IN DEPTH ARTICLE: COMMENTARY

DSM-5 and the Five Missions Shoulderedby Chairs of Psychiatry

Laura Weiss Roberts

Received: 4 November 2013 /Accepted: 5 November 2013 /Published online: 14 January 2014# Academic Psychiatry 2014

Abstract The author provides a department chairmans per-spective on the opportunities and challenges inherent in theDSM-5 transition. The author discusses these topics in relationto the missions of science, clinical innovation and service,education, community engagement, and leadership. To provideaccurate information for their faculty, learners, and staff, chairswill need to provide venues for dialogue, minimize divisive-ness, support departmental leaders to helpwith transition issues,and speak up for patients and the profession in the process.

Keywords Leadership . Faculty Development . ResearchTraining . Community Engagement

Chairs of academic departments of psychiatry are responsiblefor creating a context in which the missions of science, clinicalinnovation and service, education, community engagement,and leadership come together to address the needs of peoplewith mental illness and to foster health and wellbeing, nowand in the future [1]. Psychiatry chairs see the importance ofbuilding new knowledge across the spectrum of basic, trans-lational, clinical, community, and population sciences, andthey understand the need for providing and developing valu-able assessment and therapeutic approaches for people of allages who live with diverse illnesses. Chairs understand theimperative to train professionals from many disciplines atmany different levels. Chairs value the critical role of com-mitting to the concerns and interests of communities andpopulations and of standing up as professionals to lead bybringing expertise to bear on important concerns in broader

society. Chairs, in my experience, have a desire to do thingsthat matter and want to help others to do the same.

Some of this work of the chair involves rolling up onessleeves, but much of it, perhaps most of it, is performedindirectly by establishing a vision, communicating its impor-tance in multiple venues, inspiring and protecting people, andbuilding excellent and sustainable programs that make a dif-ference over time. By virtue of the job description, chairs musthonor the greatest strengths and traditions of a professionaldiscipline while at the same time leaning forward to define andenable a better future.

The introduction of the Diagnostic and Statistical Manualof Mental Disorders (DSM)-5 represents a major milestonefor the medical and mental health professions in this decade.Chairs of psychiatry departmentspast, present, and futurehave been involved with the science, writing, and vetting ofthe DSM-5. Chairs, as leaders in medical schools, healthsystems, scientific institutes, the professions, and the public,with others will be responsible for the integration of the DSM-5 in all of these domains. And chairs, when the time comes,will help develop and assure the rigor and utility of subsequenteditions of the DSM, simultaneously holding the past andworking for the future.

DSM-5 and the Missions of Academic Psychiatry

Advancing Science and Clinical Innovation and Service

Chairs advance science on national and institutional levels, andthey shape the scientific careers of their faculty and trainees.TheDSM-5 relies on scientific constructs informed by evidenceand concepts, and it incorporates measures that will allow formore comprehensive and more systematic data gathering goingforward. The DSM-5, as with prior versions of the DSM,employs a phenomenological approach to diagnosis rather than

L. W. Roberts (*)Stanford University School of Medicine,Stanford, CA, USAe-mail: RobertsL@stanford.edu

Acad Psychiatry (2014) 38:6163DOI 10.1007/s40596-013-0010-x

an etiological approach, due to the underdevelopment of basic,translational, and clinical neuroscience necessary to move to amore validity (as opposed to reliability) methodology fordiagnosis [2]. Chairs, in supporting the full portfolio of science,from basic to population, will facilitate the maturation of diag-nosis in psychiatry, which in turn, will help in the design,testing, and application of therapies that are more attuned tothe underlying causes of illness. Scientific work seeking toclarify issues of human health and diagnosis may be translatedinto the clinicsbecoming a basis for clinical improvementand innovation as well as the new designs for clinics andclinical care systems. In addition to these considerations, thereis also the observation that many psychopharmacological andpsychosocial treatments have been tested in relation to specificdiagnostic criteria from the past. As diagnoses evolve in sub-stantive ways, many of the original studies, or studies currentlyunderway, will need to be performed in light of new criteria inorder to retain their credibility scientifically and their position(clinical indications) from a regulatory perspective.

