Our Diagnostic Dilemma: A Critical Review of the Diagnostic and Statistical Manual of Mental Disorders Framework

Byline: Rajiv. Tandon Introduction Our modern system of classifying and diagnosing psychiatric disorders originated in Emil Kraepelin's dichotomization between dementia praecox (schizophrenia) and manic-depressive insanity (bipolar and unipolar disorders). Since that time, there have been separate sections on psychotic disorders and mood disorders in both the International Classification of Diseases (ICD) and Diagnostic and Statistical Manual of mental disorders-5 (DSM-5) diagnostic manuals. This dichotomy has increasingly been called into question [sup][1],[2] and genetic, other neurobiological, and pharmacological data suggest that bipolar disorders may be on a continuum between schizophrenia and unipolar depression. [sup][2],[3] In addition, the definitions of these disorders in DSM-IV present a number of problems in clinical practice, including high use of not otherwise specified (NOS) diagnoses, high rates of spurious comorbidity, unclear boundaries schizoaffective disorder, discrepant treatment of catatonia, and poor explanation of the significant heterogeneity within each diagnostic category. DSM-5 [sup][4] sought to address these limitations and incorporate new knowledge about these conditions generated over the past 20 years. Changes in the section on psychotic disorders were summarized in a prior issue of the Journal. [sup][5] Some of those changes relevant to the clinical description of the mood disorders include a single set of criteria to diagnose catatonia and its treatment as a specifier across all disorders [sup][6],[7] and more stringent criteria for schizoaffective disorder. [sup][8],[9],[10] In this article, we address the major changes made in the mood disorders section in DSM-5. Separation of Bipolar Disorders from Depressive Disorders One of the major changes made in DSM-5 is the division of the mood disorders section into two units, one on bipolar and related disorders and the other on depressive disorders. [sup][11] The unit on bipolar and related disorders is placed in between the section on schizophrenia spectrum and other psychotic disorders on the one side and the section on depressive disorders on the other. A conglomerate of genetic and neurobiological findings supports this intermediate position of bipolar disorder between schizophrenia and unipolar depression. Whereas bipolar depression shares clinical features unipolar depression (depressive symptoms, tendency toward an episodic course, family history, comorbidities), bipolar disorder also shares significant features schizophrenia (symptomatology, genetic markers, family history, response of mania to antipsychotic agents). [sup][2],[3],[12],[13],[14] This lends support to the change made in DSM-5 and is also consistent observations that neurocognitive deficits and various neurobiological findings are seen across the spectrum of psychotic disorders, spanning schizophrenia through bipolar disorder to major depression. [sup][15],[16] Although there is much empirical support and sound rationale for this separation between bipolar and depressive (unipolar) disorders, it has been criticized [sup][17] because it conflicts Kraepelinian orthodoxy. [sup][18] Since DSM-5 has also been criticized for being too conservative in its approach, [sup][19] this illustrates the challenges in updating our system of psychiatric classification. [sup][20] Whereas the research implications of this change are evident, placement of bipolar and related disorders and unipolar and related disorders in separate chapters reinforces the clinical imperative of recognizing important differences between bipolar and unipolar depression regard to comorbidities, treatment, and outcome. Bipolar and Related Disorders Five relatively modest changes were made in an effort to improve clinical utility and specificity in the diagnosis of bipolar and related disorders. These include: *The elimination of the category of bipolar disorder, mixed, and its replacement by a new specifier with mixed features; *Addition of a requirement that abnormal and persistently increased goal-directed activity or energy accompany elated or irritable mood as an essential criterion (criterion A) for diagnosing mania or hypomania; *Addition of anxious distress and other specifiers to improve the precision of characterizing these disorders in a clinically pertinent manner; *Provision of specific criteria for defining sub-threshold bipolar disorders; and *Elimination of antidepressant medication as an exclusion criterion for diagnosing mania or hypomania. …

