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Abstract
The recent release of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) by the
American Psychiatric Association has led to much debate. For this forum article, we asked BMC Medicine Editorial
Board members who are experts in the field of psychiatry to discuss their personal views on how the changes in
DSM-5 might affect clinical practice in their specific areas of psychiatric medicine. This article discusses the influence
the DSM-5 may have on the diagnosis and treatment of autism, trauma-related and stressor-related disorders,
obsessive-compulsive and related disorders, mood disorders (including major depression and bipolar disorders), and
schizophrenia spectrum disorders.
Keywords: DSM-5, Psychiatry, Autism, PTSD, Mood disorders, Bipolar, Obsessive-compulsive disorders, Depression,
Schizophrenia
* Correspondence: bmcmedicineeditorial@biomedcentral.com
Full list of author information is available at the end of the article
2013 Nemeroff et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
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psychological mechanisms, in contrast to trainees from a bipolar disorder, that exclusion criterion present in
more biologically oriented program, and the resulting DSM-IV has now been removed. Similarly, the reloca-
diagnoses would diverge, often dramatically. DSM-III tion of premenstrual dysphoric disorder from the Ap-
introduced explicit criteria that allowed a psychiatrist on pendix to the Mood Disorders section is based on a
the west coast of the USA to have a much higher likeli- decade of research validating this diagnosis.
hood of reaching a similar diagnosis to a colleague on So why all the controversy? Do the American
the east coast. Although the approach was never meant Neurological Association or the American Cancer
to establish disease validity, it rescued the field from de- Society meetings have demonstrators outside their na-
cades of diagnostic unreliability. It is therefore poten- tional meetings protesting their disease classifications?
tially worrisome that classification using biological Do they have those in their ranks refusing to use
phenomena, such as working memory or amygdala their new ICD-10 disease classification? Clearly not.
responsivity, both of which are highly dependent on Was DSM-5 handed down to our field on tablets from
context and research protocols, may reintroduce some Mount Sinai? Of course not. Were the designers of
of this earlier vagueness, subjectivity, and imprecision. DSM-5 intentionally anti-scientific? Of course not.
Much has been made of the apparent overlap of Will DSM-5 further the field by clarifying categorical
some genes found to be associated with multiple disease classification? Yes.
psychiatric disorders, but the implications of these Overall, is it an improvement over DSM-IV? Yes,
findings for a new diagnostic approach is unclear. but perhaps not what we all wished for at this stage
Although the genetics of psychiatric diagnoses may in our field.
show some overlap, so do the genetics of multiple Will DSM-6 include sensitive and specific diagnostic
sclerosis and Crohns disease, which are distinct clinical tests that are biologically based for schizophrenia, bipo-
conditions requiring different clinical interventions. lar disorder, and PTSD, to name a few? We all certainly
The fact that there may be shared genetic and envi- hope so.
ronmental contributors to both major depression and
PTSD, such as early life trauma and FKBP5 polymor-
phisms, should not be surprising, and does not in any Competing interests
way detract from the utility of these categorical diag- CBN has received grants or research support from the
noses for the practicing physician. Ultimately, a National Institutes of Health (NIH) and Agency for
principle reason for clinical diagnosis is to predict the Healthcare Research and Quality (AHRQ); has provided
course of illness and to prescribe treatment. Current consultation for Xhale, Takeda, SK Pharma, Shire,
psychiatric medications are symptomatic treatments Roche, Lilly, Allergan, and Mitsubishi Tanabe Pharma
and although many are helpful beyond a single diag- Development America; is a stockholder of CeNeRx
nosis, there are some dissociations of efficacy that BioPharma, PharmaNeuroBoost, Revaax Pharma, and
conform to the existing diagnostic boundaries and ex- Xhale; and has received income or equity from
emplify their continuing utility. For example, lithium AstraZeneca Pharmaceuticals, PharmaNeuroBoost,
is not an effective antipsychotic, but it is nearly cura- CeNeRx BioPharma, NovaDel Pharma, Reevax Pharma,
tive for many patients who fulfill the diagnostic cri- American Psychiatric Publishing, and Xhale. Other
teria for bipolar disorder. Likewise, stimulants tend to financial interests include CeNeRx BioPharma and
make patients with psychosis worse, but they help PharmaNeuroBoost. CBN also holds patents for
most patients with an ADHD diagnosis. Clozapine, an methods and devices for transdermal delivery of lithium
especially effective treatment for schizophrenia, is not (US 6,375,990B1) and methods of assessing anti-
effective in autism, intellectual disability, ADHD, or depressant drug therapy via transport inhibition of
PTSD. monoamine neurotransmitters by ex vivo assay (US
Although imperfect, and we could be critical of one or 7,148,027B2). He is also on the scientific advisory
another of the individual changes in DSM-5, it is the boards of American Foundation for Suicide Prevention
natural and appropriate evolution of the DSM based (AFSP), CeNeRx BioPharma (2012), National Alliance
on current evidence, from the original classification for Research on Schizophrenia and Depression
system that started with DSM-I in 1952. One (NARSAD), Xhale, PharmaNeuroBoost (2012), Anxiety
example of a solid improvement is the removal of the Disorders Association of America (ADAA), Skyland
exclusion criterion for bipolar disorder if a patient Trail, and AstraZeneca Pharmaceuticals (2009); and is
switched into a manic episode after treatment with on the board of directors of AFSP, Mt. Cook Pharma
an antidepressant. Because there is now overwhelming (2010), NovaDel (2011), Skyland Trail, Gratitude
evidence that such switches occur uniquely in pa- America, and ADAA.
tients with bipolar disorder and not in those without DW has no competing interests to declare.
