BACKGROUND:Personality disorders are highly prevalent worldwide imposing substantial personal and social challenges. Schema Therapy is an effective psychotherapeutic approach for personality pathology and other complex characterological problems. New scientific insights prompted a re-evaluation of its theoretical underpinnings leading to a reformulated Schema Therapy theory. Furthermore, the assumed cross-cultural universality of the Schema Therapy model has not been tested. AIMS:This project has two primary aims: (1) To develop revised instruments based on the reformulated theory that are psychometrically sound and valid across diverse cultures and languages. (2) To validate the Schema Therapy-related constructs and their inter-relationships across cultures. METHODS:New draft versions of the Young Schema Questionnaire, Schema Coping Inventory, and Schema Mode Inventory were developed. Before dissemination, these instruments will undergo rigorous psychometric evaluation to refine item sets and ensure linguistic and conceptual consistency. A minimum of 100 adult mental health patients and 100 non-patients from each participating country will complete the revised instruments. Sociodemographic and mental health-related variables will also be assessed. Statistical analyses will evaluate (a) internal consistency, (b) unidimensionality, (c) cross-cultural invariance, (d) factorial validity (if possible), and (e) known-group validity. Malfunctioning items will be deleted, and subscales will be shortened, if possible, targeting internal consistency of ≥.80. EXPECTED OUTCOMES:This study is expected to yield optimized versions of the three instruments aligned with the reformulated theory. These findings will inform subsequent international studies to further assess the structural and cross-cultural validity of the revised scales. The resulting empirically validated scales will be openly accessible, facilitating worldwide utilization. DISCUSSION:This protocol outlines the first international study based on the reformulated theory, aiming to extend the psychopathological coverage and enhance the cross-cultural application of evidence-based treatments for personality pathology. Results will be disseminated through peer-reviewed publications and conference presentations. Potential limitations are discussed.

OBJECTIVE:To review the history of the term atypical anorexia nervosa and the challenges surrounding its current description and to propose a new name and diagnostic criteria. METHOD:We review the use of the term "atypical" in the literature on eating disorders and in the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM) and note several terms in the current description that are in need of clarification. We also describe how the ICD-11 has grappled with atypical anorexia nervosa. RESULTS:The first use of atypical anorexia nervosa was by Hilde Brȕch to describe individuals who had lost substantial weight but who lacked the characteristic psychological features of anorexia nervosa. In the section on Eating Disorders Not Otherwise Specified, the DSM-IV included a description of a disorder very similar to the description of atypical anorexia nervosa; the DSM-5 slightly changed the wording and applied the term atypical anorexia nervosa. Features in the description in need of definition include "significant weight loss" and "normal or above normal weight," and the current name is problematic. DISCUSSION:We discuss these issues and several potential options for defining features in the current description and for a new name. Following other examples in the DSM-5-TR, we propose the disorder be named "anorexia nervosa-like eating disorder (weight in normal or above normal range)" (acronym: ANLED) and suggest diagnostic criteria which could be included in the DSM-5-TR section on Conditions for Further Study.

Major depressive disorder (MDD) is a leading cause of disability worldwide. Risk for MDD is heritable, and the genetic structure of founder populations enables investigation of rare susceptibility alleles with large effect. In an extended Old Order Mennonite family cohort, we identified a rare missense variant in GPR156 (c.1599G>T, p.Glu533Asp) associated with a two-fold increase in the relative risk of MDD. GPR156 is an orphan G protein-coupled receptor localized in the medial habenula, a region implicated in mood regulation. Insertion of a human sequence containing c.1599G>T into the murine Gpr156 locus induced medial habenula hyperactivity and abnormal stress-related behaviors. This work reveals a human variant that is associated with depression, implicates GPR156 as a target for mood regulation, and introduces informative murine models for investigating the pathophysiology and treatment of affective disorders.

Although social determinants of health (SDOH) have a significant impact on health outcomes and many are already included among the "Other Conditions That May Be a Focus of Clinical Attention" in the DSM-5, general awareness of these codes and the importance of using them to communicate SDOH has not occurred. This Open Forum proposes that the DSM-5 adopt a biaxial system of assessment to enhance their consideration and reporting. A biaxial approach, the authors argue, when combined with financial incentives, will increase the likelihood of SDOH reporting and potentially improve care.