Pediatric Bipolar Disorder: A Case Presentation and Discussion

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) mixed features specifier provides a less restrictive definition of mixed mood states, compared to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), including mood episodes that manifest with subthreshold symptoms of the opposite mood state. A limited number of studies have assessed the efficacy of treatments specifically for DSM-5-defined mixed features in mood disorders. As such, there is currently an inadequate amount of data to appropriately inform evidence-based treatment guidelines of DSM-5 defined mixed features. However, given the high prevalence and morbidity of mixed features, treatment recommendations based on the currently available evidence along with expert opinion may be of benefit. This article serves to provide these interim treatment recommendations while humbly acknowledging the limited amount of evidence currently available. Second-generation antipsychotics (SGAs) appear to have the greatest promise in the treatment of bipolar disorder (BD) with mixed features. Conventional mood stabilizing agents (ie, lithium and divalproex) may also be of benefit; however, they have been inadequately studied. In the treatment of major depressive disorder (MDD) with mixed features, the comparable efficacy of antidepressants versus other treatments, such as SGAs, remains unknown. As such, antidepressants remain first-line treatment of MDD with or without mixed features; however, there are significant safety concerns associated with antidepressant monotherapy when mixed features are present, which merits increased monitoring. Lurasidone is the only SGA monotherapy that has been shown to be efficacious specifically in the treatment of MDD with mixed features. Further research is needed to accurately determine the efficacy, safety, and tolerability of treatments specifically for mood episodes with mixed features to adequately inform future treatment guidelines.

Impulse control disorder comorbidity among patients with bipolar I disorder

Over a half of all proteins are glycosylated, and their proper glycosylation is essential for normal function. Unfortunately, because of structural complexity of nonlinear branched glycans and the absence of genetic template for their synthesis, the knowledge about glycans is lagging significantly behind the knowledge about proteins or DNA. Using a recently developed quantitative high throughput glycan analysis method we quantified components of the plasma N-glycome in 99 children with attention-deficit hyperactivity disorder (ADHD), 81 child and 5 adults with autism spectrum disorder, and a total of 340 matching healthy controls. No changes in plasma glycome were found to associate with autism spectrum disorder, but several highly significant associations were observed with ADHD. Further structural analysis of plasma glycans revealed that ADHD is associated with increased antennary fucosylation of biantennary glycans and decreased levels of some complex glycans with three or four antennas. The design of this study prevented any functional conclusions about the observed associations, but specific differences in glycosylation appears to be strongly associated with ADHD and warrants further studies in this direction.

Factors related to suicidal behavior in patients with bipolar disorder: the effect of mixed features on suicidality.

ABSTRACTObjective: To compare the cost and utilization of health care services for various comorbid conditions among employees with bipolar disorder (BPD) and two other population cohorts: employees without BPD and employees with other mental disorders (OMD).Methods: Retrospective database analysis on a 2‐year study period, from January 1, 2001, through December 31, 2002 using adjudicated health insurance medical claims on more than 230 000 employees plus their eligible dependents. Study comparisons were performed among employees with BPD (cohort BPD), employees without BPD (cohort NBD), and employees with OMD (cohort OMD). Outcome measures included the cost and utilization of health services for various comorbid conditions as defined by the Agency for Healthcare Research and Quality (AHRQ); using 261 specific categories (SCs) and the 17 Major Diagnostic Categories (MDCs).Results: Employees in cohort BPD ( n = 761) had greater average annual medical and prescription drug costs than the two other employee cohorts. Costs for cohort BPD were significantly greater ( p ≤ 0.05) than for cohort NBD ( n = 229 145) for six of the 17 MDCs, including the categories of mental disorders ($2036 vs. $65), injury and poisoning ($544 vs. $162), musculoskeletal/connective tissue ($607 vs. $315), other conditions ($274 vs. $134), respiratory system ($217 vs. $104), and nervous system/sensory organs ($225 vs. $119). Similarly, comparisons across AHRQ's 261 SCs found the annual medical costs associated with BPD were greater in 137 (52%) of the 261 categories. Differences between cohort BPD and cohort OMD ( n = 26 776) were significant ( p ≤ 0.05) in three MDCs, with BPD 3.4 times greater than OMD in the mental disorders category: $2036 vs. $596, respectively.Conclusion: Employees with BPD have greater cost and utilization of services due to various mental and physical comorbidities than either employees without BPD or employees with OMD. The findings are consistent with current literature concerning the comorbidities associated with BPD, and suggest that further longitudinal and observational investigation is necessary to attempt to improve diagnosis and treatment of not only BPD, but also associated targeted diseases commonly found in employees with BPD.

