Other justifications for change, such as those arising from clinical experience or need or from a conceptual reframing of diagnostic categories, were generally seen as outside the purview of the SRC. The reviewers’ scores, which varied substantially across the different proposals, and an accompanying brief commentary were then returned to the APA Board of Trustees and the work groups for consideration and response.
The Clinical and Public Health Committee (CPHC), composed of a chair, vice-chair, and six members, was appointed to consider additional clinical utility, public health, and log- ical clarification issues for criteria that had not yet accumulated the type or level of evi- dence deemed sufficient for change by the SRC. This review process was particularly important for DSM-IV disorders with known deficiencies for which proposed remedies had neither been previously considered in the DSM revision process nor been subjected to replicated research studies. These selected disorders were evaluated by four to five exter- nal reviewers, and the blinded results were reviewed by CPHC members, who in turn made recommendations to the APA Board of Trustees and the work groups.
Forensic reviews by the members of the APA Council on Psychiatry and Law were con- ducted for disorders frequently appearing in forensic environments and ones with high potential for inﬂuencing civil and criminal judgments in courtroom settings. Work groups also added forensic experts as advisors in pertinent areas to complement expertise pro- vided by the Council on Psychiatry and Law.
The work groups themselves were charged with the responsibility to review the entire re- search literature surrounding a diagnostic area, including old, revised, and new diagnostic cri- teria, in an intensive 6-year review process to assess the pros and cons of making either small iterative changes or major conceptual changes to address the inevitable reification that occurs with diagnostic conceptual approaches that persist over several decades. Such changes in- cluded the merger of previously separate diagnostic areas into more dimensional spectra, such as that which occurred with autism spectrum disorder, substance use disorders, sexual dys- functions, and somatic symptom and related disorders. Other changes included correcting ﬂaws that had become apparent over time in the choice of operational criteria for some disor- ders. These types of changes posed particular challenges to the SRC and CPHC review pro- cesses, which were not constructed to evaluate the validity of DSM-IV diagnostic criteria.
However, the DSM-S Task Force, which had reviewed proposed changes and had responsi- bility for reviewing the text describing each disorder contemporaneously with the work groups during this period, was in a unique position to render an informed judgment on the sci- entific merits of such revisions. Furthermore, many of these major changes were subject to field trial testing, although comprehensive testing of all proposed changes could not be accommo- dated by such testing because of time limitations and availability of resources.
A final recommendation from the task force was then provided to the APA Board of
Trustees and the APA Assembly’s Committee on DSM-5 to consider some of the clinical utility and feasibility features of the proposed revisions. The assembly is a deliberative body of the APA representing the district branches and wider membership that is com- posed of psychiatrists from throughout the United States who provide geographic, prac- tice size, and interest-based diversity. The Committee on DSM-5 is a committee made up of a diverse group of assembly leaders.
Following all of the preceding review steps, an executive ”summit committee” session was held to consolidate input from review and assembly committee chairs, task force chairs, a forensic advisor, and a statistical advisor, for a preliminary review of each disor- der by the assembly and APA Board of Trustees executive committees. This preceded a preliminary review by the full APA Board of Trustees. The assembly voted, in November 2012, to recommend that the board approve the publication of DSM-5, and the APA Board of Trustees approved its publication in December 2012. The many experts, reviewers, and advisors who contributed to this process are listed in the Appendix.