Alternative futures for the DSM revision process: iteration v. paradigm shift

The Influence of Using Novel Predictive Technologies on Judgments of Stigma, Empathy, and Compassion among Healthcare Professionals

BACKGROUND

Our objective was to evaluate whether the description of a machine learning (ML) app or brain imaging technology to predict the onset of schizophrenia or alcohol use disorder (AUD) influences healthcare professionals' judgments of stigma, empathy, and compassion.

METHODS

We randomized healthcare professionals (N = 310) to one vignette about a person whose clinician seeks to predict schizophrenia or an AUD, using a ML app, brain imaging, or a psychosocial assessment. Participants used scales to measure their judgments of stigma, empathy, and compassion.

RESULTS

Participants randomized to the ML vignette endorsed less anger and more fear relative to the psychosocial vignette, and the brain imaging vignette elicited higher pity ratings. The brain imaging and ML vignettes evoked lower personal responsibility judgments compared to the psychosocial vignette. Physicians and nurses reported less empathy than clinical psychologists.

CONCLUSIONS

The use of predictive technologies may reinforce essentialist views about mental health and substance use that may increase specific aspects of stigma and reduce others.

Bipolar disorder in the International Classification of Diseases-Eleventh version: A review of the changes, their basis, and usefulness

The World Health Organization’s 11^th revision of the International Classification of Diseases (ICD-11) including the chapter on mental disorders has come into effect this year. This review focuses on the “Bipolar or Related Disorders” section of the ICD-11 draft. It describes the benchmarks for the new version, particularly the foremost principle of clinical utility. The alterations made to the diagnosis of bipolar disorder (BD) are evaluated on their scientific basis and clinical utility. The change in the diagnostic requirements for manic and hypomanic episodes has been much debated. Whether the current criteria have achieved an optimum balance between sensitivity and specificity is still not clear. The ICD-11 definition of depressive episodes is substantially different, but the lack of empirical support for the changes has meant that the reliability and utility of bipolar depression are relatively low. Unlike the Diagnostic and Statistical Manual of Mental Disorders, 5^th edition (DSM-5), the ICD-11 has retained the category of mixed episodes. Although the concept of mixed episodes in the ICD-11 is not perfect, it appears to be more inclusive than the DSM-5 approach. Additionally, there are some uncertainties about the guidelines for the subtypes of BD and cyclothymic disorder. The initial results on the reliability and clinical utility of BD are promising, but the newly created diagnostic categories also appear to have some limitations. Although further improvement and research are needed, the focus should now be on facing the challenges of implementation, dissemination, and education and training in the use of these guidelines.

Psychiatric diagnosis and treatment in the 21st century: paradigm shifts versus incremental integration

Psychiatry has always been characterized by a range of different models of and approaches to mental disorder, which have sometimes brought progress in clinical practice, but have often also been accompanied by critique from within and without the field. Psychiatric nosology has been a particular focus of debate in recent decades; successive editions of the DSM and ICD have strongly influenced both psychiatric practice and research, but have also led to assertions that psychiatry is in crisis, and to advocacy for entirely new paradigms for diagnosis and assessment. When thinking about etiology, many researchers currently refer to a biopsychosocial model, but this approach has received significant critique, being considered by some observers overly eclectic and vague. Despite the development of a range of evidence-based pharmacotherapies and psychotherapies, current evidence points to both a treatment gap and a research-practice gap in mental health. In this paper, after considering current clinical practice, we discuss some proposed novel perspectives that have recently achieved particular prominence and may significantly impact psychiatric practice and research in the future: clinical neuroscience and personalized pharmacotherapy; novel statistical approaches to psychiatric nosology, assessment and research; deinstitutionalization and community mental health care; the scale-up of evidence-based psychotherapy; digital phenotyping and digital therapies; and global mental health and task-sharing approaches. We consider the extent to which proposed transitions from current practices to novel approaches reflect hype or hope. Our review indicates that each of the novel perspectives contributes important insights that allow hope for the future, but also that each provides only a partial view, and that any promise of a paradigm shift for the field is not well grounded. We conclude that there have been crucial advances in psychiatric diagnosis and treatment in recent decades; that, despite this important progress, there is considerable need for further improvements in assessment and intervention; and that such improvements will likely not be achieved by any specific paradigm shifts in psychiatric practice and research, but rather by incremental progress and iterative integration.

