on DSM-5 Initial
Proposals (APA Meeting 2010)
Opinions About Inclusion

Disorder New Further Not

Spec- Sub-
Dis- Research accept- Other
ifier sumed
order / Appendix able

Sensory Processing Disorder

27% 37% 36%
(Children without autism)

Schizoaffective Disorder 47% 20%

Attenuated Psychotic
33% 17% 17% 33%
Disorder
Hypersexual Disorder (Not
29% 43% 28%
Addiction)
Paraphilic Coercive Disorder
27% 33% 40%
(Rapists)
Internet Addiction 27% 13% 40%
Public Survey on DSM-5 Initial
Proposals (APA Meeting 2010)
Opinions About Inclusion

Disorder New Further Not

Spec- Sub-
Dis- Research accept- Other
ifier sumed
order / Appendix able

Sensory Processing Disorder

27% 37% 36%
(Children without autism)

Schizoaffective Disorder 47% 20%

Attenuated Psychotic
33% 17% 17% 33%
Disorder
Hypersexual Disorder (Not
29% 43% 28%
Addiction)
Paraphilic Coercive Disorder
27% 33% 40%
(Rapists)
Internet Addiction 27% 13% 40%
Fetal Alcohol Syndrome 44% 19% 6%
Public Survey on DSM-5 Initial
Proposals (APA Meeting 2010)
Opinions About Inclusion

Disorder New Further Not

Spec- Sub-
Dis- Research accept- Other
ifier sumed
order / Appendix able

Sensory Processing Disorder

27% 37% 36%
(Children without autism)

Schizoaffective Disorder 47% 20%

Attenuated Psychotic
33% 17% 17% 33%
Disorder
Hypersexual Disorder (Not
29% 43% 28%
Addiction)
Paraphilic Coercive Disorder
27% 33% 40%
(Rapists)
Internet Addiction 27% 13% 40%
Fetal Alcohol Syndrome 44% 19% 6%
Binge Eating Disorder 33% 27% 33%
Public Survey on DSM-5 Initial
Proposals (APA Meeting 2010)
OPINIONS
OTHER QUESTIONS Agree Disagree
Agree Disagree
Strongly Strongly

Is the label “Drug and Alcohol Use

63% 25% 10% 2%
Disorder” acceptable?
Public Survey on DSM-5 Initial
Proposals (APA Meeting 2010)
OPINIONS
OTHER QUESTIONS Agree Disagree
Agree Disagree
Strongly Strongly

Is the label “Drug and Alcohol Use

63% 25% 10% 2%
Disorder” acceptable?

Shall “Gambling Disorder” be moved

33% 7% 40% 20%
to Addiction Disorders?
Public Survey on DSM-5 Initial
Proposals (APA Meeting 2010)
OPINIONS
OTHER QUESTIONS Agree Disagree
Agree Disagree
Strongly Strongly

Is the label “Drug and Alcohol Use

63% 25% 10% 2%
Disorder” acceptable?

Shall “Gambling Disorder” be moved

33% 7% 40% 20%
to Addiction Disorders?
Is “Autism Spectrum Disorder”
56% 19% 13% 13%
acceptable?
Public Survey on DSM-5 Initial
Proposals (APA Meeting 2010)
OPINIONS
OTHER QUESTIONS Agree Disagree
Agree Disagree
Strongly Strongly

Is the label “Drug and Alcohol Use

63% 25% 10% 2%
Disorder” acceptable?

Shall “Gambling Disorder” be moved

33% 7% 40% 20%
to Addiction Disorders?
Is “Autism Spectrum Disorder”
56% 19% 13% 13%
acceptable?
Should “Fetal Alcohol Syndrome” be
considered a Developmental 44% 20% 5% 6%
Neurocognitive Disorder?
Public Survey on DSM-5 Initial
Proposals (APA Meeting 2010)
OPINIONS
OTHER QUESTIONS Agree Disagree
Agree Disagree
Strongly Strongly

Is the label “Drug and Alcohol Use

63% 25% 10% 2%
Disorder” acceptable?