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Competing interests
From the 1960s up to early 2013 and mid-2011 respectively,
MR has served on various committees concerned with ICD
or DSM or the harmonization of the two. This paper,
however, presents a personal view and should not be
interpreted as reflecting the views of either the WHO or
the APA. MR has no financial competing interests.
Competing interests
RB has served on the DSM-5 PTSD/Trauma/Dissociative
Work Group and the ICD-11 Working Party on Stress
related Disorders. SW has served on the ICD-11 Working
Party on Stress related Disorders. These comments reflect
the opinions of the authors, and are not necessarily those
of the APA, the DSM-5 Work Group, or the ICD 11
Working Party. Neither author has any other competing
interests to declare. Dan J. Stein is Professor and Chair of the Dept of Psychiatry
and Mental Health at the University of Cape Town, and
Obsessive-compulsive and Related Disorders Director of the MRC Unit on Anxiety and Stress Disorders. His
research interests include the psychobiology and management of
DSM-5 and obsessive-compulsive and related disorders
the anxiety, obsessive-compulsive and related disorders, and
Dan J. Stein traumatic and stress disorders. He also served as Chair of the DSM-5
DSM-5 includes a number of changes with respect to Sub-work Group on Obsessive-Compulsive Spectrum Disorders.
obsessive-compulsive disorder and related conditions
(OCRDs) [1]. First, the chapter on OCRDs is an entirely
new one, and includes obsessive-compulsive disorder cases by a clinical and public health committee, and
(OCD), body dysmorphic disorder (BDD), and trichotillo- by the DSM-5 taskforce. This piece briefly reviews the
mania (hair-pulling disorder). Second, the chapter includes implications for clinical practice.
several new conditions, including hoarding disorder and ex- The new chapter on OCRDs reflects growing data that
coriation (skin-picking) disorder. Third, some of the disor- OCD differs from the anxiety disorders on a number of
ders, such as trichotillomania (hair-pulling disorder), have diagnostic validators, and that there are important phe-
new names. Fourth, there are a number of new approaches nomenological and psychobiological overlaps between
to the sub-typing of OCRDs. Fifth, there are a number OCD and a number of related conditions [19]. At the
of changes to the diagnostic criteria of conditions now same time, it is important to emphasize that there are
classified as OCRDs. Finally, the text relating to OCRDs both strong overlaps between OCD and the anxiety disor-
has been revised. ders, and important differences between the OCRDs. The
These changes were based on a range of scientific data close relationship between OCD and the anxiety disorders
including those published in the form of a research confer- is reflected in the order of the chapters in DSM-5, and the
ence [17], systematic reviews [18-25], secondary analyses of differences between the OCRDs are emphasized in the
existing datasets [26], and DSM-5 field surveys [27-29]. DSM-5 text [31].
Input was also obtained from members of the OCRD The potential advantage for clinical practice of a new
clinician and research community, consumer advocates, chapter is that clinicians and the public will be made
and the professional and lay public at large [30]. more aware of these underdiagnosed and undertreated
Recommendations made by the DSM Sub-work conditions. The hope is that clinicians will screen more
Group on Obsessive-Compulsive Spectrum Disorders rigorously for these conditions, and that researchers will
were reviewed by a scientific review committee, in some use structured diagnostic interviews and standardized
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symptom measures to investigate and evaluate the full specified with excessive acquisition, again reflecting the
range of these often-neglected conditions in a systematic data that such specifiers have clinical implications
way. A potential disadvantage of having a single chapter [18,21,22].
is that some clinicians will fail to appreciate the import- Several changes to the diagnostic criteria for
ant differences that exist between these conditions. OCRDs have been made. It is notable that some of
The DSM-5 chapter on OCRDs includes several these changes help to emphasize the overlapping fea-
new diagnoses, namely hoarding disorder, excoriation tures of conditions in the OCRD chapter. Thus, BDD
(skin-picking) disorder, substance/medication-induced includes a new diagnostic criterion, which emphasizes
OCRD, OCRD due to another medical disorder, and that individuals respond to their appearance preoccu-
other specified OCRD. The inclusion of hoarding dis- pations with repetitive behaviors or mental state or
order and excoriation disorder reflects a growing acts. Similarly, the criteria for trichotillomania (hair-
database on the diagnostic validity of these condi- pulling disorder) no longer include diagnostic criteria
tions, and the clinical utility of recognizing them in that conform to the pattern of impulse control disor-
the nosology [23,32]. The inclusion of substance/ ders, but include an extra criterion, which emphasizes
medication-induced OCRD, OCRD due to another that individuals have attempted to decrease or stop
medical disorder, and other specified OCRDs is a lo- the hair-pulling. The validity of such changes have
gical consequence of having a separate chapter on been confirmed by secondary analyses and field sur-
OCRD. veys [23,28].
