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Lessons for ICD-11 coming after DSM-5

Bernard J Carroll Aust N Z J Psychiatry 2014 48: 90 DOI: 10.1177/0004867413515953 The online version of this article can be found at: http://anp.sagepub.com/content/48/1/90

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90

ANZJP Correspondence optimally using DSM-5 or ICD-11 is for clinicians and researchers alike to treat these diagnostic systems as crude approximations based on best current guesses, and not to reify and concretize these criteria or to treat them as revealed truths. Funding
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
with major depressive episodes in the Bridge Study: Validity and comorbidity. European Archives of Psychiatry and Clinical Neurosciences 263: 663673. Axelson DA, Birmaher B, Findling RL, etal. (2011) Concerns regarding the inclusion of temper dysregulation disorder with dysphoria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Journal of Clinical Psychiatry 72: 12571262. Cuthbert BN and Insel TR (2013) Toward the future of psychiatric diagnosis: The seven pillars of RDoC. BMC Medicine. Epub ahead of print 14 May 2013. DOI: 10.1186/1741-7015-11-126. Leibenluft E (2011) Severe mood dysregulation, irritability, and the diagnostic boundaries of bipolar disorder in youths. American Journal of Psychiatry 168: 129142. Malhi GS (2013) Diagnosis of bipolar disorder: Who is in a mixed state? The Lancet 381: 15991600. Zimmerman M (2012) Would broadening the diagnostic criteria for bipolar disorder do more harm than good? Implications from longitudinal studies of subthreshold conditions. Journal of Clinical Psychiatry 73: 437443.

Conclusions
In the absence of clear evidence for the validity of diagnostic categories, all diagnostic systems including DSM-5 and ICD-11 will be inherently imperfect creations with compromises based on our fields ignorance, not necessarily willful thoughtlessness. Alternatively, the US National Institute of Mental Health has proposed an entirely different system of classification, the Research Domain Criteria, consisting of five behavioral dimensions (e.g. arousal/modulatory systems) for which the underlying neural circuitry has been articulated (Cuthbert and Insel, 2013). Whether this will be an improvement upon the symptom-based systems of DSM-5 or ICD-11 will be unclear for many years. Until we have firmer answers to these questions, the key in

Declaration of interest
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

References
Angst J, Gamma A, Bowden CL, et al. (2013) Evidence-based definitions of bipolar-I and bipolar-II disorders among 5,635 patients

Lessons for ICD-11 coming after DSM-5 Bernard J Carroll

Pacific Behavioral Research Foundation, Carmel, USA Corresponding author: Bernard J Carroll, Pacific Behavioral Research Foundation, 100 Del Mesa Carmel, Carmel, CA 93923, USA. Email: bcarroll40@comcast.net DOI: 10.1177/0004867413515953

ICD Insights

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM5) has arrived, and we await the International Classification of Diseases, 11th Revision (ICD-11). Without trying to be exhaustive, here are suggestions for improving matters. 1. Avoid the nominalist fallacy (I name, therefore I know). Classifications are always provisional, to be improved over time by convergent validation and new science.

2. Expand the frame of reference for convergent validation. In DSM-III through DSM-5, four key sources of information were mostly excluded. These are: course of illness, response to treatment, family history, and biomarkers (Robins and Guze, 1970). 3. Avoid the appearance of closure. Like classifications, diagnoses also are always provisional. Diagnoses are casewise probability statements, open to revision as new information arrives (Carroll, 2013). 4. Maintain a clear distinction between making a diagnosis and defining a disorder. This speaks to a fundamental category error that appeared soon after DSM-III and that still persists in the form of checklist menu diagnoses ironically mostly in research settings. DSM-5 did not fix that (Carroll, 2012a). 5. Allow for uncertainty. DSM-5 gives the impression that initial, crosssectional diagnoses are the norm. Neurologists, in contrast, do not allow the diagnosis of probable Parkinsons disease (PD) without at least 3 years of observation

(Gelb etal., 1999). In keeping with this provisional approach, the likelihood of PD is specified initially as possible, probable, or definite. During the 3 years of observation in patients with possible PD, neurologists document significant clinical events that would modify or support the possible diagnosis. A similar approach is needed for psychiatric presentations with psychosis, mood disturbance, anxiety, cognitive decline, and more. 6. Get numerate! The perversion of checklist diagnoses is fostered by the innumerate style of DSM-5, which provides no sensitivity and specificity data for definitional signs and symptoms. In making clinical diagnoses, not all signs and symptoms carry equal weight, but learners would never know that from reading the diagnostic criteria in DSM-5. Neurologists have operationalized this understanding by specifying cardinal symptoms and accessory symptoms (Gelb etal., 1999). 7. Do not allow reliability to trump validity. As DSM-III taught us, that

