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Editorial   |    
Including Laboratory Tests in DSM-V Diagnostic Criteria
Michael B. First, M.D.; Mark Zimmerman, M.D.
Am J Psychiatry 2006;163:2041-2042. doi:10.1176/appi.ajp.163.12.2041

Despite widespread acceptance that most psychiatric disorders are “diseases of the brain” (1), the field of psychiatry has thus far failed to identify a single neurobiological marker that is diagnostic of a mental disorder (2). There are a number of potential advantages to including laboratory tests in diagnostic criteria. In contrast to the clinical signs and symptoms that form the basis for the current DSM criteria, laboratory tests are more objective (3), would facilitate detection of mental disorders in primary care settings (4), and would highlight the neurobiological basis of psychiatric disorders.

Although many candidate laboratory tests have been proposed over the years—for example, the dexamethasone suppression test (5) and shortened REM latency for major depression (6)—none has been found to be sufficiently sensitive and specific to be suitable for psychiatric diagnosis. However, despite these limitations, it may still be possible and indeed advantageous to include laboratory tests in at least some of the criteria sets in DSM-V. Many disorders in DSM-IV are defined polythetically, that is, a minimum number of items are required from a list of symptoms (e.g., three out of a list of seven symptoms for substance dependence). In polythetically defined disorders, the individual criteria vary in their sensitivity and specificity (for examples, see references 7–12). Consequently, rather than considering whether a laboratory test by itself is sufficiently sensitive and specific to make a particular psychiatric diagnosis, we should ask how well the laboratory test performs as compared to the other criteria used to define the disorder. A methodology for exploring this issue was established by a group of investigators including one of us (13), using data from 1,138 psychiatric outpatients obtained through the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project. We demonstrated significant variability in the sensitivities and specificities for the symptom criteria for major depressive disorder. The sensitivity and specificity values ranged from 90.2% and 84.9%, respectively, for depressed mood down to 66.9% and 78.2% for appetite/weight disturbance. By contrast, a study examining all-night EEG sleep studies (14) was able to correctly classify 82% of a mixed group of normal subjects, patients with primary depression, and patients with primary insomnia. Although these diagnostic efficiency statistics were determined in separate studies that used different definitions of depression, thereby limiting the validity of a direct comparison, it suggests the possibility that the diagnostic efficiency of EEG sleep analysis might perform as well as, or better than, some of the current symptom criteria for major depressive disorder. Potentially, the combination of clinical signs and symptoms and laboratory tests that optimally defines major depressive disorder (in terms of predictive validity of course and treatment response) could be determined and incorporated into the polythetic list of criteria for major depression.

During DSM-IV deliberations, practical concerns were raised about including laboratory test results in the definition of psychiatric disorders; this might render it impossible for a general clinician without access to the necessary laboratory equipment or facilities to make a psychiatric diagnosis (15). However, since polythetic criteria sets do not require the presence of any one particular item to make the diagnosis, the general clinician will still be able to make the diagnosis even if laboratory testing is not available.

Ultimately, the decision as to whether to include laboratory tests in DSM-V diagnostic criteria sets will require a careful balancing of the benefits versus costs. However, embedding laboratory tests with less-than-perfect diagnostic sensitivity and specificity parameters in polythetic criteria sets may finally allow the inclusion of objective laboratory tests into DSM-V diagnostic definitions.

1.Andreasen NC: The Broken Brain. New York, Harper & Row, 1984
 
2.Charney D, Barlow D, Botteron K, Cohen J, Goldman D, Gur R, Lin K-M, Lopez JF, Meador-Woodruff JH, Moldin SO, Nestler EJ, Watson SJ, Zalcman SF: Neuroscience research agenda to guide development of a pathophysiologically based classification system, in A Research Agenda for DSM-V. Edited by Kupfer D, First M, Regier D. Washington, DC, American Psychiatric Association, 2002, pp 31–84
 
3.Widiger T, Clark L: Toward DSM-V and the classification of psychopathology. Psychol Bull 2000; 126:946–963
 
4.Rounsaville B, Alarcon R, Andrews G, Jackson J, Kendell R, Kendler K: Basic nomenclature issues for DSM-V, in A Research Agenda for DSM-V. Edited by Kupfer D, First M, Regier D. Washington, DC, American Psychiatric Association, 2002, pp 1–29
 
5.Arana G, Baldessarini R, Ornsteen M: The dexamethasone suppression test for diagnosis and prognosis in psychiatry. Arch Gen Psychiatry 1985; 42:1193–1204
 
6.Kupfer D: A psychobiologic marker for primary depressive disease. Biol Psychiatry 1976; 11:159–174
 
7.Blais M, Hilsenroth M, Fowler J: Diagnostic efficiency and hierarchical functioning of the DSM-IV borderline personality disorder criteria. J Nerv Ment Dis 1999; 187:167–173
 
8.Grilo CM, McGlashan TH, Morey LC, Gunderson JG, Skodol AE, Shea MT, Sanislow CA, Zanarini MC, Bender D, Oldham JM, Dyck I, Stout RL: Internal consistency, intercriterion overlap and diagnostic efficiency of criteria sets for DSM-IV schizotypal, borderline, avoidant, and obsessive-compulsive personality disorders. Acta Psychiatr Scand 2001; 104:264–272
 
9.Breslau N: Refining DSM-III criteria in major depression: an assessment of the descriptive validity of criterion symptoms. J Affect Disord 1985; 9:199–206
 
10.Faraone SV, Biederman J, Sprich-Buckminster S, Chen W, Tsuang MT: Efficiency of diagnostic criteria for attention deficit disorder: toward an empirical approach to designing and validating diagnostic algorithms. J Am Acad Child Adolesc Psychiatry 1993; 32:166–174
 
