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Psychiatric diagnosis in ICD-11: Lessons learned (or not) from the mood disorders section in DSM-5
Michael J Gitlin and David J Miklowitz Aust N Z J Psychiatry 2014 48: 89 DOI: 10.1177/0004867413515952 The online version of this article can be found at: http://anp.sagepub.com/content/48/1/89

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ANZJP Correspondence

89 proper boundaries of psychiatric disorders; and (2) how to set the proper balance between being inclusive enough to ensure the proper treatment of suffering individuals while not overpathologizing human conditions. A few examples from the mood disorders section will be illustrative. easier to diagnose mixed mania and by introducing depression with a mixed mania specifier. The latter category was introduced on the basis of many studies demonstrating that this mixed depression subgroup had other features (such as family history of mania and a greater likelihood of antidepressant-induced switches) compared to those with classic unipolar depression. Yet, the specific manic features used for the mixed depression specifier have been criticized (Malhi, 2013), especially the exclusion of irritability and agitation. As with the diagnostic boundaries of bipolar disorder noted above, however, the lack of controlled studies examining the treatment responses of patients with mixed depression makes the clinical utility of this new DSM-5 diagnosis unknown. DSM-5 includes a new, controversial category, disruptive mood dysregulation disorder (DMDD), to characterize children with severe and recurrent temper outbursts along with persistent irritability who do not meet criteria for a manic or hypomanic episode. The intent of this category is to reduce false-positive diagnoses of bipolar disorder in children; chronically irritable children later develop depression, but not mania (Leibenluft, 2011). Others argue that this category introduces new problems (e.g. Axelson etal., 2011). DMDD has a high overlap with oppositional defiant disorder, and there are no known treatments for it. Perhaps most importantly, the relevant research supporting inclusion of DMDD is based on severe mood dysregulation (Leibenluft, 2011), a childhood disorder that includes hyperarousal and other attention deficit hyperactivity disorder (ADHD)-like symptoms, as well as temper outbursts (e.g. Axelson etal., 2011). Here, too, whether this new category will advance diagnostic clarity and/or more appropriate treatment is unknown.

Psychiatric diagnosis in ICD-11: Lessons learned (or not) from the mood disorders section in DSM-5 Michael J Gitlin and David J Miklowitz
University of California, Los Angeles, Los Angeles, CA 90095, USA Corresponding author: Michael Gitlin, University of California, Los Angeles, 300 UCLA Medical Plaza, Ste 2200, Los Angeles, CA 90095, USA. Email: mgitlin@mednet.ucla.edu DOI: 10.1177/0004867413515952

Proposals for expanding the boundaries of bipolar disorder

Proposals for bipolar disorder focused on: decreasing the time criterion for hypomania from 4 to 2 days; and/or defining hypomania using increased energy as the core A criterion (Angst etal., 2013) (as opposed to a mood criterion alone or mood plus energy as in DSM-5). The justification for these proposals was to ensure that patients with bipolar spectrum disorders those who would not have been diagnosed as bipolar in DSM-IV are both accurately diagnosed and then properly treated. DSM-5 rejected both of these proposals for a number of reasons. (1) Shifting the epidemiology of mood disorders towards bipolar versus unipolar diagnoses will simply change the number of false-positive bipolar diagnoses at the expense of false-negatives (Zimmerman, 2012). Inherent in this logic is the notion that there is no intrinsic advantage in shifting the diagnoses of those with unipolar depression and/or borderline personality disorder to a bipolar diagnosis in the absence of validation of the proper diagnosis. (2) There is a lack of controlled studies demonstrating that patients in this broader bipolar spectrum are more effectively treated by mood stabilizers versus other agents used for major depression or borderline personality disorder, thereby making the treatment implications of expanding the bipolar spectrum unknown. In contrast, DSM-5 properly expanded the boundaries of mixed mood pathology, both by making it

ICD Insights

Even before its publication in May 2013, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) had been criticized by a large number of leaders in our field for a myriad of reasons: using phenotypic categories with no basis in biology (virtually the entire manual); medicalizing human conditions that should not be lumped with psychiatric pathologies (such as eliminating the bereavement criteria in diagnosing major depression); and forcing into categories what might be better conceptualized along dimensional lines (e.g. personality disorders). Others have bemoaned the missed opportunity to shift boundaries between disorders (expanding the boundaries of bipolar disorder at the expense of major depression). There is basis for all of these criticisms. Yet, finding a better diagnostic system with greater validity, not just reliability may prove just as difficult for the International Classification of Diseases, 11th Revision (ICD-11) as it was for the authors of DSM-5. We are limited by our ignorance on two major issues: (1) the biological underpinnings and