BackgroundRelapse and hospital admission are common among, and carry a heavy burden in, patients with schizophrenia and bipolar disorder. The aim of this study was to assess the risk of relapse and hospitalizations in patients with schizophrenia and bipolar disorder at the St Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia.Patients and methodsA hospital-based comparative cross-sectional study was conducted in June 2016. Systematic random sampling technique was used to recruit 521 (260 schizophrenia cases and 261 bipolar disorder cases) study participants. Face-to-face interviews were conducted by trained psychiatry professionals. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) criteria and Structured Clinical Interview of DSM-IV (SCID) were used.ResultsThe risk of relapse and hospitalizations was slightly higher in patients with bipolar disorder than in patients with schizophrenia. A majority of schizophrenic (213 [81.92%]) and bipolar (215 [82.37%]) patients had a history of hospital admission, and 228 (87.69%) schizophrenic and 230 (88.12%) bipolar patients had a history of relapse. Patients who had a history of hospitalizations also had co-occurring substance use disorders compared to those who had no history of hospitalizations for schizophrenia (81.5% vs 37.9%) and bipolar disorder (82.56% vs 38.2%), respectively. Similarly, those patients who had a history of relapse had high comorbid substance use disorders than those who had no history of relapse for both schizophrenia (87.88% vs 47.37%) and bipolar disorder (88.37% vs 47.19%), respectively.ConclusionIt is vital that, in the local context, mental health professionals strengthen their therapeutic relationships with patients and their caregivers. This might enable patients and their caregivers to express their needs and concerns to them, as well as help to plan proper interventions for patients. Attention needs to be given to screening for comorbid substance use disorders in patients with schizophrenia and bipolar disorder, especially in those who have had a history of relapse and hospitalizations.