11.Waldman I, Lilienfeld S: Diagnostic efficiency of symptoms for oppositional-defiant disorder and attention-deficit hyperactivity disorder. J Consult Clin Psychol 1991; 59:732–738
 
12.Hiller W, Mombour W, Mittelhammer J: A systematic evaluation of the DSM-III criteria for alcohol dependence. Compr Psychiatry 1989; 30:403–415
 
13.Zimmerman M, Chelminski I, McGlinchey JB, Young D: Diagnosing major depressive disorder, VI: performance of an objective test as a diagnostic criterion. J Nerv Ment Dis 2006; 194:565–569
 
14.Gillin J, Duncan W, Pettigrew K, Frankel B, Snyder F: Successful separation of depressed, normal, and insomniac subjects by EEG sleep data. Arch Gen Psychiatry 1979; 36:85–90
 
15.Buysse D, Reynolds C, Kupfer D: DSM-IV sleep disorders: final overview, in DSM-IV Sourcebook, vol 4. Edited by Widiger TA, Frances AJ, Pincus HA, Ross R, First MB, Davis W, Kline M. Washington, DC, American Psychiatric Association, 1998, pp 1103–1122
 

This editorial is one of a series on issues to be considered for DSM-V. Authors are encouraged to submit 500 word editorials for consideration to the Journal at http://appi.manuscriptcentral.com/.

Address correspondence and reprint requests to Dr. First, New York State Psychiatric Institute, 1051 Riverside Dr., Unit 60, New York, NY 10032; mbf2@columbia.edu (e-mail).

Dr. First is a paid consultant to the American Psychiatric Institute for Research and Education; receives book royalties from American Psychiatric Publishing and from John Wiley & Sons; and has received money in the past 12 months from Cephalon, AstraZeneca, and Eli Lilly for conducting diagnostic trainings at investigator meetings. Dr. Zimmerman is on the speaker’s bureau for GlaxoSmithKline, Bristol-Myers Squibb, and Wyeth Pharmaceuticals and receives royalties from Western Psychological Services. Dr. Freedman has reviewed this editorial and found no evidence of influence from these relationships.

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References

1.Andreasen NC: The Broken Brain. New York, Harper & Row, 1984
 
2.Charney D, Barlow D, Botteron K, Cohen J, Goldman D, Gur R, Lin K-M, Lopez JF, Meador-Woodruff JH, Moldin SO, Nestler EJ, Watson SJ, Zalcman SF: Neuroscience research agenda to guide development of a pathophysiologically based classification system, in A Research Agenda for DSM-V. Edited by Kupfer D, First M, Regier D. Washington, DC, American Psychiatric Association, 2002, pp 31–84
 
3.Widiger T, Clark L: Toward DSM-V and the classification of psychopathology. Psychol Bull 2000; 126:946–963
 
4.Rounsaville B, Alarcon R, Andrews G, Jackson J, Kendell R, Kendler K: Basic nomenclature issues for DSM-V, in A Research Agenda for DSM-V. Edited by Kupfer D, First M, Regier D. Washington, DC, American Psychiatric Association, 2002, pp 1–29
 
5.Arana G, Baldessarini R, Ornsteen M: The dexamethasone suppression test for diagnosis and prognosis in psychiatry. Arch Gen Psychiatry 1985; 42:1193–1204
 
6.Kupfer D: A psychobiologic marker for primary depressive disease. Biol Psychiatry 1976; 11:159–174
 
7.Blais M, Hilsenroth M, Fowler J: Diagnostic efficiency and hierarchical functioning of the DSM-IV borderline personality disorder criteria. J Nerv Ment Dis 1999; 187:167–173
 
8.Grilo CM, McGlashan TH, Morey LC, Gunderson JG, Skodol AE, Shea MT, Sanislow CA, Zanarini MC, Bender D, Oldham JM, Dyck I, Stout RL: Internal consistency, intercriterion overlap and diagnostic efficiency of criteria sets for DSM-IV schizotypal, borderline, avoidant, and obsessive-compulsive personality disorders. Acta Psychiatr Scand 2001; 104:264–272
 
9.Breslau N: Refining DSM-III criteria in major depression: an assessment of the descriptive validity of criterion symptoms. J Affect Disord 1985; 9:199–206
 
10.Faraone SV, Biederman J, Sprich-Buckminster S, Chen W, Tsuang MT: Efficiency of diagnostic criteria for attention deficit disorder: toward an empirical approach to designing and validating diagnostic algorithms. J Am Acad Child Adolesc Psychiatry 1993; 32:166–174
 
11.Waldman I, Lilienfeld S: Diagnostic efficiency of symptoms for oppositional-defiant disorder and attention-deficit hyperactivity disorder. J Consult Clin Psychol 1991; 59:732–738
 
12.Hiller W, Mombour W, Mittelhammer J: A systematic evaluation of the DSM-III criteria for alcohol dependence. Compr Psychiatry 1989; 30:403–415
 
13.Zimmerman M, Chelminski I, McGlinchey JB, Young D: Diagnosing major depressive disorder, VI: performance of an objective test as a diagnostic criterion. J Nerv Ment Dis 2006; 194:565–569
 
14.Gillin J, Duncan W, Pettigrew K, Frankel B, Snyder F: Successful separation of depressed, normal, and insomniac subjects by EEG sleep data. Arch Gen Psychiatry 1979; 36:85–90
 
15.Buysse D, Reynolds C, Kupfer D: DSM-IV sleep disorders: final overview, in DSM-IV Sourcebook, vol 4. Edited by Widiger TA, Frances AJ, Pincus HA, Ross R, First MB, Davis W, Kline M. Washington, DC, American Psychiatric Association, 1998, pp 1103–1122
 
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