DSM-5 Revision Research Articles

DSM‐5 grief scorecard: Assessment and outcomes of proposals to pathologize grief

Where does grief stand diagnostically, now that the dust has settled and the DSM-5 has been approved? The DSM-5 Task Force considered an unprecedented series of proposals to identify grief-related mental disorders where now there are assumed to be normal variations. The proposals taken together had the potential to transform psychiatry's conceptualization of grief and the clinician's response to bereaved patients. Targets for pathologization included both depressive symptoms during grief and grief itself – the yearning, disbelief, and other experiences distinctive of grief. Four grief-related proposals made it to the final leg of the DSM-5 revision process, a major event in itself. Here I review the proposals, assess their validity, and present the Task Force's final decisions, providing an overview of the status of grief post-DSM-5.

Controversies in Gender Diagnoses

This article presents the author's thoughts on gender diagnosis controversies during his tenure at the DSM-5 Workgroup on Sexual and Gender Identity Disorders and the ICD-11 Working Group on the Classification of Sexual Disorders and Sexual Health. The work summarizes some of the published conclusions of the DSM-5 and ICD-11 revision processes regarding three particular controversies: (1) stigma versus access to care; (2) the retention of a child gender diagnosis; and (3) the treatment of prepubescent transgender children. Both the DSM and ICD work groups decided that despite the stigma associated with a diagnosis, retaining an adolescent and adult gender diagnosis is necessary to maintain access to care. As for the child gender diagnosis, given the heterogeneity of this clinical population and that gender dysphoria does not persist in most children, a child diagnosis of Gender Dysphoria (DSM) and Gender Incongruence (ICD) should be retained to facilitate ongoing evaluation and management in childhood while acknowledging the uncertainty of the outcome. The treatment of extremely gender variant prepubescent children remains a controversial subject since some underlying assumptions of the treating clinicians are a matter of opinion rather than of empirical data.

DSM-5 —The Future Arrived

THE NEXT REVISION OF PSYCHIATRY’S DIAGNOSTIC AND Statistical Manual of Mental Disorders (DSM-5) will be published in May 2013 and is the first revision of this psychiatric nomenclature in almost 2 decades. DSM-5 involved an international, multidisciplinary team of more than 400 individuals who volunteered vast amounts of their time throughout this 6-year official process, as well as many contributions from numerous international conferences that were held during the last decade. Readers will recognize a few notable differences from DSMIV. One distinction is DSM-5’s emphasis on numerous issues important to diagnosis and clinical care, including the influence of development, gender, and culture on the presentation of disorders. This is present in select diagnostic criteria, in text, or in both, which include variations of symptom presentations, risk factors, course, comorbidities, or other clinically useful information that might vary depending on a patient’s gender, age, or cultural background. Another distinct feature is ensuring greater harmony between this North American classification system and the International Classification of Diseases (ICD) system. For example, the chapter structure of DSM now begins with those in which neurodevelopmental influences produce early-onset disorders in childhood. This restructuring brings greater alignment of DSM-5 to the structuring of disorders in the future ICD-11 but also reflects the manual’s developmental emphasis, rather than the previous edition’s sequestering of all childhood disorders to a separate chapter. A similar approach to harmonizing with the ICD was taken to promote a more conceptual relationship between DSM-5 and classifications in other areas of medicine, such as the classification of sleep disorders. Many of the revisions in DSM-5 will help psychiatry better resemble the rest of medicine, including the use of dimensional (eg, quantitative) approaches. Disorder boundaries are often unclear to even the most seasoned clinicians and underscore the proliferation of residual diagnoses (ie, “not otherwise specified” disorders) from DSM-IV. But a large proportion of DSM-5 users will not be psychiatrists; most patients, for instance, will first present to their primary care physician—not to a psychiatrist—when experiencing psychiatric symptoms. The use of definable thresholds that exist on a continuum of normality is already present throughout much of general medicine, such as in blood pressure and cholesterol measurement, and these thresholds aid physicians in more accurately detecting pathology and determining appropriate intervention. Thus DSM-5 provides a model that should be recognizable to nonpsychiatrists and should facilitate better diagnosis and follow-up care by such clinicians. In addition, the multiaxial system that characterized earlier editions of DSM—wherein clinicians recorded diagnoses, comorbid medical conditions, nondisorder reasons for clinical visit (eg, partner/relational problems), and ratings of disability and functioning on 5 separate axes— has been discontinued. This is largely due to its incompatibility with diagnostic systems in the rest of medicine, as well as the result of a decision to place personality disorders and intellectual disability at the same level as other mental disorders. The above major changes represent those throughout the entire volume. What follows is a sampling from a larger summary of select recommended changes for specific disorders that will be found in the new DSM-5 manual: • Autism spectrum disorder: The criteria from DSMIV ’s autistic disorder, Asperger disorder, childhood disintegrative disorder, and pervasive developmental disorder (not otherwise specified) have been combined into a single diagnosis of autism spectrum disorder. The aim is to more accurately characterize children with social communication and interaction deficits as well as restrictive, repetitive behaviors, activities, or interests. This revision is not expected to significantly alter prevalence rates. The criteria were developed with enough sensitivity and specificity such that most children (91%) previously diagnosed with a pervasive developmental disorder under DSM-IV would meet criteria for autism spectrum disorder, allowing them to retain a diagnosis and continue receiving treatment and educational services.

