Michael B. First, MD

The approach that has been used for revising the 

 since its inception has been to overhaul the diagnostic classification in its entirety at fixed intervals. While revising the entire DSM in this way has some advantages, such as ensuring the uniformity and stability of the diagnostic definitions during the interval in which the manual is in effect, a significant disadvantage is that it prevents the incorporation of new scientific knowledge into DSM as it emerges.

Advances in digital publishing that allow instantaneous dissemination of changes at minimal cost have paved the way toward the adoption of a continuous improvement model for DSM, in which revisions are pegged to specific scientific advances. Thus, rather than waiting until the next wholesale revision to implement a clinically useful change (such as incorporating a clinically validated biomarker into the definition of a disorder), such a change could be put into effect as soon as it has been determined that it is diagnostically advantageous to do so. Moreover, implementing a continuous data-driven approach has the added advantage of discouraging changes that are not well supported by empirical evidence.

It is expected that most submissions will originate from interested persons who are external to the APA committee overseeing the DSM revision process (eg, psychiatric researchers, individual clinicians). This is in marked contrast to the way prior DSM revisions were done, during which proposals were drafted by DSM workgroup members who were also responsible for providing supportive literature reviews and data re-analyses.

) was set up by the APA at the beginning of this year to field proposals for changes to DSM-5. Proposals must be accompanied by supportive information including the reasons for the change and, depending on the nature of the proposal, data documenting improvements in validity across a range of validators, evidence of reliability and clinical utility, and a consideration of potential deleterious consequences associated with the proposed change.

This new continuous revision process is being overseen by a Steering Committee (analogous to the DSM Task Force). Five standing Review Committees, with about 6 members each, will work with the Steering Committee to consider the evidence in support of the proposed change. Proposals submitted to the DSM web portal will first be reviewed by the Steering Committee, which will refer the proposal to the appropriate review committee if it appears that the evidence for the proposal is substantially likely to meet the criteria for approval.

The Review Committee will undertake whatever additional investigation might be needed, such as consultation with relevant experts. It will then forward the reviewed proposal back to the Steering Committee to decide whether the proposal is suitable to be posted for public comment.

If the Steering Committee determines that the proposal has met the criteria for approval, it will submit the proposal and a summary of the public comments for review by the Board of Trustees of the APA. Once approved, changes will be publicized by the APA and digital versions of the manual will be updated to reflect the change.

The DSM-5 web portal has identified 3 types of proposals that require substantial empirical support, each with explicit criteria regarding the type of evidence that is expected to be submitted. In general, proposals should include a thorough review of the relevant literature and the results of any secondary data analyses conducted by those making the proposal.

 proposals involve changes to an existing diagnostic criteria set that purport to markedly improve the validity, reliability, or clinical utility of a criteria set, or to substantially reduce identified deleterious consequences

 proposals involve the addition of a new diagnostic category, subtype, or specifier

 proposals entail deleting an existing category or subtype or specifier

Proposals involving corrections and clarifications of existing criteria that do not require empirical support (type 4 proposals) are being considered on an expedited basis by a subcommittee of the Steering Committee. Included here are instances of lack of clarity or ambiguity in the meaning of the wording of criteria or text; inconsistencies or contradictions within the text or criteria (eg, diagnostic criteria that conflict with corresponding descriptions in the text); and errors of omission or inadvertent inclusion.

The first set of proposed changes to DSM-5 since the web portal was opened for submissions are now being posted for public comment on the DSM-5 web site, with comments being accepted from November 22, 2017 until December 22, 2017.

The first proposal concerns the ICD-10-CM diagnostic codes that apply to situations in which in a patient taking a medication, which is capable of causing physiological dependence, that is being taken as prescribed (ie, not abused), a withdrawal syndrome in the context of stopping the medication develops. The ICD-10-CM codes currently listed in DSM-5 for the categories of Opioid Withdrawal, Sedative, Hypnotic, or Anxiolytic Withdrawal, Cannabis Withdrawal, and Stimulant Withdrawal apply only to cases of withdrawal that develop in the context of a diagnosis of a substance use disorder. This proposal involves a change to the coding notes for these conditions so that they include the ICD-10-CM codes, which apply to cases of withdrawal that occur in the absence of a substance use disorder.

The second proposed change involves the definitions of Other/Unspecified Depressive Disorder and Other/Unspecified Anxiety Disorder, categories respectively reserved for cases in which the patient presents with depressive (or anxiety) symptoms that do not meet diagnostic criteria for any of the specific depressive disorders (or anxiety disorders). Since DSM-III, patients who present with mood or anxiety symptoms that do not meet criteria for one of the specified DSM disorders receive a diagnosis of either an Adjustment Disorder (if there is an identified causative psychosocial stressor) or the appropriate depressive or anxiety residual category (eg, Atypical Depression in DSM-III, Depressive Disorder NOS in DSM-III-R and DSM-IV, and Other/Unspecified Depressive Disorder in DSM-5). To make Adjustment Disorder take precedence over the residual categories, the definition of the residual category must indicate that the residual category NOT be diagnosed if the criteria are met for an Adjustment Disorder. This exclusion for Adjustment Disorder, inadvertently omitted from DSM-5, has been added.

 The third proposal applies to situations in which a patient’s response to exposure to a traumatic stressor does not meet criteria for PTSD. According to DSM-5, if the duration of the symptomatic response lasted 6 months or less, the diagnosis should be Adjustment Disorder. If the symptoms persist for more than 6 months, however, the Adjustment Disorder diagnosis no longer applies, since the 6-month limit on duration has been exceeded. Such cases should be diagnosed instead as Other Trauma- and Stressor-related Disorder. To clarify that this is the correct diagnosis for such scenarios, the following example has been added to the definition of Other Specified Trauma- and Stressor-related Disorder: “Persistent response to trauma with PTSD-like symptoms (ie, symptoms occurring in response to a traumatic event that fall short of the diagnostic threshold for PTSD and that persist for longer than 6 months).”

