Dimensional approaches to psychiatric diagnosis in DSM-5.

BACKGROUND: The Diagnostic and Statistical Manual of Mental Disorders is the compendium of disorder listings and diagnostic criteria used by clinicians in the United States and many other countries. The forthcoming fifth edition of the manual (DSM-5) represents an opportunity to not only update diagnostic information in concert with recent advances in the science and practice of psychiatry, but also to more strongly consider the integration of systematically gathered patient self-assessments of symptom severity. AIMS OF THE STUDY: To present information on planned changes to the DSM diagnostic assessment strategies that incorporate patient-reported data.
METHODS: Activities of the DSM-5 work groups and study groups related to patient-reported assessments are summarized. These activities include critical reviews of past research, reviews of assessment instruments, development of assessment strategies incorporating dimensional assessments of patients' clinical symptoms, and testing of proposed strategies.
RESULTS: Limitations of the current DSM diagnostic assessment system are discussed. With the current approach to diagnosis used in DSM-IV, clinicians must decide whether a patient meets the diagnostic criteria set forth for a disorder and then diagnose the disorder as present or absent. This categorical approach to the diagnostic threshold constricts the range of clinical information that may be of high importance to treatment planning, prognosis, and monitoring treatment outcomes. Advantages to incorporation of a dimensional assessment strategy are also discussed. A dimensional approach to psychiatric diagnosis provides clinicians with more information, and with standardized dimensional rating scales, can give patient self-reports a greater role in the clinical process. A description of the proposed methods for integrating dimensional assessments into DSM-5 is presented. Initial pilot testing of these changes to DSM indicate that clinicians and patients/patient informants found the dimensional measures to be useful, simple, and relevant to clinical care. DISCUSSION: The introduction of patient-reported symptom assessments as part of the DSM would represent a major change in psychiatric practice, with implications for patient care, mental health policy, and health care funding. The ultimate goal of such a change is to increase patient satisfaction with care and improve treatment outcomes. These goals will be the subject of continuing evaluation after the DSM-5 is published. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: The use of patient-reported dimensional assessments of symptom severity will aid in more comprehensive and systematized characterizations of baseline clinical status and subsequent changes in clinical status with treatment. IMPLICATIONS FOR HEALTH POLICIES: The use of principles of evidence-based medicine and measurement-based care are likely to increase in the United States as health care reform measures are put into place. The DSM-5 proposals for patient-reported measures can serve as an initial method for gauging the outcomes of treatments. IMPLICATIONS FOR FURTHER RESEARCH: As with previous editions of the DSM, the changes implemented in DSM-5 will continue to be the focus of research efforts after publication. Results from this research will serve as the basis for further refinements in measurement recommendations.