A New Characterization of Mental Health Disorders Using Digital Behavioral Data: Evidence from Major Depressive Disorder

Mental health disorders are ambiguously defined and diagnosed. The established diagnosis technique, which is based on structured interviews, questionnaires and data subjectively reported by the patients themselves, leaves the mental health field behind other medical areas. We support these statements with examples from major depressive disorder (MDD). The National Institute of Mental Health (NIMH) launched the Research Domain Criteria (RDoC) project in 2009 as a new framework to investigate psychiatric pathologies from a multidisciplinary point of view. This is a good step in the right direction. Contemporary psychiatry considers mental illnesses as diseases that manifest in the mind and arise from the brain, expressed as a behavioral condition; therefore, we claim that these syndromes should be characterized primarily using behavioral characteristics. We suggest the use of smartphones and wearable devices to passively collect quantified behavioral data from patients by utilizing digital biomarkers of mental disorder symptoms. Various digital biomarkers of MDD symptoms have already been detected, and apps for collecting this longitudinal behavioral data have already been developed. This quantified data can be used to determine a patient’s diagnosis and personalized treatment, and thereby minimize the diagnosis rate of comorbidities. As there is a wide spectrum of human behavior, such a fluidic and personalized approach is essential.

Fractures in the framework: limitations of classification systems in psychiatry

This article examines the limitations of existing classification systems from the historical, cultural, political, and legal perspectives. It covers the evolution of classification systems with particular emphasis on the DSM and ICD systems. While pointing out the inherent Western bias in these systems, it highlights the potential of misuse of these systems to subserve other agendas. It raises concerns about the reliability, validity, comorbidity, and heterogeneity within diagnostic categories of contemporary classification systems. Finally, it postulates future directions in alternative methods of diagnosis and classification factoring in advances in artificial intelligence, machine learning, genetic testing, and brain imaging. In conclusion, it emphasizes the need to go beyond the limitations inherent in classifications systems to provide more relevant diagnoses and effective treatments.


Epidemiology of anxiety disorders: from surveys to nosology and back

On the basis of epidemiological survey findings, anxiety disorders are the most prevalent mental disorders around the world and are associated with significant comorbidity and morbidity. Such surveys rely on advances in psychiatric nosology and may also contribute usefully to revisions of the nosology. There are a number of questions at the intersection of psychiatric epidemiology and nosology. This review addresses the following: What is the prevalence of anxiety disorders and how do we best explain cross-national differences in prevalence estimates? What are the optimal diagnostic criteria for anxiety disorders, and how can epidemiological data shed light on this question? What are the comorbidities of anxiety disorders, and how do we best understand the high comorbidities seen in these conditions? What is the current treatment gap for anxiety disorders, and what are the implications of current understandings of psychiatric epidemiology and nosology for policy-making relevant to anxiety disorders? Here, we emphasize that anxiety disorders are the most prevalent of the psychiatric conditions, and that rather than merely contrasting cross-national prevalence in anxiety disorders, it is more productive to delineate cross-national themes that emerge about the epidemiology of these conditions. We discuss that optimizing diagnostic criteria for anxiety disorders is an iterative process to which epidemiological data can make a crucial contribution. Additionally, high comorbidity in anxiety disorders is not merely artefactual; it provides key opportunities to explore pathways to mental disorders and to intervene accordingly. Finally, work on the epidemiology and nosology of anxiety disorders has provided a number of important targets for mental health policy and for future integrative work to move between bench and bedside, as well as between clinic and community.

Natural kinds, psychiatric classification and the history of the DSM

This paper addresses philosophical issues concerning whether mental disorders are natural kinds and how the DSM should classify mental disorders. I argue that some mental disorders (e.g. schizophrenia, depression) are natural kinds in the sense that they are natural classes constituted by a set of stable biological mechanisms. I subsequently argue that a theoretical and causal approach to classification would provide a method for classifying natural kinds that is superior to the purely descriptive approach adopted by the DSM since DSM-III My argument suggests that the DSM should classify natural kinds in order to provide predictively useful (i.e. projectable) diagnostic categories and that a causal approach to classification would provide a more promising method for formulating valid diagnostic categories.