 The fourth proposal corrects an error in the hallucinations dimension that is a component of the Clinician-Rated Dimensions of Psychotic Symptom Severity scale included in DSM-5 Section III (“Emerging Measures and Models”). The anchor points for the hallucination severity dimension incorrectly focus exclusively on the impact of voices on the patient, when it should instead include all types of hallucinations.

 The final proposal corrects an unintended discrepancy between the wording of the stressor criterion (criterion A) in Posttraumatic Stress Disorder and Acute Stress Disorder. Criterion A in PTSD requires “exposure to actual or threatened death, serious injury, or sexual violence,” whereas criterion A in Acute Stress Disorder includes “exposure to actual or threatened death, serious injury, or 

” (italics added). The correct wording for both versions of criterion A is “exposure to . . . sexual violence.”

This article was originally posted on 11/16/17 and has since been updated.

Articles

Advances in digital publishing that allow instantaneous dissemination of changes at minimal cost have paved the way towards the adoption of a continuous improvement model for DSM, in which revisions are pegged to specific scientific advances.

Public Comment Period Opens for First Set of New Proposals to Update DSM-5

Once a year, the National Center for Health Statistics (NCHS), the federal agency responsible for the use of the International Classification of Diseases – 10th revision (ICD-10) in the US, releases an updated version of the ICD-10-CM, the HIPAA-adopted code set for medical diagnoses used by medical providers, insurers, and health care administrators. The 2018 update of the ICD-10-CM took effect on October 1, 2017, meaning that users of the ICD-10-CM are required to start using the updated codes as of that date.

Coding updates affect the ICD-10-CM codes across all areas in medicine and typically are made to improve coding specificity. For example, the diagnostic code for Type 2 Diabetes Mellitus with Ketoacidosis (E11.1) has been altered to allow the clinician to indicate whether the ketoacidosis was accompanied by coma. This year, there are several coding updates that affect the diagnostic coding in the Mental, Behavioral, and Neurodevelopmental chapter (F00-F99) and thus affect the diagnostic codes used by mental health practitioners. As is the case with most of the other coding updates, the changes to the mental disorder codes aim to improve the coding specificity of the diagnoses, which in turn can help optimize medical reimbursement.

One important update involves the diagnostic codes for substance use disorders. The ICD-10-CM diagnostic codes recommended by DSM-5 are F1x.10 for the diagnosis of mild substance use disorder, and F1x.20 for both moderate substance use disorder and severe substance use disorder, where x indicates the class of substance: 0 for alcohol use disorder; 1 for opioid use disorder; 2 for cannabis use disorder; 3 for sedative, hypnotic, or anxiolytic use disorder; 4 for cocaine use disorder; 5 for amphetamine or other stimulant use disorder; 6 for phencyclidine or other hallucinogen use disorder; 7 for tobacco use disorder; 8 for inhalant use disorder; and 9 for other or unknown substance use disorder. Currently, the clinician indicates that the substance use disorder is in early or sustained remission either by writing in the applicable specifier on the chart or by selecting it from a drop-down menu on an electronic health record. Either way, the fact that the substance use disorder is in remission is not reflected in the diagnostic code. For example, mild alcohol use disorder and mild alcohol use disorder in sustained remission have the same diagnostic code: F10.10.

The October 1 update remedies this by providing different ICD-10-CM codes for active substance use disorder and substance use disorder in remission. Whereas mild substance use disorder continues to be F1x.10, moderate substance use disorder continues to be F1x.20, and severe substance use disorder continues to be F1x.20, mild substance use disorder in remission is now coded as F1x.11 and moderate and severe substance use disorder in remission is now coded as F1x.21 (

The other coding update effective October 1, 2017, involves the ICD-10-CM code for avoidant/restrictive food intake disorder (ARFID). It is now changed from F50.89 (a diagnostic code which is shared by other specified eating or feeding disorder) to F50.82, which will be unique to ARFID.

Dr. First is Professor of Clinical Psychiatry at Columbia University in New York.

Several updates to ICD-10-CM affect the diagnostic codes used by mental health practitioners. One important update involves the codes for substance use disorders. Details here.

New Diagnostic Codes for Substance Use Disorders and Avoidant/Restrictive Food Intake Disorder

“Got a challenging case-a patient for whom the diagnosis is unclear or uncertain? Want a diagnostic opinion?

If so, we invite you to submit a brief description of key clinical details (no more than 800 words) plus a description of why you find the case to be diagnostically challenging.

Michael First, MD-nationally recognized expert on psychiatric diagnosis and assessment issues will review those details and offer insights on select cases.

Dr First, Professor of Clinical Psychiatry at Columbia University, is the Editorial and Coding Consultant for DSM-5, Chief Technical and Editorial Consultant on the WHO’s ICD-11 Revision project, an external consultant to the NIMH’s RDoC (Research Domain Criteria) Project and author of a number of books about psychiatric diagnosis, including the DSM-5 Handbook of Differential Diagnosis.”

Only submissions from mental health professionals will be considered. Please include your name and degree with your case along with an e-mail address in case Dr. First needs to contact you for additional information. To help preserve confidentiality, if your case is selected for publication in 

AMENDMENT TO OUR INVITATION: If you are a nurse or nurse practitioner, you may send your case to editor@psychiatrictimes.com for consideration. -The Editors

Got a challenging case-a patient for whom the diagnosis is unclear or uncertain? Want a diagnostic opinion? This is a call for cases. Michael First, MD-a nationally recognized expert on psychiatric diagnosis and assessment issues-will review details and offer insights on select cases.

