March 12, 2010

Updating psychiatry manual no easy task

Stephan Heckers, MD, MS

Updating psychiatry manual no easy task

The chairman of Vanderbilt's Department of Psychiatry played a key role in working on the fifth edition of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders.”

The DSM, first published in 1952, provides a common language and standard criteria for the classification of mental disorders.

Stephan Heckers, M.D., chair of the Department of Psychiatry, is serving on the Psychotic Disorders Work Group, responsible for reviewing schizophrenia and other psychotic disorders. This is the first major revision of the DSM in more than a decade. The proposed revisions,

Stephan Heckers, M.D.

Stephan Heckers, M.D.

The major change, proposed by the DSM work groups, is a shift toward dimensions of mental illness.

“The DSM is trying to move toward a system that uses dimensions, rather than categories,” Heckers said. “For many of the current diagnoses — bipolar disorder, for example — it's a categorical decision: Either you're in or you're out. What we really need to understand is that human behavior is a dimension that goes from one extreme to the other — for example, from very shy to very outgoing or risk seeking. You can place people along several of such dimensions.”

This concept fits well with personalized medicine, Heckers said. “For personalized medicine — to develop a treatment plan, to choose the right medication — we need a dimensional approach, a more personalized, individualized assessment.”

The DSM work groups covered another controversial proposed change, the notion of “risk syndromes.”

The group proposes that it is possible to identify a person at risk for psychiatric illness, and that it might be possible to diagnose the risk state before the illness presents itself — similar to trying to thwart heart attacks in patients by measuring blood pressure, cholesterol levels, etc.

“The premise is, if we do a good job, then we can prevent people from developing these full-blown illnesses. The idea is well accepted in medicine,” Heckers said.

One work group is proposing to add “mild cognitive impairment” as a diagnosis. “This diagnosis captures a person on the edge, who has an increased risk of developing Alzheimer's disease. It's not a given, but this person would have a much higher chance than the rest of the population,” Heckers said.

“The controversy about psychiatric risk syndromes is driven by the stigma that comes with the label, and by the question of how effective our treatments are at this point,” Heckers said.

“If you want to control your cholesterol level, you can take a statin. They have side effects, but at the end of the day they are more helpful than harmful. For psychiatric treatments, it's more difficult to make this case. It's not so clear that, even if we diagnose an early stage of a schizophrenia-like illness, that we can actually prevent it, and we know all of the medications have adverse effects.”

Coming up with the proposals for DSM-V has been a lengthy and thorough process that isn't taken lightly by Heckers and the other 160 top mental health researchers and clinicians from around the world who are members of the DSM-5 Task Force, work groups and study groups. The groups met for more than two years to come up with proposed revisions.

The draft criteria will be reviewed and refined over the next two years, as two phases of field trials are conducted to test some of the proposed diagnostic criteria in real-world clinical settings.

The work groups were asked to follow guidelines for recommended revisions to the DSM-5: making sure the manual is based on scientific evidence; is useful to clinicians; and maintains continuity with DSM-IV, where feasible.

The DSM came about after World War II to provide some guidance for psychiatrists dealing with patients, among them soldiers, presenting with what is now called post-traumatic stress disorder. There were about 60 diagnoses listed in the first edition. Now there are more than 400.