A reappraisal of Kendell and Jablensky's account of validity

Kendell and Jablensky argue that validity in psychiatry requires either unique biological characteristics or a zone of rarity, where few symptoms of one syndrome are present in another syndrome. Meeting either of these criteria allows the inference that the syndrome is caused by a specific biological mechanism not present in other syndromes. Failing to meet either of these criteria means the syndrome has been arbitrarily grouped and is invalid. Kendell and Jablensky's account of validity is too restrictive. Scientific phenomena are generally produced by a multiplicity of unstable overlapping causes, the causes for one phenomenon typically also present in other phenomena. Despite this, scientific phenomena are not automatically arbitrary. Science employs idealistic models that can successfully describe phenomena produced by overlapping causes and can gain approximately true knowledge of that phenomenon. The specific biological mechanisms that Kendell and Jablensky see as delivering validity are only specific in an idealized sense. Also, approximate truth means Kendell and Jablensky are mistaken to see validity as invariant and independent of context. An alternative approach to inferring causes is the common cause and unifications. Scientists often see otherwise unrelated phenomena regularly co-occur, and this legitimizes inferring common causes responsible for the phenomena. Applied to psychiatry, I show how syndromes that cover many different unrelated phenomena allow an inference to common causes, and this delivers validity. Zones of rarity can actually decrease validity. Idealized models often produce more information about causes by covering more phenomena, whereas zones of rarity often reduce the number of symptoms covered by a syndrome. Ignoring zones of rarity in favour of syndromes that cover many symptoms can sometimes increase validity. This can also occur when validating syndromes through corroborations with other factors. Increasing corroborations may require reducing the number of symptoms, potentially reducing validity.

Optimizing Prediction of Psychosocial and Clinical Outcomes With a Transdiagnostic Model of Personality Disorder

Transdiagnostic models hold promise for transforming research and treatment practices for personality disorders (PDs), but widespread acceptance and implementation of such approaches will require persuasive evidence of construct validity and clinical utility. Toward that end, the authors examined the criterion-related validity of a transdiagnostic PD model in relation to psychosocial and clinical outcomes in a high-risk community sample of 700 young adults. Participants and their mothers completed semistructured interviews to assess young adults' PD symptomatology, psychosocial functioning, suicidality, and mental health treatment use. Bifactor modeling revealed an overarching dimension of PD severity-capturing symptoms across all PD categories-that strongly predicted all functional and clinical outcomes in multivariate analyses. Effect sizes for lower-order, specific PD processes were comparatively modest for functional outcomes; however, they provided clinically significant information about suicide risk and treatment use. The authors discuss implications of a transdiagnostic perspective for research on PD etiology, classification, and treatment.

HowNutsAreTheDutch (HoeGekIsNL): A crowdsourcing study of mental symptoms and strengths

HowNutsAreTheDutch (Dutch: HoeGekIsNL) is a national crowdsourcing study designed to investigate multiple continuous mental health dimensions in a sample from the general population (n = 12,503). Its main objective is to create an empirically based representation of mental strengths and vulnerabilities, accounting for (i) dimensionality and heterogeneity, (ii) interactivity between symptoms and strengths, and (iii) intra-individual variability. To do so, HowNutsAreTheDutch (HND) makes use of an internet platform that allows participants to (a) compare themselves to other participants via cross-sectional questionnaires and (b) to monitor themselves three times a day for 30 days with an intensive longitudinal diary study via their smartphone. These data enable for personalized feedback to participants, a study of profiles of mental strengths and weaknesses, and zooming into the fine-grained level of dynamic relationships between variables over time. Measuring both psychiatric symptomatology and mental strengths and resources enables for an investigation of their interactions, which may underlie the wide variety of observed mental states in the population. The present paper describes the applied methods and technology, and presents the sample characteristics. Copyright © 2015 John Wiley & Sons, Ltd.

Psychiatric classification: Current debate and future directions

Classification of health related conditions can be a complex task. This is particularly so in case of psychiatric disorders. The present paper reviews the fundamentals of psychiatric classification, including its basis, history, methods of evaluation, the journey so far and future directions. The various criticisms of current classificatory systems and possible solutions are discussed. Special reference to the research domain criteria (RDoC) approach has been made and implications discussed.

The Evolution of the Classification of Psychiatric Disorders

This article traces the history of classification systems for mental illness and then reviews the history of the American diagnostic system for mental disorders. The steps leading up to each publication of the Diagnostic and Statistical Manual (DSM) are described including leaders, timelines, pre-publication meetings, and field trials. Important changes in the purpose of the manuals are described with a focus on events leading to the manual’s third edition (DSM-III), which represented a paradigm shift in how we think about, and use, the classification system for mental illness. For the first time, DSM-III emphasized empirically-based, atheoretical and agnostic diagnostic criteria. New criticisms of the DSM-III and subsequent editions have arisen with a call for a new paradigm shift to replace diagnostic categories with continuous dimensional systems of classification, returning to etiologically-based definitions and incorporating findings from neurobiological science into systems of diagnosis. In the foreseeable future, however, psychiatric diagnosis must continue to be accomplished by taking a history and assessing the currently established criteria. This is necessary for communication about diseases and education of clinicians and scientists in medical fields, as well as advancement of research needed to further advance the diagnostic criteria of psychiatry.