Call for Challenging Cases

Since 1979, all clinicians-psychiatrists and non-psychiatrists-who practice in the US have had to submit valid ICD-9-CM diagnostic codes with their billing submissions in order to meet government- and insurer-imposed coding requirements. Starting October 1, 2015, we will have to switch from ICD-9-CM to a new coding system, ICD-10-CM.

The reason for this switchover is straightforward: ICD-9-CM was simply running out of codes. ICD-9-CM is a 5-digit numerical coding system that contains approximately 13,000 codes. ICD-10-CM is an alpha-numeric system that contains approximately 68,000 codes: each code starts with a letter followed by anywhere from 2 to 7 numbers. Moreover, these additional available codes allow the clinician to be much more specific when communicating information about the patient’s diagnostic condition. For example, there is a single ICD-9-CM code for diabetes mellitus complicating pregnancy or childbirth: 648.01. In ICD-10-CM, there are 21 corresponding ICD-10-CM codes that require you to indicate whether the diabetes is type 1 or type 2; whether it developed during the first, second, or third trimester or during childbirth; or whether it predated the pregnancy.

[[{"type":"media","view_mode":"media_crop","fid":"40276","attributes":{"alt":"DSM-5 and ICD-10-CM","class":"media-image media-image-right","id":"media_crop_8315134067382","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4100","media_crop_rotate":"0","media_crop_scale_h":"162","media_crop_scale_w":"175","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image"}}]]This is the first time that many clinicians have had to deal with such a radical overhaul of the diagnostic coding system.

For most clinicians, the ICD-9-CM to ICD-10-CM transition requires extensive retraining of themselves and their staff so that they can take advantage of the increased specificity and maximize appropriate reimbursement. The transition has also required a massive reprogramming of billing and other data collection systems to accommodate the new code set. For this reason, over the years there has been pushback from both the clinical and administrative communities to delay implementation of ICD-10-CM. In fact, its implementation has already been delayed twice. It was originally scheduled for implementation on October 1, 2013, but postponed to 2014. Then, last year-under pressure from the AMA, a provision was added to the annual 1-year “fix” of the Sustainable Growth rate formula for Medicare physician reimbursement. This delayed implementation yet again, this time until October 1, 2015.

But no further delays are likely to happen, and you and your colleagues must now bite the bullet and accept that-in a matter of a few weeks-you will be required to submit bills using ICD-10-CM codes.

The good news? Compared with our non-psychiatric colleagues, psychiatrists are in very good shape when it comes to switching over to ICD-10-CM.

When DSM-5 was published in May 2013, in anticipation of the impending ICD-9-CM to ICD-10-CM switchover, both ICD-9-CM and ICD-10-CM codes were assigned to each of the DSM-5 diagnoses. For example, as can be seen on page 190 of DSM-5, the diagnostic codes for Separation Anxiety Disorder “309.21 (F93.0)” are listed in the upper right hand corner of the criteria set. In this case, 309.21 is the ICD-9-CM code for Separation Anxiety Disorder, and F93.0 is the ICD-10-CM code. Starting October 1, all you need do to become ICD-10-CM–compliant is to start using F93.0 instead of 309.21 when submitting payment for a case of Separation Anxiety Disorder.

Because the diagnostic codes sometimes reflect the use of applicable specifiers, for some disorders the coding is less straightforward. For example, on page 338 of DSM-5, the criteria set for Anorexia Nervosa does not list any diagnostic codes in the upper right hand corner. This is because the diagnostic code depends on which subtype applies. As is seen on page 339, the ICD-10-CM code is F50.01 for the restricting type (no binge eating or purging episodes during the past 3 months) and F50.02 for the binge eating–purging type (recurrent episodes of binge eating or purging).

The reason that both ICD-9-CM and ICD-10-CM codes are included in DSM-5 is that it came out during the time when clinicians were still required to use ICD-9-CM codes. Presumably, future printings of DSM-5 will excise the ICD-9-CM codes and will include only the ICD-10-CM codes.

Part of the reason for the impending anxiety among some psychiatrists about what they need to do to become ICD-10-CM–compliant stems from the mistaken notion that they will be required to use ICD-10-CM instead of the “DSM codes” included in DSM-5. There are, in fact, no “DSM codes” in the DSMs. Since DSM-III, diagnostic codes appearing in DSM have all been valid ICD-9-CM codes.

Let me take a short historical detour here to explain yet another major source of confusion about the ICD coding system. Since 1948, the International Classification of Diseases (ICD) has been produced by the World Health Organization (WHO) to promote uniform collection of health statistics around the world. All countries that are members of the WHO are obligated by treaty to use ICD codes for collecting data about medical diagnoses. The current version of the ICD coding system used internationally since 1992 is ICD-10, ie, the 10th revision of the ICD. Work is now under way by the WHO to produce the next revision, ICD-11, which is expected to be approved by the World Health Assembly in May 2018.

Back in the 1970s, the US government decided that the ICD system was not specific enough for clinical use and developed its own version of the ICD for use in the US. It is called ICD-CM (the CM stands for “Clinical Modification”). The version of the ICD currently used in the US is ICD-9-CM, which became “official” in 1979. So while the rest of the world has been using ICD-10 for reporting health care statistics since the 1990s, the US continues to use the ICD-9-CM system, which is based on the older ICD-9 classification. The US is finally ready to catch up to the rest of the world and implement ICD-10-CM, which as the “CM” designation indicates, is a modified version of ICD-10 for use in the US.

ICD-10-CM was actually ready for use in the US by the mid-1990s, but its implementation was delayed for 20+ years because of opposition from various groups on the grounds that implementation would be costly and not worth it.