Beyond this broad effort, it is clear that several of thediagnostic constructs in the DSM-5 have less of an evidencebase than others, and certain categories may not withstand thetest of time. Further, as in prior versions of the DSM, certaindiagnostic entities remain proposed rather than adopted.Among the most controversial of these is the category ofpersonality disorders, where the DSM-5 workgroup soughtto bring a substantial reconceptualization to this area. Insetting and supporting research priorities, chairs will be ableto help their scientists and clinicians to question, test, verify,and further refine understanding on the diagnostic categoriesand criteria as presented in the DSM-5. With the electronicmedical record widely adopted across many countries, the useof dimensional criteria and consistent measures, as advancedin the DSM-5, will also allow for the integration of datagathering into the routines of clinics. These data, in turn, canstrengthen both clinical care and science and better inform thenext version of DSM.

The National Institute for Mental Health has proposed theResearch Domain Criteria (RDoC) that will permit clearerscientific study on key areas, including Negative Valence Sys-tems, Positive Valence Systems, Cognitive Systems, Systemsfor Social Processes, and Arousal Regulatory Systems [3]. TheRDoC approach and the DSM-5 approach do not have the sameintention [4]. This said, the two schemata are not orthogonal orincompatible, as many have worried. Scientific inquiry orga-nized by the concepts of the RDoC as well as the DSM-5,although there may be a greater burden to translate the meaningand impact of findings, promises to bring great mutual benefit.For instance, studies of habit and learning in the Posi-tive Valence System will bring important insights to the areaof addiction, and work in cognitive systems and systems forsocial processes will inform nearly every diagnosis, as well asunderstanding on health, neurodevelopment, and resilience.

Chairs actively engaged with their basic and clinical scientistswill help define research priorities and find commonground across these conceptual frameworks, in timegiving rise to greater clinical innovation and improvedhealth outcomes.

Education

Academic departments of psychiatry always carry significanteducational responsibilities, and often learners come frommultiple disciplines and are at different stages of training. Inmy department, each year, we teach, supervise, mentor, grad-uate, and collaborate in the professional development of 1,800learners. We have college students, graduate students, medicalstudents, residents, fellows, interns, and post-docs, plus par-ticipants in continuing education programs. Our learners comefrom many backgrounds, including medicine, psychology,and neuroscience. Other departments across the country haveequal or more diverse training, including nurses, physicianassistants, and other mental health professionals.

Each of these learners, in order to work in the field ofmedicine, psychology, and clinical neuroscience, must under-stand the approach and content of the DSM-5. For basicscientists to talk with their academic colleagues and often tocreate the significance arguments of research proposals, itwould be strategic to have a working knowledge as well. Forestablished faculty who are responsible for teaching othersand for clinical care in and beyond the walls of the psychiatrydepartment, learning the DSM-5 is also fundamental. Physi-cians in the community will look to the academic departmentto explain the differences from the prior versions of the DSM-5 and to help create the rationale for change.

The DSM-5 has bearing on clinical education, in particular,because diagnostic categories and terms become very impor-tant to patients. Clinical trainees should be encouraged tothink not only about the technical aspects of arriving at sounddiagnoses but also should be given prompts and opportunitiesto think reflectively and deeply on how the refinements of theDSM-5 may affect their patients. Diagnoses can shape pa-tients personal attitudes, family perspectives, self-care behav-iors, and sense of the future. Diagnostic labels can have animpact on financial, insurance, disability, and other practicalrealities that the patients must work through in the context oftheir lives. A key role for chairs is in elevating the understand-ing of learners regarding the therapeutic impact for a patient,and the family, of being given a diagnosis, and then havingunderstanding on the patient, the patients diagnosis, and eventhe basis of understanding the diagnosis itself evolve.

Community Engagement and Leadership

With the planning and publicity surrounding the DSM-5,many chairs of psychiatry departments were called by the

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media to explain the proposed changes in criteria and, to someextent, to justify the underlying science and behind-the-sceneprocesses related to the new manual. The controversies asso-ciated with certain diagnoses or diagnostic categories (e.g.,autism spectrum disorders, gambling-related disorders, hoard-ing disorder, disruptive mood dysregulation disorder, person-ality disorders) figured prominently inmajor news outlets, andprofessional and advocacy organizations alike raised manydifficult issuesissues for which science has been insufficientor inconclusive and for which expert opinion has been lessthan uniform. As leaders of the field of psychiatry, Chairs areasked to articulate the reasons or at least the benefits of thenewDSM. Given how divided our field has been, many chairshave emphasized the importance of standing together asleaders of the profession.