Byline: David. Bond, Lakshmi. Yatham According to the Diagnostic and Statistical Manual of Mental Disorders, 4[sup] th Edition, Text Revision (DSM-IV-TR)[sup] [1], bipolar II disorder (BDII) consists of recurrent episodes of depression and hypomania. Although the lifetime prevalence of BDII remains a matter of debate, with some studies reporting rates as high as 5% [sup] [2], most epidemiological surveys suggest a prevalence of 1%-2% [sup] [3],[4] .[sup] This makes BDII at least as common as bipolar I disorder (BDI), which has a lifetime prevalence of 1% [sup] [4] .[sup] BDII is sometimes viewed as a form of bipolar illness, but this is a misconception, as it is associated with rates of disability that are comparable to BDI [sup] [5] .[sup] As well, BDII may have the highest frequency of suicidal behaviour of any mood disorder[sup] [6] . Although BDII is defined by the occurrence of hypomania, for many patients it appears to be a predominantly depressive illness. Studies in treated samples demonstrate that BDII patients spend approximately half of their lives with depressive symptoms [sup] [7],[8] ,[sup] In fact, BDII is likely the most common cause of depression after major depressive disorder, with studies suggesting that 18.5% of family practice patients with depression and 40% of depressed patients in psychiatric specialty settings suffer from BDII [sup] [9],[10] . This[sup] is indicative of both the frequency of depressive symptoms, and the possibility that depressions do not respond as well to treatment as hypomanias. Hypomanias, in contrast to depressions, are often brief and are not uncommonly associated with minimal to mild disability[sup] [2],[5] . The frequency and severity of depression in BDII, coupled with the difficulties inherent in retrospectively ascertaining a history of hypomania, commonly lead to the misdiagnosis of BDII as major depressive disorder (MDD). To avoid this pitfall, clinicians should be finely attuned to the possibility of BDII as a cause of depression, and must be rigorous in screening all depressed patients for a history of hypomania. Furthermore, it is important to be aware of a number of barriers to the diagnosis of hypomania. First, patients and their families often do not recognize hypomania as a pathological state, and they frequently do not volunteer a history of hypomanic symptoms. Second, although the DSM-IV-TR requires a 4-day duration of symptoms to diagnose hypomania, hypomania is frequently briefer, with some studies suggesting a median duration of 1-3 days[sup] [2] .[sup] Thus, in addition to thoroughly screening patients for hypomanic symptoms, we have found a number of clinical tools useful in making the diagnosis. These include obtaining collateral history from family members; having patients keep daily mood diaries; and also having them complete the Mood Disorders Questionnaire (MDQ), a 13-item self reported questionnaire with queries about common hypomanic symptoms [sup] [11] .[sup] Although the MDQ has not been as rigorously studied as a screening instrument in BDII as it has in BDI, our clinical experience suggests that it can be a helpful diagnostic aid. Finally, the value of long-term follow-up cannot be overstated, as hypomanic symptoms often become obvious during long-term follow-up. Partly as a result of difficulties in making the correct diagnosis, the prevalence of hypomania has until recently been underestimated, and its treatment consequently understudied. Lacking an adequate evidence base, physicians are sometimes left with no alternative but to make treatment decisions for BDII patients based on the results of BDI studies. However, genetic [sup] [12] ,[sup] family history [sup] [13] ,[sup] and long-term follow-up studies [sup] [14] clearly indicate that BDI and BDII are distinct illnesses. More importantly, a number of clinical trials suggest that BDII patients may respond quite differently to mood stabilizing medications [sup] [15],[16],[17] and antidepressants [sup] [18] compared to patients with BDI. …

BackgroundIn psychiatric literature stretching over a century, there have been glaring discrepancies in the findings describing the relationship between bipolar disorder (BD) and socioeconomic status (SES). Early studies indicated an overall association between manic-depressive illness and higher social class. However, recent epidemiologic studies have failed to find an association between BD and SES. Instead, they report a similar distribution of BD among social classes and educational levels, and in one particular study, a lower family income was reported. The determinants of SES are complex, and the early findings are now interpreted as having been incorrect and stemming from past methodological weaknesses.MethodsFor this analysis we explored the relationship between SES and BD in a sample of patients who had participated in prior clinical and therapeutic studies. These patients met the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for BD, required long-term stabilizing treatment, and were assessed in terms of their response to lithium stabilization and a number of other clinical characteristics in accordance with research protocol. Good response to lithium stabilization (LiR) served as a proxy for identifying a subtype of manic-depressive illness, the classical form of BD. Non-responders to stabilizing lithium (LiNR) were considered belonging to other subtypes of bipolar spectrum disorder. The SES of the parents was measured upon entry into treatment using the Hollingshead SES scale, which despite its limitations has been used in psychiatry most widely to determine SES. The groups of LiR and LiNR were compared statistically in terms of SES. The influence of bipolar subtype and gender on SES was investigated.Results and discussionA significantly higher SES was associated with the lithium-responsive form (LiR) of BD when compared with patients continuing to relapse despite adequate lithium treatment (representing other types of bipolar spectrum). Our observation suggests that the discrepant literature findings about SES and BD may be better explained by the change in diagnostic practices: early studies describing a positive relationship included mostly classical manic-depressive disorder, while the patients in recent studies have been diagnosed according to much broader criteria, reflecting the era of bipolar spectrum disorder.

