Int J Psychiatry Clin Pract 2014; 18: 78–85. © 2014 Informa Healthcare ISSN 1365-1501 print/ISSN 1471-1788 online. DOI: 10.3109/13651501.2014.890228

REVIEW ARTICLE

The consequences of DSM-5 for psychiatric diagnosis and psychopharmacotherapy

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Hans-Jürgen Möller

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Department of Psychiatry and Psychotherapy, Ludwig Maximilian University, Munich, Germany Abstract Objective. After 10 years of preparation, DSM-5 was published in 2013. This paper will examine the possible effects of DSM-5 on psychiatric diagnosis and psychopharmacotherapy. Methods. DSM-5 was compared with DSM-IV to identify the important changes in psychiatric diagnosis and possible consequences for psychopharmacotherapy. Results. Contrary to the original plans, DSM-5 did not make radical changes and move towards dimensional diagnosis but preserved the previous categorical system of disorders and a primarily symptom-based descriptive approach. The dimensional approach was only adopted through the introduction of several transnosological specifiers and the option to make symptom- or syndrome-related assessments. The criteria for some disorders were changed, including affective, dependence and schizophrenic disorders, and a few new disorders were added. Conclusion. The DSM-IV diagnostic system was largely preserved, although some changes were made, primarily in the field of affective disorder and in several criteria sets. The new transnosological specifiers, severity assessments and cross-cutting dimensional assessments may help to individualise treatment. Key words: DSM-5, classification, diagnosis, psychopharmacotherapy (Received 14 January 2014; accepted 14 January 2014)

Introduction In May 2013, the newest version of the Diagnostic and Statistical Manual of Mental Disorders, DSM-5 (American Psychiatric Association 2013), was presented at the annual congress of the American Psychiatric Association (APA). The publication was preceded by about 10 years’ developmental work that included a multitude of prominent American and international experts. The DSM diagnostic system is used throughout psychiatric care and research in the USA. In countries that mostly use the ICD-10 in psychiatric care, the DSM system is mainly relevant for clinical research, because DSM-based diagnoses are common or even compulsory in scientific studies published in North American journals. In addition, DSM-5 will have a precursory role for the revision of the psychiatric classification published by the World Health Organization (WHO) and the International Classification of Diseases (ICD), currently available in version 10 (World Health Organization 2010). This system is obligatory in health care and statistics in almost all countries of the world. Although preparations are already well advanced, the revised version, ICD-11, will probably not appear until 2017, because of the necessary national decision-making processes, among other things. The ICD-11 is planned to correlate as closely as possible with the DSM-5 system. Submitted as a Review to International Journal of Psychiatry in Clinical Practice. Correspondence: Hans-Jürgen Möller, MD, Department of Psychiatry and Psychotherapy, Ludwig Maximilian University, Nussbaumstrasse 7, 80336 Munich, Germany, Tel: ⫹ 49 89 5160 5514. Fax: ⫹ 49 89 5160 5528, E-mail: [email protected]

Months before the appearance of DSM-5, the manual was discussed intensively, not only among professionals but also in the general public, and was subject to considerable criticism by the mass media. The main points of criticism were the allegations that the number of diagnosable mental disorders had again increased (e.g. through new additions such as ‘disruptive mood regulation disorder’ in children/adolescents, previously considered to be and diagnosed as bipolar I disorder), the threshold criteria for the diagnosis of certain disorders had been lowered and treatment possibilities or requirements had been further increased through the introduction of dimensional evaluations of various syndromes, in addition to the disease (disorder) units. These issues are considered problematic, particularly from a health economic perspective. Accusations have also been made (Maj 2013) that ‘natural’ psychological reactions have been pathologised, for example, when the grief resulting from the death of a close relative can no longer be clearly differentiated from a depressive disorder. The omission in DSM-5 of the differentiation between alcohol abuse and alcohol dependence is seen as problematic for the same reasons, particularly among experts, who see it as a mistake not to take into account the many biological findings about alcohol dependence. DSM-5 was particularly criticised by some top-class research institutions, for example, because of the relatively traditional, symptom-oriented, descriptive approach that did not sufficiently refer to neurobiological parameters. Tom Insel, the director of the National Institute of Mental Health (NIMH), stressed in a statement that the NIMH will not adopt DSM-5 (Insel 2013). One of the reasons was the descriptive approach, which in his view was too traditional and did not sufficiently consider the neurobiological level. When considering this