What about “differences” between the mental disorders section of ICD-10-CM and DSM-5? Besides the substance use disorder codes (for which there are 3 times as many codes in ICD-10-CM as there are substance use disorders in DSM-5), there are hardly any more diagnostic codes in the mental disorders section of ICD-10-CM as there are in DSM-5. In fact, if you look closely at the mental disorders section of the ICD-10-CM (available on the Web site of the National Center for Health Statistics), you will see that the ICD-10-CM mental disorder section looks essentially the same as DSM-IV-TR in terms of categories and names of disorders. This is not an accident-the APA had a big hand in the development of the ICD-10-CM content and we made a strong effort to get it as close to DSM-IV as possible, since we were expecting the ICD-10-CM to go into effect in the late 1990s, well before any work started on DSM-5.

By the way, the reason for the proliferation of substance use disorder codes is that the ICD-10-CM coding system requires the clinician to combine substance use disorder diagnoses (eg, substance dependence) with substance-induced diagnoses (eg, substance-induced depressive disorder): if you want to make a diagnosis of a substance-induced disorder, you must also indicate the comorbid substance use disorder. For example, when choosing the diagnostic code for a patient with cocaine-induced depression, you must indicate the comorbid pattern of cocaine use as follows: F14.14 for cocaine-induced depressive disorder occurring in the context of mild cocaine use disorder; F14.24 for cocaine-induced depressive disorder occurring in the context of moderate to severe cocaine use disorder; and F14.94 for cocaine-induced depressive disorder occurring without a comorbid cocaine use disorder (see DSM-5, page 176).

So . . . you don’t need to lose sleep over the coming transition. If you already have a copy of DSM-5, you have all of the codes you need for successful ICD-10-CM implementation.

 about the coming transition to ICD-10-CM, please post them in the comment box.

The good news? Compared with our non-psychiatric colleagues, we psychiatrists are in very good shape when it comes to switching over to ICD-10-CM. 

What You Need to Know About DSM-5 and ICD-10-CM

How do you use the DSM, doctor? Is it an integral part of your diagnostic decision making? Do you use it to help you select treatment or gauge a patient’s prognosis? Do you rely on it mainly for coding and billing? For something else entirely?

There is strikingly little information available in the literature regarding how clinicians actually use the DSM in their everyday practice.

Getting a better understanding of how the DSM is used by clinicians is important for several reasons:

• Many of the uses of the DSM (eg, communicating diagnostic information to other clinicians, accurately applying research studies that define study groups using DSM criteria) depend on a relatively faithful application of the DSM criteria.

• Given that one of the primary goals of making DSM revisions is to improve its clinical utility, establishing a baseline of current usage is critical to inform future proposals.

• Knowledge about how clinicians use the DSM is important in determining the likely impact of changes to the diagnostic system on practice patterns-a major source of criticism during the DSM-5 revision process.

 and his fellow members of the Group for the Advancement of Psychiatry (GAP) Psychopathology Committee recently called for additional research that focuses on determining clinicians’ actual use of the DSM. 

 subsequently posted a survey on its Web site that was developed by the GAP Psychopathology Committee.

Although the survey will be analyzed in detail at a later date, we wanted to take this opportunity to provide you with some preliminary results.

 The survey is open for a few more weeks and we welcome your participation: 

To date, 894 readers have completed the survey. The demographic breakdown:

• 62% of respondents reported that they currently use DSM-5; 38% still use DSM-IV

• 92% of respondents provide more than 4 hours per week of direct patient care

• 5% are under age 30; 30% are 30 to 49; 43% are 50 to 64; and 22% are over 65

• 60% of the respondents report being a psychiatrist; 14% are psychologists; 5%, social workers; 6%, counselors; 11%, nurse practitioners or physician’s assistants; and 4%, lawyers, administrators, or “other”

• 88% report being Adult clinicians; 31%, Child clinicians; 19%, Geriatric clinicians; 13%, Forensic clinicians; 20%, Addiction specialists; 17%, Community-based clinicians; and 14%, Consultation-liaison (the percentages do not add up to 100%, since respondents were allowed to indicate more than one specialty)

• 59% report being in outpatient private practice, 35% practice public sector psychiatry, 28% are academically based, and 16% are non-academic hospital-based

• Respondents report spending average times of up to 72% clinical, 16% administrative, 11% research, 13% teaching, 14% consultation, and 12% other.

Respondents were first asked about their everyday DSM usage when making initial diagnoses during the assessment phase of treatment across a variety of different uses (

). They were then asked the same question-but as it pertains to ongoing treatment (

). They were also asked about usefulness of DSM in everyday practice (

In both initial and ongoing everyday practice, the majority of the respondents use DSM codes for administrative/billing purposes. About half report that they “sometimes,” “often,” or “always” use DSM to review specific criteria with the pa-tient or family and more than 60% use it “sometimes,” “often,” or “always” to review relevant text for specific disorders. In the initial evaluation of a patient, close to 85% “sometimes,” “often” or “always” use DSM diagnostic criteria from memory-but not as much during ongoing treatment.

Overall, a significant minority do not find the DSM to be very helpful in selecting treatment, and about half do not find it helpful for determining prognosis. It is seen as most useful in meeting administrative requirements, in communicating with colleagues, and in teaching.

Whatever controversies surround the DSM, this manual is already in widespread use for multiple purposes. This survey gives us the first picture of how clinicians are using the DSM-and for what purposes. We hope that these preliminary findings will stimulate further study of DSM use in clinical practice as part of the American Psychiatric Association’s plans for further revisions.

 First MB, Bhat V, Adler D, et al. How do clinicians actually use the 

Diagnostic and Statistical Manual of Mental Disorders

 in clinical practice and why we need to know more. 

 Kweskin S. Why we need to know how clinicians use the DSM. 

