Perspective offered on changes in DSM psychosis section

SAN FRANCISCO – Changes to the psychosis section of the long-awaited fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) are hardly dramatic, but they are still likely to advance the field and make the classification system more clinically relevant and easier to use, according to the authors.

Representatives of the 12-member Work Group on Psychotic Disorders detailed some of the revised elements of this section of the new manual, which was released with the start of the annual meeting of the American Psychiatric Association.

Key changes are outlined

"When we were approaching the DSM-5, we thought we learned so much in the last 20 years about the nature of all these psychotic disorders – such incredible advances in imaging and genetics and all these different areas of neurobiology – that, somehow, we were going to revolutionize diagnosis with an etiopathophysiological classification, if you will," commented Dr. Rajiv Tandon of the University of Florida, Gainesville. "And relatively early in the process, we recognized that that was impossible to accomplish, because although we learned a lot, we didn’t know enough yet to be able to do that."

Still, the new edition differs from its predecessor, the DSM-IV, released nearly a decade ago, in a variety of key respects, he said.

For example, gone are the subtypes of schizophrenia, along with shared psychotic disorder. Newly added is catatonia not elsewhere classified, referring to a fully defined catatonic syndrome in the absence of an identifiable medical disorder.

The DSM-5 also sees the debut of assessment of the dimensions of psychosis, which captures the presence and severity of various symptoms. In addition, the criteria for diagnosing schizoaffective disorder have been modified, and catatonia is now treated more uniformly across the manual.

"What we have come up with regard to psychotic disorders are iterative changes, modest improvements, improved clinical utility, simplicity – we have actually reduced the number of disorders in our section by about 20%," Dr. Tandon said. "Very importantly, in addition to improved clinical utility and incorporating the new information we have learned to the extent possible, the DSM-5 look at psychotic disorders provides a much better platform to a future etiopathophysiological classification."

DSM, RDoC called complementary

The DSM-5’s new dimensional approach to assessing psychotic disorders will not only help advance the study of these disorders, but will also help to track their course in patients over time and ensure appropriate treatment, said Dr. Dolores Malaspina of the NYU Langone Medical Center in New York.

Clinicians will rate the presence and severity of eight symptoms – hallucinations, delusions, disorganized speech, psychomotor behavior, negative symptoms, impaired cognition, depression, and mania – on a scale from 0 to 4.

In particular, this approach will promote patient-centered care, she maintained. "We want our treatments to be person specific. For a treatment to be person specific, it’s not simply based on a diagnosis."

Dr. Malaspina further noted that dimensional assessment addresses some of the National Institute of Mental Health’s reservations about the DSM classification system.

"The NIMH has come to see the categories of the DSM as getting in the way of progress forward," she explained. The NIMH, therefore, developed its own classification system, called Research Domain Criteria (RDoC).

"Their goal is to do studies where symptoms have been assessed along a continuum. This approach is not antagonistic to the DSM – there is actually no dueling that will take place in the Moscone Center," she quipped, referring to the location of the APA meeting in San Francisco. "There actually is a great amount of agreement. The future of psychiatric assessment should see that the DSM-5 and the RDoC are complementary, not competing frameworks."

Cognitive impairment left out

Patients with schizophrenia commonly have impaired cognition, so clinicians might be surprised to find that this feature is still not listed as a core feature in the DSM-5, noted Dr. Raquel E. Gur of the University of Pennsylvania, Philadelphia.

"To meet the core features of hallucinations, delusions, and disorganized thinking, you must have impaired cognition, otherwise you will not perceive events around you differently than other people. There is something that happens in the brains of these people that make them distort reality, and those things are measurable," she commented.

Moreover, cognitive status is important when assessing the ability of patients to engage in treatment and when it comes to setting realistic goals of care.

To be sure, the DSM-5 describes assessment of cognitive status as vital to the differential diagnosis when distinguishing entities on the schizophrenia spectrum from other psychotic disorders.

The work group, however, stopped short of including it among core features because of its uncertain specificity to schizophrenia, lack of agreed-on measures that can be readily used in the real world, and absence of evidence that assessment is clinically indicated and applicable in this setting. In other words, more research is needed in this area, Dr. Gur said.

