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Letters to the Editor   |    
Response to Barglow Letter
Darrel A. Regier, M.D., M.P.H.; Matthew J. Friedman, M.D., Ph.D.; Helena C. Kraemer, Ph.D.; William E. Narrow, M.D., M.P.H.; David J. Kupfer, M.D.
Am J Psychiatry 2013;170:680a-681. doi:10.1176/appi.ajp.2013.13010087r
View Author and Article Information

The authors’ disclosures accompany the original article.

From the American Psychiatric Association, Division of Research and American Psychiatric Institute for Research and Education, Arlington, Va.; the Department of Psychiatry, Dartmouth University, Hanover, N.H.; the Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, Calif.; and the Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh.

Copyright © 2013 by the American Psychiatric Association

Accepted March , 2013.

To the Editor: Dr. Barglow’s commentary on the Freedman et al. editorial (1) regarding publication of the DSM-5 field trial results (2) addresses the distinction between the validity and the reliability of mental disorder diagnoses now contained in the DSM-5 revision. Dr. Barglow is correct in noting the additional requirements for validity in the Robins and Guze criteria, which include distinct boundaries, family history, laboratory tests, and clinical course, modified by Kendler to include treatment response (3). However, the original Kraepelinian and the Robins and Guze neo-Kraepelinian conceptualization of categorical diagnoses with distinct boundaries between disorders has been called into question by the failure to find “zones of rarity” between diagnoses based on symptomatic overlap and epidemiologic findings in the historic paper of Kendell and Jablensky (4). More recently, the molecular genetic findings of the Cross-Disorder Group of the Psychiatric Genomics Consortium (5) put to rest the distinct genetic vulnerability theory for many mental disorders by showing common genetic vulnerabilities for neurodevelopmental disorders (autism spectrum disorder and attention deficit hyperactivity disorder), schizophrenia, bipolar disorder, and major depressive disorder—the first four chapters of DSM-5. Even Kraepelin in his later years dropped the concept of a strict separation of schizophrenia and the affective psychoses in favor of a spectrum approach that would include schizotypal personality disorder, schizophrenia, schizoaffective disorder, and bipolar disorder in today’s classification (6).

So how should we interpret the comorbidity of posttraumatic stress disorder (PTSD), major depressive disorder, generalized anxiety disorder, mild traumatic brain injury, and alcohol use disorder identified in the DSM-5 field trials—with the highest reliability among those disorders for PTSD? In the routine clinical practice field trial settings, clinicians identified a spectrum of related disorders that may well have common genetic and environmental exposure vulnerabilities, but with a central tendency for PTSD to be the dominant clinical presentation in Veterans Affairs health care settings. Given the heterogeneity of PTSD with or without one or more of these comorbid presentations, the clinical course and response to treatment may well be “moderated” by these comorbidities (7). In this regard, the Institute of Medicine study notwithstanding, and as attested by several clinical practice guidelines (8), the PTSD diagnosis does predict a favorable response to a number of treatments, in addition to prolonged exposure therapy. Finally, brain imaging and other laboratory tests are emerging to add to the list of potential moderators that will predict differential response to treatment, but we have not yet reached a point where a biomarker will qualify as a diagnostic criterion for PTSD or any other DSM-5 disorder.

Freedman  R;  Lewis  DA;  Michels  R;  Pine  DS;  Schultz  SK;  Tamminga  CA;  Gabbard  GO;  Gau  SS;  Javitt  DC;  Oquendo  MA;  Shrout  PE;  Vieta  E;  Yager  J:  The initial field trials of DSM-5: new blooms and old thorns.  Am J Psychiatry 2013; 170:1–5
[CrossRef] | [PubMed]
 
Regier  DA;  Narrow  WE;  Clarke  DE;  Kraemer  HC;  Kuramoto  SJ;  Kuhl  EA;  Kupfer  DJ:  DSM-5 field trials in the United States and Canada, part II: test-retest reliability of selected categorical diagnoses.  Am J Psychiatry 2013; 170:59–70
[CrossRef] | [PubMed]
 
Robins  E;  Guze  SB:  Establishment of diagnostic validity in psychiatric illness: its application to schizophrenia.  Am J Psychiatry 1970; 126:983–987
[PubMed]
 
Kendell  R;  Jablensky  A:  Distinguishing between the validity and utility of psychiatric diagnoses.  Am J Psychiatry 2003; 160:4–12
[CrossRef] | [PubMed]
 
Cross-Disorder Group of the Psychiatric Genomics Consortium:  Identification of risk loci with shared effects on five major psychiatric disorders: a genome-wide analysis.  Lancet (Epub ahead of print, Feb 27, 2013)
 
Kraepelin  E:  Patterns of mental disorder (1920), in  Themes and Variations in European Psychiatry . Edited by Hirsch  SR;  Shepherd  M.  Charlottesville,  University Press of Virginia, 1974, pp 7–30
 
Wallace  ML;  Frank  E;  Kraemer  HC:  A novel approach for developing and interpreting treatment moderator profiles in randomized clinical trials.  JAMA Psychiatry (in press)
 
Forbes  D;  Creamer  MC;  Bisson  JI;  Cohen  JA;  Crow  BE;  Foa  EB;  Friedman  MJ;  Keane  TM;  Kudler  HS;  Ursano  RJ:  A guide to guidelines for the treatment of PTSD and related conditions.  J Trauma Stress 2010; 23:537–552
[CrossRef] | [PubMed]
 
References Container
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References

Freedman  R;  Lewis  DA;  Michels  R;  Pine  DS;  Schultz  SK;  Tamminga  CA;  Gabbard  GO;  Gau  SS;  Javitt  DC;  Oquendo  MA;  Shrout  PE;  Vieta  E;  Yager  J:  The initial field trials of DSM-5: new blooms and old thorns.  Am J Psychiatry 2013; 170:1–5
[CrossRef] | [PubMed]
 
Regier  DA;  Narrow  WE;  Clarke  DE;  Kraemer  HC;  Kuramoto  SJ;  Kuhl  EA;  Kupfer  DJ:  DSM-5 field trials in the United States and Canada, part II: test-retest reliability of selected categorical diagnoses.  Am J Psychiatry 2013; 170:59–70
[CrossRef] | [PubMed]
 
Robins  E;  Guze  SB:  Establishment of diagnostic validity in psychiatric illness: its application to schizophrenia.  Am J Psychiatry 1970; 126:983–987
[PubMed]
 
Kendell  R;  Jablensky  A:  Distinguishing between the validity and utility of psychiatric diagnoses.  Am J Psychiatry 2003; 160:4–12
[CrossRef] | [PubMed]
 
Cross-Disorder Group of the Psychiatric Genomics Consortium:  Identification of risk loci with shared effects on five major psychiatric disorders: a genome-wide analysis.  Lancet (Epub ahead of print, Feb 27, 2013)
 
Kraepelin  E:  Patterns of mental disorder (1920), in  Themes and Variations in European Psychiatry . Edited by Hirsch  SR;  Shepherd  M.  Charlottesville,  University Press of Virginia, 1974, pp 7–30
 
Wallace  ML;  Frank  E;  Kraemer  HC:  A novel approach for developing and interpreting treatment moderator profiles in randomized clinical trials.  JAMA Psychiatry (in press)
 
Forbes  D;  Creamer  MC;  Bisson  JI;  Cohen  JA;  Crow  BE;  Foa  EB;  Friedman  MJ;  Keane  TM;  Kudler  HS;  Ursano  RJ:  A guide to guidelines for the treatment of PTSD and related conditions.  J Trauma Stress 2010; 23:537–552
[CrossRef] | [PubMed]
 
References Container
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