This article narrates a consensus history of the proposal to include diagnostic criteria for a psychosis risk syndrome in the DSM-5, in part, to document what happened, but also to potentially help ...focus future efforts at clinically useful early detection. The purpose of diagnosing a risk state would be to slow and ideally prevent the development of the full disorder. Concerns about diagnosing a psychosis risk state included a high false positive rate, potentially harmful use of anti-psychotic medication with people who would not transition to psychosis, and stigmatization. Others argued that educating professionals about what 'risk' entails could reduce inappropriate treatments. During the revision, the proposal shifted from diagnosing risk to emphasizing current clinical need associated with attenuated psychotic symptoms. Within the community of researchers who studied psychosis risk, people disagreed about whether risk and/or attenuated symptoms should be an official DSM-5 diagnosis. Once it became clear that the DSM-5 field trials did not include enough cases to establish the reliability of the proposed criteria, everyone agreed that the criteria should be put in a section on conditions for further study rather the main section of the DSM-5. We close with recommendations about some practical benchmarks that should be met for including criteria for early detection in the classification system.
According to the DSM-5 Task Force, improving clinical utility is among the top priorities for the DSM revision. Psychiatric classifications are used to help clinicians: (1) communicate; (2) select ...effective interventions; (3) predict course, prognosis, and future management needs; and (4) differentiate disorder from non-disorder for the purpose of determining who might benefit from treatment. Any change in the DSM that improves clinicians' ability to achieve any of these goals can be said to improve its clinical utility. The types of potential changes to the DSM that might serve each of these goals are reviewed (e.g., the addition of specifiers to facilitate the communication of clinically salient features of disorders). The paper emphasizes the importance of user acceptability when making proposals to improve clinical utility. If proposed changes make the DSM too complicated for clinicians to use, then the purported benefits will be moot. Changes are also more likely to be accepted if they address flaws in the DSM that clinicians themselves consider to be problematic. In order to be generalizable across DSM users, assessments of clinical utility require a large and diverse sample drawn from a wide variety of settings, professional backgrounds, and levels of experience. The paper concludes by reviewing changes proposed for DSM-5 (i.e., specifiers for Not Otherwise Specified (NOS) and other categories, dimensional assessments, and the addition and deletion of categories) to evaluate their possible impact on clinical utility and the likelihood of their being accepted by clinicians.
The World Health Organization (WHO) Department of Mental Health and Substance Abuse has developed a systematic program of field studies to evaluate and improve the clinical utility of the proposed ...diagnostic guidelines for mental and behavioral disorders in the Eleventh Revision of the International Classification of Diseases and Related Health Problems (ICD-11). The clinical utility of a diagnostic classification is critical to its function as the interface between health encounters and health information, and to making the ICD-11 be a more effective tool for helping the WHO's 194 member countries, including the United States, reduce the global disease burden of mental disorders. This article describes the WHO's efforts to develop a science of clinical utility in regard to one of the two major classification systems for mental disorders. We present the rationale and methodologies for an integrated and complementary set of field study strategies, including large international surveys, formative field studies of the structure of clinicians' conceptualization of mental disorders, case-controlled field studies using experimental methodologies to evaluate the impact of proposed changes to the diagnostic guidelines on clinicians' diagnostic decision making, and ecological implementation field studies of clinical utility in the global settings in which the guidelines will ultimately be implemented. The results of these studies have already been used in making decisions about the structure and content of ICD-11. If clinical utility is indeed among the highest aims of diagnostic systems for mental disorders, as their developers routinely claim, future revision efforts should continue to build on these efforts.
DSM-5-TR : Rationale, Process, and Overview of Changes First, Michael B; Clarke, Diana E; Yousif, Lamyaa ...