APS inclusion proves controversial

One of the most controversial aspects of the DSM-5 is its inclusion of attenuated psychosis syndrome (APS), acknowledged Dr. Ming T. Tsuang of the University of California, San Diego.

About a third of patients with this constellation of symptoms develop a full-blown psychotic disorder, raising hopes that the APS diagnosis could help identify patients who will benefit from early intervention.

Some, however, have expressed concern that adding APS to the classification system might lead to inappropriate antipsychotic therapy.

"From our experience, that is not the case," Dr. Tsuang said. "Actually, the APS category may educate clinicians about the relative lack of utility of antipsychotic medication in this population. So we hope that if we have this category, inappropriate antipsychotic use among youth may be reduced."

"In the end, our task force decided not to put APS into the main body of the DSM-5, but rather into the appendix, because more research needs to be done to really test its validity and usefulness, particularly for clinicians," he concluded. "For the DSM-6, once we have more experience in this area and [more information from research], we may be able to put this condition in the main body. At that time, the name may change."

Closer to ICD but still distinct

The DSM-5 is likely to share much with the psychosis section of the forthcoming International Classification of Diseases, 11th revision (ICD-11), of the World Health Organization, expected out in 2015. Yet the two will still have their differences.

For example, both classification systems have deleted schizophrenia subtypes, replacing them with dimensional assessments in the case of DSM-5 and symptom specifiers in the case of ICD-11, noted Dr. Wolfgang Gaebel of the Heinrich Heine University Düsseldorf in Germany.

The two differ, though, with respect to diagnostic criteria, such as the requirement for functional impairment to make a diagnosis of schizophrenia and the inclusion of longitudinal criteria to make a diagnosis of schizoaffective disorder.

"There is some harmonization," he commented, while adding that there is still justification for having two classification systems, even if they are generally converging over time.

"Of course, on one hand, we would like to see one system which fits all. On the other hand, the two systems have different foci and always have," Dr. Gaebel said. "ICD is the system which has been used worldwide, mainly for administrative reasons. Some countries, in the clinical situation, use DSM, whereas many other countries use ICD, but when it comes to research, they use in addition DSM, also for publication because, of course, many papers you want to submit to Anglo-American journals that prefer the DSM. And I think the DSM has – this is my personal opinion – a more research-based focus.

"But I think the two systems profit from each other. I doubt for various, and I would say political, reasons that in the future we will have one system, although it would be very good to have it," he concluded.

Dr. Tandon, Dr. Malaspina, Dr. Gur, and Dr. Tsuang disclosed no relevant conflicts of interest. Dr. Gaebel disclosed that he is on the scientific advisory board of Lundbeck International Neuroscience Foundation and receives symposium support from Lilly Germany and Janssen Cilag Germany.

SAN FRANCISCO – Changes to the psychosis section of the long-awaited fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) are hardly dramatic, but they are still likely to advance the field and make the classification system more clinically relevant and easier to use, according to the authors.

Representatives of the 12-member Work Group on Psychotic Disorders detailed some of the revised elements of this section of the new manual, which was released with the start of the annual meeting of the American Psychiatric Association.

Key changes are outlined

"When we were approaching the DSM-5, we thought we learned so much in the last 20 years about the nature of all these psychotic disorders – such incredible advances in imaging and genetics and all these different areas of neurobiology – that, somehow, we were going to revolutionize diagnosis with an etiopathophysiological classification, if you will," commented Dr. Rajiv Tandon of the University of Florida, Gainesville. "And relatively early in the process, we recognized that that was impossible to accomplish, because although we learned a lot, we didn’t know enough yet to be able to do that."

Still, the new edition differs from its predecessor, the DSM-IV, released nearly a decade ago, in a variety of key respects, he said.

For example, gone are the subtypes of schizophrenia, along with shared psychotic disorder. Newly added is catatonia not elsewhere classified, referring to a fully defined catatonic syndrome in the absence of an identifiable medical disorder.

The DSM-5 also sees the debut of assessment of the dimensions of psychosis, which captures the presence and severity of various symptoms. In addition, the criteria for diagnosing schizoaffective disorder have been modified, and catatonia is now treated more uniformly across the manual.