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criticism one has to remember that changes to a classification system represent a large problem for every psychiatric research facility, because new findings will not necessarily be comparable with earlier ones. For this reason, the introduction of a new classification system only appears to be justified if it has significant advantages for research. Despite the disappointment that many of the objectives – which may have been too far-reaching from the beginning – were not achieved, a positive aspect is that during the long preparations for DSM-5 a large number of recognised experts dealt intensively with the current state of knowledge on the various mental disorders and attempted to reach a consensus after critical examination of the empirical knowledge and many conceptual and pragmatic considerations. The respective publications by the individual working groups (e.g. Fawcett 2010; Phillips et al. 2010) are remarkable in terms of the quality and intensity of the discussion of the respective problem and can be recommended as very good presentations of the status quo. However, a lot has fallen by the wayside, which is painful particularly from the perspective of traditional German-language and European psychiatry (Moller 2008a), especially in the field of differentiated psychopathology. DSM-5 continues to follow the path of an ever stronger renunciation of differentiated phenomenological methods, an approach already criticised in DSM-IV (Andreasen 2007). The fact that many other expectations, including better neurobiology-based classification (Hyman 2008), could not be fulfilled on the basis of the abovementioned examination of the empirical knowledge base gives a realistic picture of our current knowledge (Moller 2008b). The DSM-5 consortium cannot be blamed for this unsatisfactory outcome. Rather, it shows how slowly we make progress in our field, despite immense research efforts. For reasons of space, in this article the DSM-5 system cannot be presented and explained in detail; the interested reader is referred to the DSM-5 manual (American Psychiatric Association 2013) and detailed publications on individual chapters or disorder groups. Rather, this article will present a few relevant, fundamental perspectives and some important changes to psychiatric diagnosis in DSM-5. In addition, it will examine the extent to which the changes introduced in DSM-5 have consequences for psychopharmacotherapy. Unachieved objectives and adaptation to reality As mentioned above, despite all its efforts the DSM-5 consortium did not manage to adequately base the DSM disorder (or disease) categories on neurobiological facts. This is not the fault of the DSM-5 consortium but rather reflects the general state of research in our field. Despite the original objectives, biological markers were also not described for the individual disorders, apart from the biological causes of organic brain diseases such as dementia disorders. Biological markers have in fact been described by different research groups for various diseases on different diagnostic levels, for example the recently described serum marker approach for depression (Papakostas et al. 2013) and the brain-ageing–related structural magnetic resonance imaging (sMRI) marker to differentiate between schizophrenic and depressive disorders (N. Koutsouleris,