Objectives: Lifetime DSM-5 diagnoses generated by the lay-administered Composite International Diagnostic Interview for DSM-5 (CIDI) in the World Mental Health Qatar (WMHQ) study were compared to diagnoses based on blinded clinician-administered reappraisal interviews. Methods: Telephone follow-up interviews used the non-patient edition of the Structured Clinician Interview for DSM-5 (SCID) oversampling respondents who screened positive for five diagnoses in the CIDI: major depressive episode, mania/hypomania, panic disorder, generalized anxiety disorder, and obsessive-compulsive disorder. Concordance was also examined for a diagnoses of post-traumatic stress disorder based on a short-form versus full version of the PTSD Checklist for DSM-5 (PCL-5). Results: Initial CIDI prevalence estimates differed significantly from the SCID for most diagnoses ( chi(2)(1) = 6.6-31.4, p = 0.010 < 0.001), but recalibration reduced most of these differences and led to consistent increases in individual-level concordance (AU-ROC) from 0.53-0.76 to 0.67-0.81. Recalibration of the short-form PCL-5 removed an initially significant difference in PTSD prevalence with the full PCL-5 (from chi(2)(1) = 610.5, p < 0.001 to chi(2)(1) = 2.5, p = 0.110) while also increasing AU-ROC from 0.76 to 0.81. Conclusions: Recalibration resulted in valid diagnoses of common mental disorders in the Qatar National Mental Health Survey, but with inflated prevalence estimates for some disorders that need to be considered when interpreting results.

The use of electronic devices and social media is becoming a ubiquitous part of most people's lives. Although researchers are exploring the sequelae of such use, little attention has been given to the importance of digital media use in routine psychiatric assessments of patients. The nature of technology use is relevant to understanding a patient's lifestyle and activities, the same way that it is important to evaluate the patient's occupation, functioning, and general activities. The authors propose a framework for psychiatric inquiry into digital media use, emphasizing that such inquiry should focus on quality of use, including emotional and behavioral consequences, rather than simply the amount of use.

Abstract Objective The Mental and Substance Use Disorders Prevalence Study (MDPS) builds upon previous epidemiologic studies to provide estimates of prevalence and treatment rates of mental and substance use disorders among adults aged 18–65 in the U.S. The study background and methods are described. Method The MDPS employed novel techniques such as the inclusion of household, prison, homeless and state psychiatric hospital populations, a semi‐structured clinical interview administered by trained clinical interviewers to assess disorders, the assessment of both past year and lifetime schizophrenia spectrum disorder (SSD) using full Diagnostic and Statistical Manual 5 criteria, as well as other mental and substance use disorders, and video‐based interviewing. Population specific and combined sample weights were developed to estimate nationally representative prevalence and treatment rates. Results Data collection was conducted between October 2020 and October 2022 resulting in 5679 clinical interviews. The statistical weighting and analytic plan are described. Weighted response rates and reasons for non‐response are provided for each study population. Conclusions The MDPS successfully developed and employed novel techniques to estimate the prevalence and treatment rates of mental and substance use disorders in both household and non‐household populations, including some of the most impairing disorders such as SSD.

A video featuring the author of the DSM-5 Handbook, Dr Michael First describes differential diagnosis and assessment, central components of clinical practice.

ABSTRACT:Recent surveys show rising numbers of young people who report anxiety and depression. Although much attention has focused on mental health of adolescent youth, less attention has been paid to young people as they transition into adulthood. Multiple factors may have contributed to this steady increase: greater exposure to social media, information, and distressing news via personal electronic devices; increased concerns regarding social determinants of health and climate change; and changing social norms due to increased mental health literacy and reduced stigma. The COVID-19 pandemic may have temporarily exacerbated symptoms and impacted treatment availability. Strategies to mitigate causal factors for depression and anxiety in young adults may include education and skills training for cognitive, behavioral, and social coping strategies, as well as healthier use of technology and social media. Policies must support the availability of health insurance and treatment, and clinicians can adapt interventions to encompass the specific concerns and needs of young adults.