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ANZJP Correspondence course is a fools trade-off, evidenced most notably by 35 wasted years of research into a fictive entity labeled major depressive disorder. DSM-5 did not fix that. 8. Get serious about diagnostic unreliability! It is not enough just to declare mediocre kappa values or worse and quickly move on, as happened in DSM-5. One can demonstrate conclusively by mathematical modeling that such poor diagnostic agreement is an insurmountable obstacle in research settings (Carroll, 1989). 9. Get serious about diagnostic instability! We have known for decades that stability data are poor, even with contemporary operational criteria for diagnosis, but we averted our gaze. An essential part of every description of a disorder needs to be an account of how the diagnosis is known to change over time. Systematic data on this issue for most diagnoses are hard to find. 10. Balance the idiographic and nomothetic aspects of nosology. It would be a plus for ICD-11 to keep the case vignette approach of ICD-10, while avoiding the DSM-5 emphasis on fixed numbers of decontextualized qualifying symptoms. 11. Get Bayesian! A key part of Bayesian thinking is recognition of casewise prior probabilities. That is crucial in the process of sorting through differential diagnoses (Carroll, 2013). 12. Get with biomarkers! Biomarkers are absent from DSM-5, yet current biomarkers perform at least as well as many definitional signs and symptoms. Adding biomarkers to signs and symptoms in defining disorders will bring psychiatry into alignment with the rest of medicine. On the other hand, demanding perfection of biomarkers while tolerating demonstrably insensitive and non-specific definitional signs and symptoms will be self-defeating (Carroll, 2013). That is especially true if we remain blind to the problems of diagnostic unreliability and longitudinal instability. 13. Keep commerce out of the process. Nobody owns diagnostic criteria. The American Psychiatric Association (APA) threw its weight around with threats of SLAPP (strategic lawsuits against public participation) lawsuits and the like during the DSM-5 process, aiming to deter critics in advance of publication of the manual. This uncollegial behavior was driven by the corporate commercial interest of the APA (Carroll, 2012b). 14. Keep the process truly open. Science progresses bottom-up rather than top-down. So, the organizers of Disorders, Fifth Edition (DSM-5) changes in relation to autism spectrum disorder (ASD) is timely, the Commentary by Basu and Parry (2013) focuses on apparent overdiagnoses prior to DSM5, with an increased prevalence from two to five per 10,000 in 1960 to 50 to 114 per 10,000 in recent years. This diagnostic upcoding is postulated as being due to educational and welfare resource allocation needs, particularly in the Aspergers disorder category. The removal of Aspergers syndrome from the DSM-5 and its replacement by more strict criteria is predicted by the authors to correct a growing epidemic of ASDs, with a deleterious effect
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91 ICD-11 should view themselves as facilitating editors rather than as bosses who call the shots. In this respect, the ICD process seems preferable to the DSM process. There should be no commercial subtexts or undeclared professional guild issues in the ICD process. Funding
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.

Declaration of interest
The author declares no competing financial or professional interests. This commentary was commissioned by the Editor-in-Chief.

References
Carroll BJ (1989) Diagnostic validity and laboratory studies: Rules of the game. In: Robins LN and Barrett JE (eds) The Validity of Psychiatric Diagnosis. New York: Raven Press, pp.229245. Carroll BJ (2012a) Bringing back melancholia. Bipolar Disorders 14: 15. Carroll BJ (2012b) Self inflicted damage. Health Care Renewal, 4 January. Available at: hcrenewal.blogspot.com/2012/01/self-inflicted-damage.html (accessed 27 November 2013). Carroll BJ (2013) Biomarkers in DSM-5: Lost in translation. Australian and New Zealand Journal of Psychiatry 47: 676681. Gelb DJ, Oliver E and Gilman S (1999) Diagnostic criteria for Parkinson disease. Archives of Neurology 56: 3339. Robins E and Guze S (1970) Establishment of diagnostic validity in psychiatric illness: Its application to schizophrenia. American Journal of Psychiatry 126: 983987.

The autism spectrum disorder epidemic: Need for biopsychosocial formulation Florence Levy
School of Psychiatry, Prince of Wales Hospital, Sydney, Australia Corresponding author: Florence Levy, School of Psychiatry, Prince of Wales Hospital, Sydney, NSW 2031, Australia. Email: f.levy@unsw.edu.au DOI: 10.1177/0004867413506756

While a discussion of the Diagnostic and Statistical Manual of Mental

on a childs psychosocial development via self, family, teacher, peer and others reduced expectations, as well as denial of trauma, maltreatment and insecure attachment. While concerns about over- and misdiagnosis are understandable, there are con sides to the argument. First, the strict nature of the new criteria may disadvantage younger children whose symptomatic phenomena may still be emerging. Second, the overlap with language disorder is downplayed in the DSM-5, possibly leading to diminished funding for speech pathologists in this population one of the more useful treatments for younger

Australian & New Zealand Journal of Psychiatry, 48(1)