Given that one of the primary goals of making DSM revisions is to improve its clinical utility, establishing a baseline of current usage is critical to inform future proposals. For this and other reasons, the authors provide preliminary results from research focused on determining clinicians’ actual use of DSM.

How Clinicians Actually Use the DSM: Psychiatric Times Survey Results

An expert on psychiatric diagnosis and assessment, Dr First is Professor of Clinical Psychiatry at Columbia University and a Research Psychiatrist at the Biometrics Department at the New York State Psychiatric Institute in New York.

He is a speaker at a preconference program for this year's PsychCongress. In this program, he focuses on the publication of DSM-5, for which he is Editorial and Coding Consultant, and he will give an overview of proper use of the manual. He will also discuss issues related to ICD-9 and ICD-10-CM coding, as well as the 6-step differential diagnosis framework from his book.

Published by American Psychiatric Publishing, Inc., the 

 offers a framework for diagnosing patients, as described on the 

The handbook offers an assortment of approaches to differential diagnosis, and a number of features designed to benefit clinicians in the exam room, including:

A 6-step framework for diagnosing patients that proceeds from determining if the symptom is real to establishing the boundary between disorder and normality, with intermediary steps to rule out substance etiology and medical conditions, as well as to determine the primary disorder and to differentiate adjustment disorders from other mental disorders.

Twenty-nine symptom-oriented decision trees that provide detailed decision points to facilitate the process of generating the differential diagnosis based on the presenting symptoms and eliminate formulating premature conclusions.

Sixty-six differential diagnosis tables, one for each of the most important DSM-5® disorders, cross-referenced with the terminal branches of the decision trees presented in the handbook to provide a head-to-head comparison of each disorder, highlighting similarities and differences.

 classification, to facilitate coding and to provide an overview of all of the DSM-5

 diagnoses that must be considered in formulating a differential diagnosis.

Alphabetical indexes of the decision trees and differential diagnosis tables to help readers readily locate desired material.

A proper psychiatric diagnosis requires the ability to elicit information, identify symptoms, and recognize behavioral patterns. Dr Michael First, author of DSM-5 Handbook of Differential Diagnosis, summarizes key points in this brief video.

Essentials of Making an Accurate Psychiatric Diagnosis

On Monday, May 5, attendees at the APA Annual Meeting, will have the opportunity to meet Dr Michael First, author of 

DSM-5 Handbook of Differential Diagnosis.

An expert on psychiatric diagnosis and assessment, Dr First summarizes his book in this brief video. Dr First is Professor of Clinical Psychiatry at Columbia University and a Research Psychiatrist at the Biometrics Department at the New York State Psychiatric Institute in New York.

A six-step framework for diagnosing patients that proceeds from determining if the symptom is real to establishing the boundary between disorder and normality, with intermediary steps to rule out substance etiology and medical conditions, as well as to determine the primary disorder and to differentiate adjustment disorders from other mental disorders.

A video featuring the author of the DSM-5 Handbook, Dr Michael First describes differential diagnosis and assessment, central components of clinical practice.

DSM-5 Handbook of Differential Diagnosis: Meet the Author

Here, Drs Michael First and Robert Spitzer respond to comments made in an essay by Rene Muller, PhD. Dr Muller’s essay is also posted on this website 

” makes a number of assertions about DSM-III

and its successors that reflect a mischaracterization of its “descriptive approach.” Dr Muller misinterprets the DSM-III

descriptive approach, erroneously claiming that DSM-III

“decreed that diagnosis should be made without regard to the meaning of symptoms that constitute the behavioral criteria for a mental disorder.” He goes on to assert that “behavior alone was sufficient to define and diagnose the disorder…The meaning of psychiatric symptoms was relegated to the slag heap.” The introduction to DSM-III

explains that “the definitions of disorders generally consist of descriptions of the clinical features of the disorders…which are described at the lowest order of inference necessary,”

 a strategy adopted to improve interrater reliability which was shown to be notoriously problematic at the time.

recognized the need for clinicians to understand patient’s subjective experience in order to validly apply many of the diagnostic criteria. For example, the DSM-III introduction goes on to note that a high level of inference is required of the clinician in evaluating features of some disorders, such as “identity disturbance [in the definition of Borderline Personality Disorder] manifested by uncertainty about several issues related to identity, such as self-image, gender identity, long-term goals or career choice, friendship patterns, values and loyalties.”

 Thus, contrary to Dr Muller’s claim that “to the makers of DSM-III, subjectivity became a dirty word,” it would be impossible to make the diagnosis of Borderline Personality Disorder without an understanding of the patient’s subjective experience.

One of the most important caveats regarding the use of the DSM is that the “diagnostic categories, criteria, and textual descriptions are meant to be employed by individuals with appropriate clinical training and experience in diagnosis…The specific diagnostic criteria included in DSM are meant to serve as guidelines to be informed by clinical judgment and are not meant to be used in a cookbook fashion.”

 An important part of this need to exercise clinical judgment is determining the patient’s subjective experience of a symptom before deciding whether it fulfills the diagnostic requirement of a particular criterion. One of the central points that we repeatedly emphasize when training researchers and clinicians in how to properly use the Structured Clinical Interview for DSM-IV

(SCID) is the need to have the patient provide the interviewer with his or her subjective experience of a behavioral symptom. For example, if a patient were to say, during the assessment of the criteria for a Major Depressive Episode, that he has not wanted to get out of bed in the morning for the past two weeks, the interviewer needs to find out why he does not want to get out of bed before determining which criterion for major depressive disorder this might represent. Does it reflect a pervasive lack of interest in participating in activities, which would qualify for Criterion A(2)? Does it represent extreme fatigue which would qualify for Criterion A(6)? Does it represent extreme indecisiveness about what to do after getting out of bed, which would qualify for Criterion A(8)? Or does the patient want to avoid falling secondary to severe vertigo that he developed as a side effect of a medication, in which case the behavior would not count towards the diagnosis of any mental disorder?