The DSM-5 text revision (DSM-5-TR) is the first published revision of the DSM-5 since its publication in 2013. Like the previous text revision (DSM-IV-TR), the main goal of the DSM-5-TR is to comprehensively update the descriptive text accompanying each DSM disorder on the basis of reviews of the literature over the past 10 years. In contrast to the DSM-IV-TR, in which updates were confined almost exclusively to the text, the DSM-5-TR includes many other changes and enhancements of interest to practicing clinicians, such as the addition of diagnostic categories (prolonged grief disorder, stimulant-induced mild neurocognitive disorder, unspecified mood disorder, and a category to indicate the absence of a diagnosis); the provision of ICD-10-CM symptom codes for reporting suicidal and nonsuicidal self-injurious behavior; modifications, mostly for clarity, of the diagnostic criteria for more than 70 disorders; and updates in terminology (e.g., replacing "neuroleptic medications" with "antipsychotic medications or other dopamine receptor blocking agents" throughout the text and replacing "desired gender" with "experienced gender" in the text for gender dysphoria). Finally, the entire text was reviewed by an Ethnoracial Equity and Inclusion Work Group to ensure appropriate attention to risk factors such as the experience of racism and discrimination, as well as the use of nonstigmatizing language.

ABSTRACT:In the early 1990s, a research group that included Holly Prigerson and Charles Reynolds established that disordered grief overlaps with depression and anxiety but is not the same. They also developed a research inventory for studying disordered grief. Subsequently, Prigerson focused on measuring disordered grief using advanced psychometric techniques. Because treatment for grief-related depression reduced symptoms of depression but not grief, Katherine Shear was recruited to develop a more effective therapy. Prigerson came to conceptualize disordered grief as prolonged grief that is associated with negative outcomes. Shear came to conceptualize disordered grief as intense grief that is complicated by features that interfere with adaption to the loss. In 2013 a hybrid disorder composed of criteria from both groups was placed in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) appendix. Under the leadership of the DSM Steering Committee, a summit meeting in 2019 helped break an impasse, and a revised prolonged grief disorder became an official DSM diagnosis.

Abstract Background The Composite International Diagnostic Interview (CIDI) has been clinically reappraised in several studies conducted mainly in the US and Europe. This report describes the methodology used to conduct one of the Middle East's largest clinical reappraisal studies. The study was carried out in conjunction with the World Mental Health Qatar—the first national psychiatric epidemiological study of common mental disorders in the country. This study aimed to evaluate the diagnostic consistency of core modules of the newly translated and adapted Arabic version of the CIDI 5.0 against the independent clinical diagnoses based on the Structured Clinical Interview for DSM‐5 (SCID‐5). Methods Telephone follow‐up interviews were administered by trained clinicians using the latest research edition of the SCID for DSM‐5. Telephone administered interviews were key in the data collection, as the study took place during the COVID‐19 pandemic. Results Overall, within 12 months, 485 interviews were completed. The response rate was 52%. Quality control monitoring documented excellent adherence of clinical interviews to the rating protocol. Conclusions The overall methods used in this study proved to be efficient and effective. For future research, instrument cultural adaptation within the cultural context is highly recommended.

Changes made to the DSM Eating Disorders over the years have aimed to reduce the prevalence of the residual DSM Eating Disorder categories (e.g., Other Specified Eating Disorder). Atypical Anorexia Nervosa (AN), included since DSM-IV as an example of a presentation not meeting criteria for a specific eating disorder, appears to be more prevalent than AN. It is defined as meeting all of the criteria for AN except that, after significant weight loss, weight is at or above normal. As suggested by the Walsh et al. review, lack of definitional precision will likely complicate efforts to determine whether atypical AN is best considered a variant of AN or a distinct category. Problems with the current definition of atypical AN include (1) a lack of precision regarding what constitutes "significant " weight loss; (2) whether the weight loss can occur at any point in the individual's lifetime; and (3) whether there an upper limit to weight being above normal. It is suggested that researchers develop consensus diagnostic criteria and assessment tools to facilitate the collection of empirical data about atypical AN in order to lay the groundwork for future decisions about its nosological status.