Independent Review Of Social And Population Variation In Mental Health Could Improve Diagnosis In DSM Revisions

At stake in the May 2013 publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), are billions of dollars in insurance payments and government resources, as well as the diagnoses and treatment of millions of patients. We argue that the most recent revision process has missed social determinants of mental health disorders and their diagnosis: environmental factors triggering biological responses that manifest themselves in behavior; differing cultural perceptions about what is normal and what is abnormal behavior; and institutional pressures related to such matters as insurance reimbursements, disability benefits, and pharmaceutical marketing. In addition, the experts charged with revising the DSM lack a systematic way to take population-level variations in diagnoses into account. To address these problems, we propose the creation of an independent research review body that would monitor variations in diagnostic patterns, inform future DSM revisions, identify needed changes in mental health policy and practice, and recommend new avenues of research. Drawing on the best available knowledge, the review body would make possible more precise and equitable psychiatric diagnoses and interventions.

Response to Ritvo and Ritvo Letter

Response to Ritvo and Ritvo Letter

The Forthcoming DSM-5, Critical Care Medicine, and Pediatric Neuropsychiatry: Which New Concepts Do We Need?

Examination and comparison of the current DSM-IV-TR and the proposed revisions for the forthcoming DSM-5, with regard to neuropsychiatric aspects of critical illness, identified five important issues. These remain to be addressed in order to improve the care of critically ill patients. These are 1) sickness behavior, as part of the organic reaction types of the brain; 2) delirium in children and the "Differential Diagnosis of Mental Disorders Due to a General Medical Condition" in children; 3) catatonia; 4) regressive disorders in childhood in relation to somatic disorders (e.g., anti-NMDAR encephalitis); 5) age-related diagnostic criteria in relation to neuro-psychiatric disorders.

Diagnostic Issues of Binge Eating in Eating Disorders

Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for eating disorders (EDs) are problematic and due to be revised. One area of debate concerns binge eating. We investigated the impact of four aspects of binge eating (binge size, loss of control, frequency of objective and subjective binge eating) assessed by questionnaire and interview in adult ED patients on concurrent and follow-up symptoms. Data came from two independent naturalistic Swedish ED databases (N = 2354, with 12-month follow-up; and N = 597, with 36-month follow-up). We found fair concurrent validity of criteria assessed using questionnaire, but poor concurrent validity for interview assessment, and no prognostic validity regardless of assessment method. The findings give support to some planned DSM-5 revisions, but challenge the assumption of binge eating as a useful diagnostic criterion, as well as having implications for measurement.