Engagement of the community and being accountable part-ners with community stakeholders together represent anotherresponsibility of academic departments led by chairs of psy-chiatry. With the arrival of the DSM-5, colleagues within themedical school community (e.g., faculty in other clinicaldepartments, hospital administrators) may be affected by thechanges in DSM-5 and yet may not have much informationabout it. These colleagues may be unaware of the thinkingbehind the new diagnostic criteria, and chairsas visibleleaders of psychiatry in the local environmentwill likelyneed to explain the reasons for change and help with thetransitions in the institution. Other partners outside the medi-cal school, such as the courts or county officials or nationalpolicy makers, will similarly look to academic departments toexplain the importance and impact of the changes in diagnos-tic criteria, e.g., with respect to standards of care for specialpopulations, new health services imperatives, or issues thatmay pertain to public safety and wellbeing.

Chairs shoulder responsibility for academic departmentsthat are entrusted with creating a better future through the fivemissions of advancing science, clinical innovation and ser-vice, education, community engagement, and leadership.Chairs will be required to commit their own efforts andinfluence to help assure that the DSM-5 has the best possibleimpact for people living with mental illnesses, their families,and systems of care.

Chairs will also need to commit real resources to helpfaculty, learners, and key stakeholders such as hospital part-ners and community collaborators with the changes thatDSM-5 entails. Many of these ramifications certainly seemfar removed from the remarkable conversations and efforts ofscientists, multidisciplinary clinicians, and international opin-ion leaders as they sought to refine and advance the diagnosesof the DSM-5. Examples include everything from local prac-tical considerations such as migrating billing systems andtemplates in electronic medical records and updating insur-ance agreements and insurance contracts to activities withbroader impact such as mentoring early career colleagues

and dealing with the media, regulators, policy makers, andcommunity stakeholders.

In order to perform all of this work that pertains to the fivemissions of their departments, chairs will need to master theirunderstanding on the new DSM, a document quite differentfrom the DSM-II or DSM-III that chairs cut their teeth on.Chairs will also need to be able to answer controversies,including how to reconcile differences among RDoC, ICD,and DSM-5 criteria. Thoughtful chairs will be invested in theprovision of accurate information for their faculty, learners,and staff, creating venues for dialog, minimizing divisiveness,supporting champions to help with transition issues, andspeaking up for our patients and our profession in the process.

Implications for Educators

& Chairs are leaders in medical schools, health systems, scientificinstitutes, the professions, and the public and, with others, areresponsible for integrating the DSM-5 in all these areas.

& Chairs understand the imperative to train professionals from manydisciplines at many different levels.

& Chairs establish a vision, communicate its importance inmultiple venues,inspire and protect people, and build excellent and sustainable programsthat make a difference over time.

Implications for Academic Leaders

& Chairs see the importance of building newknowledge across the spectrumof basic, translational, clinical, community, and population sciences.

& Chairs value the critical role of committing to the concerns and interestsof communities and populations and of standing up as professionals tolead by bringing expertise to bear on important concerns in broadersociety.

& Chairs need to commit resources to help faculty, learners, and keystakeholders such as hospital partners and community collaboratorswith the changes that DSM-5 entails.

References

1. Roberts LW. Leadership in academic psychiatry: the vision, thegivens, and the nature of leaders. Acad Psychiatry. 2009;33(2):858.

2. Ohayon MM, Roberts LW. Understanding different approaches todiagnostic classification. In: Roberts LW, Louie AK, editors. DSM-5study guide. Arlington: American Psychiatric Publishing, Inc.; 2013.

3. Cuthbert BN, Insel TR. Toward the future of psychiatric diagnosis: theseven pillars of RDoC. BMC Med. 2013;11:126. doi:10.1186/1741-7015-11-126.

4. Insel T, Cuthbert B, Garvey M, Heinssen R, Pine DS, Quinn K, et al.Research domain criteria (RDoC): toward a new classification frame-work for research on mental disorders. Am J Psychiatry. 2010;167(7):74851. doi:10.1176/appi.ajp.2010.09091379.

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DSM-5 and the Five Missions Shouldered by Chairs of PsychiatryAbstractDSM-5 and the Missions of Academic PsychiatryAdvancing Science and Clinical Innovation and ServiceEducationCommunity Engagement and Leadership

References