DSM Classification Research Articles

Acute stress in patients with brain cancer during primary care

This study investigated whether diagnosis and neurosurgical removal of a brain tumour induced Acute Stress Disorder (ASD) in adults. We also aimed to identify factors associated with the development of ASD in this specific patient group and setting. Forty-seven consecutive patients with intracranial neoplasms completed a variety of self-report questionnaires and underwent a structured clinical interview (SCID) within the first 4 weeks after tumour detection on average 1 week after neurosurgical treatment. Moreover, the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), A1 and A2 criterion and thus the characteristics of the traumatic event were explored in detail. ASD symptoms were common. Twenty-three percent of the patients met stringent criteria of ASD and another 4% suffered from subsyndromal ASD. Predisposing factors previously reported in literature with the exception of previous trauma could not be identified in this study (e.g., sex, age, intelligence). It has been critically discussed whether the diagnosis of ASD is appropriate in cancer patients due to the often future-related nature of cancer-related traumatic events. The diagnosis of ASD was justified in the vast majority of affected patients due to the specific, acute and past traumatic experiences in concordance with the DSM and International Statistical Classification of Diseases and Related Health Problems (ICD) trauma definitions. Thus, ASD is a common and relevant psychiatric comorbidity in patients with brain tumours. Our data highlight both the need for the routine psychological assessment as well as of psychosocial support in this early treatment phase.

Synthèse pour la rééducation périnéo-sphinctérienne

The 2 most well-known classification systems that include sexual medicine diagnoses are the International Classification of Diseases and Statistics (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM). Sexual medicine experts from international societies representing an array of disciplines have revised and redefined female sexual dysfunctions (FSDs) to reflect current scientific evidence and the state of the art.To summarize the evidence and interactive and chronological process by which sexual medicine societies’ consensus groups developed the current nomenclature, classifications, and definitions for FSDs.We review the contributions and collaborations of the Fourth International Consultation in Sexual Medicine (ICSM), the International Society for the Study of Women’s Sexual Health (ISSWSH), and the World Association of Sexual Health in conjunction with the World Health Organization.The ICSM and ISSWSH diagnostic systems are contrasted with the DSM classification. We discuss innovations and strengths; relevant evidence regarding epidemiology, etiology, and risk factors; and key differences. We describe how sexual medicine expertise informed FSD codes in the ICD-11 classification.ICSM and ISSWSH published evidence-based guidelines on the definitions, nomenclature, and diagnostic criteria for FSD that diverge from the DSM psychiatric compendia. These definitions and nomenclature recommend the separation of female sexual desire and arousal disorders, elaborate on subtypes of arousal problems, broaden the scope of sexual pain definitions, and provide a greater understanding of etiologies and risk factors for FSDs.These collaborations among sexual medicine experts and their role in the ICD-11 development process provide confidence that the ICD-11 Sexual Dysfunction codes are based on current scientific evidence for diagnosing and coding FSDs in clinical settings worldwide, can serve as endpoints in clinical trials, and will provide specificity for treatment outcomes for FSD therapies.Parish SJ, Cottler-Casanova S, Clayton AH, et al. The Evolution of the Female Sexual Disorder/Dysfunction Definitions, Nomenclature, and Classifications: A Review of DSM, ICSM, ISSWSH, and ICD. Sex Med 2021;9:36–56.

The Importance of History for Philosophy of Psychiatry: The Case of the DSM and Psychiatric Classification

Abstract Recently, some philosophers of psychiatry (viz., Rachel Cooper and Dominic Murphy) have analyzed the issue of psychiatric classification. This paper expands upon these analyses and seeks to demonstrate that a consideration of the history of the Diagnostic and Statistical Manual of Mental Disorders (DSM) can provide a rich and informative philosophical perspective for critically examining the issue of psychiatric classification. This case is intended to demonstrate the importance of history for philosophy of psychiatry, and more generally, the potential benefits of historically-informed approaches to philosophy of science.