Shall “Gambling Disorder” be moved

33% 7% 40% 20%
to Addiction Disorders?
Is “Autism Spectrum Disorder”
56% 19% 13% 13%
acceptable?
Should “Fetal Alcohol Syndrome” be
considered a Developmental 44% 20% 5% 6%
Neurocognitive Disorder?
Is a distinction between “Major” and
“Minor” Cognitive Disorder 47% 13%
acceptable?
Public Survey on DSM-5 Initial
Proposals (APA Meeting 2010)
OPINIONS
OTHER QUESTIONS Agree Disagree
Agree Disagree
Strongly Strongly

Should Personality Disorders be

27% 33%
integrated into Axis I?
Public Survey on DSM-5 Initial
Proposals (APA Meeting 2010)
OPINIONS
OTHER QUESTIONS Agree Disagree
Agree Disagree
Strongly Strongly

Should Personality Disorders be

27% 33%
integrated into Axis I?

Is the use of Personality Disorder

14% 14% 57% 14%
labels derogatory?
Public Survey on DSM-5 Initial
Proposals (APA Meeting 2010)
OPINIONS
OTHER QUESTIONS Agree Disagree
Agree Disagree
Strongly Strongly

Should Personality Disorders be

27% 33%
integrated into Axis I?

Is the use of Personality Disorder

14% 14% 57% 14%
labels derogatory?
Should the label Schizophrenia
69% 10% 10% 6%
remain?
Meta-structure proposals for
DSM-5 and ICD-11, Chapter V

To serve as a chapter organization for
DSM-5, and as linear structure for ICD-11

May influence the text of DSM-5 but is
neutral re: individual disorders’ criteria

Meeting of WHO International Advisory
Group and APA, Geneva, June 21-22,
2010

Overall goal: Harmonization of the two
classifications
Meta-structure proposals for
DSM-5 and ICD-11, Chapter V

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

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

DSM-5 will then have a maximum of 10
chapters, instead of DSM-IV’s 16, and the 14
current Work Groups

Construction of Primary Care version of ICD-11,
and NIMH’s Research Domain Diagnostic Criteria
(RDoC)
Meta-structure proposals for
DSM-5 and ICD-11, Chapter V

DSM-5’s initial clustering was based on etiology,
pathophysiology or neuropathology

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

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

Proposal of two alternative versions of the Meta-
structure
Meta-structure proposals for
DSM-5 and ICD-11, Chapter V
VERSION 1

PDs distributed (dispersed) across the
classification structure rather than clustered,
based on:
– Clinical similarities with disorders from other chapters
(i.e. Schizotypal PD and Schizophrenia)
– Desirability of investigating shared etiology,
pathophysiology and clinical features
** ADHD is placed in F6, Impulse Control
Disorders
Meta-structure proposals for
DSM-5 and ICD-11, Chapter V
VERSION 2

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

Two alternative placements for ADHD:
Developmental Disorders (F1) because of age of
onset and delays in cerebral cortex maturation;
and Impulse Control Disorders (F6), based on
cognitive and behavioral deficits and high
frequency of comorbidities
Meta-structure proposals for
DSM-5 and ICD-11, Chapter V
OTHER POINTS OF DEBATE

Externalizing Disorders instead of Impulse Control

Disorders and to include Substance Use Disorders

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

Placement of GAD with Major Depression based on:
– Shared genetic risks
– High rates of comorbidity
– Implications for primary care
Draft Meta-structure for DSM-5
DSM-5 Category DSM-5 DSM-5 Proposed
Subcategory Disorders
F-0 General Intellectual Disability
Neurodevelopmental Neurodevelopmental Intllectual or Global
Disorders Cognitive Disorders Developmental Delay

Learning Disorders Learning Disability,

Unspecified Type
LD, Dyslexia Type
LD, Dyscalculia Type
Autism Spectrum Autism Spectrum
Disorders Disorders (Fragile X, Rett,
??Asperger, etc.)
Draft Meta-structure for DSM-5
DSM-5 Category DSM-5 DSM-5 Proposed
Subcategory Disorders
F-0 Attention ADHD *Specify
Neurodevelopmental Deficit/Hyperactivity Combined Presentation
Disorders Disorder Predominantly Hyperactive
Predominantly Inattentive
Inattentive/Restrictive
Communication Child-onset Fluency
Disorders Disorder (Stuttering)
Late language emergence
Language Impairment (LI)
LI, specific
LI, Social Communication
Disorder
Draft Meta-structure for DSM-5
DSM-5 Category DSM-5 DSM-5 Proposed
Subcategory Disorders
F-1 Schizophrenia Schizophrenia Schizophrenia
Spectrum and Spectrum Schizophreniform Disorder
Psychotic Disorders Schizoaffective Disorder
Personality Disorder,
Schizotypal
Other Psychotic Delusional Disorder
Disorders Brief Psychotic Disorder
Attenuated psychotic sx
syndrome
Psychotic Disorder due to
general medical condition (w/
delusions, hallucinations)
ETOH or Drug-induced
psychoses (w/ delusions,
hallucinations)
Draft Meta-structure for DSM-5
DSM-5 Category DSM-5 DSM-5 Proposed
Subcategory Disorders
F-2 Mood Disorders Bipolar and Related Bipolar I Disorder –Most
Disorders Recent Episode …..
Bipolar II Disorder
Bipolar Disorder Not
Elsewhere Classified
(subsyndromal subtypes)
Cyclothymic Disorder
Distress Disorders MDD (Single, Recurrent)
(primary negative Chronic MDD
affect) GA and Worry Disorder
Mixed Anxiety Depression
PMDD
TDD with Dysphoria
Depressive CNEC
Draft Meta-structure for DSM-5