Psychiatric services (Washington, D.C.),
2023-Aug-01, 2023-08-01, 20230801, Letnik:
74, Številka:
8
Journal Article
Recenzirano
The
text revision (
) is the first published revision of the
since its publication in 2013. Like the previous text revision (
), the main goal of the
is to comprehensively update the descriptive text ...accompanying each
disorder on the basis of reviews of the literature over the past 10 years. In contrast to the
, in which updates were confined almost exclusively to the text, the
includes many other changes and enhancements of interest to practicing clinicians, such as the addition of diagnostic categories (prolonged grief disorder, stimulant-induced mild neurocognitive disorder, unspecified mood disorder, and a category to indicate the absence of a diagnosis); the provision of
-
symptom codes for reporting suicidal and nonsuicidal self-injurious behavior; modifications, mostly for clarity, of the diagnostic criteria for more than 70 disorders; and updates in terminology (e.g., replacing "neuroleptic medications" with "antipsychotic medications or other dopamine receptor blocking agents" throughout the text and replacing "desired gender" with "experienced gender" in the text for gender dysphoria). Finally, the entire text was reviewed by an Ethnoracial Equity and Inclusion Work Group to ensure appropriate attention to risk factors such as the experience of racism and discrimination, as well as the use of nonstigmatizing language.
Among the important changes in the ICD‐11 is the addition of 21 new mental disorders. New categories are typically proposed to: a) improve the usefulness of morbidity statistics; b) facilitate ...recognition of a clinically important but poorly classified mental disorder in order to provide appropriate management; and c) stimulate research into more effective treatments. Given the major implications for the field and for World Health Organization (WHO) member states, it is important to examine the impact of these new categories during the early phase of the ICD‐11 implementation. This paper focuses on four disorders: complex post‐traumatic stress disorder, prolonged grief disorder, gaming disorder, and compulsive sexual behaviour disorder. These categories were selected because they have been the focus of considerable activity and/or controversy and because their inclusion in the ICD‐11 represents a different decision than was made for the DSM‐5. The lead authors invited experts on each of these disorders to provide insight into why it was considered important to add it to the ICD‐11, implications for care of not having that diagnostic category, important controversies about adding the disorder, and a review of the evidence generated and other developments related to the category since the WHO signaled its intention to include it in the ICD‐11. Each of the four diagnostic categories appears to describe a population with clinically important and distinctive features that had previously gone unrecognized as well as specific treatment needs that would otherwise likely go unmet. The introduction of these categories in the ICD‐11 has been followed by a substantial expansion of research in each area, which has generally supported their validity and utility, and by a significant increase in the availability of appropriate services.
This article narrates a history of several important changes to the substance-related disorders chapter in the
(DSM-5), based on interviews with people involved in the pre-planning and the ...development of the revisions. These changes include collapsing substance abuse and substance dependence into a single substance use disorder, adding craving as a diagnostic criterion, and incorporating a behavioral addiction--gambling disorder--into the substance-related disorders chapter. Studies using Item Response Theory (IRT) supported the new substance use disorder diagnosis. The IRT analyses demonstrated that the abuse and dependence items can be ordered on a single latent dimension and that some of the presumably milder abuse items indexed a greater level of severity than the presumably more pathological dependence items. Those who opposed collapsing abuse and dependence emphasized the validity and clinical utility of the dependence syndrome on which much important treatment research was based. Both those who favored and those who opposed adding craving agreed that it was redundant with the other diagnostic criteria and did not improve the performance of the criterion set. Nevertheless, some clinicians supported adding craving because of its importance in the conceptualization of substance use disorders, and some researchers supported it because of its potential to be validated as a diagnostically useful biomarker. Those who opposed adding craving argued that considering the validity of an individual criterion alone rather than its contribution to the incremental validity of the criterion set represented a major shift in diagnostic philosophy that had potentially far-reaching implications for future revisions of the DSM.
We conclude by observing that, unlike what occurred in the broader DSM-5 process, despite differences of opinion the work group reached consensus. In part, this may be explained by some shared standards within the work group versus the disagreement about standards across the broader DSM-5 process.