Catatonia from its creation to DSM-V: Considerations for ICD

Catatonia was delineated only as a type of schizophrenia in the many American Psychiatric Association DSM classifications and revisions from 1952 until 1994 when “catatonia secondary to a medical condition” was added. Since the 1970s the diagnosis of catatonia has been clarified as a syndrome of rigidity, posturing, mutism, negativism, and other motor signs of acute onset. It is found in about 10% of psychiatric hospital admissions, in patients with depressed and manic mood states and in toxic states. It is quickly treatable to remission by benzodiazepines and by ECT. The DSM-V revision proposes catatonia in two major diagnostic classes, specifiers for 10 principal diagnoses, and deletion of the designation of schizophrenia, catatonic type. This complex recommendation serves no clinical or research purpose and confuses treatment options. Catatonia is best considered in the proposed ICD revision as a unique syndrome of multiple forms warranting a single unique defined class similar to that of delirium.

Personality and risk of dementia

We review the personality construct and its disorders according to the categorical and dimensional approaches, and the present understanding of dementia and its risk factors. This study shows a relationship between pre-morbid personality and risk of developing dementia. Data with speculative character, and indirect proofs from studies on life style, habits and pathological behaviors are reported. Categorical and dimensional parameters of personality are studied respectively by cluster analysis of the DSM classification, and by two contributive instruments: the Cloninger's temperament and character inventory (TCI) with seven dimensions, and the Costa and McCrae's NEO personality inventory (NEO PI) with five factors. Risk of dementia is higher in patients with the DSM C personality cluster, and, by order of severity, the dependent, avoidant and obsessive types of personality. According to the TCI, these three personality types have a high score on the dimension "harm avoidance", which increases the risk of dementia. With the five factor model investigated by the NEO PI, the risk of dementia is increased by low levels of extraversion, openness, agreeableness and conscienciousness, and high level of neuroticism. Biological correlations are mixed up with these two personality models, which have coherent correlations between their respective dimensions. High levels of neuroticism and harm avoidance are associated with low serotonin activity, deficient neuroplasticity, cortisol abnormalities and greater deleterious impact according to the type of stressing situations. Cortisol levels regulation differs according to the type of personality and cortisol axis dysregulation could play a key part in dementia occurrence. Detecting vulnerable personalities should lead to recommendations for dementia prevention.

Scientific progress and the prospects for culture-bound syndromes

This paper aims to show that the classification by the American Psychiatric Association (APA) in the Diagnostic and Statistical Manual of Mental Disorders (DSM) of a distinct listing of disorders known as Culture-Bound Syndromes (CBS) is misguided. I argue that the list of CBS (in Appendix I of the manual) comprises either (a) genuine disorders that should be included within the main body of the DSM; or (b) ersatz-disorders that serve a practical role for psychiatrists dealing with patients from certain cultures but will one day be eliminated or assimilated by bona fide DSM classifications. In support of these views I draw on claims from two key themes in the philosophy of science: (1) the claim that all folk (that is, non-scientific) explanations for phenomena are thoroughly theoretical and therefore fallible; and (2) the occurrence of theoretical elimination in the history of science. I contend that any ersatz-disorders located in the DSM that are judged to be radically false do not differ in kind from eliminated theories in the history of pre-science.

The failure of the schizophrenia concept and the argument for its replacement by hebephrenia: applying the medical model for disease recognition

The failure of the schizophrenia concept and the argument for its replacement by hebephrenia: applying the medical model for disease recognition

The network perspective will help, but is comorbidity the question?

Latent variable modeling has revealed important conundrums in the DSM classification system. We agree that the network perspective has potential to inspire new insights and resolve some of these conundrums. We note, however, that alone it cannot really help us understand etiology. Etiology, not comorbidity, is the fundamental question.