There are various ways that a psychiatric classification can be constructed. Disorders can be defined in terms of their underlying etiological factors or in terms of descriptive symptoms, they can be defined in terms of individual symptoms or syndromes (i.e., groups of symptoms that co–vary together), and they can be defined categorically (i.e., with sharp boundaries between normal and disorder and between disorders) or dimensionally. This chapter focuses on the current classification system used in the United States, the DSM-IV, beginning with a historical overview covering its immediate predecessors (i.e., DSM-I through DSM-III), an overview of the organization and contents of the DSM-IV, and a look toward the future of DSM-V and ICD-11.

The Hierarchical Taxonomy of Psychopathology (HiTOP) has emerged out of the quantitative approach to psychiatric nosology. This approach identifies psychopathology constructs based on patterns of co-variation among signs and symptoms. The initial HiTOP model, which was published in 2017, is based on a large literature that spans decades of research. HiTOP is a living model that undergoes revision as new data become available. Here we discuss advantages and practical considerations of using this system in psychiatric practice and research. We especially highlight limitations of HiTOP and ongoing efforts to address them. We describe differences and similarities between HiTOP and existing diagnostic systems. Next, we review the types of evidence that informed development of HiTOP, including populations in which it has been studied and data on its validity. The paper also describes how HiTOP can facilitate research on genetic and environmental causes of psychopathology as well as the search for neurobiologic mechanisms and novel treatments. Furthermore, we consider implications for public health programs and prevention of mental disorders. We also review data on clinical utility and illustrate clinical application of HiTOP. Importantly, the model is based on measures and practices that are already used widely in clinical settings. HiTOP offers a way to organize and formalize these techniques. This model already can contribute to progress in psychiatry and complement traditional nosologies. Moreover, HiTOP seeks to facilitate research on linkages between phenotypes and biological processes, which may enable construction of a system that encompasses both biomarkers and precise clinical description.

Structural racism has received renewed focus over the past year, fueled by the convergence of major political and social events. Psychiatry as a field has been forced to confront a legacy of systemic inequities. Here, we use examples from our clinical and supervisory work to highlight the urgent need to integrate techniques addressing racial identity and racism into psychiatric practice and teaching. This urgency is underlined by extensive evidence of psychiatry's long-standing systemic inequities. We argue that our field suffers not from a lack of available techniques, but rather a lack of sustained commitment to understand and integrate those techniques into our work; indeed, there are multiple published examples of strategies to address racism and racial identity in psychiatric clinical practice. We conclude with recommendations geared toward more firmly institutionalizing a focus on racism and racial identity in psychiatry, and suggest applications of existing techniques to our initial clinical examples.