Transitioning to a dimensional model of personality disorder in DSM 5.1 and beyond

PURPOSE OF REVIEW

To propose options for gradually transitioning to a thoroughgoing dimensional model of personality disorder.

RECENT FINDINGS

The American Psychiatric Association was less willing to implement a dimensional approach to the diagnosis of personality disorder than the leadership of the DSM-5 anticipated. The next opportunity to implement such an approach will be in the ICD-11 and the DSM 5.1.

SUMMARY

Instead of seeking a revolutionary change, attempting a more gradual transition that leads to something significantly better in the long run is likely to be more successful. For the long run, in addition to clinical utility and scientific validity, new diagnostic models must possess user acceptability. Professionals will be more likely to accept a new model if they believe it will allow them to do good work. Competent use of a dimensional model is not only a matter of increased familiarity with personality trait profiles, it requires a different kind of clinical expertise.

Brain Dysfunctions, Psychopathologies, and Body Image Distortions

The major features in eating disorders are a preoccupation with food and its consumption and body dissatisfaction. Diagnostic manuals provide clusters of criteria according to which affected individuals can be categorized into one or other group of eating disorder. Yet, when considering the high proportion of comorbidities and ignoring the content of the symptoms (food, body), the major features seem to yield obsessional-compulsive, addictive, and impulsive qualities. In the present article, we review studies from the neuroscientific literature (mainly lesion studies) on eating disorder, obsessive-compulsive disorder, impulse control disorder, and addiction to investigate the possibility of a wider phenotype that can be related to a common brain network. The literature localizes this network to the right frontal lobe and its connectivities. This network, when dysfunctional, might result in a behavior that favors the preoccupation with particular thoughts, behaviors, anxieties, and uncontrollable urges that are accompanied by little scope for ongoing behavioral adjustments (e.g., impulse control). We reason that this network may turn out to be equally involved in understudied mental conditions of dysfunctional body processing such as muscle dysmorphia, body dysmorphic disorder (including esthetic surgery), and xelomelia. We finally consider previous notions of a wider phenotype approach to current diagnostic practice (using DSM), such as the possibility of a model with a reduced number of diagnostic categories and primary and secondary factors, and to etiological models of mental health conditions.

Young children with language difficulties: a dimensional approach to subgrouping

A dimensional approach was used to create bottom-up constructed subgroups that captured the behavioral heterogeneity in 36 Dutch-speaking children with language difficulties. Four subgroups were delineated based upon differences in cognitive ability, symbol understanding, joint attention and autism spectrum disorder related characteristics. Children with a different developmental disorder were found within a single cluster. Therefore, the results of this study suggest that bottom-up constructed subgroups might capture the heterogeneous behavioral profiles of young children with developmental difficulties in a more meaningful way. Furthermore, joint attention and symbol understanding seem important skills to assess in young children presenting with language difficulties.

Classification systems in psychiatry: diagnosis and global mental health in the era of DSM-5 and ICD-11

PURPOSE OF REVIEW

The development of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and- of the 11th edition of the International Classification of Disease (ICD-11) have led to renewed attention to the conceptual controversies surrounding the nosology of mental disorder. This article reviews recent work in this area, and suggests potential ways forward for psychiatric nosology, focusing in particular on the need for improved classification approaches for public and global mental health.

RECENT FINDINGS

DSM-5 and ICD-11 have taken somewhat different approaches, but both appropriately emphasize the importance of clinical utility and diagnosic validity in psychiatric nosology. The Research Domain Criteria framework provides a useful focus on the individual-level causal mechanisms that are relevant to vulnerability to mental disorder. An analogous approach to societal-level causal mechanisms would be useful from a public and global mental health perspective.

SUMMARY

In their day-to-day work, clinicians will continue to use the fuzzy constructs operationally defined and narratively depicted in DSM-5 and ICD-11. Advances in our understanding of the individual-level and society-level causal mechanisms that contribute to vulnerability to mental disorder may ultimately lead to improved classification systems, and in turn to better individualized care as well as improved global mental health.

The Puzzle of Neuroimaging and Psychiatric Diagnosis: Technology and Nosology in an Evolving Discipline

Brain imaging provides ever more sensitive measures of structure and function relevant to human psychology and has revealed correlates for virtually every psychiatric disorder. Yet it plays no accepted role in psychiatric diagnosis beyond ruling out medical factors such as tumors or traumatic brain injuries. Why is brain imaging not used in the diagnosis of primary psychiatric disorders, such as depression, bipolar disease, schizophrenia, and ADHD? The present article addresses this question. It reviews the state of the art in psychiatric imaging, including diagnostic and other applications, and explains the nonutility of diagnostic imaging in terms of aspects of both the current state of imaging and the current nature of psychiatric nosology. The likely future path by which imaging-based diagnoses will be incorporated into psychiatry is also discussed. By reviewing one well-known attempt to use SPECT-scanning in psychiatric diagnosis, the article examines a real-world practice that illustrates several related points: the appeal of the idea of image-assisted diagnosis for physicians, patients and families, despite a lack of proven effectiveness, and the mismatch between the categories and dimensions of current nosology and those suggested by imaging.