Comorbidity of borderline personality disorder and posttraumatic stress disorder in the U.S. population

While placed on different axes of the DSM classification system, borderline personality disorder (BPD) and posttraumatic stress disorder (PTSD) have important relationships with trauma, and overlap between these disorders has long been recognized. The current study is the first to examine comorbidity of PTSD and BPD in a large nationally representative sample using a reliable and valid method of assessing Axis I and II mental disorders. Data came from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) Wave II (N = 34,653; response rate 70.2%). Multiple regression models were used to examine differences in psychopathology, traumatic events and health-related quality of life across individuals with PTSD alone (n = 1820), BPD alone (n = 1290) and those with comorbid PTSD–BPD (n = 643). The lifetime prevalence of PTSD and BPD were 6.6% and 5.9%, respectively. Of individuals with BPD, 30.2% were also diagnosed with PTSD, whereas 24.2% of individuals with PTSD were also diagnosed with BPD. Individuals with comorbid PTSD–BPD had a poorer quality of life, more comorbidity with other Axis I conditions, increased odds of a lifetime suicide attempt, and a higher prevalence of repeated childhood traumatic events than individuals with either condition alone. These results show that PTSD and BPD have a high degree of lifetime co-occurrence but are not entirely overlapping. Their concurrence is associated with poorer functioning compared to either diagnosis alone, emphasizing the clinical utility of diagnosing both conditions. Future research should explore the determinants of having either or both diagnoses with an aim toward improved identification, prevention, and intervention.

Reconciling specific and unspecific risk factors: the interplay between theory and data

From this issue onwards, one of the editors will introduce the published set of papers by an editorial. This may serve to both highlight some papers as well as to provide a personal touch to a relevant topic of child and adolescent psychiatry. A basic premise of our understanding of the origins of child and adolescent psychopathology is that both genes and the environment are crucially and equally important. Put into a simple formula: the effect of genes = 100% and the effect of the environment = 100%. No developing organism without genes, but neither one without environmental influences, structure and context. The challenge of research is to unravel the complicated interplay between genetic and environmental risk factors in shaping development and translate this understanding to clinically relevant approaches to intervention and prevention. A key finding has been that variation in the promoter region of the human serotonin transporter gene influences the sensitivity to stressful life events and having been exposed to childhood maltreatment. Those carrying the short allel have increased risk for depression and suicidal thought following exposure to stressful life events and childhood maltreatment [1]. This landmark paper led to a long series of attempts to replicate, and many did successfully. Recent meta-analyses, however, took a critical stance, questioning what would constitute a real replication of such a gene by environment interaction finding [3, 4]. These meta-analyses, in turn, appeared to have missed the broader biological theory and well-established neuroscience foundation for this interaction effect [2] and to have taken a selective sample of studies for review [5]. One element of this discussion is how specific the risk factors, be it in the gene or the environment, should be defined and whether the more specific is always the better. Getting it as specific as possible clearly may detract from the possibility to generalise the findings to a broader theory of functioning. The paper by Floury et al. in this issue bears on this topic and shows that a cumulative, thus more general or unspecific, measure of environmental risk factors provides the strongest account of psychopathology in a large sample of 3-year-old children in the UK. At the same time, however, the authors demonstrate that the effects of environmental adversity are moderated by very specific protective factors. Non-verbal ability moderated the effect of proximal family risk on conduct and emotional problems, and developmental milestones moderated the effect of proximal family risk on conduct problems. The lesson to be learned is that it is the interplay between theory (in this case that the protective factors would be located in the children’s cognitive domain) and data that will provide the most useful answers in this discussion. The paper by van Oort et al. adds another perspective by examining whether anxiety and depression, which are so often co-occurring, have similar or different correlates in the family environment. Van Oort et al. show that there are differential associations between risk factors from the family environment and anxiety and depression in adolescents. Family dysfunction appears to be more strongly associated with anxiety than with depression, whereas parenting stress is more strongly associated with depression. Finally, Noterdaeme et al. focus on the issue of how specific and distinct our diagnostic categories should be. In a follow-up study of a well-characterized sample of subjects with Asperger syndrome and high-functioning autism, the distinctions between the two groups of subjects at about 10 years of age in terms of psychopathology, cognition and level of functioning were minor. The differences in verbal-IQ and language skills between the two groups were not surprising and could be explained through the definition of the syndromes. This questions the validity of the diagnostic distinction between Asperger syndrome and high-functioning autism within the category of autism spectrum disorders and links with the recent proposals for the revised DSM classification (http://www.dsm5.org).

