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Online ISSN: 1099-176X    Print ISSN: 1091-4358
The Journal of Mental Health Policy and Economics
Volume 14, Issue 4, 2011. Pages: 197-200
Published Online: 30 December 2011

Copyright © 2011 ICMPE.


 

PERSPECTIVES:
Dimensional Approaches to Psychiatric Diagnosis in DSM-5

William E. Narrow,1* Emily A. Kuhl2

1M.D., M.P.H., Associate Director, Division of Research, American Psychiatric Association; Research Director, DSM-5 Task Force, Arlington, VA, USA
2Ph.D., Science Writer, Division of Research, American Psychiatric Association, Arlington, VA, USA

* Correspondence to: William E. Narrow, M.D., M.P.H., Division of Research, American Psychiatric Association, 1000 Wilson Blvd, Suite 1825, Arlington VA 22209
Tel.: +1-703-907 8628
Fax: +1-703-907 1087
E-mail: wnarrow@psych.org

Source of Funding: The authors have no significant affiliations or financial support to disclose.

Abstract

The forthcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) represents an opportunity to update diagnostic practice in accordance with current research evidence, including consideration of integrating standardized patient self-assessments of symptom severity. The categorical approach to diagnosis used in DSM-IV, in which a diagnosis is determined to be present or absent according to specified diagnostic criteria, can neglect additional clinical information that may be of importance to prognosis and to treatment planning and outcomes. A dimensional approach, added to a categorical diagnosis, would provide clinicians with more information, and can give patients a greater role in the clinical process. This article describes proposed methods for integrating standardized dimensional assessments into DSM-5. Initial testing of these changes gave evidence of their usefulness and relevance to clinical care. Future directions in the use of dimensional measures in psychiatric diagnosis after the release of DSM-5 are discussed.

 

Background: The Diagnostic and Statistical Manual of Mental Disorders is the compendium of disorder listings and diagnostic criteria used by clinicians in the United States and many other countries. The forthcoming fifth edition of the manual (DSM-5) represents an opportunity to not only update diagnostic information in concert with recent advances in the science and practice of psychiatry, but also to more strongly consider the integration of systematically gathered patient self-assessments of symptom severity.

Aims of the Study: To present information on planned changes to the DSM diagnostic assessment strategies that incorporate patient-reported data.

Methods: Activities of the DSM-5 work groups and study groups related to patient-reported assessments are summarized. These activities include critical reviews of past research, reviews of assessment instruments, development of assessment strategies incorporating dimensional assessments of patients' clinical symptoms, and testing of proposed strategies.

Results: Limitations of the current DSM diagnostic assessment system are discussed. With the current approach to diagnosis used in DSM-IV, clinicians must decide whether a patient meets the diagnostic criteria set forth for a disorder and then diagnose the disorder as present or absent. This categorical approach to the diagnostic threshold constricts the range of clinical information that may be of high importance to treatment planning, prognosis, and monitoring treatment outcomes. Advantages to incorporation of a dimensional assessment strategy are also discussed. A dimensional approach to psychiatric diagnosis provides clinicians with more information, and with standardized dimensional rating scales, can give patient self-reports a greater role in the clinical process. A description of the proposed methods for integrating dimensional assessments into DSM-5 is presented. Initial pilot testing of these changes to DSM indicate that clinicians and patients/patient informants found the dimensional measures to be useful, simple, and relevant to clinical care.

Discussion: The introduction of patient-reported symptom assessments as part of the DSM would represent a major change in psychiatric practice, with implications for patient care, mental health policy, and health care funding. The ultimate goal of such a change is to increase patient satisfaction with care and improve treatment outcomes. These goals will be the subject of continuing evaluation after the DSM-5 is published.

Implications for Health Care Provision and Use: The use of patient-reported dimensional assessments of symptom severity will aid in more comprehensive and systematized characterizations of baseline clinical status and subsequent changes in clinical status with treatment.

Implications for Health Policies: The use of principles of evidence-based medicine and measurement-based care are likely to increase in the United States as health care reform measures are put into place. The DSM-5 proposals for patient-reported measures can serve as an initial method for gauging the outcomes of treatments.

Implications for Further Research: As with previous editions of the DSM, the changes implemented in DSM-5 will continue to be the focus of research efforts after publication. Results from this research will serve as the basis for further refinements in measurement recommendations.


Received 15 November 2011; accepted 28 November 2011

Copyright 2011 ICMPE