The DSM-5: Maybe Dr. Insel is right

As a practicing child and adolescent psychiatrist, I have extensive experience in assessing and treating individuals with pervasive developmental disorders and executive functioning deficits. I also have been investigating technologies – primarily games – that represent opportunities as screening tools and treatment modalities.

At its annual meeting, starting last week, the American Psychiatric Association released the new DSM – the standard for classifying mental health disorders. Field testing for the new criteria for diagnosing mental health conditions involved reanalyzing survey data collected in 1994, originally for the DSM-IV in some cases, in addition to recently obtained field trial data.

Though the survey data collected 18 years ago and more recently might be valuable to measure the accuracy of the current diagnostic criteria, our current DSM – and the new version – continue to be largely subjective, and our ability to evaluate behavior objectively through different modalities has not been factored into the DSM-5.

The DSM-5 continues to include many standards found in the DSM-IV-TR but has made significant changes to others. Take for example, a class of disorders called pervasive developmental disorders, which previously included diagnoses such as autistic disorder, Asperger’s disorder, and pervasive developmental disorder, not otherwise specified (NOS). The criteria used to include three classes of symptoms, with at least one of the areas of deficit present prior to the age of 3:

• Deficits in social communication, including the use of language and the ability to start and maintain conversations and engage in make-believe play with peers.

• Impairment in social interaction, including in the use of nonverbal cues, the development of peer relationships, and social and/or emotional reciprocity.

• Restricted and repetitive behaviors, such as marked focus on particular subjects or parts of objects, inflexible routines/rituals, and repetitive movements.

Autistic disorder, the most severe, was marked by deficits in all three classes of symptoms; Asperger’s disorder, described as moderate severity, by deficits in two classes of symptoms without language delay; and pervasive developmental delay, NOS, the mild form of the illness, by deficits in one of the classes of symptoms.

The criteria have now been modified to include only two classes of symptoms: Deficits in social communication and interaction, including difficulty using nonverbal communication, deficits in initiating and maintaining peer relationships, and lack of spontaneous sharing of emotions and interests as well as lack of emotional reciprocity. There must also be restricted and repetitive behaviors similar to the description above, with the addition of hypersensitivity to sensory input or unusual interest in sensory aspects of the environment.

The requirement of language delay and symptoms manifesting prior to age 3 has been eliminated and replaced by deficits manifested when social requirements of these behaviors exceed patients’ limited abilities. Based on the severity and number of their symptoms, patients will be placed on the continuum of autism spectrum disorder as level 1 (mild), level 2 (moderate), and level 3 (severe). The difference between the levels of severity appears be less well delineated and based more on the severity of the deficits.

This change to the DSM exemplifies the challenge that many assessments of symptoms continue to be subjective, or based on self- and parent report. This poses a large problem to the initial evaluators of conditions similar to ASD. These evaluations are frequently conducted by pediatricians and family medicine physicians with very limited time.

In the context of overall health care changes, time constraints of primary care physicians will become even more significant, which is a problem with current approaches to evaluating symptoms.

Through advancements in health care technology, we now have the ability to collect large amounts of objective data from electronic health records and various medical sources such as EKGs, EEGs, and even wearable devices. The disciplines of statistics and computer science have provided new approaches to data analysis that can be used to guide treatments, as these sophisticated algorithms have been clinically evaluated and approved by regulatory agencies.

These innovations are allowing patients to both capture an extensive amount of data about their behavior and then explain that behavior in an objective way to parents, providers, and patients. Over time, properly analyzed objective data describing patterns of behavior might be valuable to use for diagnostic criteria in future iterations of the DSM. This would transform approaches for diagnostics in mental health conditions into something that is already being done in other areas of medicine, for example, with the classification of hypertension that uses blood pressure as the basis of diagnosis.

This perspective is shared by Dr. Thomas Insel, director of the National Institute of Mental Health. Dr. Insel has outlined a new framework for the diagnosis of mental illness, including the use of objective data of brain circuitry and physiology, genetics, as well as self-reported data – a approach known as "precision medicine." This approach is similar to the use of genetics to customize cancer treatments. It also has shifted NIMH research funding away from mental health diagnoses such as depression and anxiety to symptoms and their measures, including genetics, behavior, physiology, and self-report, which are referred to as research domain criteria.

In addition, companies such as 23andMe and the Parkinson’s Institute are combining their data banks to accelerate research.

The future of psychiatry, including diagnosis, will most likely continue to integrate objective data with subjective reports given by patients, parents, and teachers/providers. The DSM-5, which mainly relies on symptoms endorsed by self-reported data, will continue to be a tool to help with diagnosis and treatment, but might require revisions to include objective measures as assessment tools to arrive at an accurate diagnosis. Integration of information should be the ultimate goal, not only to aid the time it takes to diagnose but also the accuracy of diagnosis – further improving the quality of the care our patients are receiving.

Dr. Heller is chief medical officer of CogCubed, a company that develops cognitive games aimed at identifying and treating executive function disorders. She also is a practicing child and adolescent psychiatrist, and adjunct professor at the University of Minnesota.

