Tightening the DSM
Date: November 29, 2010
It’s a bit like hearing Moses was on his way with the two stone tablets. You can’t have much to do with psychiatry and not know that the DSM-5, the latest version of the Diagnostic and Statistical Manual of Mental Disorders comes out in May 2013.
There’ll be all manner of revisions to reflect advances in neuroscience, brain imaging and genetics. But one key difference in this DSM is that creators see it as more than a catalogue of disorders: It’s also a vehicle to improve clinicians’ grasp of how patients experience their illness.
Recently, psychiatrist Bernadette Cullen and psychiatric epidemiologist Holly Wilcox saw how that might work. This fall, they directed some short-but-necessary research—a precursor to the upcoming field trials of the DSM changes. “You need to ensure the method’s right before rolling out what’s new into larger studies,” says Cullen. The upcoming trials at 11 academic medical centers will involve some 3,000 patients.
The Hopkins “pilot pilot study” recruited 70 patients being seen at the East Baltimore Community Psychiatric Program that Cullen heads. It was more complicated than this, but basically, the patients, on two separate occasions, filled out a DSM-generated survey and then were interviewed by a new clinician. In an unusual move, each clinician used the surveys during interviews—something the DSM folks hope to encourage.
The surveys weren’t typical. Patients—iPads in hand—tapped out answers to “cross-cutting” questionnaires that cover symptoms in a variety of disorders, explains Cullen. Exploring mood, concentration, signs of psychosis, anxiety levels and present health—all were there.
“As clinicians, we’d use the surveys to flag where most of a patient’s symptoms lie,” she adds, “and then, following the interview, turn to an online, tentative DSM-5 to choose our diagnosis.” That version, for the first time, reflects illness severity.
Then, diagnoses made by the two new clinicians were compared.
With fine-tuning, the whole process should transfer well to the field trials. But was the new approach of survey and online checklist a keeper? “I’m not sure doing this would change a diagnosis I would have made,” says Cullen, “but it does increase your awareness of severity. And patients really like the surveys; they feel more engaged.”