Will DSM-5 affect diagnosis and treatment? 79 manuscript in preparation). However, the consortium considered these approaches to be not yet fully developed and not sufficiently replicated. Even the marker diagnostics for Alzheimer’s dementia, which appear to be the furthest advanced (Blennow et al. 2010; Ewers et al. 2011; Hampel et al. 2010), were not included because apparently doubts still existed. Psychiatric diagnosis therefore continues to be primarily based on symptoms and course (Moller 2005). At the same time, psychiatric diagnosis appears to be very consensus oriented, despite all the efforts to achieve empirically based validity (Berk 2013; Cuthbert and Insel 2013). The DSM-IV option to use multiaxial diagnosis was dispensed with, because apparently it had been little used, even though it was originally considered to be a significant advance in terms of refined and individualised diagnosis (Moller 2005) and consequently raised expectations that the resulting comprehensive data sets would allow the further development of psychiatric classification and diagnosis in the sense of a multifactorial pathogenetic approach. One of the main objectives of DSM-5 was to replace categorical diagnosis, that is, the principle of categorisation according to disorder (disease) entities (Moller 2009a), and to attach greater importance to dimensional diagnosis, that is, to a syndrome-related approach, and hence to become even more atheoretical than DSM-IV (Moller 2005). However, this objective was largely abandoned in the course of the intensive discussions in both the general DSM-5 working groups and the disease-related ones, primarily for pragmatic reasons. Only very little of this original dimensional approach remains, for example transnosological specifiers, severity assessments and cross-cutting dimensional assessments. Particularly noteworthy in this context is the last minute reversion from a dimensional diagnosis of personality disorder – the chapter already existed in a final version! – to the chapter on personality disorders from DSM-IV-TR (see below). The struggle between the categorical and dimensional approaches becomes especially clear from the example of schizophrenic and affective disorders. Despite initial enthusiasm for the idea, the original plans to replace the previous symptom-based classification of schizophrenic and bipolar diseases/disorders with a ‘psychotic spectrum’, with the option of a dimensional subdivision, were ultimately abandoned because of manifold theoretical (Maier et al. 2006; Moller 2008a) and pragmatic concerns (Moller 2009a). Although this idea seemed very plausible to many (reversion to the concept of the unitary psychosis, Einheitspsychose), consideration of some simple clinical questions already shows that it is more problematic than at first appears. For example, why should only bipolar disorder be included and not unipolar depression (Maj 2013, who describes among other things the continuum between unipolar and bipolar depression)? Why stop at unipolar depression and not also include generalised anxiety disorder (GAD) (in view of the difficulties in differentiating between major depressive disorder [MDD] and GAD; Starcevic and Portman 2013)? The term ‘psychotic’ is also not defined as uniformly as one might initially think, that is, by the presence of delusional symptoms and hallucinations (Moller In Press). Do productive symptoms have to

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be present to allow a diagnosis of ‘psychotic disorder’ or is it sufficient that a disorder such as mania or depression can potentially be associated with positive symptoms? The recent scientific literature includes publications that classify mania but not depression primarily as a psychotic disorder, which is not fully comprehensible from a naïve perspective. What has changed with respect to classification and criteria? A preliminary inspection shows that the classification has not changed much, apart from some rearrangements in the overall system, a few additions of disorders (such as ‘hoarding disorder’ or ‘disruptive mood regulation disorder’), and the removal of some subgroups, for example, subtypes of schizophrenia. The criteria have changed for some of the individual disorders but have remained more or less the same for others, for example, MDD (Regier et al. 2013a). Table I shows the main disorder categories in DSM-5. All disorders relevant for psychopharmacotherapy are still present, even though some of the diagnostic terms or criteria have been changed, including those for MDD, manic or depressive episodes as part of bipolar disorder, schizophrenia, anxiety disorders (such as panic disorder, social phobia and GAD), attention deficit hyperactivity disorder, alcohol and drug dependence, personality disorder and dementias. A few noteworthy, selectively chosen details of some disorders will be described below. For example, the main category of affective diseases has been omitted and replaced with the categories ‘bipolar disorders’ and ‘depressive disorders’ Table IIa and b. The category ‘bipolar disorders’ includes not only mania but also depression. The chapter includes bipolar I disorder, bipolar II disorder and cyclothymic disorder, among others, as well as manic-like phenomena caused by medicines or medical conditions. The symptom-related diagnosis requirements for manic and hypomanic episodes have been Table I. Main DSM-5 disorder categories. Neurodevelopmental disorders Schizophrenia spectrum and other psychotic disorders Bipolar and related disorders Depressive disorders Anxiety disorders Obsessive–compulsive and related disorders Trauma- and stressor-related disorders Dissociative disorders Somatic symptom and related disorders Feeding and eating disorders Elimination disorders Sleep-wake disorders Sexual dysfunctions Gender dysphoria Disruptive, impulse-control and conduct disorders Substance-related and addictive disorders Neurocognitive disorders Personality disorders Paraphilic disorders Other mental disorders Medication-induced movement disorders and other adverse effects of medication Other conditions that may be a focus of clinical attention