The Unstructured Clinical Interview

In mental health, family, and community counseling settings, master's‐level counselors engage in unstructured clinical interviewing to develop diagnoses based on the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM‐IV‐TR; American Psychiatric Association, 2000). Although counselors receive education about diagnosis and the DSM classification system, the majority of them are not specifically trained in clinical interviewing. This article provides information about using the unstructured clinical interview to make a DSM‐IV‐TR diagnosis for adult clients with Axis I and Axis II disorders.

Postpartum depression: a disorder in search of a definition

The Diagnostic and Statistical Manual (DSM-IV) has the following goal: “to provide clear descriptions of diagnostic categories in order to enable clinicians and investigators to diagnose, communicate about, study, and treat people with various mental disorders.” The DSM-IV also includes specifiers for mood disorders that are intended to increase diagnostic specificity and create homogeneous subgroups, drive treatment selection, and improve the prediction of prognosis. With postpartum onset is a specifier with two requirements: 1) a time criterion (onset of episode within 4 weeks after birth), and 2) application to the current or most recent episode of four diagnoses (major depressive disorder; major depressive, manic, or mixed episode in bipolar I or II disorder; or brief psychotic disorder). However, the term postpartum depression has been used to describe a broad variety of childbearing-related mood episodes not included in the DSM-IV definition. Gaynes et al. (2005) used an expanded concept of perinatal depression (during pregnancy through one year postpartum) in their report (commissioned by the Agency for Healthcare Research and Quality) to inform national policy. From a public health perspective, women, families and communities suffer regardless of when the maternal episode begins. The purpose of this paper is to examine the DSM-IV definition of with postpartum onset and challenges in its clinical and research application. Our goal is to frame the discussion about the specifier as revisions of the DSM and International Classification of Diseases (ICD) codes are considered. We focus on major depressive disorder (MDD) to highlight the ways in which the definition of the postpartum onset specifier might be modified.

Premenstrual dysphoric disorder: out of the appendix

Both the International Classification of Diseases (ICD-11) and the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) are in development to produce revised diagnostic categories and updated diagnostic coding. Optimally, the new classification systems would increase the ability to match DSM codes with ICD codes for mental disorders. In general, the process for updating psychiatric disorders in DSM-V involves literature reviews, research plans for field trials, secondary data analyses and revision of the DSM-IV-TR text. The DSM has traditionally utilized a categorical classification system of disorders, and there is consideration of classifying disorders along symptom dimensions. Controversies exist about the addition of new disorders (e.g. internet addiction) and removal of current disorders (e.g. gender identity disorder). The approach planned for updating premenstrual dysphoric disorder (PMDD) in DSM-V has not been revealed. Currently the “Research Criteria for Premenstrual Dysphoric Disorder” is included in the “Criteria Sets and Axes Provided for Further Study” in Appendix B of the DSM-IV-TR. Women who meet the PMDD criteria are coded on axis I with 311, Depressive Disorder Not Otherwise Specified (NOS). PMDD is an example of the mismatch between the ICD and DSM classification systems. ICD-10 defines premenstrual tension syndrome as the presence of one or more emotional or physical premenstrual symptoms. Symptom severity and duration are not specified. ACOG published diagnostic criteria of premenstrual syndrome (PMS) in 2000 that requires at least one emotional or physical premenstrual symptom, the symptom(s) must resolve postmenses, and the symptom(s) must be severe enough to interfere with social or work functioning. In addition, prospective confirmation of the symptoms by daily ratings for two menstrual cycles is required. The DSM-IV-TR PMDD criteria require at least 5 of 11 potential symptoms, one of which must be marked depressed mood, anxiety, affective lability or irritability. Symptoms must remit following menses, be present in most menstrual cycles, interfere with social and work functioning, and be confirmed by prospective daily ratings over two menstrual cycles. Women who meet criteria for PMDD are viewed as the severe end of the spectrum of PMS. At this point, the criteria for PMDD should be its own diagnostic classification outside of the appendix. Since the inclusion of research criteria for late luteal phase dysphoric disorder in the DSM-III-R in 1987, many studies have been conducted in women with PMDD evaluating etiology, comorbidity, burden of illness and treatment. Studies of pathophysiology suggest serotonin abnormalities, allopregnanolone and GABAA receptor dysfunction, and heightened sensitivity to normal fluctuations of estrogen and progesterone (Cunningham et al. 2009). The link between gonadal hormones, neurotransmitters, and neurosteroids may also underlie perinatal and perimenopausal depression (Payne et al. 2009). The existence of PMDD criteria has led to two decades of pharmacological and nonpharmacological treatment studies (Pearlstein and Steiner 2008; Cunningham T. Pearlstein Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI 02912, USA