As a practicing child and adolescent psychiatrist, I have extensive experience in assessing and treating individuals with pervasive developmental disorders and executive functioning deficits. I also have been investigating technologies – primarily games – that represent opportunities as screening tools and treatment modalities.

At its annual meeting, starting last week, the American Psychiatric Association released the new DSM – the standard for classifying mental health disorders. Field testing for the new criteria for diagnosing mental health conditions involved reanalyzing survey data collected in 1994, originally for the DSM-IV in some cases, in addition to recently obtained field trial data.

Though the survey data collected 18 years ago and more recently might be valuable to measure the accuracy of the current diagnostic criteria, our current DSM – and the new version – continue to be largely subjective, and our ability to evaluate behavior objectively through different modalities has not been factored into the DSM-5.

The DSM-5 continues to include many standards found in the DSM-IV-TR but has made significant changes to others. Take for example, a class of disorders called pervasive developmental disorders, which previously included diagnoses such as autistic disorder, Asperger’s disorder, and pervasive developmental disorder, not otherwise specified (NOS). The criteria used to include three classes of symptoms, with at least one of the areas of deficit present prior to the age of 3:

• Deficits in social communication, including the use of language and the ability to start and maintain conversations and engage in make-believe play with peers.

• Impairment in social interaction, including in the use of nonverbal cues, the development of peer relationships, and social and/or emotional reciprocity.

• Restricted and repetitive behaviors, such as marked focus on particular subjects or parts of objects, inflexible routines/rituals, and repetitive movements.

Autistic disorder, the most severe, was marked by deficits in all three classes of symptoms; Asperger’s disorder, described as moderate severity, by deficits in two classes of symptoms without language delay; and pervasive developmental delay, NOS, the mild form of the illness, by deficits in one of the classes of symptoms.

The criteria have now been modified to include only two classes of symptoms: Deficits in social communication and interaction, including difficulty using nonverbal communication, deficits in initiating and maintaining peer relationships, and lack of spontaneous sharing of emotions and interests as well as lack of emotional reciprocity. There must also be restricted and repetitive behaviors similar to the description above, with the addition of hypersensitivity to sensory input or unusual interest in sensory aspects of the environment.

The requirement of language delay and symptoms manifesting prior to age 3 has been eliminated and replaced by deficits manifested when social requirements of these behaviors exceed patients’ limited abilities. Based on the severity and number of their symptoms, patients will be placed on the continuum of autism spectrum disorder as level 1 (mild), level 2 (moderate), and level 3 (severe). The difference between the levels of severity appears be less well delineated and based more on the severity of the deficits.

This change to the DSM exemplifies the challenge that many assessments of symptoms continue to be subjective, or based on self- and parent report. This poses a large problem to the initial evaluators of conditions similar to ASD. These evaluations are frequently conducted by pediatricians and family medicine physicians with very limited time.

In the context of overall health care changes, time constraints of primary care physicians will become even more significant, which is a problem with current approaches to evaluating symptoms.

Through advancements in health care technology, we now have the ability to collect large amounts of objective data from electronic health records and various medical sources such as EKGs, EEGs, and even wearable devices. The disciplines of statistics and computer science have provided new approaches to data analysis that can be used to guide treatments, as these sophisticated algorithms have been clinically evaluated and approved by regulatory agencies.

These innovations are allowing patients to both capture an extensive amount of data about their behavior and then explain that behavior in an objective way to parents, providers, and patients. Over time, properly analyzed objective data describing patterns of behavior might be valuable to use for diagnostic criteria in future iterations of the DSM. This would transform approaches for diagnostics in mental health conditions into something that is already being done in other areas of medicine, for example, with the classification of hypertension that uses blood pressure as the basis of diagnosis.

This perspective is shared by Dr. Thomas Insel, director of the National Institute of Mental Health. Dr. Insel has outlined a new framework for the diagnosis of mental illness, including the use of objective data of brain circuitry and physiology, genetics, as well as self-reported data – a approach known as "precision medicine." This approach is similar to the use of genetics to customize cancer treatments. It also has shifted NIMH research funding away from mental health diagnoses such as depression and anxiety to symptoms and their measures, including genetics, behavior, physiology, and self-report, which are referred to as research domain criteria.

In addition, companies such as 23andMe and the Parkinson’s Institute are combining their data banks to accelerate research.

The future of psychiatry, including diagnosis, will most likely continue to integrate objective data with subjective reports given by patients, parents, and teachers/providers. The DSM-5, which mainly relies on symptoms endorsed by self-reported data, will continue to be a tool to help with diagnosis and treatment, but might require revisions to include objective measures as assessment tools to arrive at an accurate diagnosis. Integration of information should be the ultimate goal, not only to aid the time it takes to diagnose but also the accuracy of diagnosis – further improving the quality of the care our patients are receiving.

Dr. Heller is chief medical officer of CogCubed, a company that develops cognitive games aimed at identifying and treating executive function disorders. She also is a practicing child and adolescent psychiatrist, and adjunct professor at the University of Minnesota.