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partially reduced. On the other hand the criteria for mania/ hypomania are more specific/tighter such that euphoric or irritated mood alone is not sufficient for a diagnosis but has to be accompanied by an increase in activity or energy. Conditions similar to bipolar disorders that do not fulfil all the criteria for a bipolar I or II disorder or cyclothymic disorder, that is, brief hypomanic episodes and major depressive episode (brief hypomania), hypomanic episodes without previous major depressive episode and brief cyclothymia, fall under the diagnosis ‘Other specified bipolar and related disorder’. Particularly the introduction of the ‘mixed features’ specifier has facilitated the likelihood (probability) of diagnosing bipolar disorder or bipolarity (Angst 2013; Fawcett 2013; Nusslock and Frank 2011; Severus and Bauer 2013). Mixed episodes are no longer characterised as a separate episode type. The mixed features specifier allows every depressive or manic episode to be characterised as having features from the other pole of the bipolar disorder. Mixed episodes are no longer characterised as a separate episode type. The psychopharmacological consequences of a more or less restrictive diagnosis of bipolar II disorder and consequently a more or less restrictive diagnosis of hypomania (normally a retrospective diagnosis that is hence susceptible to bias) are discussed very well in the publication by Severus and Bauer (2013). The criteria for MDD have been preserved and a dimensional approach in the strict sense, although imaginable (Andrews et al. 2007), not realised (Fawcett 2013). The long-discussed ‘mixed anxiety depressive disorder’, the mixed clinical picture between depressive and anxiety disorder that is particularly common in general medicine, was not incorporated into the main part of DSM-5, but only into Section III, which includes disorders that require further research before they can be included in the main part. However, the specifier ‘with anxious distress’ was introduced that allows one to indicate that anxious symptoms are also present (which is important because studies, e.g. the STAR-D study, found that such symptoms are prognostic for poor treatment response in MDD patients, Fava et al. 2008). This specifier can be used for both unipolar and bipolar depression. In addition, a ‘postpartum’ specifier is available for bipolar and depressive disorder. New introductions include ‘premenstrual dysphoric disorder’, which was previously only a research category, and ‘persistent depressive disorder’, which covers the earlier diagnoses of dysthymia and chronic major depression. The diagnostic criteria for schizophrenia – a disorder that time and again is viewed in the scientific literature as a conglomerate of various disorders (Tandon 2012), as is probably also the case for most of the other disorders listed in DSM and ICD (Moller 2005) – were considerably simplified (Tandon and Carpenter 2013). Hence every reference to first-rank symptoms according to Kurt Schneider was omitted, including the psychotic ego disorders (referred to in DSM-IV as ‘bizarre delusional ideas’) and conversing voices, because of ‘insufficient specificity’ (Cermolacce et al. 2010; Nordgaard et al. 2008). In DSM-IV, one of these symptoms was sufficient to fulfil the A criterion. In DSM-5, two criterion A symptoms are required for a diagnosis of schizophrenia, whereby

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Table IIa. Depressive disorders in DSM-5: Differences compared to DSM-IV and their relevance for therapeutic decisions. Differences in the definition of depressive disorders between DSM-IV and DSM-5 Specifiers for depressive episodes (unipolar, bipolar): – With anxious distress – With mixed features – Peripartal (in DSM-IV postpartal!) New disorders, for example: – Disruptive mood regulation disorder (previously bipolar disorder in children/adolescents) – Premenstrual dysphoric disorder – Persistent depressive disorder (dysthymia or chronic major depression) Other Specified Depressive Disorder, for example: – Recurrent brief depression – Short duration depressive episode – Depressive episode with insufficient symptoms

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Relevance of these differences for therapeutic decisions New specifiers for major depressive disorder: “with anxious distress”. Will a worse response to antidepressant mean that augmentation is started earlier? Other Specified Depressive Disorder: cognitive behavioural therapy (CBT), poor pharmacological response Premenstrual Dysphoric Disorder: selective serotonin reuptake inhibitors (SSRIs), gonadotrophin-releasing hormone (GnRH) antagonists Disruptive Mood Regulation Disorder: stimulants or antidepressants? Table IIb. Bipolar disorders in DSM-5: Differences compared to DSM-IV and their relevance for therapeutic decisions. Differences in the definition of depressive disorders between DSM-IV and DSM-5 Bipolar and related disorders (I, II, cyclothymia, other) now a separate disorder group (the term “affective disorders” has been dropped!) “Mixed feature specifier” for mania and depressive episode; symptomatic thresholds have been lowered. New category: Other specified bipolar and related disorder, for example: – Short duration hypomania episodes (2–3 days) and major depression – Hypomanic episodes with insufficient symptoms and major depressive episodes – Hypomanic episode without prior major depressive episode Relevance of these differences for therapeutic decisions Stricter separation of bipolar depression: – Relevance of guidelines for bipolar disorders: focus on mood stabilisers, second generation antipsychotics (SGAs), less frequently antidepressants(?) – “Mixed Features”: SGAs, mood stabilisers, – Separate indication: major depressive disorder ⫹ mixed features, mania ⫹ mixed features?