Definitions of psychiatric disorder continue to be The updated DSM-5 text on OCRDs includes new
debated, and it is surely important not to medicalize prob- information that has emerged since the publication of
lems of daily living [33]. However, those who meet diag- DSM-IV, and provides details on key clinical issues
nostic criteria for these conditions experience distress or such as prevalence, development, and course, risk and
impairment, and deserve appropriate intervention. The cat- prognostic factors, culture-related and gender-related
egory of other specified OCRD brings attention to those in- diagnostic issues, suicide risk, and functional conse-
dividuals, who do not meet the diagnostic criteria for a quences. For example, the section on OCD describes
DSM-5 mental disorder, but who nevertheless experience the main obsessive-compulsive symptom dimensions
clinical distress or impairment; this category includes that have emerged from studies around the world
individuals with olfactory reference syndrome, obsessional over the past two decades [36]. Differential diagnosis
jealousy, and body-focused repetitive behavioral disorders of OCRDs is not always straightforward, and the text
other than trichotillomania (hair-pulling disorder) and may usefully guide clinicians towards a correct
excoriation (skin-picking) disorder. diagnosis.
The name trichotillomania has been felt by some con- This brief piece does not allow a comprehensive
sumer advocates to be inappropriate and confusing, as discussion of all of the changes made in the DSM-5
mania is not a defining symptom of this condition. While chapter on OCRDs. Although any particular change
some consumer advocates have expressed preference for a to the nosology has both pros and cons [37,38], the
plain language term such as hair-pulling disorder, others rationale for many of the changes is provided in sys-
have felt that such a term would not have sufficient med- tematic reviews and proposals published by the
ical gravitas. Furthermore, there would not be continuity DSM-5 Sub-work Group, which has attempted to
with the previous literature. Thus, the name trichotillo- take an evidence-based approach, making changes
mania (hair-pulling disorder) was proposed, allowing that are based on accumulating data on diagnostic
individuals the choice of which name to use. A simi- validity and clinical utility. The hope is that such
lar set of considerations led to a proposal for the name changes will help clinicians to recognize individuals
excoriation (skin-picking) disorder. with OCRDs, and to diagnose them appropriately.
In DSM-5, OCD, BDD, and hoarding disorder have an Such recognition and diagnosis may in turn lead to
insight specifier that ranges from good insight through better treatments and improved outcomes.
fair insight and on to no insight/delusional [34,35]. This
sub-typing reflects the dimensional nature of insight in Competing interests
OCRDs, the existence of data indicating that different DJS served as Chair of the DSM-5 Sub-work Group
levels of insight require different treatment approaches, on obsessive-compulsive spectrum disorders. He has
and a scientific consensus that patients with an OCRD received research grants and/or consultancy honor-
that reaches delusional levels should be diagnosed with aria from Abbott, AstraZeneca, Biocodex, Eli Lilly,
an OCRD rather than delusional disorder. In DSM-5, GlaxoSmithKline, Jazz Pharmaceuticals, Johnson &
OCD can be specified as tic-related, BDD can be specified Johnson, Lundbeck, Orion, Pfizer, Pharmacia, Roche,
with muscle dysmorphia, and hoarding disorder can be Servier, Solvay, Sumitomo, Takeda, Tikvah, and Wyeth.
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Mood Disorders such as in their social or professional life; and second and
DSM-5 and depressive disorders: yet more ado about crucially because no clinically competent doctor would
nothing? do so. Two scenarios clarify this.
Carmine M. Pariante Scenario 1. A young woman loses her husband in a car
Critics have accused the new DSM-5 [1] of multiplying crash. She has no history of psychiatric disorders. She is
the number of psychiatric diagnoses and of medicalizing grief-stricken and has to take time off work. Because of
normal human experience. Two changes in the clinical the removal of the bereavement exclusion, after 2 weeks,
area of Depressive Disorders have been used as examples to she clinically fulfills the new criteria for major depression, .
support this accusation: the removal of the bereavement She consults her primary care doctor, who reassures her
exclusion, and the introduction of the new Disruptive that she is going through a very difficult process but that
Mood Dysregulation disorder (DMDD) for use in children. this is normal, and advises her to mobilize the support of
In both cases, the accusation is wrong. her friends and family and that she will feel better in time.