Age-dependent symptomatology of depression in hospitalized patients and its implications for DSM-5

BackgroundWe investigated effects of current age and age at onset on symptomatology of depression with reference to proposed revisions in DSM-5. MethodsThe study entailed medical records of 326 inpatients diagnosed with major depressive disorder, including 520 depressive episodes, with 113 first episodes lifetime. Subjects were divided into three groups: young-adults, middle-aged adults and older adults. ResultsIn young-adults, active suicidal ideation, lifetime suicidal attempts, irritability, anhedonia and persistent depressive symptoms between the episodes were more frequent than in the other groups. Among older adults, depression was associated with insomnia, hypochondriasis, somatization, decreased appetite, weight loss, memory impairment and decreased activity. The older age was not associated with higher number of previous episodes of depression, bigger severity or duration of a single episode or a different degree of remission. Early-onset depression was associated with more suicidal attempts. LimitationsThe study was retrospective and the sample may be treated only as representative for hospitalized depressed patients. ConclusionsAge and age at onset are important factors influencing the course and symptomatology of a depressive episode. Depressive episodes with anxiety and with suicide risk severity are important specifiers that vary with the age at onset and/or age of the patient and should be considered for inclusion in the DSM-5 revision.

An item response theory analysis of DSM-IV diagnostic criteria for personality disorders: findings from the national epidemiologic survey on alcohol and related conditions.

The purpose of this study was to evaluate the psychometric properties of DSM-IV symptom criteria for assessing personality disorders (PDs) in a national population and to compare variations in proposed symptom coding for social and/or occupational dysfunction. Data were obtained from a total sample of 34,653 respondents from Waves 1 and 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). For each personality disorder, confirmatory factor analysis (CFA) established a 1-factor latent factor structure for the respective symptom criteria. A 2-parameter item response theory (IRT) model was applied to the symptom criteria for each PD to assess the probabilities of symptom item endorsements across different values of the underlying trait (latent factor). Findings were compared with a separate IRT model using an alternative coding of symptom criteria that requires distress/impairment to be related to each criterion. The CFAs yielded a good fit for a single underlying latent dimension for each PD. Findings from the IRT indicated that DSM-IV PD symptom criteria are clustered in the moderate to severe range of the underlying latent dimension for each PD and are peaked, indicating high measurement precision only within a narrow range of the underlying trait and lower measurement precision at lower and higher levels of severity. Compared with the NESARC symptom coding, the IRT results for the alternative symptom coding are shifted toward the more severe range of the latent trait but generally have lower measurement precision for each PD. The IRT findings provide support for a reliable assessment of each PD for both NESARC and alternative coding for distress/impairment. The use of symptom dysfunction for each criterion, however, raises a number of issues and implications for the DSM-5 revision currently proposed for Axis II disorders (American Psychiatric Association, 2010).

Somatoform, Factitious, and Related Diagnoses in the National Hospital Discharge Survey: Addressing the Proposed DSM-5 Revision

The DSM-5 working group on the somatoform (SFD) and factitious (FD) disorders has recommended substantial revisions of these categories. The recommendations are based, in part, on anecdotal evidence that the diagnoses are infrequently used. To assess the assignment rates for SFD, FD, and related diagnoses among general medical inpatients. The National Hospital Discharge Survey was queried for instances of SFD and FD, along with related diagnoses identifying medical cases in which psychological factors play a role. Diagnoses of major depression and generalized anxiety disorder were queried for comparison purposes. The target diagnoses were assigned far less frequently than published prevalence and recognition rates suggest. Nearly half of the assigned target diagnoses were generic diagnoses (esp. physiological malfunction due to psychological factors) other than SFD or FD. However, the apparent degree of underassignment of the target diagnoses was not dramatically greater than the underassignment observed for major depression and generalized anxiety disorder. The results provide empirical support for the impression that physicians do not assign SFD and FD diagnoses in recognized cases, but do not strongly support the assertion that these diagnoses are uniquely problematic.