The DSM-5 Text Revision (DSM-5-TR)1 is the first published revision of DSM-5 since its original publication in 2013. Like the previous text revision (DSM-IV-TR), the main goal of DSM-5-TR is to comprehensively update the descriptive text that is provided for each DSM disorder based on reviews of the literature since the release of the prior version. However, in contrast to DSM-IV-TR, in which updates were confined almost exclusively to the text2, there are a number of significant changes and improvements in DSM-5-TR that are of interest to practicing clinicians and researchers. These changes include the addition of diagnostic entities, and modifications and updated terminology in diagnostic criteria and specifier definitions. The updates to the diagnostic criteria and text in DSM-5-TR are the product of two separate but concurrent processes: the iterative revision process that allows the addition or deletion of disorders and specifiers as well as changes in diagnostic criteria to be made on an ongoing basis3, which commenced soon after the publication of DSM-5, and a complementary text revision process which began in 2019. While most of the changes instituted since publication of DSM-5 and included in this text revision involve relatively minor changes and serve to correct errors, clarify ambiguities, or resolve inconsistencies between the diagnostic criteria and text, some are significant enough to have an impact on clinical practice4. Here we outline the main changes in DSM-5-TR, subdivided into four categories: addition of diagnostic entities and symptom codes; changes in diagnostic criteria or specifier definitions; updated terminology; and comprehensive text updates. Diagnostic entities added to DSM-5-TR include Prolonged Grief Disorder, Unspecified Mood Disorder, and Stimulant-Induced Mild Neurocognitive Disorder. Prolonged Grief Disorder is characterized by the continued presence, for at least 12 months after the death of a loved one, of intense yearning for the deceased and/or persistent preoccupation with thoughts of the deceased, along with other grief-related symptoms such as emotional numbness, intense emotional pain and avoidance of reminders that the person is deceased, that are sufficiently severe to cause impairment in functioning5, 6. Unspecified Mood Disorder is a residual category for presentations of mood symptoms which do not meet the full criteria for any of the disorders in either the bipolar or the depressive disorders diagnostic classes, and for which it is difficult to choose between Unspecified Bipolar and Related Disorder and Unspecified Depressive Disorder (e.g., acute agitation). Stimulant-Induced Mild Neurocognitive Disorder has been added to the existing types of substance-induced mild neurocognitive disorders (alcohol, inhalants, and sedative, hypnotics or anxiolytic substances), in recognition of the fact that neurocognitive symptoms, such as difficulties with learning and memory and executive function, can be associated with stimulant use7. Free-standing symptom codes have been added to the chapter Other Conditions that May Be a Focus of Clinical Attention, to indicate the presence (or history of) suicidal behavior (“potentially self-injurious behavior with at least some intent to die”) and nonsuicidal self-injury (“intentional self-inflicted damage to the body likely to induce bleeding, bruising, or pain in the absence of suicidal intent”)1. These codes will allow the clinician to record these clinically important behaviors independent of any particular psychiatric diagnosis. Changes in diagnostic criteria or specifier definitions have been implemented for more than 70 disorders. While most of these changes are relatively minor, a number are more significant, and address identified problems that could lead to misdiagnosis. Diagnostic criteria sets or specifier definitions with more significant changes include those to criterion A for Autism Spectrum Disorder; changes in severity specifiers for Manic Episode; addition of course specifiers to Adjustment Disorder; and changes to criterion A for Delirium. Autism Spectrum Disorder is defined by persistent difficulties in the social use of verbal and nonverbal communication (criterion A) along with restricted repetitive patterns of behavior (criterion B). While the minimum threshold for the restricted repetitive behavior component was straightforward (at least two of four), the minimum required number of types of deficits in social communication was ambiguous. Specifically, the criterion A phrase “as manifested by the following” could be interpreted to mean “any of the following” (one of three) or “all of the following” (three of three). Since the intention of the DSM-5 Work Group was always to maintain a high diagnostic threshold by requiring all three, criterion A was revised to be clearer: “as manifested by all of the following”. The “mild” severity specifier for Manic Episode (few, if any, symptoms in excess of required threshold; distressing but manageable symptoms, and the symptoms result in minor impairment in social or occupational functioning) was inconsistent with Manic Episode criterion C, which requires that the mood disturbance be sufficiently severe to cause marked impairment in social or occupational functioning, necessitate hospitalization, or include psychotic features. The severity specifiers from DSM-IV have now been adopted: “mild” if only minimum symptom criteria are met; “moderate” if there is a very significant increase in activity or impairment in judgment, and “severe” if almost continual supervision is required. Specifiers indicating the duration of symptoms in Adjustment Disorder were inadvertently left out of DSM-5 and have now been reinstated: “acute” if symptoms have persisted for less than 6 months, and “persistent” if symptoms have persisted for 6 months or longer after the termination of the stressor or its consequences. The essential cognitive features in Delirium are disturbances of attention and awareness of the environment. While the nature of the attentional disturbance – characterized in criterion A as a reduced ability to direct, focus, sustain, and shift attention – is clear, the characterization of the awareness component as “reduced orientation to the environment” is confusing, given that “disorientation” already appears as one of the “additional disturbances in cognition” listed in criterion C. Consequently, criterion A has been reformulated to avoid using “orientation”, so that it now reads “A disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) accompanied by reduced awareness of the environment”. DSM-5 terminology has been updated to conform to current preferred usage, and includes replacing “neuroleptic medications”, which emphasize side effects, with “antipsychotic medications or other dopamine receptor blocking agents”; replacing “intellectual disability” with “intellectual developmental disorder”; and changing “conversion disorder” to “functional neurological syndrome”. Reflecting the evolving terminology in the area of gender dysphoria, “desired gender” is replaced with “experienced gender”; “natal male/natal female” with “individual assigned male at birth” or “individual assigned female at birth”; and “cross-sex treatment regimen” with “gender-affirming treatment regimen”. The updates to the text were the result of a three-year process involving over 200 experts, most of whom had participated in the development of DSM-5. There were 20 Review Groups to cover the Section II chapters, each headed by a Section Editor. Experts were asked to review the text to identify material that was out-of-date. This was supplemented by literature reviews that covered the period of the prior 10 years. Three cross-cutting Review Groups (Sex and Gender, Culture, Suicide) reviewed every chapter, focusing on material involving their specific expertise. Revisions to the text also underwent a forensic review. Finally, an Ethnoracial Equity and Inclusion Work Group reviewed the entire text to ensure among other things that explanations of ethno-racial and cultural differences in symptomatic presentations and prevalence took into consideration the impact of experiences such as racism and discrimination. Most disorder texts had at least some revisions, with the overwhelming majority having significant revisions. Text sections most extensively updated were Prevalence, Risk and Prognostic Factors, Culture-Related Diagnostic Features, Sex- and Gender-Related Diagnostic Features, Association with Suicidal Thoughts and Behaviors, and Comorbidity. The text sections with the fewest updates were Diagnostic Features and Differential Diagnosis. The American Psychiatric Association continues to welcome empirically-grounded proposals for change. Guidelines for submitting such proposals can be found at www.dsm5.org.