Facing the Challenges of Understanding and Managing Behavior and Psychiatric Issues

This study aimed to test the effects of omega-3 fatty acids (O3FA), given as fish oil capsules, with and without oral cytidine (CYT), a pyrimidine with reported preclinical and clinical antidepressant-like effects, in patients with bipolar disorder (BD). A total of 45 outpatients with diagnosed BD (type I) according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition - Text Revision, were recruited for this 4-month, randomized, double-blind, placebo-controlled, add-on study. Treatment groups were (1) oral CYT + O3FA, (2) placebo + O3FA, and (3) placebo + placebo control. O3FA was given 2 g twice a day and CYT was administered as 1 g twice a day. There was no statistically significant difference among the groups in the primary outcome: study retention. Clinical measures improved in all treatment groups, and there were no significant differences between groups, including change in probability of symptoms of depression or mania, change in positive ratings of depression or mania, or change in Global Assessment of Functioning scores. Neither CYT + O3FA nor placebo + O3FA treatment was superior to placebo treatment. Rather, there was a statistically nonsignificant trend for both groups treated with O3FA to do worse than the placebo group. Despite preclinical studies suggesting that the effect of O3FA might be augmented with pyrimidines, add-on CYT did not substantially improve mood symptoms in BD. In addition, although a power analysis indicated that the sample size would be adequate to see beneficial effects similar to those previously reported, O3FA treatment by itself was not superior to placebo for BD.

Concern over rising health care costs has put pressure on providers to reduce costs, purportedly by reducing inpatient care and increasing outpatient care. Inpatient and outpatient claims were analyzed for adult users of mental health services (180,000/year on average) from a national study group of 3.9 million privately insured individuals per year from 1993 to 1995. Costs and treatment days per patient were compared across diagnostic groups and stratified by whether patients were hospitalized. Inpatient mental health costs fell $2,507 (30.4%) over the period, driven primarily by decreases in hospital days per patient per year (19.9%), with smaller changes in the proportion of enrollees who received inpatient care (increase of 0.8%) and a decrease in per diem costs (9.1%). Outpatient mental health costs also declined over the period, falling 13.6% for patients also using inpatient services and 14.6% for patients receiving only outpatient care. Patients whose primary diagnosis was mild to moderate depression saw the largest decreases in inpatient cost per patient (42.8%); those diagnosed with schizophrenia experienced the smallest decrease (23.5%). For patients using outpatient services only, those diagnosed with substance abuse experienced the largest decrease in costs (23.5%); those diagnosed with schizophrenia experienced the smallest decrease (8.6%). Substantial cost reductions for mental health services are primarily a result of reductions in inpatient and outpatient treatment days. Declines in inpatient service use were not accompanied by increases in outpatient service use, even for severely ill patients requiring hospitalization. Managed care has not caused a shift in the pattern of care but an overall reduction of care.

Temperament and character traits in patients with bipolar disorder and associations with attempted suicide