Testing a hierarchical model of anxiety and depression in adolescents: A tri-level model

The present study examined the structural relationships among anxiety and depressive symptoms in a sample of high school juniors. The best-fitting structural representation was a tri-level hierarchical arrangement with a broad general factor (general distress), two factors of intermediate breadth (anxious-misery and fears), and five conceptually meaningful, narrow group factors. In accord with the integrative hierarchical model of anxiety and depression, the results supported a structure with a symptom factor central to major depression, and other symptom factors specific to particular anxiety disorders. These group factors displayed significant, unique associations with clinician severity ratings (CSRs) for their respective DSM diagnoses. The hierarchical arrangement demonstrated temporal invariance over a one-year period and configural and partial metric invariance in females and males. Implications for DSM classification and arrangement of anxiety and depressive disorders are discussed as is how present findings help bridge existing research conducted at symptom and diagnostic levels.

The Age at Onset of Attention Deficit Hyperactivity Disorder

Whilst the contemporary concept of attention deficit/hyperactivity disorder (ADHD) is relatively recent, the typical pattern of ADHD symptoms has been described in the literature since the nineteenth century, and these early descriptions all emphasised an onset early in life. ADHD symptoms and impairments are often present during the preschool period. However making a diagnosis during this period is challenging due to the greater variability in normal behaviours during this developmental period. The ADHD construct has been refined over time, and with the introduction of the DSM and ICD classification systems, an age of onset (AOO) criterion was introduced making it a requirement that symptoms, and later on impairment, were present before the age of 7 years. This criterion was challenged as arbitrary and lacking empirical support. In DSM-5 the AOO criterion for ADHD was adjusted such that only some symptoms appearing before the age of 12 years are required to make a diagnosis. ADHD was traditionally thought of as a disorder of childhood, and perhaps adolescence. It is now clear that ADHD often persists into adulthood, either as the full disorder or partially remitted but with continuing impairment. Several recent studies have challenged the notion that ADHD always begins in childhood. Four large community studies have identified a group of adults who did not have ADHD as children but who do meet diagnostic criteria for ADHD as adults. These findings have resulted in considerable debate, and several lines of argument have been put forward to explain the findings.

Pervasive refusal syndrome as part of the refusal–withdrawal–regression spectrum: critical review of the literature illustrated by a case report

Pervasive refusal syndrome (PRS) is a rare child psychiatric disorder characterized by pervasive refusal, active/angry resistance to help and social withdrawal leading to an endangered state. Little has been written about PRS. A literature search yielded only 15 relevant articles, all published between 1991 and 2006. This article presents a critical review of the published literature, illustrated by a case report of an 11-year-old girl. PRS most often affects girls (75%). The mean age of the known population is 10.5 years. A premorbid high-achieving, perfectionist, conscientious personality seems to play an important role in the aetiology of PRS, as can a psychiatric history of parents or child and environmental stressors. PRS shows a symptom overlap with many other psychiatric disorders. However, none of the current DSM diagnoses can account for the full range of symptoms seen in PRS, and the active/angry resistance can be considered as the main distinguishing feature. Treatment should be multidisciplinary and characterized by patience, gentle encouragement and tender loving care. Hospitalization, ideally in a child and adolescent psychiatric unit, is almost always required. Although the recovery process is painfully slow (average duration of therapy 12.8 months), most children recover fully (complete recovery in 67% of known cases). In our opinion, it is important to increase knowledge of PRS, not only because of its disabling, potential life-threatening character, but also because there is hope for recovery through suitable treatment. We therefore propose an incorporation of PRS into the DSM and ICD classifications. However, an adaptation of the current diagnostic criteria is needed. We also consider PRS closely related to regression, which is why we introduce a new concept: “the refusal–withdrawal–regression spectrum”.