The removal of bereavement exclusion will allow indi- Scenario 2. A young woman loses her husband in a car
viduals who have been clinically depressed for less than crash. She has had several previous episodes of severe
2 months after the loss of a loved one to be diagnosed depression, which have lasted for 1 year or more. During
with Major Depression. In the previous (fourth) edition these previous periods of depression, she has not been
of the DSM, the diagnosis of major depression could be able to hold on to a job, and has tried to commit suicide.
made only if the depression had persisted for at least 2 Like the woman in Scenario 1, this woman is grief-stricken,
months after the bereavement. has to take time off work, and after 2 weeks, clinically
Does this mean that hordes of individuals who have fulfills the new criteria for major depression. She sees
just lost their partner or their parent will be started on her primary care doctor, who is aware of the research
antidepressants? Obviously not: first, because individuals evidence showing the similarities between bereavement-
will still need to fulfill the diagnostic criteria for depression, related depression and other forms of depression [39],
including the impairment in important areas of functioning and is therefore rightly concerned that this stressful
event will precipitate yet another severe episode in this
predisposed woman. Until recently, the clinical manage-
ment of such patients within the American health system
would have been influenced by the bereavement exclu-
sion, which would have complicated the reimbursement
from the medical insurances companies. However, no
longer impinged by this exclusion, the doctor immediately
starts the patient on treatment with an antidepressant that
has proven effective for the patient in the past, and this
prevents the repetition of a downward spiral.
Hence, clinical competency and personalized decisions
are, as always, key to clinical management, and diagnostic
textbooks will not make good doctors take bad decisions.
What about the disruptive mood dysregulation disorder?
Accused of being a diagnosis for grumpy children, this
disorder requires persistent irritability and frequent
episodes of behavior outbursts, three or more times a
week, for more than a year to be present in order to
make the diagnosis. Is this a situation that any sensible
parents (let alone doctors) would call a grumpy child?
I am sure that many parents would ask for help if they
had a child with such difficulties.
Moreover, the criticism is particularly misplaced
(and ironic) because DSM-5 has introduced this new
disorder to prevent the (ab)use of the diagnosis of bipolar
Carmine M. Pariante is Professor of Biological Psychiatry at disorder in children. The rates of bipolar disorder in
Institute of Psychiatry, Kings College London. children have grown almost six-fold between 1996 and
His research focuses on the biological effects of stress, the 2004 [40], and this diagnosis is accompanied by the pre-
pathogenesis of depression, and the molecular mechanisms of
mature use of antipsychotics and mood stabilizers in very
antidepressant drugs.
young individuals, and by a much more stigmatizing
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label, especially in a child. Perhaps sometimes a new schizoaffective disorder ( = 0.50), mild neurocognitive
disorder is a good thing? disorder ( = 0.48), alcohol use disorder ( = 0.40) and
binge eating disorder ( = 0.56) still showed good reliabil-
Competing interests ity, the test-retest reliability was questionable for condi-
CP receives research funding from the Medical Research tions such as generalized anxiety disorder ( = 0.20),
Council and other governmental agencies, the National mixed anxiety-depressive disorder ( = 0.004)
Institute of Health Research and other NHS-related obsessive-compulsive personality disorder = 0.31)
funding, the Wellcome Trust and other charities, and antisocial personality disorder ( = 0.21) and major
pharmaceutical companies. depression ( = 0.28) [41].
Therefore, in order to improve the test-retest reli-
Elimination of the major depression bereavement ability and to reduce the number of false positives,
exclusion in DSM-5 tightening of the diagnostic criteria for such problem
Florian Seemller diagnoses would have been desirable; however, with
Major depression is the worldwide leading cause of the elimination of the major depression bereavement
disability in terms of total years lost due to the dis- exclusion in the DSM-5 [1], the diagnostic boundaries
ability. Correct diagnosis is a prerequisite for the early have again been widened. Thus, a major depressive
and correct treatment of this disorder. The DSM-5 episode can be diagnosed if a person grieves for a
field trials have shown that the DSM-IV diagnostic loved one for more than 2 weeks. This challenges the
criteria for major depression have a very disappoint- view that grief after the loss of a loved one, which
ing test-retest reliability. Although some diagnoses, frequently comprises depressive symptoms, belongs to
such as PTSD and major neurocognitive disorder had the category of healthy psychic reactions and coping
a very good test-retest reliability ( values of 0.67 and strategies. This has been the reason why bereavement
0.78), and others such as bipolar I disorder ( = 0.56), has been an exclusion criterion (Criterion E) for the
diagnosis of major depression since DSM-III. The be-
reavement exclusion criterion further specified that a
bereavement-related depressive episode will not be ex-
cluded as major depression and should be diagnosed as
such if it lasts longer than 2 months, or if the patient dis-
plays any one of the several symptoms suggestive of severe
depression, including suicidal ideation and psychomotor re-
tardation. Grief usually resolves in about 80% of all cases
after a couple of weeks or months.
