Schizophrenic illness is characterized by several psychopathological domains, with a distinctive course, patterns of treatment-response, and prognostic implications. The relative severity of symptom dimensions—positive, negative, mood, disorganization, motor, and cognitive—vary among patients and also within patients at different stages of their illness. Measuring the relative severity of these symptom dimensions throughout the illness course can provide clinicians with useful information about the nature of a patient’s schizophrenic illness and the specific impact of treatment on different aspects of his or her illness (Table 2). In addition to being clinically useful, dimensional measurement also should improve schizophrenia research because having dimensional information will permit studies on etiology and pathogenesis that cut across current diagnostic categories. Although field trials are evaluating 9 dimensions—delusions, hallucinations, disorganization, depression, mania, cognitive impairment, restricted emotional expression, avolition, and psychomotor—it is likely that fewer dimensions will be recommended for DSM-5, based on reliability results of these trials, clinical utility, and logistic feasibility in routine clinical settings.
Table 2
Goals of a dimensional approach to schizophrenia
| Better understanding of schizophrenia |
| Distinct dimensions of illness |
| Distinct stages of illness |
| Elucidation of neurobiology |
| More precise delineation of etiology |
| More refined treatment development |
| Direction at specific dimension-endophenotype |
| Stage-specific treatment |
| Novel treatment targets |
Attenuated psychosis syndrome
Some clinicians and researchers believe that many patients with schizophrenia experience unsatisfactory outcomes because we identify the illness and initiate treatment after substantial brain tissue damage has occurred. Introducing attenuated psychosis syndrome will support clinicians’ efforts to recognize mild psychotic symptoms early in their evolution and to monitor—and if necessary, intervene—during these crucial early stages. Risks include possible stigma and inappropriate use of medications and other treatments. This controversial proposal is being field tested. It is unclear if this category will be included in DSM-5 and if it does, whether it will be in the main text or the appendix.
Catatonia
Catatonia will be used as a specifier for various psychotic disorders, major mood disorders, and associated with a general medical condition. Additionally, the same criteria will be used to diagnose catatonia across DSM-5. Catatonia Not Elsewhere Classified might be added as a residual category for other conditions in which a clear catatonic syndrome is present and the parent disorder has not yet been identified.2
Other psychotic disorders
Relatively minor changes are proposed in criteria for other disorders in this section. There are likely to be changes in the text, however, that incorporate new information about these conditions generated since publication of DSM-IV-TR in 2000. Some proposed changes include:
- deleting shared delusional disorder (folie à deux) as a separate diagnosis and instead characterizing it as a specifier for delusional disorder
- clarifying the distinction between substance-induced psychotic disorder and other psychotic disorders accompanied by comorbid substance use.
Current status of DSM-5
Field trials are being completed and their results remain to be analyzed. Major changes being evaluated in the field trials include:
- the impact of the change in concept and criteria for schizoaffective disorder
- the addition of a series of psychopathology dimensions
- the impact of adding attenuated psychosis syndrome as a new class.
Changes proposed by the Psychosis Disorders Work Group are intended to increase clinical utility (fewer diagnoses, better demarcation between disorders, greater treatment relevance [dimensions]) and modestly improve validity (more consistent with current information about the nature of various psychotic disorders), while retaining reliability in diagnosing various psychotic disorders (and improving it for schizoaffective disorder). Proposed changes are modest by and large but hope to set a better stage for a future etiopathophysiological classification.
The Psychosis Disorders Work Group’s recommendations are posted on the DSM-5 Web site2 at www.dsm5.org and are being reviewed by 2 expert committees established by the American Psychiatric Association Board of Trustees: a Scientific Review Committee and a Clinical and Public Health Implications Committee. Based on the results of the field trials, ongoing reviews, and other emerging data and discussions, additional changes to the current DSM-5 proposals may occur. DSM-5 is likely to be finalized in early 2013 and the published manual will be released in May 2013.
Related Resources
- American Psychiatric Association. DSM-5 Development. www.dsm5.org.
- Woods SW, McGlashan TH. The risk-benefit ratio of the proposed DSM-5 attenuated psychosis syndrome. Am J Psychiatry. 2011;168(12):1338.
Disclosure
Dr. Tandon is a member of the DSM-5 Psychotic Disorders Work Group. He is solely responsible for the content of this article.