DSM-5 task force: Dimensional assessments crucial in diagnostic manual update

PHILADELPHIA — Proposed changes to the current Diagnostic and Statistical Manual of Mental Disorders include the addition of dimensional assessments, which would address psychiatric disorders that do not fall neatly into discrete categories, according to the American Medical Association.

Presenting here at the 2012 American Psychiatric Association Annual Meeting, William Narrow, MD, MPH, research director of the task force assigned to oversee the creation of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), said the strictly categorical system represented in the current diagnostic manual (DSM-IV) does not reflect the presentation of symptoms that often merge across diagnostic boundaries. Examples of these “cross-cutting” symptoms include depression in schizophrenia, sleep problems in anxiety disorders and anxiety in depressive disorders.

“In order to get a complete, credible picture of our patients, we don’t just say they have schizophrenia and look at psychotic symptoms,” Narrow said. “We know that our patients with schizophrenia have depression, and we often treat that depression. However, there are no depression symptoms in the schizophrenia criteria [in the DSM-IV]. So, these measures are an attempt to draw the attention of the clinician to these cross-cutting symptoms.”

A significant part of the DSM-5 field trials involved patient assessments, which Narrow said were crucial in formulating new diagnostic criteria that will include cross-cutting disorders. Throughout the process of developing new diagnostic criteria for the DSM-5, patients, including adults, children and adolescents aged 11 years and older, parents or caregivers of children aged 6 years and older and caregivers for adults with limited capacity were asked to complete a series of assessments that measured their symptoms, such as depressed mood, anxiety, substance use or sleep problems. Designed to show clinicians how symptoms overlap, the assessments were given before each clinical visit and administered on iPads or laptops, with the scores transmitted to the clinicians. If any of the symptoms were rated as “clinically significant,” according to the AMA, patients would answer additional questions for a more precise evaluation.

“In psychiatry, as you know, we don’t use a lot of laboratory tests, so patient reports are very important,” Narrow said. “In that sense, I think it is important for us to start looking in our diagnosis and treatment for ways that we systematically get information from patients.”

To illustrate the way in which mental disorder symptoms overlap, Darrel Regier, MD, MPH, vice chair of the DSM-5 task force, referred to psychiatrist Emil Kraepelin’s analogy of organ pipes.

“You can have a very distinct range or register … but then you can use a mixture, and you start pulling out all the other stops, and think of those stops as genes or epigenetic releases. You get a much better sense how the brain actually works and how these disorders tend to bleed into one another.”

For more information: DSM-5. Symposium S011-4. Presented at: the 2012 American Psychiatric Association Annual Meeting; May 5-9, 2012; Philadelphia.

Disclosure: The presenters report no relevant financial disclosures.