Current Controversies in Psychiatry: how might the DSM-5 impact clinical practice?

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The release of the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) by the American Psychiatric Association in May 2013 has stimulated much discussion on psychiatric diagnosis. Debate articles on the topic have been published in BMC Medicine in an article collection on Current Controversies in Psychiatry and described in a previous blog. The latest additions to this article collection focus on the impact and future directions of DSM-5 on the diagnosis and treatment of psychiatric disorders in clinical practice.

In an interview with BMC Medicine, David Kupfer, chair of the DSM-5 task force, discusses the future directions of DSM-5 in light of the Research Domain Criteria (RDoC) and 11th Revision of the International Classification of Diseases (ICD-11). He also indicates that DSM-5 will facilitate improved communication for global mental health classification, which he also discussed recently in a keynote lecture at the international meeting DSM-5 and the Future of Psychiatric Diagnosis: Where is the roadmap taking us? held at the Institute of Psychiatry at King’s College London.

You can listen to David Kupfer’s interview in this podcast:

Views from a wider collection of psychiatrists have also been published in our first Forum article, where several of our Editorial Board members and their colleagues provide their personal opinions on how the DSM-5 might affect their specific areas of medicine. These areas include autism, trauma-and stressor-related disorders, obsessive-compulsive and related disorders, mood disorders (including major depression and bipolar disorders) and schizophrenia spectrum disorders which we summarize below.

Charles Nemeroff and Daniel Weinberger discuss that even though there are no current biomarkers for psychiatric disorders there is an overall improvement for mental health classification in DSM-5 compared with the older revision DSM-IV. This includes disorders such as autism – but as Michael Rutter points out, the elimination of the sub-classification of autism spectrum disorders (ASD) such as Asperger’s syndrome in DSM-5 may affect accessibility to services, particularly with individuals who have higher functioning autism. Understandably, this is an issue that divides opinion. Recently at the Royal College of Psychiatrists International Congress 2013, David Skuse mentioned that when criteria were validated for ASD diagnosis there was largely improvement in DSM-5 compared with DSM-IV. Continuing on the topic of neurodevelopmental disorders, attention deficit hyperactivity disorder (ADHD) is now classified in DSM-5 under this group of conditions rather than as a disruptive disorder. In an interview with BMC Medicine, Eric Taylor explains that although he welcomes the changes in DSM-5 on ADHD diagnosis, he feels they have missed the opportunity to move to a continuum approach of describing an individual’s characteristics in terms of severity, staging and impairment.

You can listen to Eric Taylor’s interview in this podcast:

Another change in the DSM-5 is the introduction of a new chapter termed trauma-and stressor-related disorders (TRSD). Harriet MacMillan comments that over-diagnosis of these disorders in childhood will be minimized with the need for history of exposure, specific trauma symptoms and association with significant distress or impairment. Furthermore, posttraumatic stress disorder (PTSD) has been restructured in DSM-5, and Richard Bryant and Simon Wessely argue that the new definition of the disorder increases heterogeneity and raises serious concerns about using this diagnosis in research settings. In addition, an entirely new chapter on the topic of obsessive-compulsive and related disorders (OCRDs) has been included, and Dan Stein (who served as Chair of the DSM-5 Sub-work Group on OCRDs) suggests that these changes will help clinicians to diagnose patients with OCRDs.

With regard to depressive disorders there are two specific changes: exclusion of bereavement and the introduction of the new “disruptive mood dysregulation disorder (DMDD)” for use in children. Carmine Pariante emphasizes that the introduction of this new disorder will prevent the diagnoses of bipolar disorder in children, which is accompanied with the premature use of medication in such young individuals. He further highlights that removal of the bereavement exclusion for diagnosis of major depression will allow individuals who have been clinically depressed for less than two months following the loss of a loved one to have a diagnosis of the disorder. Florian Seemüller, however, argues that broadening of diagnostic boundaries for the risk for recurrent depression in people who experience severe grief will label them unnecessarily as having the illness and to receive needless treatment.

DSM-5 dropped the high risk states for psychosis and made several amendments on schizophrenia spectrum disorders. Key concerns addressed by Paul Lysaker shows that DSM-5 seems unlikely to change clinical practice as it has focused on defining the individual components of schizophrenia spectrum disorders rather than understanding the core psychopathological processes on how the components are related to provide better treatments. The topic of schizophrenia treatment was discussed extensively at the 7th National conference on Treating Schizophrenia focusing on pharmacogenetics, early interventions and psychosocial interventions and how the Schizophrenia Commission report aims to provide practical steps to improve the quality of care of psychotic patients.

However, given the current challenges in psychiatric medicine, Klaas Wardenaar and Peter de Jonge argue that evidence-based diagnostic methods should be developed by using multimode analysis and modeling to assess heterogeneity across persons and symptoms over time, to accurately identify optimal homogeneous subgroups.

We hope that potential developments on the integration of different classification systems including RDoC and ICD-11, along with the DSM-5, will ultimately improve the diagnosis, management, treatment and care of psychiatric patients.