Clinical research further suggests that the risk for recur-
rent depression in people experiencing severe grief is not
different from that of healthy controls [42]. Although some
individuals, especially elderly people with complicated grief,
may benefit from this change, possibly by earlier receipt of
intensive treatment after having lost a loved one, millions
of other people might be unnecessarily labeled as having an
illness, and consequently receive treatment that they do not
need. Because both human and financial resources in men-
tal health care are restricted, such broadening of diagnostic
boundaries always poses the risk that patients with more
severe mental illness who are in need of more and expen-
sive treatments do not receive adequate care. In addition,
this removal of the bereavement exclusion means that
clinicians are not required to distinguish between nor-
mal grief and major depression any longer, and thus it
Florian Seemller is consultant for psychiatry at the may mean that this skill will soon disappear from the
Department of Psychiatry at the Ludwig-Maximilians-University clinical training of psychiatry.
Munich. His research interests focuses on suicide research, bipolar
disorder, and the systematic, course-related, and clinically oriented Competing interests
evaluation of longitudinal data from patients with depressive
FS has received grants and research support from Lilly,
disorders and disorders among patients with schizophrenia.
Astra Zeneca, and Glaxo-Smith Kline. He has been on
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respect to clinical, treatment response, and prognostic Myers Squibb, Eli Lilly, Glaxo SmithKline, Meat and
factors, and the growing risk of overdiagnosis of bipolar Livestock Board, Organon, Novartis, Mayne Pharma,
disorder in childhood. However, longitudinal studies Servier and Woolworths; has been a speaker for Astra
suggest that DMDD has poor diagnostic reliability, and Zeneca, Bristol Myers Squibb, Eli Lilly, Glaxo SmithKline,
cannot be differentiated adequately from oppositional Janssen Cilag, Lundbeck, Merck, Pfizer, Sanofi Synthelabo,
defiant disorder and conduct disorder. Furthermore, it Servier, Solvay and Wyeth; and has served as a consultant
is not associated with current, future-onset, or parental to Astra Zeneca, Bristol Myers Squibb, Eli Lilly, Glaxo
history of mood or anxiety disorders, confirming the SmithKline, Janssen Cilag, Lundbeck Merck, and Servier.
utility of the revision [49]. GSM has received grant or research support from the
Removal of the bereavement exclusion for a depressive National Health and Medical Research Council, NSW
diagnosis is arguably the most contentious loss to the Health, AstraZeneca, Eli Lilly & Co, Organon, Pfizer,
field of mood disorders. Early studies suggested that Servier, and Wyeth; has been a speaker for AstraZeneca, Eli
after bereavement, depressive syndromes are common Lilly & Co, Janssen Cilag, Lundbeck, Pfizer, Ranbaxy, Servier,
but transient, and do not require treatment. Based on and Wyeth; and has been a consultant for AstraZeneca, Eli
research studies published since 2006, Zisook and col- Lilly & Co, Janssen Cilag, Lundbeck, and Servier.
leagues [50] argued persuasively that depression related
to bereavement that occurs in the context of bereavement Impact of the DSM-5 on the diagnosis of bipolar and
is no different phenomenologically from depression in related disorders
other contexts, and has similar genetic and familial Martin Preisig
patterns, comorbidities, course, outcome, and treatment The DSM-5 [1] includes the following changes to the
response. Hence, the bereavement exclusion was itself diagnoses of bipolar and related disorders.
excluded from DSM-5. This has been critiqued [51], and a First, Criterion A for manic and hypomanic episodes
number of potential advantages and disadvantages that are now requires not only elated, expansive, or irritable mood,
likely to ensue have been identified. The key argument is but also abnormally and persistently increased goal-directed
that DSM does not meaningfully distinguish between a nor- activity or energy. Although activity and energy are highly
mal reaction to loss and the threshold for a disorder, and relevant features of mania or hypomania, the inclusion of an
that abandoning the bereavement exclusion risks overdiag- additional criterion for mania and hypomania raises
nosis of depression and consequent overtreatment, and in the diagnostic threshold for the diagnoses of bipolar-I
this regard, the criteria for major depression are arguably and bipolar-II disorder, and accordingly, it will reduce the
already broad and non-specific. Alternatively, some have number of patients qualifying for these bipolar diagnoses.
argued for a narrowing of the construct and a return to
the concepts of endogenous and melancholic depression,
suggesting, for example, that greater severity predicts
higher treatment response [52,53].
The changes to the mood disorders taxonomy in
DSM-5 are important because of the widespread in-
fluence of this classification system. As in many other
sections of DSM-5, the underpinning of diagnoses by
neurobiology remains to be achieved, and thus the
diagnoses are largely descriptive and limited by their
dependence on phenomenology and grouping of
symptoms and signs according to clinically defined
cut-offs and associations. Despite these limitations,
the revisions meaningfully incorporate recent advances,
the system has widespread applicability, and alternate
conceptual frameworks such as RDoC do not yet have
overt clinical applicability [54].
