The publication of DSM-5 can be an opportunity for creative teaching about psychiatric diagnosis at educational institutions.
That was the consensus of psychiatric educators and residents at a symposium on “DSM-5 and Residency Training: Opportunities and Challenges” at APA’s 2013 annual meeting in San Francisco in May.
The new manual, published last month, may present challenges to educational institutions around how case logs are written up by residents, medical records are transcribed, and varying timetables for conversion to DSM-5 criteria in licensing and board examinations.
But Sheldon Benjamin, M.D., vice chair for education and a professor of psychiatry and neurology at the University of Massachusetts, said the publication of the revised manual should be an exciting opportunity for everyone involved in academic psychiatry—department chairs, training directors, faculty, and residents—to engage in a creative educational dialogue about the reasons for changes in criteria and more generally about the evolving nature of psychiatric diagnosis and nosology.
From left: Richard Summers, M.D., Sheldon Benjamin, M.D., and Laura Roberts, M.D., speak at a symposium on DSM-5 and psychiatric education.
He was joined by DSM-5 Task Force Chair David Kupfer, M.D.; Laura Roberts, M.D., chair of the Department of Psychiatry at Stanford University; Arden Dingle, M.D., program director for child and adolescent psychiatry at Emory University; and Neisha D’Souza, M.D., a resident at Oregon Health Sciences University. The session was chaired by Richard Summers, M.D., director of residency training at the University of Pennsylvania.
Benjamin presented results from an informal survey of residents and faculty at his institution about DSM-5 that found that generally respondents understood and agreed with the need for an updated diagnostic manual and were positive about its effect on practice.
Nonetheless, he said, a central challenge for educators is that the changing and evolving nature of diagnostic nosology for psychiatry may be viewed by students as evidence that psychiatry lacks the underpinnings of basic science that exist in other fields.
“I think our faculty and our residents will need to be prepared to confront this and discuss the reasons for change with medical students,” he said. “We need to have a departmentwide conversation about the fact that we are doing syndromal diagnoses that evolve as the research evolves.
“And we need to take great care in our exams for medical students that we are testing underlying concepts and avoiding simplistic questions about diagnostic criteria that are really asking ‘Why was this answer right last year and wrong this year?’ ”
Benjamin said that at his institution residents will be required to review DSM-5 criteria and compare them with DSM-IV criteria for all resident-presented conferences. “So it won’t be enough to talk about the diagnoses,” he said. “We are going to ask each resident to say how they are different [from those in DSM-IV], and how the diagnoses they are talking about may be affected by evolving research knowledge.”
Importantly, Benjamin said his institution would also be incorporating the NIMH Research Domain Criteria (RDoC) for learning purposes. In that program basic dimensions of functioning (such as fear circuitry or working memory) are being studied across multiple units of analysis, from genes to neural circuits to behaviors, cutting across disorders as traditionally defined by DSM.
So faculty, residents, and students would be thinking about both underlying neurocircuitry—which may be shared by multiple disorders—as well as the clusters of behavioral symptoms that are labeled in DSM-5 for diagnostic purposes. “We believe having to think about two different systems will stretch us to do more,” Benjamin said. “We are going to be emphasizing syndromes and neurobiology over nomenclature as this sinks in.”
He added, “In terms of clerkships and electives, we think it’s important to establish communication between residency, clerkship, and elective directors so that residents who are tutoring medical students are on the same page. We are going to recommend that our medical [school] faculty talk about how nosology changes and how research has led to these changes, and not be so concerned about the exact criteria.”
Benjamin noted that one major change to a diagnostic category is the elimination of subtypes for schizophrenia. He said the schizophrenia criteria alone will offer a good platform for discussing why diagnostic criteria and nosology change over time.
“We think this is going to provide us an opportunity to review the history of DSM and of psychiatric nosology and to review etiological hypotheses by comparing classic descriptions of schizophrenia with the new DSM-5 criteria,” Benjamin said at the symposium. “I think it will really change the tenor of our seminars because we are going to be constantly looking at why these changes were made and what other research is going on.”
Benjamin also emphasized the utility for teaching purposes of Section III in the revised manual, which includes patient-rated cross-cutting symptoms measures and dimensional and severity measures that are incorporated throughout the criteria. “This will be positive in terms of moving our field more toward using rating scales,” he said.
Invariably there will be some logistical hurdles, particularly around the varying timetables for conversion to new criteria among different licensing and certifying exams. For instance, the Psychiatry Resident-In-Training Examination (PRITE) conversion to DSM-5 criteria is slated for the 2014 exam, so that PGY-2 and -3 residents will be tested on the PRITE using DSM-5 criteria but will be tested on the American Board of Psychiatry and Neurology (ABPN) exam using DSM-IV criteria. (The date for conversion to DSM-5 criteria for the ABPN exam is September 2017.)
But Benjamin and fellow panel members emphasized that changing to the new diagnostic system, though it may involve some difficulty, can ultimately be a creative teaching opportunity.
“The conversion to DSM-5 in educational institutions will require communication among student course, clerkship, and residency training directors, as well as with medical record-keeping and other departments and clinicians,” he said. “But this is an opportunity, and I think we need to acknowledge the controversies and focus on evidence and the goals of diagnostic nosology.” ■