Back to table of contents Previous article Next article LettersFull AccessICD-11 and DSM-5 Classifications: A Survey of Japanese PsychiatristsToshimasa Maruta, M.D., Ph.D., Yutaka Ono, M.D., Ph.D., and Chihiro Matsumoto, M.A.Toshimasa MarutaSearch for more papers by this author, M.D., Ph.D., Yutaka OnoSearch for more papers by this author, M.D., Ph.D., and Chihiro MatsumotoSearch for more papers by this author, M.A.Published Online:1 Dec 2013https://doi.org/10.1176/appi.ps.201300396AboutSectionsView articleSupplemental MaterialPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail View articleTo the Editor: The World Health Organization is currently working on the 11th revision of the International Classification of Diseases (ICD-11) (1), and DSM-5 (2) was released in May 2013. Some criticized the process of developing DSM-5 (3). Thus we thought that it would be worthwhile to investigate how Japanese psychiatrists view the ICD and DSM revision processes and how they would like the diagnostic classifications to change.The aim of this study was to clarify how ICD-10 (4) and DSM-IV-TR (5) have been perceived in clinical, administrative, and forensic settings in Japan. In addition, we solicited opinions on the diagnostic classifications proposed for ICD-11. A questionnaire was mailed in February 2011 to 452 members of the council of the Japanese Society for Psychiatric Diagnosis and 80 chief professors from every psychiatry department at universities in Japan. They were asked to provide their opinions and perspectives on issues regarding diagnostic classification in general, rather than on specific disorders or domains in the ICD-10 and DSM-IV-TR.Data were collected from 245 respondents (response rate of 46%), of which 219 were men and 26 were women. The mean±SD age of respondents was 50.0±12.9 years, and the mean length of their experience as a psychiatrist was 23.9±12.4 years. [A table presenting the 12 questions and the responses is available in an online data supplement to this letter.]Survey results appeared to indicate that respondents were rather hesitant about making major changes, such as reorganizing the classification system. The coexistence of two major diagnostic systems, namely the ICD and DSM, has been a concern among many clinicians. The Research Domain Criteria proposed by the National Institute of Mental Health in the United States were favorably seen by Japanese psychiatrists; 74% approved this approach.Hesitation about making major changes was evident in responses to an item about recent molecular genetic research suggesting that bipolar disorder is closer to schizophrenia than to depression. Respondents were not comfortable combining bipolar disorder and schizophrenia as psychotic disorders; instead, 69% agreed that bipolar disorder should continue to be included in the category of mood disorders.Two items asked about the many “not otherwise specified” (NOS) diagnoses and “comorbid” diagnoses that are yielded by the ICD-10 and DSM-IV-TR. Responses indicated a desire that revisions to the classification systems would lead to fewer such diagnoses; however, many respondents acknowledged that NOS and comorbid diagnoses were an unavoidable outcome of using operational diagnostic criteria.These results were obtained from Japanese psychiatrists and therefore cannot be generalized to psychiatrists worldwide. However, we hope that these findings will help inform ICD-11 revision efforts.Dr. Maruta and Ms. Matsumoto are affiliated with the Department of Psychiatry, Tokyo Medical University, Tokyo. Dr. Ono is with the National Center for Cognitive Behavioral Therapy and Research and the National Center of Neurology and Psychiatry, Tokyo.Acknowledgments and disclosuresThe study was supported by a Health Labor Science Research Grant H20-Kokoro-Ippan-007 from the Japanese Ministry of Health, Labor and Welfare. The authors thank the survey participants.The authors report no competing interests.References1 International Advisory Group for the Revision of ICD-10 Mental and Behavioural Disorders: A conceptual framework for the revision of the ICD-10 classification of mental and behavioural disorders. World Psychiatry 10:86–92, 2011Crossref, Medline, Google Scholar2 Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Arlington, Va, American Psychiatric Association, 2013Google Scholar3 Frances A: Whither DSM-V? British Journal of Psychiatry 195:391–392, 2009Crossref, Medline, Google Scholar4 International Statistical Classification of Diseases and Related Health Problems, 10th Revision. Geneva, World Health Organization, 1992Google Scholar5 Diagnostic and Statistical Manual of Mental Disorders, 4th ed, Text Revision. Washington DC, American Psychiatric Association, 2000Google Scholar FiguresReferencesCited byDetailsCited ByNone Volume 64Issue 12 December 2013Pages 1279-1280 Metrics Acknowledgments and disclosuresThe study was supported by a Health Labor Science Research Grant H20-Kokoro-Ippan-007 from the Japanese Ministry of Health, Labor and Welfare. The authors thank the survey participants.The authors report no competing interests.PDF download History Published online 1 December 2013 Published in print 1 December 2013