one of these symptoms has to be delusions, hallucinations or disorganised speech. The subtypes of schizophrenic psychosis have been removed, mainly for reasons of insufficient course stability. Only the catatonic syndrome can be diagnosed indirectly via such a specifier in terms of a transnosological approach, that is, it can also be applied to other disorders, for example. In addition, a few main symptoms that can affect the clinical manifestation of the disorder in different ways in different patients are to be recorded through a ‘dimensional approach to rating severity for the core symptoms of schizophrenia’. The proposed ‘attenuated psychosis syndrome’, which has been well studied in scientific research on the early recognition of schizophrenic psychoses, was not included in the main part of DSM-5, despite all the empirical evidence for a sufficiently reliable diagnosis (also in the DSM-5 field studies, Regier et al. 2013b) and high prognostic value, especially when combined with additional sMRI markers (Koutsouleris et al. 2012); it was included only in the above-mentioned Section III. The criteria for a schizophrenic disorder now look very meagre, even though schizophrenia is well known to have the richest and most complicated clinical picture, at least of the mental illnesses that used to be considered to be endogenous. The growing abandonment of a differentiated phenomenological approach that

was recognisable in DSM-IV (Andreasen 2007) is clearly being continued, with questionable validity arguments. The requirements for specificity were set very high for this range of symptoms, whereas this is not the case for the other diseases. Overall, the unequal treatment in comparison to the bipolar disorders and the tendency to decrease the possibilities for diagnosing a schizophrenic disorder are apparent. The bias in favour of the affective disorders is being continued (Moller 2005); this bias became apparent in DSM-III and may explain why the long-term prognosis for bipolar disorder has apparently become so unfavourable (perhaps through the inclusion of patients who would have been diagnosed with schizophrenia according to the more traditional criteria, for example patients with ‘mood incongruent symptoms’). As to schizoaffective disorder, which can be seen as the bridge between schizophrenia and bipolar disorder, the primary change is the requirement that a major mood episode has to be present for most of the duration of the disorder. This makes schizoaffective disorder a longitudinal instead of a cross-sectional diagnosis, a conceptualisation which already has a long tradition (Jager et al. 2011) and which has apparently increased the reliability of this diagnosis in DSM-5 (Regier et al. 2013b). The DSM-5 criteria for schizophrenia symptoms are listed in Table III.

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Table III. DSM-5 criteria for schizophrenia. A. Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated). At least one of these should include 1, 2, or 3. (1) Delusions (2) Hallucinations (3) Disorganised speech (4) Grossly abnormal psychomotor behaviour, including catatonia (5) Negative symptoms, for example, diminished emotional expression or avolition B. For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning, such as school, work, interpersonal relations, or self-care, are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement) C. Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or by an attenuated form of two or more symptoms listed in Criterion A (e.g., beliefs perceived as odd, perceptual experiences described as out of the ordinary) D. Schizoaffective Disorder and Depressive or Bipolar Disorder With Psychotic Features have been ruled out because either (1) no Major Depressive, Manic, or Mixed Episodes have occurred concurrently with the active-phase symptoms; or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been less than half of the total duration of the active periods E. The disturbance is not due to the direct physiological effects of a substance (e.g., an abused drug, a medication) or a general medical condition F. If there is a history of Autistic Disorder or another Pervasive Developmental Disorder or other communication disorder of childhood onset, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present