Field trials of diagnostic classification systems can be divided into two types: developmental field trials, which are designed to collect performance data from users during the revision process, and ...summative field trials, which aim to assess what users can expect in terms of the classification's psychometric properties after the classification has been completed. A crucial component of an empirically guided diagnostic revision process is the use of developmental field trials in which data are collected from users regarding the feasibility, reliability, validity, and clinical utility of proposed changes that can assist in refining the proposals before they are finalised. The DSM-III and ICD-10 reliability field trials are best considered summative as they were done primarily to establish whether clinicians using operationalised definitions could achieve adequate diagnostic reliability. The DSM-III-R and DSM-IV field trials, which collected performance data targeting specific diagnostic categories, heralded the use of developmental field trial data as an important component in the construction of diagnostic criteria sets, a process being continued in the ICD-11 revision process. Although initially presented as developmental in nature, the DSM-5 field trials ended up being essentially summative. Although reliability estimates with highly sophisticated methodology were provided for 23 mental disorders, the absence of information regarding the reliability of specific diagnostic items and the reasons for diagnostic disagreement prevented this information from being used to address identified reliability issues. Developmental field trials enhance the empirical basis for stating that psychiatric classifications are evidence based and they ultimately contribute to the improvement of clinical care for patients.
The purpose of this article is to provide psychiatrists and other health care professionals who treat patients with major depressive disorder and bipolar disorder a set of best practices, tools, and ...other methods to improve their ability to make a more accurate diagnosis between major depressive disorder and bipolar disorder and to reach this diagnosis sooner, given a particular set of patient-related circumstances and comorbidities..
OBJECTIVE: Changes in DSM-IV were guided by empirical data that mostly focused on improving diagnostic validity and reliability. Although many changes were made explicitly to improve clinical ...utility, no formal effort was made to empirically determine actual improvements in clinical utility. The authors propose that future revisions of DSM empirically demonstrate improvement in clinical utility to clarify whether the advantages of changing the diagnostic criteria outweigh potential negative consequences. METHOD: The authors provide a formal definition of clinical utility and then suggest that the merits of a proposed change to DSM be evaluated by considering 1) its impact on the use of the diagnostic system, 2) whether it enhances clinical decision making, and 3) whether it improves clinical outcome. RESULTS: Evaluating a change based on its impact on use considers both user acceptability and accuracy in application of the diagnostic criteria. User acceptability can be measured by surveying users' reactions, assessing user acceptability in a field trial setting, and measuring the effects on ease of use. Assessment of the correct application of diagnostic criteria entails comparing the clinician's diagnostic assessment to expert diagnostic assessment. Assessments of the impact on clinical decision making use methods developed for evaluating adherence to practice guidelines. Improvement in outcome entails measuring reduction in symptom severity or improvement in functioning or in documenting the prevention of a future negative outcome. CONCLUSIONS: Empirical methods should be applied to the assessment of changes that purport to improve clinical utility in future revisions of DSM.
Aim
In Western Christian countries, religiosity is generally believed to be associated with a lower risk for depression, which is supported by epidemiological evidence. However, the association ...between religiosity and depression in multireligious countries is unknown. The objective was to evaluate the association between religiosity and subsequent depression in a multireligious population.
Methods
A longitudinal study was conducted in a large hospital in Tokyo, Japan, from 2005 to 2018. All participants who underwent health check‐ups without a prior history of depression or depression at baseline were included. Our outcome was development of major depressive disorder (MDD), which was compared according to the degree of religiosity, adjusting for potential confounders.
Results
Among 67 723 adult participants, those who were more religious tended to be older, female, married, and to have healthier habits but also more medical comorbidities at baseline. During a median follow‐up of 2528 days, 1911 (2.8%) participants developed MDD. Compared to the reference group, religious group participants tended to have higher odds ratios (OR) for developing MDD in a dose‐dependent manner. Among them, the extremely religious group (OR, 1.51; 95% confidence interval CI, 1.28–1.78) and the moderately religious group (OR, 1.30; 95% CI, 1.14–1.49) were statistically associated with increased development of MDD compared to the not‐religious‐at‐all group. Those who had increased their religiosity from baseline had statistically lower development of MDD (OR, 0.85; 95% CI, 0.75–0.97) compared to those who remained in the same degree of religiosity from baseline.
Conclusion
Religiosity was associated with future MDD in a dose‐dependent manner in a multireligious population, which was in the opposite direction from that seen in previous Western longitudinal studies.
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