Section III of New Manual Looks to Future

The multiaxial system of earlier editions of DSM has been eliminated. Section I gives an introduction to DSM-5 with instructions on how to use the updated manual, and Section II outlines the categorical diagnoses.

In an interview earlier this year with Psychiatric News, Kupfer outlined some of the conceptual ideas that have informed the development of diagnostic criteria and the organization of the text. These include an appreciation of cultural factors in mental illness, a developmental approach to psychiatric disorders, a move toward the use of dimensional measures to rate severity and disaggregate symptoms that tend to occur across multiple disorders, and integration of genetic and neurobiological findings by grouping clusters of disorders that share genetic or neurobiological substrates (Psychiatric News, January 18).

Section III furthers those goals by moving toward a time when those genetic and neurobiological findings may make the current categorical schema less important, recognizing instead common symptoms that occur across all disorders and the varying ways in which individual patients may present.

Kupfer said that field trials of the DSM-5 criteria showed the utility of patient-rated cross-cutting symptom measures—an assessment tool that can be used to have patients rate the presence and severity of symptoms that occur in many disorders. The assessment tool, and others in Section III, will be especially useful to clinicians using electronic health records (EHRs); the questionnaire includes drop-down boxes for more specific information that patients can provide.

Similarly, Section III includes the World Health Organization’s Disability Assessment Schedule, reflecting a goal of the task force to include measures of impairment and disability. This tool, like the cross-cutting symptom measures, is especially amenable to use with EHRs.

“We do provide information about these tools in the text of the manual, but given the length of some of these tools, we are encouraging clinicians who want to ‘drill down’ to get more specific information to go electronic,” Kupfer said.

The material on cultural factors affecting presentation of mental illness was developed by the Study Group on Gender and Cross-Cultural Issues, chaired by Kimberly Yonkers, M.D. Kupfer said he believes the information there will be enormously useful to clinicians today and is likely to be incorporated into Section II in future editions of the manual.

The section also includes eight other diagnoses that were not included in Section II either because they require more research or more exposure to clinical experience to determine their usefulness. These are attenuated psychosis syndrome, depressive episodes with short-duration hypomania, persistent complex bereavement disorder, caffeine use disorder, Internet gaming disorder, neurobehavioral disorder due to prenatal alcohol exposure (ND-PAE), suicidal behavior disorder, and nonsuicidal self-injury.

Attenuated psychosis syndrome was one of the more controversial categories the task force considered. While not accepted for inclusion in Section II, the syndrome—which describes patients who experience distress and impairment from symptoms that do not rise to the clinical threshold of psychosis—points the way toward what many in psychosis research believe is the future: early identification and treatment of individuals before they become actively psychotic.

Finally, Section III also includes an alternative model for diagnosis of personality disorders. Criteria for these disorders in Section II are virtually unchanged from DSM-IV, but the alternative model points to a future that moves beyond the categorical diagnostic system of discrete disorders in DSM-IV toward a more dimensional system (Psychiatric News, May 3).

“We hope clinicians will actively use Section III, and we believe that it can help to push the field toward a system of diagnosis that more perfectly matches criteria to the individual patient in the clinician’s office,” Kupfer said. ■