As a practicing child and adolescent psychiatrist, I have extensive experience in assessing and treating individuals with pervasive developmental disorders and executive functioning deficits. I also have been investigating technologies – primarily games – that represent opportunities as screening tools and treatment modalities.

At its annual meeting, starting last week, the American Psychiatric Association released the new DSM – the standard for classifying mental health disorders. Field testing for the new criteria for diagnosing mental health conditions involved reanalyzing survey data collected in 1994, originally for the DSM-IV in some cases, in addition to recently obtained field trial data.

Though the survey data collected 18 years ago and more recently might be valuable to measure the accuracy of the current diagnostic criteria, our current DSM – and the new version – continue to be largely subjective, and our ability to evaluate behavior objectively through different modalities has not been factored into the DSM-5.

The DSM-5 continues to include many standards found in the DSM-IV-TR but has made significant changes to others. Take for example, a class of disorders called pervasive developmental disorders, which previously included diagnoses such as autistic disorder, Asperger’s disorder, and pervasive developmental disorder, not otherwise specified (NOS). The criteria used to include three classes of symptoms, with at least one of the areas of deficit present prior to the age of 3:

• Deficits in social communication, including the use of language and the ability to start and maintain conversations and engage in make-believe play with peers.

• Impairment in social interaction, including in the use of nonverbal cues, the development of peer relationships, and social and/or emotional reciprocity.

• Restricted and repetitive behaviors, such as marked focus on particular subjects or parts of objects, inflexible routines/rituals, and repetitive movements.

Autistic disorder, the most severe, was marked by deficits in all three classes of symptoms; Asperger’s disorder, described as moderate severity, by deficits in two classes of symptoms without language delay; and pervasive developmental delay, NOS, the mild form of the illness, by deficits in one of the classes of symptoms.

The criteria have now been modified to include only two classes of symptoms: Deficits in social communication and interaction, including difficulty using nonverbal communication, deficits in initiating and maintaining peer relationships, and lack of spontaneous sharing of emotions and interests as well as lack of emotional reciprocity. There must also be restricted and repetitive behaviors similar to the description above, with the addition of hypersensitivity to sensory input or unusual interest in sensory aspects of the environment.

The requirement of language delay and symptoms manifesting prior to age 3 has been eliminated and replaced by deficits manifested when social requirements of these behaviors exceed patients’ limited abilities. Based on the severity and number of their symptoms, patients will be placed on the continuum of autism spectrum disorder as level 1 (mild), level 2 (moderate), and level 3 (severe). The difference between the levels of severity appears be less well delineated and based more on the severity of the deficits.

This change to the DSM exemplifies the challenge that many assessments of symptoms continue to be subjective, or based on self- and parent report. This poses a large problem to the initial evaluators of conditions similar to ASD. These evaluations are frequently conducted by pediatricians and family medicine physicians with very limited time.

In the context of overall health care changes, time constraints of primary care physicians will become even more significant, which is a problem with current approaches to evaluating symptoms.

Through advancements in health care technology, we now have the ability to collect large amounts of objective data from electronic health records and various medical sources such as EKGs, EEGs, and even wearable devices. The disciplines of statistics and computer science have provided new approaches to data analysis that can be used to guide treatments, as these sophisticated algorithms have been clinically evaluated and approved by regulatory agencies.

These innovations are allowing patients to both capture an extensive amount of data about their behavior and then explain that behavior in an objective way to parents, providers, and patients. Over time, properly analyzed objective data describing patterns of behavior might be valuable to use for diagnostic criteria in future iterations of the DSM. This would transform approaches for diagnostics in mental health conditions into something that is already being done in other areas of medicine, for example, with the classification of hypertension that uses blood pressure as the basis of diagnosis.

This perspective is shared by Dr. Thomas Insel, director of the National Institute of Mental Health. Dr. Insel has outlined a new framework for the diagnosis of mental illness, including the use of objective data of brain circuitry and physiology, genetics, as well as self-reported data – a approach known as "precision medicine." This approach is similar to the use of genetics to customize cancer treatments. It also has shifted NIMH research funding away from mental health diagnoses such as depression and anxiety to symptoms and their measures, including genetics, behavior, physiology, and self-report, which are referred to as research domain criteria.

In addition, companies such as 23andMe and the Parkinson’s Institute are combining their data banks to accelerate research.

The future of psychiatry, including diagnosis, will most likely continue to integrate objective data with subjective reports given by patients, parents, and teachers/providers. The DSM-5, which mainly relies on symptoms endorsed by self-reported data, will continue to be a tool to help with diagnosis and treatment, but might require revisions to include objective measures as assessment tools to arrive at an accurate diagnosis. Integration of information should be the ultimate goal, not only to aid the time it takes to diagnose but also the accuracy of diagnosis – further improving the quality of the care our patients are receiving.

Dr. Heller is chief medical officer of CogCubed, a company that develops cognitive games aimed at identifying and treating executive function disorders. She also is a practicing child and adolescent psychiatrist, and adjunct professor at the University of Minnesota.