Despite long discussions about whether or not to keep GAD (discussed as an atypical subtype of depression, among other things) as an independent diagnostic category, in the end it was left as a separate category and the criteria were essentially preserved (Starcevic and Portman 2013). The other typical anxiety disorder groups like agoraphobia, panic disorder, social anxiety disorder (social phobia and specific phobia) were also preserved, with a few changes to their diagnostic criteria. Posttraumatic stress disorder and acute stress disorder are now included in the chapter on trauma and stress-related disorders. Obsessive–compulsive disorder (OCD) was removed from the chapter on anxiety disorders and included as a separate diagnostic group in a chapter on OCD and related disorders. Hoarding disorder and excoriation (skin-picking) disorder were added to this chapter as new categories. The ‘with poor insight’ specifier for OCD was refined to allow a distinction between individuals with good insight, poor insight and ‘absent insight/delusional’ OCD beliefs. Analogous ‘insight’ specifiers have been included for body dysmorphic disorder and hoarding disorder. The former chapter on somatoform disorder has been considerably simplified and the term somatoform disorder replaced with ‘somatic symptom disorder’ (Dimsdale 2013). Somatisation disorder, undifferentiated somatoform disorder, hypochondriasis and the three former variants of pain disorder were included in the category somatic symptom disorder. The diagnosis of illness anxiety disorder was introduced in recognition of the fact that a minority of hypochondriacs (about 20%) have intensive health concerns even in the absence of somatic symptoms. Instead, these patients are worried that they might become ill or that they have some undiagnosed malady even if they lack symptoms. Other disorder groups in the chapter on somatic symptoms and related disorders are conversion disorder (functional neurological symptom disorder), psychological factors affecting other medical conditions and factitious disorder.

The chapter on personality disorders remains unchanged from DSM-IV. The originally planned version with a dimensional diagnosis was considered in the final phase of the DSM-5 preparations to be insufficiently feasible. It is now included in Section III for further study. The chapter on dependence disorders no longer contains the previously central diagnoses alcohol or substance abuse and alcohol or drug dependence. The comprehensive term ‘substance use disorder’ (specified for the individual substance, e.g. alcohol) has been introduced as a new term for disorders related to dependence and abuse. This is described as a dimensional concept: a list of criteria that includes craving, tolerance development, withdrawal symptoms, social problems and physical harm allows severity to be rated as mild, moderate or severe, depending on the number of criteria met. Pathological gambling is listed as a non-substance– related disorder, but internet dependence is not (internet gaming disorder is included in Section III). The chapter ‘neurocognitive disorders’ includes the main groups ‘delirium’ (the criteria for which have been modified from DSM-IV), ‘major neurocognitive disorder’ (i.e. dementia) and ‘mild neurocognitive disorder’, the latter as a new category. The distinction between major and minor neurocognitive disorders is primarily one of severity, with the threshold for major cognitive disorder encompassing a greater degree of cognitive impairment and hence a loss of independence in instrumental activities of daily living. In most progressive disorders, such as the neurodegenerative disorders and some forms of vascular cognitive impairment, the qualifiers ‘minor’ and ‘major’ may correspond with earlier and later stages of the same disorder. The distinction between mild neurocognitive disorder and major cognitive disorder has been criticised by some neurology experts as being an artificial threshold that depends too much on the clinician’s subjective evaluation and therefore potentially blurs the fact that the neurocognitive disorder (specifically