The fact that clinicians may overly focus their attention on superficial symptoms without regard to understanding their clinical significance reflects a problem in how clinicians are actually using the DSM in practice. Whether this reflects a deficiency is how clinicians are trained to make psychiatric diagnosis

 or just the pressures put on clinicians to evaluate too many patients in too short a time, the source of the problem is outside of the DSM. Dr Muller’s inclusion of the case of his friend “Adam” is a perfect illustration of the problem. He recounts how “the doctors got him wrong from the start,” underestimating the role that drugs and alcohol played in his behavior, noting that “at different times the diagnosis was bipolar I disorder, schizophrenia, and schizoaffective disorder, in spite of the DSM-III

prohibition against making these diagnosis in someone who had used illicit drugs and alcohol heavily for several years.” The source of Adam’s misdiagnosis was the fact that his doctors ignored the diagnostic rules that were included in the DSM precisely for the purpose of encouraging the clinician to consider the etiological role of substances in the presentation of the patient’s symptoms. So rather than the DSM-III being “a virtual invitation to get a psychiatric diagnosis wrong,” built into the DSM definitions are exclusion and other criteria that serve to encourage the clinician to get the diagnosis right.

Dr Muller concludes his piece with the admonition that “in a future edition, the DSM…needs to take into account the patient’s subjectivity and the meaning or context of his symptoms-not by simply tacking on another axis, but by making the articulation of this subjective experience the principle objective of the diagnosis process.” While such goals are potentially laudable, does Dr Muller have any concrete suggestions for how this might be achieved in a way that would be reliable, valid, and clinically useful? As is demonstrated in Dr Muller’s piece, it is relatively easy to point out the shortcomings of the current system (of which there are many) but much more challenging to come up with a viable alternative that solves the problems elaborated in the critique. Dr Muller is undoubtedly aware that a revision of the DSM is currently underway. From Dr Muller’s perspective, do any of the proposed changes in DSM-5 encourage the clinician to put more focus on the patient’s subjective experiences? Our reading of the DSM-5 draft proposals, which focus primarily on developing dimensional severity measures and assessments of cross-cutting symptoms, if anything move the system away from the focus on the patient’s internal world and instead emphasize quantification of the symptom severity. While this may have the potential to enhance the clinician’s ability to monitor symptomatic improvement over time, it is unlikely to promote any deeper understanding of the patient’s problems or life history.
 

Diagnostic and Statistical Manual of Mental Disorders, 3rd ed.

 Washington, D.C: American Psychiatric Association; 1980:7.

 Beck A, Ward C, Mendelson M, Mock J, Erbaugh J. Relability of psychiatric diagnosis: II. A study of the consistency of clinical judgments and ratings. 

Sandifer M, Pettus C, Quade D. A study of psychiatric diagnosis. 

Ward C, Beck A, Mendelson M, Mock J, Erbaugh J. The psychiatric nomenclature. 

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed, Text Revision. Washington, DC: American Psychiatric Association; 2000:xxxii.

Tucker GJ. Putting DSM-IV in perspective. Am J Psychiatry. 1998;155(2):159-161.

Dr Muller, in his piece “Psychiatric Symptoms Can be Understood Even When These Symptoms Cannot Be Explained,” makes a number of assertions about DSM-III and its successors that reflect a mischaracterization of its “descriptive approach.”

Response to: “Psychiatric Symptoms Can be Understood Even When These Symptoms Cannot Be Explained”

, our current diagnostic classification system of psychiatric disorders, follows the diagnostic paradigm first established by 

in 1980. Acknowledging the field’s ignorance about the underlying etiology and pathophysiology of mental disorders, 

eschewed basing the structure of the classification and definition of disorders on unproven hypotheses about the causes of psychiatric disorders in favor of an “atheoretical” approach in which disorders were defined by their presenting symptoms.

 This reliance on purely descriptive operationalized definitions resulted in the establishment of a widely accepted reliable diagnostic system that has enhanced communication among mental health care professionals and greatly facilitated psychiatric research.

have justifiably been frustrated with the superficial nature of this descriptive approach. Paul McHugh,

editorial, complained that “because the manual fails to identify what underlies the symptomatic expression of a condition, it cannot suggest intelligible principles relating one disorder to another or illuminate why certain of them bunch together. For these reasons, faith in the criterion method has gradually faltered.” It has always been understood that the descriptive approach adopted by 

 will eventually be replaced by a classification informed by an understanding of etiology, which would put psychiatry in line with much of the rest of medicine. Given that 

 is slated for publication in 2012, has the time finally arrived for an etiologically based classification, or, falling short of those aspirations, at least one that includes objective laboratory tests as part of its diagnostic definitions?

Given the enormous advances in imaging technology and molecular genetics over the past 15 years, one might assume that such an approach is finally within our reach. In fact, when Allen Frances and I wrote the 

, given the explosion in new technologies available in the early 1990s, we were very optimistic that by the time 

 came out (which we envisioned would be sometime around 2007), it would include at least some biologically based diagnostic criteria. For example, in our explanation of the diagnostic criteria for dementia of the Alzheimer type, we wrote

, this is the one most likely tobecome quickly outdated. As of 1995, the definite diagnosis of Alzheimer disease can be made only by autopsy or brain biopsy. . . . Fortunately, research in this area is uncovering fascinating leads concerning the genetics and pathogenesis of this form of dementia. It seems likely that before 

 is published, diagnostic tests for Alzheimer disease will evolve that will supersede the current clinically based criteria set. This event should be a marvelous moment in the history of psychiatry, hopefully to be followed by . . . similar advances in the understanding and diagnosis of other psychiatric conditions (eg, schizophrenia, bipolar disorder)."