Martin Preisig is Professor at the Department of Psychiatry of
Competing interests the University Hospital of Lausanne, Switzerland, and head
MB has received grant or research support from the of the Psychiatric Epidemiology and Psychopathology
NIH, Cooperative Research Centre, Simons Autism Research Unit. His main scientific interests include the familial
Foundation, Cancer Council of Victoria, Stanley Medical aggregation and genetic determinants of psychiatric disorders,
and the association between psychiatric disorders and
Research Foundation, MBF, NHMRC, Beyond Blue, Rotary
cardiovascular risk factors.
Health, Geelong Medical Research Foundation, Bristol
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Second, antidepressant medication is no longer an and depressive features that are likely to occur with the
absolute exclusion criterion for diagnoses of manic or DSM-5 changes should also lead to increased interest in
hypomanic episodes. Indeed, these episodes can now bipolar disorders with such episodes, which are in general
also be diagnosed when they emerge under antidepres- particularly difficult to treat.
sant treatment, and when they persist after cessation of
this medication. This change is very welcome, as it Competing interests
allows clinicians to also assign the diagnoses of bipolar MP has no competing interests to declare.
disorders to the group of patients who develop manic
or hypomanic episodes under antidepressant treatment Schizophrenia Spectrum Disorders
and who otherwise hardly differ from other patients Does DSM-5 facilitate diagnosis of schizophrenia?
with bipolar disorder. Martin Brne
Third, the diagnosis of bipolar-I disorder, mixed episode, In May 2013, the APA released the DSM-5 [1], and even
has been removed. Instead, a new specifier, with mixed in its nascent state, it has already incited controversy
features, has been added. This specifier applies not only to about its usefulness and appropriateness. In this essay, I
manic but also to hypomanic episodes when at least three focus on the clinical issues relating to psychotic disorders,
depressive symptoms are present, and to major depressive although there are of course other changes made to DSM
episodes when at least three manic/hypomanic symptoms that are equally debatable. There is also a need for a more
are present but the criteria for mania are not met. This is general discussion about the usefulness of a categorical
also a very necessary change as it considerably lowers the classification versus dimensional approaches respecting
previous too-high threshold for mixed episodes. However, the applicability of DSM-5 for scientific purposes [55].
disorders involving only major depressive episodes will be With regard to psychosis, the question as to whether
classified within the category of major depressive disorders, or not high-risk states should be included in the manual
regardless of the presence of mixed episodes, according to has been a focus of intense discussion about the pros and
this specifier. cons of doing so. On the one hand, concern has arisen as
Fourth, DSM-5 introduces a new category of other to whether the inclusion of high-risk states may promote
specified bipolar and related disorders. The diagnostic stigmatization of individuals who meet the diagnostic cri-
definitions of this category apply to bipolar conditions that teria for a high-risk condition, especially in light of findings
do not meet the requirements for bipolar-I or bipolar-II suggesting that a transition to psychosis occurs in only
disorders. These conditions include 1) hypomanic episodes about 20% of cases within the first 6 months, although this
of short duration (2 to 3 days) with a history of a major does rise closer to 40% at 3-year follow-up [56]. On the
depressive episode, 2) hypomanic episodes with insufficient other hand, it has been argued that such an approach could
symptoms and a major depressive episode, 3) hypomanic actually improve mental health care by encouraging earlier
episodes without prior major depressive episodes, and 4) provision of indicated prevention based on clinical staging,
short-duration (less than 24 months) cyclothymia. This is a
big step forward with respect to DSM-IV, which did not
include an accurately defined specification of syndromes
below the diagnostic level of bipolar-II, although such syn-
dromes have been shown to occur frequently, and should
be separated from major depressive disorder.
Finally, for both manic/hypomanic and depressive
episodes, a specifier for anxious distress is delineated if
at least two anxiety symptoms are present. This new
specifier adds another feature to characterize mood ep-
isodes more accurately.
In conclusion, the changes to DSM-5 improve the diag-
nostic classification of bipolar disorders. The introduction
of accurate definitions for bipolar conditions below the level
of bipolar-II enlarges the array of accurately defined bipolar
diagnoses, and should increase clinician awareness of these
conditions. Given the currently limited evidence regarding Martin Brne is Professor of Cognitive Neuropsychiatry and
treatment of these conditions, these more accurate defini- Psychiatric Preventive Medicine at the LWL University Hospital
tions will hopefully lead to increased scientific efforts to of Psychiatry, Ruhr-University Bochum, Germany. His main
research interest is social cognition in patients with schizophrenia,
establish the efficiency of such treatments. Similarly, the
and the study of psychopathology from an evolutionary perspective.
more frequent diagnosis of episodes with mixed manic
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compared with the current clinical reality for most patients ego-boundaries (in Anglo-American conceptualizations of
with first episodes of psychosis [57]. The inclusion of high- psychosis commonly subsumed under the symptomatic
risk states for psychosis in DSM-5 was eventually dropped, spectrum of delusional beliefs) have core diagnostic validity.
