Medical Experts Reverse Diagnosis Changes

Depression and Psychosis definitions are changing

/ Author:  / Reviewed by: Robert Carlson, M.D

If a teenager in your family reports hearing voices when no one is around, how concerned should you be? 

If you feel both seriously depressed and very anxious, to the point where you are missing work, are you depressed, anxious, both, or neither?

Psychiatrists have had problems classifying these symptoms and have spent years looking for solutions.  However, medical experts with the American Psychiatric Association have announced they will recommend against proposed changes to definitions of depression and psychosis for the revision of the guidebook used by psychiatrists for diagnoses.

The proposed new definitions will be studied further but not enacted.

The psychiatrists tasked with revising the fifth edition of the Diagnostic and Statistical Manual (DSM-V) that clinicians use to evaluate patients with mental, emotional and behavioral disorders had proposed two new classifications: "attenuated psychosis syndrome" and "mixed anxiety depressive disorder."

For now, neither mixed anxiety depressive disorder nor attenuated psychosis syndrome appear to be made official diagnostic categories in DSM-V due to come out in mid-2013.

These new categories "require further research before their consideration as formal disorders," according to an APA statement. While the publication of the DSM-V is still about a year away, the expectation is now that attenuated psychosis syndrome and mixed anxiety depressive disorder will not be official diagnoses in the near future.

Much attention will be given to finding possible biological data that corresponds to mixed anxiety depressive disorder and attenuated psychosis syndrome, so clinicians in the future can draw up the best categories.

Continuing gene and brain studies of what people with these problems might have in common with each other physiologically may help the recategorization.

Considerations about Attenuated Psychosis Syndrome

Psychosis, in very general terms, can be thought of as a lack of contact with reality. An individual with this condition could have auditory hallucinations, delusions of historical importance or a dysfunctional lack of concern for family members or other experiences.

Unusual episodes can develop into a very serious disease that compromises thinking and functioning, and doctors should very carefully evaluate patients who display troubling clinical signs that may indicate psychosis.

Attenuated psychosis syndrome (or psychosis risk syndrome) would expand the current DSM's model of psychosis, reflecting the significance of symptoms that heighten risk for full-blown psychotic episodes.

The medical experts proposed this classification as a tool to help clinicians distinguish between unusual, perhaps worrisome yet not medically serious experiences of young people, and more serious episodes indicating real trouble may be coming.

This classification would designate certain at-risk persons, who could then receive appropriate attention, tracking, consultations, therapy and possibly medications. Many medical experts and public health officials urge diagnosing and treating diseases as early as possible, and the new categorization would have been useful to clinicians who want to develop a treatment plan before more serious episodes occur.

However, there is a potential for misdiagnosis or overdiagnosis if a child or adolescent who reports a single unusual episode is otherwise on a healthy path. Young persons in conditions of emotional intensity or unusual distress may exhibit behavior that is abnormal and a source of concern, yet go on to develop more or less normally into productive and even flourishing adults.

Clinicians in these situations have to weigh competing priorities. An understanding of psychosis that is too restrictive leaves open the possibility that at-risk children or adolescents will not receive proper monitoring and clinical attention.

Such people may go from occasional instances of inappropriate acting out or reports of strange beliefs to later developing serious problems functioning and fulfilling life goals.

Doctors must consider the possibility that an unusual episode may not lead to a future disorder, but they do not want to miss a developing problem either. A diagnosis of developing psychosis may mean recommending drugs, which often have serious side effects, yet this actually may be the more prudent option.

Balancing these needs requires judgment calls by psychiatrists, who want the best guidelines possible based on the most current medical evidence.

After considerable messages from laypersons and psychiatric professionals alike and reviews of evidence from tests known as field trials, the APA Task Force reworking DSM categories is no longer recommending that the DSM-V adopt the new designation.

However, it is still possible that attenuated psychosis syndrome may eventually become a diagnostic category, pending new evidence and debate.

The Mixed Anxiety Depressive Disorder Categorization

The mixed anxiety depressive disorder designation refers to a situation where the patient experiences both depression and anxiety, yet their symptoms do not quite match the diagnostic rules for a depression disorder or anxiety disorder.

This has posed a dilemma for the clinician: should the diagnosis be anxiety disorder, depression, or neither, since the situation doesn't quite meet existing DSM definitions?

As with attenuated psychosis syndrome, there is risk associated with both under- and overdiagnosis. On the one hand, people who are in potential danger of mental, emotional and/or behavioral states worsening should be examined and tracked for progression of symptoms and possibly given medication.

Again in this case, there are side effects associated with the medication that all too often is the main component of a treatment plan, so overdiagnosis presents risks as well.

Psychiatrists and other clinicians want flexibility in choosing the right diagnosis for a person so they can appropriately categorize the person’s struggles with serious emotional and psychological problems. These struggles may include symptoms of both anxiety and depression.

Over time, the idea of the category called mixed anxiety depressive disorder was developed and recognized by individual clinicians as well as systems such as the International Classification of Diseases (ICD). The APA's DSM revisions committee conducted field trials to see how well the designation fit individual patients, where physicians tested the concepts in a number of different settings with patients.

Apparently evidence from the field trials reviewed by the APA suggests the current definition of mixed anxiety depressive disorder is not yet a reliable diagnostic category. While there is still a year to go before the publication of DSM-V, the APA seems to be signaling for now that mixed anxiety depressive disorder will not be an official disorder.

Feedback from clinicians and laypersons alike has led the task force to be cautious about approving this new diagnostic listing. It is reasonable to infer that the APA is will err on the side of avoiding overdiagnosis.

Over time, researchers should likely learn more about the neurological and psychological changes in emotion, thinking, consciousness and behavior associated with "attenuated psychosis syndrome" and "mixed anxiety depressive disorder."

Continuing accumulation of basic science may yet solve the riddle of these disorders that can cause such problems. 

Reviewed by: 
Review Date: 
May 10, 2012