Aim: This study aimed to identify whether clinicians’ gender, clinical experience, and personal attitudes influenced their perception of criminality of specific sexual behaviours, their judgments about criminal liability if mentally disordered, and the need for treatment as part of criminal settings for those having ICD-11 paraphilic disorders. Method: In a secondary analysis of data only vignettes with the least (do not meet paraphilic disorder diagnostic requirements) and most extreme (met paraphilic disorder diagnostic requirements) descriptions of ICD-11 frotteuristic, coercive sexual sadism, and exhibitionistic arousal patterns and related behavior were randomly presented to participants. A total of 1,101 clinicians rated one to three vignettes (a total of 1,884) answering questions regarding diagnosis, criminal features, and their own attitudes. Results: The ICD-11 diagnostic guidelines were adequately used to distinguish paraphilic disorders from non-pathological arousal patterns.Vignette severity was the most important predictor for clinicians’ determination that a crime was committed. Results showed an interaction of the classification of paraphilic disorders, clinicians’ gender, and personal attitudes with judgments about concepts associated with criminality, criminal liability if a diagnosis was indicated, and the need for treatment in forensic settings. Conclusions: Increased formal education, clinical training about these disorders, and evidence-based treatment guidelines are required to avoid biases that may come from preconceived ideas and personal attitudes. Laws and policies that unnecessarily restrict the treatment of these patients in non-forensic settings—for example, when the individual is distress about the arousal pattern but no crime has been committed—should be examined.

ABSTRACT:Structural racism has received renewed focus over the past year, fueled by the convergence of major political and social events. Psychiatry as a field has been forced to confront a legacy of systemic inequities. Here, we use examples from our clinical and supervisory work to highlight the urgent need to integrate techniques addressing racial identity and racism into psychiatric practice and teaching. This urgency is underlined by extensive evidence of psychiatry's long-standing systemic inequities. We argue that our field suffers not from a lack of available techniques, but rather a lack of sustained commitment to understand and integrate those techniques into our work; indeed, there are multiple published examples of strategies to address racism and racial identity in psychiatric clinical practice. We conclude with recommendations geared toward more firmly institutionalizing a focus on racism and racial identity in psychiatry, and suggest applications of existing techniques to our initial clinical examples.