possibly owing to recent reports suggesting that early inter- This need not be a bad thing, and it would not be justifiable
vention such as cognitive therapy does not reduce the tran- to keep Schneiders first-rank symptoms simply based
sition rate to psychosis [58], and may at best lead to a delay on historical grounds. However, this paradigmatic shift
of psychosis onset [59]. reflects inconsistency of the diagnostic validity of schizo-
With regard to the diagnostic criteria for schizophrenia, phrenia symptoms occurring with high-risk symptoms. In
changes include the elimination of the special attribution of fact, auditory hallucinations in the form of commenting
bizarre delusions and first-rank auditory hallucinations voices and other first-rank symptoms are core to all early
according to Schneider's criteria. Because Schneider's recognition manuals, including the most widely used
first-rank symptoms were considered non-specific by Structured Interview for Psychotic Symptoms (SIPS) [62]
the DSM-5 Task Force, and the distinction between or the Comprehensive Assessment of At-Risk Mental States
bizarre and non-bizarre delusions vague, two Criterion (CAARMS) [63]. Put another way, how can a clinician
A symptoms are now required in DSM-5 for a diagnosis diagnose an at-risk state based on symptoms that are
of schizophrenia. In addition, Criterion A now requires discarded for the full-blown syndrome?
that a patient must meet at least one of three symptoms In a similar vein, dropping the traditional sub-types
comprising the presence of delusions, hallucinations, and of schizophrenia in DSM-5 based on alleged diagnostic
disorganized speech, which are now regarded as core posi- instability over time can be criticized based on evi-
tive symptoms. The traditional sub-typing of schizophrenia dence from older work suggesting the opposite, espe-
into paranoid, disorganized (hebephrenic), catatonic, cially when rigorous diagnostic criteria apply [64]. The
undifferentiated, and residual forms is also now being lack of evidence with regard to differences between the
discarded altogether, based on the view that sub-types sub-types in response to treatment or longitudinal
are diagnostically unstable, unreliable, and invalid. In- course is probably based more on a lack of research,
stead, a severity rating of the core symptoms has been rather than on a genuine lack of differences in these
introduced in recognition of the heterogeneity of the respects. In fact, it was the explicit goal of the early
symptomatology. protagonists in psychiatry such as Kahlbaum and
From a clinician's perspective, it is probably a wise deci- Kraepelin to describe clinical entities based on symp-
sion not to assign a diagnostic category to high-risk states tomatology (which at the time included not just the sub-
for psychosis. Although improvement of early detection of jective aspect of symptomatology, but also non-verbal and
early stages of psychosis is still an important mental health paraverbal abnormalities in expression), course and out-
issue, there is little evidence to suggest that the inclusion come. This approach has certainly failed, at least to some
of high-risk states in diagnostic systems can contribute to degree, yet many clinicians probably share the view that an
resolving this clinical imperative. Using a comparison of insidious early onset of schizophrenia, rapid development
psychiatry with other medical domains, this would mean of negative symptoms, poor insight, and behavioral
that a clinician should include sub-threshold raised blood abnormalities (that is, hebephrenia) is generally associated
pressure as a risk factor for hypertension, whereas what with a poorer prognosis respecting recovery, social
actually helps to detect increased risk for hypertension is functioning, and quality of life, compared with patients
the regular checking of resting state blood pressure [60]. with acute paranoid schizophrenia.
By analogy, regular mental health checks on a much larger DSM-5 has been designed to assist clinicians in arriving
scale than is current in clinical practice may help to dis- at reliable diagnoses of psychiatric conditions. Despite the
cover not only high-risk states of psychosis [61], but also often heated debate about more or less important detail
early stages of much more common psychiatric conditions questions, it can be conceded that most changes are
such as depression, anxiety disorder, substance abuse, or minor, with others perhaps being of greater significance.
dementia. Classification systems can do little about these Some diagnoses have been rearranged and reshuffled into
issues, because they are designed, in the first place, for cli- new categories, such as OCD, for which, interestingly, a
nicians to reliably diagnose existing, rather than incipient, specifier for poor insight reflects a dimensional overlap
conditions of medical (including psychiatric) interest. with delusional disorder. Whether or not DSM-5 will
With regard to the changes made in DSM-5 respecting change clinical practice very much is a matter for critical
the diagnostic criteria for schizophrenia, these seem, at evaluation of future prescription practices for both medica-
first sight, subtle, but may have more profound effects on tion and psychotherapy. Personally, I doubt it will.
how clinicians diagnose and treat patients with schizophre- Akin to naturally evolving bodies, DSM-5 is a design
nia. Discarding Schneiders first-rank symptoms as non- compromise between clinical and scientific necessities.
specific breaks with the traditional view that disturbances of It needs to be acknowledged and appreciated that a great
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deal of scholarly expertise has been spent to further were on their own sufficient for a diagnosis, but now must
improve diagnostic accuracy for psychiatric conditions. be accompanied by at least one other core symptom.
