The American Psychiatric Association’s proposed diagnostic criteria for the fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM) include a new suicide assessment tool, developed to help clinicians better identify individuals at risk for suicide. A new risk syndromes category, which would include two new diagnoses: psychosis risk syndrome and minor neurocognitive disorder, also has been proposed.
“The future of medicine in every field is moving towards earlier diagnosis to reduce the burden of disease, and DSM-5 is also moving in this direction,” said David Kupfer, M.D., chair of the DSM-5 Task Force.
DSM is the standard classification of mental disorders used by mental health and other health professionals for diagnostic and research purposes. The APA today released the proposed diagnostic criteria, which will be available for public comment until April 20. The proposed criteria will be reviewed and refined over the next two years. During this time, the APA will conduct three phases of field trials to test some of the proposed diagnostic criteria in real-world clinical settings.
Proposed Assessment for Suicide Risk
The proposed DSM-5 revisions include two new scales for assessing individuals’ risk factors for committing suicide, one for adolescents and one for adults. While the current version of DSM includes thoughts of suicide as a symptom of some mental disorders, such as major depression, the proposed suicide risk techniques have been designed to be applied to anyone receiving an evaluation for a mental disorder, regardless of diagnosis, to help clinicians identify those at risk for suicide.
“While clinicians must currently evaluate individuals in their care for suicide risk, there are a number of different scales in use and the evaluation is sometimes not included in the written record,” said David Shaffer, M.D., a member of the Disorders in Childhood and Adolescence Work Group. “The use of a single research-based scale and accompanying record of assessment may help clinicians better assess suicide risk as well as provide important information for researchers to help us more accurately identify and treat those at greatest risk for suicide.”
The proposed suicide assessment scales are based on research identifying significant risk factors for suicide from follow up studies and from “psychological autopsies” in which the past history of suicides and closely matched controls are compared. Important risk factors for young males (who are one of the groups at highest risk for suicide) include impulsive behavior and heavy alcohol use. The assessment tool for adolescents consists of a series of questions answered on paper or on a computer, which has been found to be better than in-person questions for obtaining truthful answers about planned suicide in teens. The risk factors that will be sought in adults include detailed planning of a potential suicide, chronic severe pain or illness, high or increased alcohol use, worsening of depression, increased anxiety and agitated behavior.
New Risk Syndromes Category
The APA is also considering inclusion of a new category in DSM-5 for risk syndromes, in which symptoms are identified which place a person at higher risk of later developing a mental disorder. The first risk conditions proposed for inclusion are psychosis risk syndrome and minor neurocognitive disorder, also known as mild cognitive impairment.
Psychosis Risk Syndrome
Psychosis risk syndrome presents in people as mild versions of the symptoms found in psychotic disorders, such as excessive suspicion, delusions, and disorganized speech or behavior. It is anticipated that 25 to 30 percent of people with these symptoms go on to develop a psychotic disorder. Because many of these symptoms, in their milder forms, can also be found in the normal population, the Psychotic Disorders Work Group recommended that the risk syndrome designation should only be made for those people whose symptoms are distressing or disabling enough to lead to seeking help.
“The concern in trying to identify people at the earliest stages of psychosis is that we may inaccurately diagnose some who are not at risk,” explained William Carpenter, M.D., chair of the Psychotic Disorders Work Group. “But given the severity of psychotic disorders, and evidence that early treatment may mitigate its long-term consequences, we believed that it was important to begin to recognize these conditions as early as possible.” Carpenter noted that the addition of criteria such as help-seeking behavior could help ensure that those being evaluated are already in clinical care and that the criteria would serve to guide a more accurate diagnosis. Over the next two years, the work group will determine whether there is sufficient research data to recommend that psychosis risk syndrome be included in the final criteria in DSM-5, or whether it should instead be included in the manual’s appendix, with a goal of encouraging additional study.
Minor Neurocognitive Disorder
The APA is also considering a new diagnosis to be called minor neurocognitive disorder to identify those people at greatest risk for eventually developing major neurocognitive disorder (dementia), which includes symptoms of severe loss of memory, language, attention, reasoning and level of independence. Major neurocognitive disorders include Alzheimer’s dementia, vascular dementia, frontotemporal dementia, and dementia with Lewy bodies, traumatic brain injury or HIV. The proposed symptoms of minor neurocognitive disorder will be similar, but milder in severity: 1 to 2 standard deviations below the level of the normal population, when adjusted for age and education. Additionally, the criteria include a requirement that the person experience a decline from their previous level of cognition, in order to exclude people with life-long learning disabilities.
“The field of neurocognitive disorders is moving in the direction of earlier diagnosis, with an eventual goal of preventing further damage to the brain as new treatments become available,” said Ronald Petersen, M.D., Ph.D., a member of the Neurocognitive Disorders Work Group. “It is increasingly important to diagnose people at this earlier stage of cognitive impairment. Even without currently available pharmaceutical treatments, early intervention may encourage patients to consider lifestyle changes such as physical exercise and intellectual activities that may reduce cognitive decline, or encourage better planning for the future.”
Public Review of Comments to Draft Changes
All proposed draft changes to DSM are being posted on the Web site www.DSM5.org for public review and comment until April 20. More information on the process for developing DSM-5 is also available on the Web site. Final publication of DSM-5 is planned for May 2013.