"What we have come up with regard to psychotic disorders are iterative changes, modest improvements, improved clinical utility, simplicity – we have actually reduced the number of disorders in our section by about 20%," Dr. Tandon said. "Very importantly, in addition to improved clinical utility and incorporating the new information we have learned to the extent possible, the DSM-5 look at psychotic disorders provides a much better platform to a future etiopathophysiological classification."

DSM, RDoC called complementary

The DSM-5’s new dimensional approach to assessing psychotic disorders will not only help advance the study of these disorders, but will also help to track their course in patients over time and ensure appropriate treatment, said Dr. Dolores Malaspina of the NYU Langone Medical Center in New York.

Clinicians will rate the presence and severity of eight symptoms – hallucinations, delusions, disorganized speech, psychomotor behavior, negative symptoms, impaired cognition, depression, and mania – on a scale from 0 to 4.

In particular, this approach will promote patient-centered care, she maintained. "We want our treatments to be person specific. For a treatment to be person specific, it’s not simply based on a diagnosis."

Dr. Malaspina further noted that dimensional assessment addresses some of the National Institute of Mental Health’s reservations about the DSM classification system.

"The NIMH has come to see the categories of the DSM as getting in the way of progress forward," she explained. The NIMH, therefore, developed its own classification system, called Research Domain Criteria (RDoC).

"Their goal is to do studies where symptoms have been assessed along a continuum. This approach is not antagonistic to the DSM – there is actually no dueling that will take place in the Moscone Center," she quipped, referring to the location of the APA meeting in San Francisco. "There actually is a great amount of agreement. The future of psychiatric assessment should see that the DSM-5 and the RDoC are complementary, not competing frameworks."

Cognitive impairment left out

Patients with schizophrenia commonly have impaired cognition, so clinicians might be surprised to find that this feature is still not listed as a core feature in the DSM-5, noted Dr. Raquel E. Gur of the University of Pennsylvania, Philadelphia.

"To meet the core features of hallucinations, delusions, and disorganized thinking, you must have impaired cognition, otherwise you will not perceive events around you differently than other people. There is something that happens in the brains of these people that make them distort reality, and those things are measurable," she commented.

Moreover, cognitive status is important when assessing the ability of patients to engage in treatment and when it comes to setting realistic goals of care.

To be sure, the DSM-5 describes assessment of cognitive status as vital to the differential diagnosis when distinguishing entities on the schizophrenia spectrum from other psychotic disorders.

The work group, however, stopped short of including it among core features because of its uncertain specificity to schizophrenia, lack of agreed-on measures that can be readily used in the real world, and absence of evidence that assessment is clinically indicated and applicable in this setting. In other words, more research is needed in this area, Dr. Gur said.

APS inclusion proves controversial

One of the most controversial aspects of the DSM-5 is its inclusion of attenuated psychosis syndrome (APS), acknowledged Dr. Ming T. Tsuang of the University of California, San Diego.

About a third of patients with this constellation of symptoms develop a full-blown psychotic disorder, raising hopes that the APS diagnosis could help identify patients who will benefit from early intervention.

Some, however, have expressed concern that adding APS to the classification system might lead to inappropriate antipsychotic therapy.

"From our experience, that is not the case," Dr. Tsuang said. "Actually, the APS category may educate clinicians about the relative lack of utility of antipsychotic medication in this population. So we hope that if we have this category, inappropriate antipsychotic use among youth may be reduced."

"In the end, our task force decided not to put APS into the main body of the DSM-5, but rather into the appendix, because more research needs to be done to really test its validity and usefulness, particularly for clinicians," he concluded. "For the DSM-6, once we have more experience in this area and [more information from research], we may be able to put this condition in the main body. At that time, the name may change."

Closer to ICD but still distinct

The DSM-5 is likely to share much with the psychosis section of the forthcoming International Classification of Diseases, 11th revision (ICD-11), of the World Health Organization, expected out in 2015. Yet the two will still have their differences.