However, what the final product of all these endeavors Schizoaffective disorder is now presented as a disorder
reflects is that psychiatry has still a long way to go until a defined more longitudinally, and in section 3, which offers
reconciliation of divergent perspectives and attitudes about emerging models and measures, a five-point from 0 to 4
human nature and well-being can be accomplished. In scale is presented for clinicians to separately rate the core
my view, this requires a conceptual integration of the disturbances of thought, affect, and behavior. Beyond
psychological and behavioral adaptations with which these changes, the supporting text on associated features
Homo sapiens is endowed. Such integral perspectives also has been updated to reflect contemporary findings that
include the necessity of reconsidering the utility of standard have overturned long-standing prejudices. Research is
biomedical concepts, such as diathesis-stress models for noted suggesting the incidence of the disorder men and
psychiatric conditions; that is, the evolved biopsychosocial women is not equivalent as was once widely touted, that
peculiarities that distinguish psychiatric conditions from random aggressiveness is uncommon, and that prevalence
other medical illnesses [65,66]. rates do vary across cultures and socioeconomic groups.
Although as a whole, the updates appear to match broad
Competing interests surveys of the literature, the new text is not without some
MB has no competing interests to declare. puzzling areas in which opinions are presented as fact.
We are told that unawareness of illness is equivalent to
Schizophrenia spectrum disorders in DSM-5: In what anosognosia in neurological disorders and that individuals
directions are the most recent changes taking us? with schizophrenia most often require lifelong living
Paul Lysaker support (p. 102) [1]. Arguments exist for both positions,
The DSM-5 [1], as noted in its own appendix, has but each is clearly an area of active debate [67-71], and it
made several amendments in its section on Schizophrenia seems important that these conversations should not be
Spectrum and Other Psychotic Disorders. These amend- limited with premature claims of consensus.
ments include the elimination of the older Kraepelinean Of interest in this essay are several questions. Will these
sub-types such as paranoid or disorganized, and the de- changes significantly affect practice? In what direction are
emphasis of bizarre positive symptoms, which previously these changes taking us? What might be the practical con-
sequences of movement in that direction? The response
to the first question seems simple. It appears unlikely the
DSM-5 will have any major effect on practice for patients
with psychosis. The sub-types and importance of symptoms
with bizarre content have not driven current treatment,
and their presence previously was possibly a distrac-
tion that most clinicians probably ignored. The rating
scale presented in section 3 may be useful, just as are
any number of existent scales for assessing the psy-
chopathology of individuals with this condition.
Perhaps a more interesting concern, however, relates
to the direction in which these changes point. Given
what we find now in DSM-5, where are we headed in
the next manual and the one after that? Here it strikes
me that there is movement in DSM-5 towards more
concerted attempts to clearly define the individual com-
ponents of the disorder but not necessarily to discern
how those components are related. It seems possible
that the DSM-5 is pointing to future manuals in which
there will be increasing efforts to make the pieces of
Paul Lysaker is Professor of Clinical Psychology in Clinical
this disorder easier to recognize, but with less concern
Psychiatry at Indiana University School of Medicine, and Clinical
Psychologist and Clinical Supervisor at the Psychiatric for core psychopathological processes such as those
Rehabilitation and Recovery Center at the Roudebush VA Medical proposed by Bleuler [72], which allow us to make sense
Center. His research interests include understanding the roots of of how schizophrenia spectrum disorders represent a
psychosocial dysfunction in individuals with schizophrenia, and the unique set of disorders.
development of new rehabilitative and psychotherapeutically
Although the new DSM seems unlikely to change
based interventions.
practice, further movement towards a more precise
Nemeroff et al. BMC Medicine 2013, 11:202 Page 17 of 19
http://www.biomedcentral.com/1741-7015/11/202
picture of separate components may deeply affect re- Parkville, VIC 3052, Australia. 12Discipline of Psychiatry, Sydney Medical
search and treatment efforts. If these more precisely de- School, University of Sydney, Sydney, Australia. 13CADE Clinic, Department of
Psychiatry, Royal North Shore Hospital, Sydney, Australia. 14Department of
fined elements of the disorder can become targets of Psychiatry, University Hospital of Lausanne, Site de Cery, Prilly 1008,
very specific treatments, or linked with very specific dis- Switzerland. 15Division of Cognitive Neuropsychiatry and Psychiatric
turbances in cortical function, then this fragmentation is Preventive Medicine, LWL University Hospital, Ruhr-University Bochum,
Alexandrinenstrae 1, Bochum D-44791, Germany. 16Richard L Roudebush VA
a cause for optimism. However, given my own reading of Medical Center, IndianapolisIN, USA. 17Department of Psychiatry, Indiana
emerging research into the complex biological, psycho- University School of Medicine, Indianapolis, IN, USA.
logical, social, and political factors that interact in
Received: 26 July 2013 Accepted: 16 August 2013
schizophrenia and interrupt the lives of human beings Published: 12 September 2013
[73], I hold out little hope for the development of a sil-
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doi:10.1186/1741-7015-11-202
Cite this article as: Nemeroff et al.: DSM-5: a collection of psychiatrist
views on the changes, controversies, and future directions. BMC
Medicine 2013 11:202.