Unfortunately, our hopes for the development of diagnostically specific tests that could be included in the 

 criteria sets for Alzheimer disease have not been borne out. One of the 12 research planning conferences, convened with the goal of reviewing the scientific literature in advance of starting formal work on

 focused on diagnostic issues in dementia.

 Biomarkers (eg, cerebrospinal fluid t) have been identified that have sufficient diagnostic sensitivity and specificity to distinguish between patients with Alzheimer disease and normal healthy controls; however, these markers have not been demonstrated to be useful in differentiating Alzheimer dementia from other types of dementia. This, of course, is precisely the diagnostic scenario most likely to be faced by the psychiatrist in actual clinical settings.

The lack of diagnostic sensitivity and specificity is even more the case for putative biomarkers in other diagnostic categories.

 The essential problem is that despite recent scientific advances, the study of the causes of mental disorders remains remarkably complex: for example, while it initially appeared possible to discover the “gene” behind a particular mental disorder, it is now clear that disorders are caused by a complex interaction of genes and the environment.

It therefore seems likely that although the text of 

 will be enriched by the fruits of neurobiological research from the past 20 years, neurobiology and genetics will not inform the development of diagnostic criteria in 

 Diagnostic criteria will therefore continue to be based on clinical findings. Cumulative research into the underlying pathophysiology of disorders may have an impact on the organization of the diagnostic groupings in 

, like diagnostic criteria, are based entirely on superficial symptoms. For example, the only thing that the disorders in the somatoform section of 

have in common is that affected patients are most likely to present in general medical settings. Several of the 

research conferences focused on exploring possible opportunities to reorganize 

 that would reflect commonalities between disorders based on underlying pathophysiological and genetic factors rather than presenting symptoms.

For example, obsessive-compulsive disorder (OCD) is currently classified among the anxiety disorders in 

. This classification is based on the observation that patients with OCD typically present with anxiety resulting from their obsessions and compulsions. Besides this superficial similarity, however, OCD appears to have little in common with the other anxiety disorders in terms of treatment response (eg, OCD responds only to medications that affect the serotonin system whereas other anxiety disorders respond to a broader range of medications), family history, neurocircuitry, and comorbidity patterns. These dissimilarities suggest that OCD belongs in a separate diagnostic grouping.

 research planning conferences, co-chaired by Drs Eric Hollander and Joseph Zohar, examined which disorders in DSM might be considered for inclusion in an obsessive-compulsive spectrum grouping, based on phenomenology, comorbidity, course of illness, treatment response, genetics, neuroimaging, and other validators.

 They proposed the following candidates for inclusion in the OC spectrum:

• Obsessive-compulsive personality disorder (OCPD)
• Hoarding
• Tic disorders
• Sydenham and other pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS)
• Trichotillomania
• Body dysmorphic disorder
• Hypochondriasis
• Autism
• Eating disorders
• Pathological gambling and other behavior addictions
• Substance dependence

Conference participants concluded that the strongest evidence for inclusion in an OC spectrum exists for tics, body dysmorphic disorder, and hypochrondriasis, with less support for hoarding, trichotillomania, PANDAS, and OCPD.

 concerns current dissatisfaction with its categorical nature: that is, in 

a person either has or does not have a particular diagnosis. Categorical systems or typologies are the predominant approach used in medical classifications for several reasons. Classifying the world into categories is a fundamental characteristic of human thinking embodied in the nouns of everyday speech (eg, animals, plants, planets, chemical elements).

The yes/no nature of categorical diagnosis also serves to facilitate clinical decision making, which is typically characterized by a number of yes/no decisions (eg, whether to treat, whether to hospitalize). Moreover, it has traditionally been assumed that most medical diseases are discrete entities. However, while this assumption might be true for a few conditions (eg, Down syndrome, fragile X syndrome, Alzheimer disease, Creutzfeldt-Jakob disease), the vast majority of psychiatric disorders exist on a continuum with no discrete boundaries between disorders (eg, schizophrenia and bipolar disorder) and between disorders and normality (eg, depression).

The imposition of arbitrary diagnostic thresholds, as in 

, leads to high rates of subthreshold and not otherwise specified diagnoses, and high rates of diagnostic comorbidity. For this reason, there has been great interest in incorporating dimensional approaches into 

 Such approaches could improve measurement-based care and allow clinicians to provide a dimensional indication of cross-cutting symptoms, such as impulsivity or lack of insight. The challenge for 

 will be to figure out how to include dimensions that clinicians will find useful rather than burdensome.

 is published in 2012, it will probably be the last of these diagnostic manuals as we know them. The current model for revising 

is to convene workgroups at certain intervals that will review the scientific literature and propose changes to the definitions of every disorder in the manual based on new findings. The obvious problem with this model is that scientific advances are made all the time-and not at the same rate for each class of disorders.

If a new finding concerning the pathophysiology of schizophrenia renders the definition obsolete, why should a new definition have to wait until the American Psychiatric Association (APA) revises the entire manual? Similarly, for disorders in which there has been little scientific research, the convening of workgroups devoted to proposing changes to the criteria would increase the likelihood that changes will be made unnecessarily.

Although this problem has long been recognized, technical constraints on how changes could be disseminated have kept the APA locked into a traditional model in which (like textbooks) the entire manual is periodically revised. Advances in electronic publishing are on the verge of freeing the APA from this model and may allow changes to be made piecemeal to 

 in response to scientific advances. It is therefore likely that future editions of 

 will be distributed as an electronic document that can be updated as needed.