F-3 Anxiety and Stress Related Disorders

F-4 Obsessive-Compulsive Spectrum, Tics
and Stereotypic Behavior Disorders

F-5 Somatic Disorders

F-6 Antisocial and Disruptive Behaviors

F-7 Substancr-Related, Gambling and
Related Disorders

F-8 Neurocognitive Disorders
Draft Meta-structure for DSM-5

DSM-5 Category DSM-5 DSM-5 Proposed

Subcategory Disorders
F-9 Other Disorders PD, Traits Specified
PD, Borderline Type
PD, O-C Type

Disorder of Infancy,
Childhood, or Adolescence
NOS
Caffeine-Induced Disorder
NOS
Catatonia due to GMC
 NIMH’s Proposal of Research
Domain Criteria (RDoC)
PREMISES

Diagnostic categories based on clinical

consensus fail to align w/ findings from clinical
neuroscience and genetics

Boundaries of the categories have not been
predictive of treatment response

Categories based on signs and symptoms may
not capture fundamental underlying mechanisms
of dysfunction  Slow development of new
targeted treatments
 NIMH’s Proposal of Research
Domain Criteria (RDoC)
ASSUMPTIONS

Mental illnesses conceptualized as brain disorders

(circuits)

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

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

Examples of circuitry-behavior relationships:
fear/extinction, reward, executive functions, impulse
control)
 NIMH’s Proposal of Research
Domain Criteria (RDoC)
STEPS

Launching of the RDoC Project (2009; Insel T.,

et al. Am J Psychiatry 2010; 176, 7: 748-751)

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

Goals
– Help identify new targets for treatment development
– Detect subgroups for treatment selection
– Better match between research findings and clinical decision-
making
 NIMH’s Proposal of Research
Domain Criteria (RDoC)
DEVELOPMENTS

Developmental Neuroscience: imaging genomics and early life

programming

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

From measures of circuitry function upwards to clinically relevant
variation or downwards to genetic and molecular/cellular factors
that influence such factor

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

Samples of patients spanning multiple DSM diagnoses: independent
variables might be specified from any level of analys; dependent
variables chosen from one or more other columns.
 Future steps in the
development of DSM-5

Field Trials (FTs) Phase I (Pilot, July/August,
2010-March/April 31, 2011) (Academic and large
clinical settings)

Beginning of text drafting (December 2010-
March 2011)

Development of casebooks (July 2010-March
2011)

Ongoing consumer feedback

Revisions of criteria and measures (March-April,
2011)
 Future steps in the
development of DSM-5 (II)

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

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

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

DSM-5 Interactive Workshops at APA and IPS
Annual Meetings (May and October 2012)
 Future steps in the
development of DSM-5 (III)

Final draft text and criteria for review
(February-August 2012)

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

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

National Center for Vital and Health
Statistics Annual ICD-10-CM Revision
Conference (September 2012)
 Future steps in the
development of DSM-5 (IV)

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

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

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

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

Publication and distribution of DSM-5 (May
2013)
 Other recent developments

El debate en torno a ubicacion de los TPs

Textos de Secciones y Subsecciones en el nuevo
Manual

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

Componentes Culturales
– En la definicion de Trastorno Mental
– Formulacion Cultural
– “Sindromes ligados a la cultura”
 Reflexiones Finales

Proceso laborioso y a veces tormentoso

Significativo impacto de factores no
necesariamente clinicos

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

Persistencia de perspectivas diferentes

Debates mas alla del 2013

El Diagnostico en Psiquiatria como “un mal
necesario”