Modest-But Clinically Useful-Changes for Psychotic Disorders in DSM-5

After 14 years of development, the long-awaited and much-debated DSM-5 brought forth some important changes in the schizophrenia and other psychotic disorders section. Led by William Carpenter, MD, the 12-member team, complete with their 300+ years of combined clinical experience, had lofty goals for their section, Rajiv Tandon, MD, a member of the DSM-5 Work Group for Psychotic Disorders, told attendees of the US Psychiatric and Mental Health Congress. The Work Group sought to increase validity, maintain or increase reliability, simplify definitions and criteria, increase utility, and increase concordance with the International Classification of Diseases.

As a result of their countless hours of research and review, the group developed the dimensions that are now part of DSM-5. The 8 dimensions, which are used to define the presentation of psychosis, is the biggest and most clinically important of the changes, noted Tandon, who is also Professor of Psychiatry at the University of Florida College of Medicine and Chief of Psychiatric Services for North Florida/South Georgia Veterans Health System in Gainesville, Florida. Now, clinicians can assess patients for delusions, hallucinations, negative symptoms, disorganization, impaired cognition, depression, mania, and psychomotor symptoms. Accompanied by a 0 to 4 ratings scale, the dimensions were designed to help clinicians refine their diagnoses as well as the resulting treating plans, Tandon explained. At each visit, the clinician can assess and then assign a rating for each dimension. Based on positive and negative changes in the ratings, the clinician may choose to adjust their treatment strategy.

For instance, assume upon presentation a patient receives a score of 4, 3, and 4 delusions, negative symptoms, and hallucinations, respectively. If the clinician finds that delusions and hallucination scores do not improve with treatment, the clinician may consider switching antipsychotics, Tandon explained. If the hallucination rating reduced to 3 but negative symptom rating increased to 4, the clinician would know to consider extrapyramidal symptoms, would become more vigilant in monitoring and screening the patient, and would consider making appropriate changes to the medication, he added. Similarly, if the hallucination rating decreased but the depression rating of 3 remained the same, it might be necessary to consider adding an adjunctive antidepressant. Tandon said this feedback loop has great potential for assisting clinicians in making better treatment decisions.

Partially in response to adding the dimensions, the subtypes found in DSM-IV were removed from DSM-5. During their reviews, the group found that 70% of all diagnoses had no subtype, and only one or two subtypes were ever mentioned at all, Tandon said. He also noted subtypes were not stable. Armed with this knowledge, the committee agreed the subtypes lacked utility and should not be included in this iteration.

Another change revolved around the specifiers. In DSM-5, Tandon said, the diagnosis includes differentiation between first and multiple episodes as well as a designation for remission status (ie, remission, partial remission, and in acute episode). The group felt this change would assist clinicians in making treatment decisions.

With its poor validity and reliability in DSM-IV, the Work Group also tackled the schizoaffective disorder diagnosis, Tandon said. To better differentiate between schizophrenia with mood disorder and schizoaffective disorder, DSM-5 requires a look at the entire course of illness, he explained. Specific mood symptoms must be present for the majority of the illness (at least 50% of the time) to achieve the schizoaffective diagnosis. As a result of this change, Tandon expects there will be less schizoaffective diagnoses and an increase in schizophrenia with major mood disorder. Clinically speaking, that means a change in treatment approach for most patients, he added, with mood stabilizers being used more precisely in these patients.

Meanwhile, Tandon said there has been much controversy surrounded the attenuated psychosis symptom entry. The committee made changes to reflect the fact that less than one third of patients with this diagnosis will later develop psychotic disorder. With so many unanswered questions, the committee wanted to avoid prescribing antipsychotics when they were not necessary, he added. As such, antipsychotics generally should not be used in these patients. Since 60% to 70% of these patients have a psychiatric comorbidity, Tandon said clinicians should focus on treating the comorbidities. He also emphasized the importance of closely monitoring the patients for the next year, as these patients have a 500-fold greater risk of developing a psychotic disorder as compared to the general population. He reminded attendees that early identification of the disorder is important for avoiding some of the deleterious symptoms and changes associated with the early phases of schizophrenia and psychotic disorders.

Tandon noted a few other minor changes in DSM-5, such as in criterion F, which was expanded and now provides some specifics on how to differentiate autism spectrum disorders from psychotic disorders. In addition, Catatonia was standardized throughout DSM-5, eliminating discrepancies and confusions found in DSM-IV, he said. “Catatonia NEC” was created to allow clinicians greater flexibility. And, while “Not Otherwise Specified” was largely removed for psychotic disorders, Tandon said clinicians can still use this designation if they deem it necessary.

Although the Work Group started out to substantially simplify the psychotic disorders section, Tandon said the changes they finally agreed upon at the end of the long review process were relatively modest. “We were very ambitious and had grandiose goals,” he said about their onset. Yet, he added, the changes that were made were clinically useful and should assist clinicians in improving care for their patients.