Psychology and wellbeing - DSM-V: Introduction of Dimensional Assessments

One of the biggest changes anticipated in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) is the addition of dimensional assessments, explained members of the task force for the revision at the American Psychiatric Association (APA) Annual Meeting.

"The extent to which it will be incorporated into the DSM has not been decided finally, but we definitely expect that the DSM-V will go beyond what DSM-IV and DSM-III gave us, which was categorical assessments with strict diagnostic criteria," Dr. William Narrow, research director of the DSM-V task force for the APA, said. "We're expecting that we'll be giving clinicians and researchers the opportunity to assess their patients beyond the strict categories and to use dimensional assessment of severity of a range of different symptoms that go along with these disorders."

For example, clinicians would be able to assess the extent of anxiety that comes with major depressive disorder. "Currently, there are no anxiety criteria in the assessment of major depressive disorder, although we know that anxiety and depression often travel together (...)."

During the DSM-V symposium, members of 3 of the working groups were called on to update attendees on their progress.

Anxiety-disorders working group

Katherine A. Phillips is chair of the anxiety-disorders working group, an umbrella that includes obsessive-compulsive spectrum disorders as well as posttraumatic and dissociative disorders.

One potential change being considered by their group is what might be called "supraordinate dimensions," she said, that would apply to all patients regardless of their diagnosis. One possible such dimension is anxiety, which can be relevant to all patients, and perhaps specifically panic attacks. "Panic attacks are a marker of greater severity of illness and greater morbidity," she noted. Other dimensions that might be added include severity or level of avoidance.

"We are thinking about the possibility of adding dimensional specifiers to obsessive- compulsive disorder that are specific to that disorder," she noted. A large body of evidence suggests that hoarding and contamination are dimensions of OCD, she noted, but they are also considering the addition of hoarding as a separate diagnosis in DSM-V. "It differs in some important ways from OCD," Dr. Phillips said.

Posttraumatic stress disorder is being looked at particularly closely because "there's a huge amount of new data," she added. Here, developmental dimensions may have to also be considered closely, and a field trial of their diagnostic criteria in this area will certainly be done, she said.

Psychotic-disorders work group

William T. Carpenter, head of the psychotic-disorders work group, which includes schizophrenia, outlined several main changes being considered in this area that might be controversial.

One of these questions is whether to retain schizoaffective disorder as a diagnostic entity. "We had hoped to get rid of schizoaffective as a diagnostic category because we don't think it's valid and we don't think it's reliable," he said.

In field trials, they hope to try to modify the criteria for this diagnosis to see whether they can make it more reliable and simultaneously will test dimensions, such as reality distortion, disorganization of thought, cognitive impairment, depression, mania, and anxiety, in an effort to capture what clinicians may need to know without having to use "what is perhaps not a valid scientific entity such as schizoaffective."

They also plan to propose the addition of a risk syndrome for psychosis paralleling others in medicine such as hyperlipidemia or hyperglycemia. There's "a whole growth industry in our field," Dr. Carpenter noted, in identifying the prodrome to psychosis in young people at high risk for conversion to psychotic disorders, including schizophrenia.

"It's probably critical that we have a way to identify these clinically, to move to an earlier intervention, but there are questions about how you distinguish them from the normal [healthy] population and whether can we do this without creating more harm than good. The immediate concern is stigma and the possibility that there would be use of antipsychotic medications where the risks substantially outweigh the benefit."

Mood-disorders work group

Finally, Jan Fawcett, chair of the mood-disorders work group, reported on their progress.

"In general, the problems we're grappling with in the mood disorders are boundary problems," Dr. Fawcett said. For example, the boundary between bipolar and unipolar disorder is an issue "of great contention" in the literature, he pointed out.

The mood-disorders group also includes a subgroup looking at the problem of how to help clinicians categorize degree of suicide risk," he noted, "trying to come up with some sort of a mechanism for doing that."

In this setting, 1 of the main dimensions being considered is that of anxiety. "As you know, the predictors of outcome of mood disorders are often things like anxiety," he noted. "We know that the presence of high anxiety in depression is showing more and more to predict suicidal behavior."

Psychology and Wellbeing with source:
Medscape

DSM-V: Revision of the Psychiatric Diagnostic Manual, Interview video (May 2009)