Anorexia nervosa

We first discuss current diagnostic issues concerning the classification of anorexia nervosa (AN) by reference to the proposed criteria of the fifth version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). We strongly welcome the changes in the latest revision of DSM-5 (update April 2012), which in our opinion partially solve the previously delineated classification problems. Nevertheless, we still miss a standard or reference(s) for the weight criterion including the delineation between a healthy and unhealthy underweight, a better operationalization of observable behaviors including symptoms of disordered eating, readily accessible cognitions and a better allowance for cross-cultural aspects in the proposed DSM-5 classification of AN. In the second part, we review the treatment recommendations of the NICE guidelines for AN, which overall are characterized by a lack of evidence. Nevertheless, NICE recommended an outpatient treatment setting based on one randomized controlled trial with many methodological limitations. A review of the current literature shows that (a) the optimal treatment setting (inpatient vs. outpatient treatment) still is a subject of debate, and (b) the evaluation of treatment costs in AN plays an important role within this discussion. In contrast to the German Guidelines for the Treatment of Eating Disorders, NICE does not offer any specific criteria for the clinician with regard to determining the adequate treatment setting.

Where to from here for ASD and anxiety? Lessons learned from child anxiety and the issue of DSM‐5.

In this commentary, I provide additional areas of focus in moving forward with understanding and helping those with autism spectrum disorders (ASD) and anxiety. Many of these issues have been experienced by those in the child anxiety realm as well, and so insights and findings from that field seem pertinent. Although there are many topics relevant to the study of anxiety in those with ASD, I briefly highlight several that are particularly pressing, including the downward and lateral extensions of anxiety findings from the typically developing literature, the use of multiple informants in assessment, the consideration of age and intellectual functioning in development and diagnosis, and the potential impact from the proposed revisions in DSM-5.

A genetic perspective on the proposed inclusion of cannabis withdrawal in DSM-5

Various studies support the inclusion of cannabis withdrawal in the diagnosis of cannabis use disorder (CUD) in the upcoming DSM-5. The aims of the current study were to (1) estimate the prevalence of DSM-5 cannabis withdrawal (criterion B), (2) estimate the role of genetic and environmental influences on individual differences in cannabis withdrawal and (3) determine the extent to which genetic and environmental influences on cannabis withdrawal overlap with those on DSM-IV-defined abuse/dependence. The sample included 2276 lifetime cannabis-using adult Australian twins. Cannabis withdrawal was defined in accordance with criterion B of the proposed DSM-5 revisions. Cannabis abuse/dependence was defined as endorsing one or more DSM-IV criteria of abuse or three or more dependence criteria. The classical twin model was used to estimate the genetic and environmental influences on variation in cannabis withdrawal, along with its covariation with abuse/dependence. Of all the cannabis users, 11.9% met criteria for cannabis withdrawal. Around 50% of between-individual variation in withdrawal could be attributed to additive genetic variation, and the rest of the variation was mostly due to non-shared environmental influences. Importantly, the genetic influences on cannabis withdrawal almost completely (99%) overlapped with those on abuse/dependence. We have shown that cannabis withdrawal symptoms exist among cannabis users, and that cannabis withdrawal is moderately heritable. Genetic influences on cannabis withdrawal are the same as those affecting abuse/dependence. These results add to the wealth of literature that recommends the addition of cannabis withdrawal to the diagnosis of DSM-5 CUD.

Comorbidity of LD and ADHD

Attention-deficit/hyperactivity disorder (ADHD) and learning disability (LD) can co-occur for a significant minority of children with each disorder. A total of 17 studies (2001–2011) examining ADHD-LD comorbidity were reviewed, revealing a higher mean comorbidity rate (45.1%) than has been obtained previously. Higher comorbidity may be the result of including students with writing disorders, not just reading and/or math disabilities. Proposed DSM-5 criteria for both disorders will likely affect comorbidity rates; however, it is unclear whether such rates will increase or decrease. Regardless of the specific impact of DSM revisions, academic skill and/or performance deficits should be assessed for students with ADHD as part of screening, comprehensive evaluation, and treatment monitoring. Comprehensive intervention services for students with comorbid ADHD and LD will require empirically supported treatment strategies that address both disorders and that are implemented across school and home settings.