The nosology of schizophrenia: toward DSM-5 and ICD-11

Although dementia praecox or schizophrenia has been considered a unique disease entity for more than a century, definitions and boundaries have changed and its precise cause and pathophysiology remain elusive. Despite uncertain validity, the construct of schizophrenia conveys useful clinical and etiopathophysiologic information. Revisions of the Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases seek to incorporate new information about schizophrenia and include elimination of subtypes, addition of psychopathological dimensions, elimination of special treatment of Schneiderian "first-rank" symptoms, better delineation of schizoaffective disorder, and addition of a new category of "attenuated psychosis syndrome".

Generalized anxiety disorder: between neglect and an epidemic

This article reviews the main issues associated with the concept and the diagnosis of generalized anxiety disorder (GAD) and examines the proposed DSM-5 diagnostic criteria for GAD. The lack of specific features, which is the primary issue for GAD, will not be addressed in DSM-5. The hallmark of the condition will remain pathological worry, although it also characterizes other disorders. Likewise, the proposed behavioral diagnostic criteria lack specificity for GAD, and it is not clear how these will be assessed. The proposed changes will lower the diagnostic threshold for GAD in DSM-5. Although this will not necessarily lead to a better recognition of GAD and an improvement in the perception of its relevance and clinical utility, many currently subthreshold cases will qualify for this diagnosis. The likely inclusion of many such "false-positives" will result in an artificial increase in the prevalence of GAD and will have further negative consequences.

Towards a genuinely medical model for psychiatric nosology

Psychiatric nosology is widely criticized, but solutions are proving elusive. Planned revisions of diagnostic criteria will not resolve heterogeneity, comorbidity, fuzzy boundaries between normal and pathological, and lack of specific biomarkers. Concern about these difficulties reflects a narrow model that assumes most mental disorders should be defined by their etiologies. A more genuinely medical model uses understanding of normal function to categorize pathologies. For instance, understanding the function of a cough guides the search for problems causing it, and decisions about when it is expressed abnormally. Understanding the functions of emotions is a foundation missing from decisions about emotional disorders. The broader medical model used by the rest of medicine also recognizes syndromes defined by failures of functional systems or failures of feedback control. Such medical syndromes are similar to many mental diagnoses in their multiple causes, blurry boundaries, and nonspecific biomarkers. Dissatisfaction with psychiatric nosology may best be alleviated, not by new diagnostic criteria and categories, but by more realistic acknowledgment of the untidy landscape of mental and other medical disorders.

The bicentennial volume of the British Journal of Psychiatry: the winding pathway of mental science

The Asylum Journal, first published in 1853, is now, as the British Journal of Psychiatry, in its 200th volume. It has changed greatly in its breadth and scope, but its core values and concerns--professional respect, removal of stigma, delivery of care, understanding of pathology, and informed treatment--have remained at its heart throughout. We predict some changes for the future, but not dramatic ones, and conclude that the impinging advances of science will elucidate and refine, but not remove, the need for a journal that is proud to represent psychiatry or, in the words of John Bucknill, its first editor, 'to render prominent its characteristics and to stamp it as a specialty'.

[Affective disorders: Evolution of nosographic models]

In the history of the nosographies in psychiatry, the affective disorders were gradually distinguished from the other categories of mental disorders, until being considered as separate illness entities, such as what Kraepelin named manic-depressive insanity at the end of the 19th century. The latter will be subsequently divided in two main categories, the bipolar disorder on the one hand and recurrent depression on the other hand, this separation being still current, and extensively diffused by the mean of the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM, whose revisions largely determine the evolution of the contemporary nosographic models, mainly relies on a categorical approach of the mental disorders. The next revision will probably continue to follow this kind of approach, even if the use of dimensional components could also be developed. In the future, true nosographic advances can be waited from clinical epidemiology studies, as those which recently made it possible to highlight various sub-types of affective disorders on the basis of clinical, biographical or temperamental characteristics. Etiological approaches, centered on the pathophysiology of the affective disorders, could also contribute to build nosographic models on the basis of an objective knowledge on these diseases.