For example, both classification systems have deleted schizophrenia subtypes, replacing them with dimensional assessments in the case of DSM-5 and symptom specifiers in the case of ICD-11, noted Dr. Wolfgang Gaebel of the Heinrich Heine University Düsseldorf in Germany.

The two differ, though, with respect to diagnostic criteria, such as the requirement for functional impairment to make a diagnosis of schizophrenia and the inclusion of longitudinal criteria to make a diagnosis of schizoaffective disorder.

"There is some harmonization," he commented, while adding that there is still justification for having two classification systems, even if they are generally converging over time.

"Of course, on one hand, we would like to see one system which fits all. On the other hand, the two systems have different foci and always have," Dr. Gaebel said. "ICD is the system which has been used worldwide, mainly for administrative reasons. Some countries, in the clinical situation, use DSM, whereas many other countries use ICD, but when it comes to research, they use in addition DSM, also for publication because, of course, many papers you want to submit to Anglo-American journals that prefer the DSM. And I think the DSM has – this is my personal opinion – a more research-based focus.

"But I think the two systems profit from each other. I doubt for various, and I would say political, reasons that in the future we will have one system, although it would be very good to have it," he concluded.

Dr. Tandon, Dr. Malaspina, Dr. Gur, and Dr. Tsuang disclosed no relevant conflicts of interest. Dr. Gaebel disclosed that he is on the scientific advisory board of Lundbeck International Neuroscience Foundation and receives symposium support from Lilly Germany and Janssen Cilag Germany.

SAN FRANCISCO – Changes to the psychosis section of the long-awaited fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) are hardly dramatic, but they are still likely to advance the field and make the classification system more clinically relevant and easier to use, according to the authors.

Representatives of the 12-member Work Group on Psychotic Disorders detailed some of the revised elements of this section of the new manual, which was released with the start of the annual meeting of the American Psychiatric Association.

Key changes are outlined

"When we were approaching the DSM-5, we thought we learned so much in the last 20 years about the nature of all these psychotic disorders – such incredible advances in imaging and genetics and all these different areas of neurobiology – that, somehow, we were going to revolutionize diagnosis with an etiopathophysiological classification, if you will," commented Dr. Rajiv Tandon of the University of Florida, Gainesville. "And relatively early in the process, we recognized that that was impossible to accomplish, because although we learned a lot, we didn’t know enough yet to be able to do that."

Still, the new edition differs from its predecessor, the DSM-IV, released nearly a decade ago, in a variety of key respects, he said.

For example, gone are the subtypes of schizophrenia, along with shared psychotic disorder. Newly added is catatonia not elsewhere classified, referring to a fully defined catatonic syndrome in the absence of an identifiable medical disorder.

The DSM-5 also sees the debut of assessment of the dimensions of psychosis, which captures the presence and severity of various symptoms. In addition, the criteria for diagnosing schizoaffective disorder have been modified, and catatonia is now treated more uniformly across the manual.

"What we have come up with regard to psychotic disorders are iterative changes, modest improvements, improved clinical utility, simplicity – we have actually reduced the number of disorders in our section by about 20%," Dr. Tandon said. "Very importantly, in addition to improved clinical utility and incorporating the new information we have learned to the extent possible, the DSM-5 look at psychotic disorders provides a much better platform to a future etiopathophysiological classification."

DSM, RDoC called complementary

The DSM-5’s new dimensional approach to assessing psychotic disorders will not only help advance the study of these disorders, but will also help to track their course in patients over time and ensure appropriate treatment, said Dr. Dolores Malaspina of the NYU Langone Medical Center in New York.

Clinicians will rate the presence and severity of eight symptoms – hallucinations, delusions, disorganized speech, psychomotor behavior, negative symptoms, impaired cognition, depression, and mania – on a scale from 0 to 4.

In particular, this approach will promote patient-centered care, she maintained. "We want our treatments to be person specific. For a treatment to be person specific, it’s not simply based on a diagnosis."

Dr. Malaspina further noted that dimensional assessment addresses some of the National Institute of Mental Health’s reservations about the DSM classification system.

"The NIMH has come to see the categories of the DSM as getting in the way of progress forward," she explained. The NIMH, therefore, developed its own classification system, called Research Domain Criteria (RDoC).

