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

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          Abstract

          The recent release of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) by the American Psychiatric Association has led to much debate. For this forum article, we asked BMC Medicine Editorial Board members who are experts in the field of psychiatry to discuss their personal views on how the changes in DSM-5 might affect clinical practice in their specific areas of psychiatric medicine. This article discusses the influence the DSM-5 may have on the diagnosis and treatment of autism, trauma-related and stressor-related disorders, obsessive-compulsive and related disorders, mood disorders (including major depression and bipolar disorders), and schizophrenia spectrum disorders.

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          636,120 Ways to Have Posttraumatic Stress Disorder.

          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.
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            Considering PTSD for DSM-5.

            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.
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              Clinical staging of psychiatric disorders: a heuristic framework for choosing earlier, safer and more effective interventions.

              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.
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                Author and article information

                Contributors
                Journal
                BMC Med
                BMC Med
                BMC Medicine
                BioMed Central
                1741-7015
                2013
                12 September 2013
                : 11
                : 202
                Affiliations
                [1 ]Department of Psychiatry and Behavioral Sciences, University of Miami, Leonard M. Miller School of Medicine, Miami, FL, USA
                [2 ]Departments of Psychiatry, Neurology, Neuroscience and The Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Lieber Institute for Brain Development, 855 North Wolfe Street, Baltimore, MD 21205, USA
                [3 ]MRC Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Kings College London, De Crespigny Park, Denmark Hill, London, UK
                [4 ]Departments of Psychiatry and Behavioural Neurosciences, and Department of Pediatrics, Offord Centre for Child Studies, McMaster University, 1280 Main St. West, Hamilton, ON, Canada
                [5 ]School of Psychology, University of New South Wales, Sydney, NSW 2052, Australia
                [6 ]Department of Psychological Medicine, Institute of Psychiatry, King’s College London, Weston Education Centre, Cutcombe Road, London, UK
                [7 ]Department of Psychiatry & Mental Health, University of Cape Town and Groote Schuur Hospital, Observatory, J2, Anzio Rd, Cape Town 7925, South Africa
                [8 ]Department of Psychological Medicine, Institute of Psychiatry, Kings College London, Room 2-055, The James Black Centre, 125 Coldharbour Lane, London, UK
                [9 ]Department of Psychiatry and Psychotherapy, Ludwig-Maximilian-University, Nussbaumstr.7, Munich 80336, Germany
                [10 ]IMPACT Strategic Research Centre, School of Medicine, Deakin University, Barwon Health, Ryrie Street, Geelong, VIC 3220, Australia
                [11 ]Department of Psychiatry, Orygen Research Centre and the Florey Institute for Neuroscience and Mental Health, The University of Melbourne, Parkville, VIC 3052, Australia
                [12 ]Discipline of Psychiatry, Sydney Medical School, University of Sydney, Sydney, Australia
                [13 ]CADE Clinic, Department of Psychiatry, Royal North Shore Hospital, Sydney, Australia
                [14 ]Department of Psychiatry, University Hospital of Lausanne, Site de Cery, Prilly 1008, Switzerland
                [15 ]Division of Cognitive Neuropsychiatry and Psychiatric Preventive Medicine, LWL University Hospital, Ruhr-University Bochum, Alexandrinenstraße 1, Bochum D-44791, Germany
                [16 ]Richard L Roudebush VA Medical Center, Indianapolis, IN, USA
                [17 ]Department of Psychiatry, Indiana University School of Medicine, Indianapolis, IN, USA
                Article
                1741-7015-11-202
                10.1186/1741-7015-11-202
                3846446
                24229007
                f0b82a8e-4bb4-4c11-a5ec-c5f476690443
                Copyright © 2013 Nemeroff et al.; licensee BioMed Central Ltd.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 26 July 2013
                : 16 August 2013
                Categories
                Forum

                Medicine
                dsm-5,psychiatry,autism,ptsd,mood disorders,bipolar,obsessive-compulsive disorders,depression,schizophrenia

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