References
				1. Spitzer RL, Williams JBW, Skodol A. DSM-III: the major achievements and an overview. Am J Psychiatry. 1980;137:151-164.
				2. McHugh PR. Striving for coherence: psychiatry’s efforts over classification. JAMA. 2005;293:2526-2528.
				3. Frances A, First MB, Pincus H. DSM-IV Guidebook. Washington, DC: American Psychiatric Press; 1995.
				4. Sunderland T, Jeste D, Baiyewu O, et al, eds. Diagnostic Issues in Dementia: Advancing the Research Agenda for DSM-V. Arlington, VA: American Psychiatric Association; 2007.
				5. Sunderland T, Hampel H, Takeda M, et al. Biomarkers in the diagnosis of Alzheimer’s disease: are we ready? J Geriatr Psychiatry Neurol. 2006;19:172-179.
				6. Charney D, Barlow D, Botteron K, et al. Neuroscience research agenda to guide development of a pathophysiologically based classification system. In: Kupfer D, First MB, Regier DA, eds. A Research Agenda for DSM-V. Washington, DC: American Psychiatric Association; 2002:31-84.
				7. Kendler KS. Reflections on the relationship between psychiatric genetics and psychiatric nosology. Am J Psychiatry. 2006;163:1138-1146.
				8. Hyman SE. Can neuroscience be integrated into the DSM-V? Nat Rev Neurosci. 2007;8:725-732.
				9. Phillips KA, Price L, Greenberg B, Rasmussen S. Should the DSM diagnostic groupings be changed? In: Phillips KA, First MB, Pincus HA, eds. Advancing DSM: Dilemmas in Psychiatric Diagnosis. Washington, DC: American Psychiatric Association; 2003:57-84.
				10. Hollander E, Kim S, Zohar J. OCSDs in the forthcoming DSM-V. CNS Spect. 2007;12:320-323.
				11. Helzer JE, Kraemer HC, Krueger RF. The feasibility and need for dimensional psychiatric diagnoses. Psychol Med. 2006;36:1671-1680.
				12. Sussman N. The developmental process for the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Prim Psychiatry. 2007;14:44-47.
				13. First MB, Westen D. Classification for clinical practice: how to make ICD and DSM better able to serve clinicians. Int Rev Psychiatry. 2007;19:473-481.
				14. First MB. Clinical utility: a prerequisite for the adoption of a dimensional approach in DSM. J Abnorm Psychol. 2005;114:560-564. 


DSM-IV-TR, our current diagnostic classification system of psychiatric disorders, follows the diagnostic paradigm first established by DSM-III in 1980.

Changes in Psychiatric Diagnosis

!" paints a picture of a world that--fortunately for all of us--does not exist. The article is peppered with absurd claims about how the 

 is perceived. According to the author, the 

 is the cause of a large number of extremely serious problems, such as the precipitous decline of psychiatry in the eyes of the general public, primary care, and other specialty physicians and mental health care practitioners. The 

 is even cited as a major reason medical students do not enter psychiatry.

, the author presents no evidence to support his claim that it is universally regarded as useless to clinicians. In fact, the contrary is true. Surveys of clinicians regarding their attitudes toward the 

 is generally viewed as clinically useful. For example, in a 1989 survey of more than 1,000 psychiatric educators, researchers, practitioners and senior residents, 95% reported a "willingness to continue to use the 

 even if it was not required" (Jampala et al., 1992). In a 1989 survey of 460 child psychiatrists, 98% reported that they found "a criterion-based diagnostic system to be useful" (Setterberg et al., 1991). In a more recent survey of 205 psychiatrists from 66 different countries conducted by the World Health Organization and the World Psychiatric Association, 80% reported that the 

 was "highly valuable" or "fairly valuable" for clinical care (Mezzich, 2002).

Our own considerable experience with colleagues, many of whom are involved in teaching medical students and residents, as well as our own experience with primary care physicians (American Psychiatric Association, 1995; Spitzer et al., 1994), runs entirely counter to perception presented in the point article. Medical students generally find the succinct presentation of the 

 criteria to be a useful introduction to psychopathology that enables them to recognize patients with psychiatric disorders and to formulate treatment plans. Not surprisingly, primary care physicians--to the extent that they are familiar with 

 classification far too complicated for their use. But does the reader really believe that psychiatrists who work with other medical colleagues feel the need to apologize for the 

, specialists in other medical domains (e.g., headaches, gastrointestinal disorders) have consulted with us to develop their own classifications, using the 

In the point article, discussion of the changing picture of bipolar disorder (BD) is telling. The author prefers, "with no apology," to idiosyncratically diagnose schizoaffective disorder for drug-taking young patients with BD than use the 

 diagnosis of superimposed drug-induced psychosis or BD with psychotic features. Surely having each clinician creatively adopt their own definitions is no solution and would inevitably lead to a diagnostic Tower of Babel. Although the definition of schizoaffective disorder has been recognized as problematic since 

, the availability of standard diagnostic criteria facilitates much-needed research.

 has no clinical value (and, in fact, is detrimental to the practice of psychiatry), it should be abandoned. While we agree that 

 is far from perfect, we strongly disagree with this assertion. One of the most important goals of the 

 is to facilitate communication among mental health care professionals, between mental health care providers and health care administrators, and between mental health care professionals and the public at large. The 

categories provide a convenient shorthand for describing an individual's symptomatic presentation. When referring a patient to a colleague, saying that "this patient has major depressive disorder" communicates a plethora of important clinical information, including the fact that the patient has either depressed mood or pervasive loss of interest, has a number of other symptoms that cluster with depressed mood (e.g., sleep disturbance, appetite change, cognitive difficulties and so forth), and that the syndrome has persisted for at least a couple of weeks. In addition, the term 

The DSM may be flawed, but it is the best available system for organizing and diagnosing mental disorders, and it remains a model for other medical specialties.

Author | Michael B. First, MD