Borderline Personality Disorder

Borderline Personality Disorder

Attention Deficit/Hyperactivity Disorder in Children and Adolescents With Autism Spectrum Disorder

Objective: This study aims to evaluate ADHD-like symptoms in children with autism spectrum disorder (ASD) based on single-item analysis, as well as the comparison of two ASD subsamples of children with ADHD (ASD+) and without ADHD (ASD-). Methods: Participants are 83 children with ASD. Dimensional and categorical aspects of ADHD are evaluated using a diagnostic symptom checklist according to DSM-IV. Results: Of the sample, 53% fulfill DSM-IV criteria for ADHD. The comparison of the ASD+ and the ASD- samples reveals differences in age and IQ. Correlations of ADHD and PDD show significant results for symptoms of hyperactivity with impairment in communication and for inattention with stereotyped behavior. Item profiles of ADHD symptoms in the ASD+ sample are similar to those in a pure ADHD sample. Conclusion: The results of our study reveal a high phenotypical overlap between ASD and ADHD. The two identified subtypes, inattentive-stereotyped and hyperactive-communication impaired, reflect the DSM classification and may theoretically be a sign of two different neurochemical pathways, a dopaminergic and a serotonergic. (J. of Att. Dis. 2009; 13(2) 117-126)

Gender identity disorder in adolescents

At a recent conference in London the problems and possibilities of clinical management in gender identity disorder (GID) of adolescents were addressed. The number of referrals of adolescents with GID has tripled in recent years. With the uncertainties of the DSM classification and the lack of reliable criteria diagnosis remains controversial. Atypical gender behaviour is rather common in children but persistent GID in adolescence is only seen in 25% of the referred children. The role of pubertal hormones in brain development is the subject of studies but no clear answers are (yet) available. Prenatal hormone exposure is clearly linked to child play behaviour but does not appear to be the most important factor for gender identity. An option for adolescents with persistent GID and an increase of distress at puberty is puberty-delaying treatment with GnRH analogues. This treatment relieves distress and no detrimental physical effects have been observed, but follow up is limited. From an ethical point of view, the developing autonomy of the adolescent with GID should receive more attention and a practical approach should underscore the experimental nature of the intervention and the possibility of withdrawal from treatment. In dealing with adolescents with GID puberty-delaying treatment is a valuable option with encouraging preliminary results, but long term outcome studies and more research are necessary.

Asperger's Disorder, Criminal Responsibility and Criminal Culpability

It was nice in the police cell. It was almost a perfect cube, 2 metres long by 2 metres wide by 2 metres high… . [The policeman asked], “Are you telling the truth?” I said, “I always tell the truth.” And he said, “Right. I am going to give you a caution.” I asked, “Is that going to be on a piece of paper like a certificate I can keep?” He replied, “No, a caution means that we are going to keep a record of what you did, that you hit a policeman but that it was an accident and that you didn't mean to hurt the policeman.” I said, “But it wasn't an accident.” M Haddon, The Curious Incident of the Dog in the Night-Time (David Fickling Books, London 2004) Asperger's syndrome was only formally accepted into the ICD and DSM classifications of psychiatric disorders in the 1990s. It has been written about extensively in the scholarly literature for two decades, but diagnostic tools are continuing to evolve, as well as understanding of its genetic component and its brain development features. In the criminal law context it poses difficult issues at trial and at sentencing. Contextualising Asperger's disorder within current knowledge about autism spectrum disorders, this article identifies relevant court decisions internationally, and particularly scrutinises selected decisions in the United Kingdom (Sultan v The Queen [2008] EWCA Crim 6), Victoria, Australia (Parish v DPP [2007] VSC 494), and Nova Scotia, Canada (R v Kagan (2007) 261 NSR (2d) 285; (2008) 261 NSR (2d) 168). It argues that Asperger's disorder needs to be distinguished by the courts from other disorders, such as personality disorders and intellectual disability, and should be recognised as having the potential to affect in important, albeit subtle, ways defendants' thinking and understanding, as well as their emotional responses to situations that are to them traumatic. This makes Asperger's disorder relevant to a number of threshold issues in relation to criminal responsibility as well as to criminal culpability.