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Alzheimer dementia) begins even before symptoms emerge (Blazer 2013). Interestingly biomarkers such as sMRI, amyloid imaging or CSF Abeta/tau ratio are not yet recommended for clinical diagnosis and are still in the realm of research criteria. Diagnostic criteria are presented for the disorders and the different aetiological subtypes. However, objective neurocognitive assessments are recommended. The term ‘major neurocognitive disorder’ avoids the term ‘dementia’ but appears with the aetiological subtypes, for example, Alzheimer dementia, probably as a concession to other medical disciplines. Interrater reliability problems of the categorical approach and individualisation through symptom-/syndrome-related evaluations A matter of concern is that some of the interrater reliability scores found in so-called field studies were very low (Regier et al. 2013b) (see Table IV); this has been explained by the methods chosen (Clarke et al. 2013) and the high comorbidity rate of the patients studied. Whether these are the only reasons or whether the change in diagnostic concepts plays a role requires further evaluation. In any case, a kappa coefficient of 0.28 for MDD is a cause for concern (Moller 2005) and highly problematic for the image of our specialty. The argument is hardly reassuring that the interrater reliability was also not much better in DSM-IV, particularly when one considers the differences in evaluation methods (why was a different method for evaluating reliability chosen that made a direct comparison more difficult?). After all, one objective of an improved diagnostic approach should be to increase interrater reliability; this objective was mentioned explicitly by the intellectual fathers of DSM-5 (Regier et al. 2013a). On the one hand, improving reliability cannot be the only objective, as stressed by the same authors, and improved validity is rather a primary objective. However, because of the lack of clear external criteria, for example, biological markers, validity is difficult to prove and can be determined at the most by a consensus of experts. Such a low interrater reliability, which is in sharp contrast to the comparatively good interrater reliability for schizophrenic and bipolar disorder, for example, and that of schizoaffective disorder, whose interrater reliability has otherwise been greatly criticised, suggests that the diagnostic criteria are not clear enough and that the overlapping areas with other disorders are too large.

A glance at the overlap pattern of the respective comorbidity picture (Regier et al. 2013b) makes clear that association/overlap, referred to in DSM as comorbidity, should rather be understood as a partial cosyndromality, for example, cosyndromality of depressive and anxiety (GAD, PTSD) symptoms. This cosyndromality can result in the respective difficulties in differential diagnosis (as was also discussed in depth in the above discussion about the questionable autonomy of GAD). Particularly the poor interrater reliability scores for MDD (like for GAD) and the even worse results for the omitted category ‘anxious depressive disorder’ may represent a phenomenon that can be easily understood by considering Jaspers’ hierarchical principle: both depressive and anxiety symptoms are so common and therefore so unspecific that it may be difficult to differentiate them into two completely separate illness/disorder groups. As mentioned above, in addition to categorical diagnosis DSM-5 allows one to give supplementary descriptions of the individual case on the syndromal level, for example, to characterise the predominance of negative symptoms in a patient with a schizophrenic disorder. These supplementary descriptions include severity assessments and cross-cutting dimensional assessments. Such options are an important advantage of DSM-5 from a clinical perspective, because individual characteristics are of particular relevance, for example, for psychopharmacotherapy. Most of the supplementary assessments are mainly included in Section III and therefore not mandatory, but just suggested for further exploration. In view of the fact that DSM-5 has abandoned multiaxial diagnosis (because of insufficient acceptance, among other things), the question remains whether these much more complicated and comprehensive assessments will be accepted and used, especially because the developmental work and conceptual penetration of the whole approach are currently insufficient and the approach has severe insufficiencies from a psychometric perspective. As regards the last point, the careless and not easily comprehensible mixture of observer- and selfrating approaches is noteworthy. It is also unclear whether some of the presented materials are more orienting interview questions rather than assessments in the psychometric sense that should correspond with the usual validity and reliability criteria. One has to wonder why these assessments rely mainly on self-rating methods (some of which are also very simple), which are known not to differentiate to the same degree

Table IV. Test–retest/interrater reliability found in the initial field trials for some of the main DSM-5 diagnoses (data from Regier et al. 2013b). DSM-5 diagnosis Major Neurocognitive Disorder Posttraumatic Stress Disorder Complex Somatic Symptom Disorder Revised Bipolar I disorder Schizoaffective Schizophrenia Alcohol Use Disorder Major Depressive Disorder Generalised Anxiety Disorder *Pooled values for data from more than one study centre.

