DSM-5: a collection of psychiatrist views on the changes, controversies, and future directions

In an attempt to capture the variety of symptoms that emerge following traumatic stress, the revision of posttraumatic stress disorder (PTSD) criteria in the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has expanded to include additional symptom presentations. One consequence of this expansion is that it increases the amorphous nature of the classification. Using a binomial equation to elucidate possible symptom combinations, we demonstrate that the DSM-IV criteria listed for PTSD have a high level of symptom profile heterogeneity (79,794 combinations); the changes result in an eightfold expansion in the DSM-5, to 636,120 combinations. In this article, we use the example of PTSD to discuss the limitations of DSM-based diagnostic entities for classification in research by elucidating inherent flaws that are either specific artifacts from the history of the DSM or intrinsic to the underlying logic of the DSM's method of classification. We discuss new directions in research that can provide better information regarding both clinical and nonclinical behavioral heterogeneity in response to potentially traumatic and common stressful life events. These empirical alternatives to an a priori classification system hold promise for answering questions about why diversity occurs in response to stressors.

This is a review of the relevant empirical literature concerning the DSM-IV-TR diagnostic criteria for PTSD. Most of this work has focused on Criteria A1 and A2, the two components of the A (Stressor) Criterion. With regard to A1, the review considers: (a) whether A1 is etiologically or temporally related to the PTSD symptoms; (b) whether it is possible to distinguish "traumatic" from "non-traumatic" stressors; and (c) whether A1 should be eliminated from DSM-5. Empirical literature regarding the utility of the A2 criterion indicates that there is little support for keeping the A2 criterion in DSM-5. The B (reexperiencing), C (avoidance/numbing) and D (hyperarousal) criteria are also reviewed. Confirmatory factor analyses suggest that the latent structure of PTSD appears to consist of four distinct symptom clusters rather than the three-cluster structure found in DSM-IV. It has also been shown that in addition to the fear-based symptoms emphasized in DSM-IV, traumatic exposure is also followed by dysphoric, anhedonic symptoms, aggressive/externalizing symptoms, guilt/shame symptoms, dissociative symptoms, and negative appraisals about oneself and the world. A new set of diagnostic criteria is proposed for DSM-5 that: (a) attempts to sharpen the A1 criterion; (b) eliminates the A2 criterion; (c) proposes four rather than three symptom clusters; and (d) expands the scope of the B-E criteria beyond a fear-based context. The final sections of this review consider: (a) partial/subsyndromal PTSD; (b) disorders of extreme stress not otherwise specified (DESNOS)/complex PTSD; (c) cross- cultural factors; (d) developmental factors; and (e) subtypes of PTSD. © 2010 Wiley-Liss, Inc.

Diagnosis in psychiatry increasingly struggles to fulfil its key purposes, namely, to guide treatment and to predict outcome. The clinical staging model, widely used in clinical medicine yet virtually ignored in psychiatry, is proposed as a more refined form of diagnosis which could restore the utility of diagnosis, promote early intervention and also make more sense of the confusing array of biological research findings in psychiatry by organizing data into a coherent clinicopathological framework. A selective review of key papers in clinical medicine and psychiatry which describe clinical and clinicopathological staging, and a range of related issues. Clinical staging has immediate potential to improve the logic and timing of interventions in psychiatry just as it does in many complex and potentially serious medical disorders. Interventions could be evaluated in terms of their ability to prevent or delay progression from earlier to later stages of disorder, and they could be selected on clear-cut risk/benefit criteria. Biological variables and a range of candidate risk factors could be studied within and across stages, and their role, specificity and centrality in risk, onset and progression of disorder could be greatly clarified. A clinicopathological framework could be progressively constructed. Clinical staging with a restructure across and within diagnostic boundaries with the explicit operationalization of criteria for extent and progression of disorder should be actively explored in psychiatry as a heuristic strategy for the development and evaluation of earlier, safer, and more effective clinical interventions, and for clarifying the biological basis of psychiatric disorders.