麻豆传媒

NEW ORLEANS -- At the American Psychiatric Association (APA) annual meeting, 麻豆传媒 sat down with Paul Appelbaum, MD, chair of the Diagnostic and Statistical Manual of Mental Disorders (DSM) steering committee. He spoke about the latest updates to the manual, released in March, and what the future might hold for the field of psychiatry.

updates the 2013 DSM-5 with a fully revised text and updated criteria to diagnose disorders that impact mood, personality, identity, and cognition.

The Text Revision includes a new diagnosis for prolonged grief disorder, as well as clarifying revisions to the diagnostic criteria sets for over 70 disorders. It also includes ICD-10-CM symptom codes for suicidal behavior and non-suicidal self-injury, plus updates to descriptive text for most disorders.

Can you discuss some of the featured updates in the DSM-5-TR?

Appelbaum: Obviously, the major new material in the text revision is the text, which has been completely updated since the publication of DSM-5 in 2013. Since then, there's been an enormous amount of research that has taken place on most of the diagnostic categories in the book. The major focus here was updating the text [and] the references, to ensure that people who have the DSM have access to the latest evidence that's available with regard to the various diagnostic categories.

There was also an update of terminology, because things change over time. So terminology -- with regard to sex and gender, with regard to race and ethnicity -- was updated, as well.

There are also several new sections in the text, including a section on sex and gender. When those vary the presentation of a particular diagnosis, that's now noted. There's a section for each disorder on suicide and whether and in what way the particular disorder potentiates the risk of suicide. Those are the major text changes.

Because the new volume was coming out, we also had an opportunity to include work that has been done since 2013. And we have a process by which iterative changes can be made to the DSM. People in the field present data to us that supports the change that they're proposing -- a modification of diagnostic criteria, a new diagnosis, take out an old diagnosis, add a specifier, etc. -- and those changes were included in this issue, as well.

For example, the one new diagnosis is prolonged grief disorder, which was the result of a two-and-a-half year-long process by which some of the researchers in the field proposed the addition of this category. We brought together major research teams in a workshop to present their data, talk through their approach. Some modifications to the proposal were made that went back to the research groups, who tested it in their existing data sets and demonstrated the validity and reliability of the proposed diagnostic criteria. And then ultimately it was adopted, so that's included as well.

There were also a large number of changes -- probably more than 70 -- that were minor modifications but where, through the text revision process, it was noticed that two descriptions that should be identical had variation in their wording or an inconsistency was noted in a particular description of a diagnosis. And so those modifications were made, as well. You might think of that as "clean up." In a book the size of the DSM, it's inevitable when a new edition comes out that there will be errors or things will be overlooked. Fortunately, they were all relatively minor, but they are now cleaned up in the DSM-5-TR.

Any plans for the DSM-6?

Appelbaum: No, although there was a long-standing tradition where the DSM editions would follow one another every 10 to 15 [years]. For DSM-5, it was close to 20 years as part of a major reconsideration of the diagnostic categories. Following DSM-5, the APA board made the decision to move to this iterative process, where as data becomes available, they can be presented and changes can be made.

There may come a point at which larger-scale changes are required by a reconceptualization of psychiatric disorders or some other factor. At that point, it's certainly possible there will be a DSM-6.

But for now, the focus is on iterative revision of what's there, only when there is sufficient data to support that change.

In your opinion, what is the hottest topic in psychiatry today?

Appelbaum: There are enormous amounts of research going on in psychiatric genetics today, with progress being made for many disorders in identifying genetic variants that are associated with a disorder. And these groups are, in many cases, developing what are called polygenetic risk scores that would allow some degree of accuracy in prediction of who is likely to experience a particular disorder. I say some degree of accuracy, because today those figures are pretty low -- they account for only a small percentage of the variance.

But as the predictive accuracy increases -- and in particular as genetic data are combined with other clinical or family history or neurophysiological information -- it may become possible to predict with increasing accuracy who is likely to develop a psychiatric disorder.

That holds exciting implications for prevention and treatment. It also holds implications that may be worrying to people with regard to what the consequence is to your telling me at age 18 that I'm at high risk for bipolar disorder or telling my parents when I'm 3 years old that I'm at high risk for schizophrenia. Those pieces of information can have profound impacts on people, and we're going to have to learn how to ameliorate the consequences.

What do you think the future holds for the field of psychiatry?

Appelbaum: I think we will continue to see advances in the biological understanding of mental disorders. And I hope that we will see those biological factors increasingly combine with environmental variables to give us a more complete understanding. Because if there's anything that's clear, it's that most psychiatric disorders are not just driven by biology -- there's a combination of biological predispositions and environmental pressures.

That's what we have to understand. And I think we're moving towards that.

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