Intraclass kappa values* 0.78 0.67 0.61 0.56 0.50 0.46 0.40 0.28 0.20

Authors’ assessment of agreement Very good Very good Very good Good Good Good Good Questionable Questionable

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as observer-rating methods and which do not correspond closely with observer ratings (Moller 2009b; Seemuller et al. 2012; Trivedi et al. 2006). Also unclear is why only some of the established scales were used and it was decided instead to invest work in and take the risk of developing new assessments (most of which are very simple global evaluations). Available measurement instruments (self-rating instruments) were used in only a few areas, for example, the Patient Health Questionnaire (PHQ-9) for the severity of depression, the National Stressful Events Survey PTSD Short Scale for the severity of post-traumatic stress symptoms and the Brief Dissociative Experience Scale for the severity of dissociative symptoms. No such measurement instruments were provided to assess the severity of other disorders, including panic disorder, social anxiety disorder and GAD. The whole field still appears to be incomplete and not well thought out. Other disorders have clinician-rated severity measures such as the clinician-rated dimensions of psychosis severity and clinician-rated severity of somatic symptom disorder. However, so far these clinician severity ratings refer to only a few areas. One wonders about the basis for the decisions. The choice of symptoms for the cross-cutting dimensional assessments for adults appears to be arbitrary and limited: depression, anger, mania, anxiety, somatic symptoms, sleep disturbances, repetitive thoughts and behaviours and substance use. The assessments use some of the established instruments, such as the PHQ for somatic symptoms, the Patient Reported Outcomes Measurement Information System (PROMIS) for depression, anger, anxiety and sleep disturbance and the Florida Obsessive-Compulsive Inventory (FOCI) for repetitive thoughts and behaviours. This part still seems to be very random, not well thought through and incomplete. Interestingly, the first respective field trial study reached an overall positive appraisal of the reliability of the evaluated assessment (Narrow et al. 2013). A large part of these assessment topics and methods is only available on the internet and only a few are printed in Section III. Overall, the arrangement appears unclear, confusing and difficult to follow. Concluding remarks The originally planned, rather radical changes to the diagnostic system were not made because they were deemed too extreme even by most of the experts involved in the revision. Consequently the familiar system from DSM-IV was largely preserved, although some changes were made. The known diagnostic background for psychoses was also essentially preserved; relevant changes were made primarily in the field of affective disorders. The transnosological specifiers, severity assessments and cross-cutting dimensional assessments can help to individualise treatment at the onset and over the course of treatment and also to describe treatment success differentially. However, these possibilities will only be realised if these new options are accepted and implemented. The negative experience with the (much simpler) multiaxial diagnosis in DSM-IV dampens the expectations from the start. The

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current suggestions for the measurement instruments seem unrefined and improvised and are not convincing. In light of the rather modest changes, one could perhaps be rather critical about whether the introduction of a revised edition of DSM was worthwhile or even necessary. Perhaps the everyday work with DSM-5 will show that it significantly improves certain aspects of diagnosis, not so much related to the illness/disorder categories but rather in view of the possibilities to better describe individual cases. Some people are convinced that a primarily neurobiologically oriented approach is the right one and already think that DSM-5 is an interim solution that will be increasingly replaced over time by a ‘brain circuit classification of mental illness’ (Stahl 2013) in the framework of the research domain criteria project (Cuthbert and Insel 2013; Insel 2013; Insel et al. 2010). However, this perspective is primarily a research-related alternative that the protagonists themselves think will only gradually become realisable and develop a clear profile in the sense of a work in progress. As a result, it cannot yet provide the necessary framework conditions for routine clinical care. The critical comments on DSM-5 by the NIMH director Tom Insel (Insel 2013) should be understood with this in mind: ‘The goal of this new manual, as with all previous editions, is to provide a common language for describing psychopathology. While DSM has been described as a “Bible” for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischaemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.’ Key points • • •

•

DSM-5 does not fulfil the original expectations that it would be a dimensionally oriented diagnostic system based on neurobiology. DSM-5 is still a primarily symptom-based, categorical, systematic classification of mental disorders. Most of the disorder categories and their criteria are similar to the DSM-IV categories. However, some relevant changes have been made, for example, in the bipolar disorder chapter. The dimensional approach was only realised to a small degree.

Acknowledgements The author thanks Jacquie Klesing, Board-certified Editor in the Life Sciences (ELS), for editing assistance with the manuscript.

DOI: 10.3109/13651501.2014.890228

Statement of interest None of the author reports conflicts of interest.

Int J Psych Clin Pract Downloaded from informahealthcare.com by University of Connecticut on 10/10/14 For personal use only.

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