Implications of Changes for the Field

This article provides a thorough discussion of the proposed DSM-5 changes and their implications for current and future approaches to assessment, identification, and service delivery for children and adolescents with ADHD. Educational and clinical implications are discussed with special attention to the individual impact of the changes, diagnostic prevalence rates, and associated societal costs. Developmental period is considered as an important factor in the potential impact of the DSM-5 changes. The authors conclude that the DSM-5 proposed revisions may improve diagnostic sensitivity and specificity; yet the overall impact of these changes remains largely unknown as many were not empirically validated. The authors suggest that the cumulative impact of the set of changes be considered when finalizing the DSM-5 revisions.

Panic Attacks as a Dimension of Psychopathology

One of the proposed revisions for DSM-5 is to rate panic attacks as a separate dimension across all mental disorders. The idea is that panic attacks occurring outside panic disorder are a dimension predicting important clinical outcomes. The aim of this study was to validate the proposition for DSM-5 that panic attacks have predictive value for overall psychopathology onset, course, and functioning. Data were derived from the Netherlands Mental Health Survey and Incidence Study (NEMESIS), a prospective population-based study. Using the Composite International Diagnostic Interview (with classifications based on DSM-III-R), 5,571 subjects were selected who had (1) no panic history, (2) a history of panic attacks (but no panic disorder), (3) current panic attacks, or (4) current panic disorder. The impact of panic status on the prevalence of anxiety, affective, alcohol, and any mental disorders; on the onset and persistence of these disorders during 3-year follow-up; and on levels of functioning during 3-year follow-up (as assessed with the 36-Item Short-Form Health Survey) was examined. Current panic attacks outside the realm of panic disorder were associated with increased prevalence of mental disorders (χ2(3) = 490.6; P < .001), increased onset of mental disorders (hazard ratio = 4.42; 95% CI, 2.88-6.80), persistence of mental disorders (odds ratio = 2.72; 95% CI, 1.53-4.82), and impaired functioning during 3-year follow-up (F = 69.67; P < .001). Although the impact was smaller than for panic disorder, the associations identified for panic attacks were consistent and significant and were, to a lesser extent, also found for a history of panic attacks. Given the consistent impact of panic attacks on various aspects of psychopathology, the proposition to dimensionally rate panic attacks across all mental disorders may be of great value for clinical care.

Differences in the Profiles of DSM‐IV and DSM‐5 Alcohol Use Disorders: Implications for Clinicians

Existing information on consequences of the DSM-5 revision for the diagnosis of alcohol use disorders (AUD) has gaps, including missing information critical to understanding implications of the revision for clinical practice. Data from Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions were used to compare AUD severity, alcohol consumption and treatment, sociodemographic and health characteristics, and psychiatric comorbidity among individuals with DSM-IV abuse versus DSM-5 moderate AUD and DSM-IV dependence versus DSM-5 severe AUD. For each pair of disorders, we additionally compared 3 mutually exclusive groups: individuals positive solely for the DSM-IV disorder, those positive solely for the DSM-5 disorder, and those positive for both. Whereas 80.5% of individuals positive for DSM-IV dependence were positive for DSM-5 severe AUD, only 58.0% of those positive for abuse were positive for moderate AUD. The profiles of individuals with DSM-IV dependence and DSM-5 severe AUD were almost identical. The only significant (p < 0.005) difference, more AUD criteria among the former, reflected the higher criterion threshold (≥ 4 vs. ≥ 3) for severe AUD relative to dependence. In contrast, the profiles of individuals with DSM-5 moderate AUD and DSM-IV abuse differed substantially. The former endorsed more AUD criteria, had higher rates of physiological dependence, were less likely to be White individuals and men, had lower incomes, were less likely to have private and more likely to have public health insurance, and had higher levels of comorbid anxiety disorders than the latter. Similarities between the profiles of DSM-IV and DSM-5 AUD far outweigh differences; however, clinicians may face some changes with respect to appropriate screening and referral for cases at the milder end of the AUD severity spectrum, and the mechanisms through which these will be reimbursed may shift slightly from the private to public sector.