"Their goal is to do studies where symptoms have been assessed along a continuum. This approach is not antagonistic to the DSM – there is actually no dueling that will take place in the Moscone Center," she quipped, referring to the location of the APA meeting in San Francisco. "There actually is a great amount of agreement. The future of psychiatric assessment should see that the DSM-5 and the RDoC are complementary, not competing frameworks."

Cognitive impairment left out

Patients with schizophrenia commonly have impaired cognition, so clinicians might be surprised to find that this feature is still not listed as a core feature in the DSM-5, noted Dr. Raquel E. Gur of the University of Pennsylvania, Philadelphia.

"To meet the core features of hallucinations, delusions, and disorganized thinking, you must have impaired cognition, otherwise you will not perceive events around you differently than other people. There is something that happens in the brains of these people that make them distort reality, and those things are measurable," she commented.

Moreover, cognitive status is important when assessing the ability of patients to engage in treatment and when it comes to setting realistic goals of care.

To be sure, the DSM-5 describes assessment of cognitive status as vital to the differential diagnosis when distinguishing entities on the schizophrenia spectrum from other psychotic disorders.

The work group, however, stopped short of including it among core features because of its uncertain specificity to schizophrenia, lack of agreed-on measures that can be readily used in the real world, and absence of evidence that assessment is clinically indicated and applicable in this setting. In other words, more research is needed in this area, Dr. Gur said.

APS inclusion proves controversial

One of the most controversial aspects of the DSM-5 is its inclusion of attenuated psychosis syndrome (APS), acknowledged Dr. Ming T. Tsuang of the University of California, San Diego.

About a third of patients with this constellation of symptoms develop a full-blown psychotic disorder, raising hopes that the APS diagnosis could help identify patients who will benefit from early intervention.

Some, however, have expressed concern that adding APS to the classification system might lead to inappropriate antipsychotic therapy.

"From our experience, that is not the case," Dr. Tsuang said. "Actually, the APS category may educate clinicians about the relative lack of utility of antipsychotic medication in this population. So we hope that if we have this category, inappropriate antipsychotic use among youth may be reduced."

"In the end, our task force decided not to put APS into the main body of the DSM-5, but rather into the appendix, because more research needs to be done to really test its validity and usefulness, particularly for clinicians," he concluded. "For the DSM-6, once we have more experience in this area and [more information from research], we may be able to put this condition in the main body. At that time, the name may change."

Closer to ICD but still distinct

The DSM-5 is likely to share much with the psychosis section of the forthcoming International Classification of Diseases, 11th revision (ICD-11), of the World Health Organization, expected out in 2015. Yet the two will still have their differences.

For example, both classification systems have deleted schizophrenia subtypes, replacing them with dimensional assessments in the case of DSM-5 and symptom specifiers in the case of ICD-11, noted Dr. Wolfgang Gaebel of the Heinrich Heine University Düsseldorf in Germany.

The two differ, though, with respect to diagnostic criteria, such as the requirement for functional impairment to make a diagnosis of schizophrenia and the inclusion of longitudinal criteria to make a diagnosis of schizoaffective disorder.

"There is some harmonization," he commented, while adding that there is still justification for having two classification systems, even if they are generally converging over time.

"Of course, on one hand, we would like to see one system which fits all. On the other hand, the two systems have different foci and always have," Dr. Gaebel said. "ICD is the system which has been used worldwide, mainly for administrative reasons. Some countries, in the clinical situation, use DSM, whereas many other countries use ICD, but when it comes to research, they use in addition DSM, also for publication because, of course, many papers you want to submit to Anglo-American journals that prefer the DSM. And I think the DSM has – this is my personal opinion – a more research-based focus.

"But I think the two systems profit from each other. I doubt for various, and I would say political, reasons that in the future we will have one system, although it would be very good to have it," he concluded.

Dr. Tandon, Dr. Malaspina, Dr. Gur, and Dr. Tsuang disclosed no relevant conflicts of interest. Dr. Gaebel disclosed that he is on the scientific advisory board of Lundbeck International Neuroscience Foundation and receives symposium support from Lilly Germany and Janssen Cilag Germany.