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Australian & New Zealand Journal of Psychiatry, 48(1)

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ANZJP Correspondence optimally using DSM-5 or ICD-11 is for clinicians and researchers alike to treat these diagnostic systems as crude approximations based on best current guesses, and not to reify and concretize these criteria or to treat them as revealed truths. Funding
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
with major depressive episodes in the Bridge Study: Validity and comorbidity. European Archives of Psychiatry and Clinical Neurosciences 263: 663673. Axelson DA, Birmaher B, Findling RL, etal. (2011) Concerns regarding the inclusion of temper dysregulation disorder with dysphoria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Journal of Clinical Psychiatry 72: 12571262. Cuthbert BN and Insel TR (2013) Toward the future of psychiatric diagnosis: The seven pillars of RDoC. BMC Medicine. Epub ahead of print 14 May 2013. DOI: 10.1186/1741-7015-11-126. Leibenluft E (2011) Severe mood dysregulation, irritability, and the diagnostic boundaries of bipolar disorder in youths. American Journal of Psychiatry 168: 129142. Malhi GS (2013) Diagnosis of bipolar disorder: Who is in a mixed state? The Lancet 381: 15991600. Zimmerman M (2012) Would broadening the diagnostic criteria for bipolar disorder do more harm than good? Implications from longitudinal studies of subthreshold conditions. Journal of Clinical Psychiatry 73: 437443.

Conclusions
In the absence of clear evidence for the validity of diagnostic categories, all diagnostic systems including DSM-5 and ICD-11 will be inherently imperfect creations with compromises based on our fields ignorance, not necessarily willful thoughtlessness. Alternatively, the US National Institute of Mental Health has proposed an entirely different system of classification, the Research Domain Criteria, consisting of five behavioral dimensions (e.g. arousal/modulatory systems) for which the underlying neural circuitry has been articulated (Cuthbert and Insel, 2013). Whether this will be an improvement upon the symptom-based systems of DSM-5 or ICD-11 will be unclear for many years. Until we have firmer answers to these questions, the key in

Declaration of interest
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

References
Angst J, Gamma A, Bowden CL, et al. (2013) Evidence-based definitions of bipolar-I and bipolar-II disorders among 5,635 patients

Lessons for ICD-11 coming after DSM-5 Bernard J Carroll

Pacific Behavioral Research Foundation, Carmel, USA Corresponding author: Bernard J Carroll, Pacific Behavioral Research Foundation, 100 Del Mesa Carmel, Carmel, CA 93923, USA. Email: bcarroll40@comcast.net DOI: 10.1177/0004867413515953

ICD Insights

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM5) has arrived, and we await the International Classification of Diseases, 11th Revision (ICD-11). Without trying to be exhaustive, here are suggestions for improving matters. 1. Avoid the nominalist fallacy (I name, therefore I know). Classifications are always provisional, to be improved over time by convergent validation and new science.

2. Expand the frame of reference for convergent validation. In DSM-III through DSM-5, four key sources of information were mostly excluded. These are: course of illness, response to treatment, family history, and biomarkers (Robins and Guze, 1970). 3. Avoid the appearance of closure. Like classifications, diagnoses also are always provisional. Diagnoses are casewise probability statements, open to revision as new information arrives (Carroll, 2013). 4. Maintain a clear distinction between making a diagnosis and defining a disorder. This speaks to a fundamental category error that appeared soon after DSM-III and that still persists in the form of checklist menu diagnoses ironically mostly in research settings. DSM-5 did not fix that (Carroll, 2012a). 5. Allow for uncertainty. DSM-5 gives the impression that initial, crosssectional diagnoses are the norm. Neurologists, in contrast, do not allow the diagnosis of probable Parkinsons disease (PD) without at least 3 years of observation

(Gelb etal., 1999). In keeping with this provisional approach, the likelihood of PD is specified initially as possible, probable, or definite. During the 3 years of observation in patients with possible PD, neurologists document significant clinical events that would modify or support the possible diagnosis. A similar approach is needed for psychiatric presentations with psychosis, mood disturbance, anxiety, cognitive decline, and more. 6. Get numerate! The perversion of checklist diagnoses is fostered by the innumerate style of DSM-5, which provides no sensitivity and specificity data for definitional signs and symptoms. In making clinical diagnoses, not all signs and symptoms carry equal weight, but learners would never know that from reading the diagnostic criteria in DSM-5. Neurologists have operationalized this understanding by specifying cardinal symptoms and accessory symptoms (Gelb etal., 1999). 7. Do not allow reliability to trump validity. As DSM-III taught us, that

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