Reflections on the DSM-5 and its Relevance to Psychiatric Nursing

Nothing stays the same. While few would disagree with this simple truth, most struggle to accept the reality associated with these words. Generally speaking, humans like constancy in their lives and, on some level, it is totally understandable. There is a certain seduction in believing in the illusion of permanency. But constancy always proves to be a fleeting guest, leading to disappointment and pain for those who are unwilling to release their grasp on it. For those who expect change, the experiment is to engage the unknown with curiosity and to have the courage of one’s confusion in dealing with new ways of knowing. For psychiatric and mental health nursing, the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5 )i s on our doorstep, and the ways in which we have conceptualized psychiatric diagnosis over the last decade are about to change significantly. Constancy is again on the run. This special issue of the journal aims to thoughtfully examine a few salient topics related to the proposed revisions in DSM-5. The literature is replete with papers that explore the various dimensions of the proposed changes, discussing the progress and laudable dedication and commitment of the DSM-5 work groups. But the goal of this issue is to provoke critical analysis of some important changes in psychiatric diagnosis and to heighten awareness of the complex contextual factors that influence the DSM revision process. The articles provide an opportunity to explore the potential impact that these changes will have on the specialty of psychiatric and mental health nursing. The breadth of the content of this issue could not expose the scope of the upcoming changes in DSM-5, though the authors here broadly address these changes within the context of their individual papers. The process of revising the DSM is a complex and carefully deliberated venture that demands a great deal from the individuals involved in the revision process. Discussions related to the modification of the taxonomy begin years in advance of the pub

ASHA Seeks More DSM-5 Changes on Behalf of SLPs

ASHA Seeks More DSM-5 Changes on Behalf of SLPs

Comparative performance of the AUDIT-C in screening for DSM-IV and DSM-5 alcohol use disorders

ObjectiveUnder the proposed DSM-5 revision to the criteria for alcohol use disorder (AUD), a substantial proportion of DSM-IV AUD cases will be lost or shifted in terms of severity, with some new cases added. Accordingly, the performance of the AUDIT-C in screening for DSM-IV AUD cannot be assumed to extend to DSM-5 AUD. The objective of this paper is to compare the AUDIT-C in screening for DSM-IV and DSM-5 AUD. MethodsUsing a broad range of performance metrics, the AUDIT-C was tested and contrasted as a screener for DSM-IV AUD (any AUD, abuse and dependence) and DSM-5 AUD (any AUD, moderate AUD and severe AUD) in a representative sample of U.S. adults aged 21 and older and among past-year drinkers. ResultsOptimal AUDIT-C cutpoints were identical for DSM-IV and DSM-5 AUD: ≥4 for any AUD, ≥3 or ≥4 for abuse/moderate AUD and ≥4 or ≥5 for dependence/severe AUD. Screening performance was slightly better for DSM-5 severe AUD than DSM-IV dependence but did not differ for other diagnoses. At optimal screening cutpoints, positive predictive values were slightly higher for DSM-5 overall AUD and moderate AUD than for their DSM-IV counterparts. Sensitivities were slightly higher for DSM-5 severe AUD than DSM-IV dependence. Optimal screening cutpoints shifted upwards for past-year drinkers but continued to be identical for DSM-IV and DSM-5 disorders. ConclusionsClinicians should not face any major overhaul of their current screening procedures as a result of the DSM-5 revision and should benefit from fewer false positive screening results.