Classification of Neurocognitive Disorders in DSM-5: A Work in Progress

doi:10.1097/JGP.0b013e3182051ab4

The American Journal of Geriatric Psychiatry

Volume 19, Issue 3, March 2011, Pages 205-210

https://doi.org/10.1097/JGP.0b013e3182051ab4 Get rights and content

(Am J Geriatr Psychiatry 2011; 19:205–210)

Section snippets

SCOPE OF THE MANDATE

Our first order of business was to define the scope of our activity, that is, to identify the common defining characteristics of our group of disorders and, accordingly, to choose a new name for the group. At one time, these disorders used to be referred to as “organic,” implying that they were the result of known structural brain disease. The term “organic” was intended to distinguish these disorders from all other mental disorders, which were designated as “functional.” Thankfully, psychiatry

NAMING THE BROAD CATEGORY

We initially considered labeling this group of disorders as “Cognitive Disorders,” also suggested by Rabins and Lyketsos² among others. We are still considering the shorter term, but note several advantages to “neurocognitive.” First, we note that cognitive impairments are present in all mental disorders including, e.g., schizophrenia, bipolar disorder, and autism. Given our initial mandate, we focused on those disorders where the cognitive deficit is the primary one, and attributable to known

IDENTIFYING THE DOMAINS

Our next task was to define more specifically the aspects or domains of brain functioning that would be involved in the diagnoses of these NCDs. Having listed these domains (complex attention, learning and memory, executive ability, language, visuoconstructional-perceptual ability, and social cognition), we developed working definitions of the neurocognitive domains and the corresponding impairments in everyday functions that the clinician may elicit or observe. It is difficult to achieve

DIAGNOSTIC THRESHOLDS AND THE ROLE OF FUNCTIONAL IMPAIRMENT

The cross-cutting DSM-5 Study Group on Function has emphasized that functional impairment is a consequence of disease/disorder and thus cannot be a criterion for diagnosing the disorder, a position consistent with the World Health Organization's publication on the International Classification of Functioning, Disability, and Health (ICF).⁷ Therefore, that Study Group has recommended to all DSM-5 Work Groups that no disorder should specify functional impairment or disability as a diagnostic

LEVELS OF COGNITIVE IMPAIRMENT AND SUBTYPES OF NEUROCOGNITIVE DISORDERS

Next, we debated how to subcategorize disorders within the broad category. A major innovation, for which we have received considerable support, is our proposal to recognize neurocognitive impairment as a focus for diagnosis (and treatment) even if it does not rise to the threshold of affecting everyday functioning. Finding a suitable name for this disorder has been difficult. We have used the term “minor NCD” as a placeholder within the draft criteria, with the more severe disorder being

DEMENTIA

Few of our draft revisions have led to as much response as the omission of the term “dementia.”¹⁰ Our intention was to not to eliminate the term dementia entirely from the nomenclature but to subsume entities currently known as dementia under the broad category of major NCDs; the category will also include major disorders that rise to the severity threshold of “major” but do not involve severe impairment in two domains (e.g., amnestic disorder). It is important for readers to understand that

THE CASE OF DELIRIUM

We appreciate the apparent inconsistency between describing the whole group of disorders as “neurocognitive” and describing delirium as a distinct disorder, separate from the major and minor NCDs. Delirium is clearly an NCD related to structural or metabolic brain dysfunction. However, delirium does not lend itself to the major/minor distinction based on severity of impairment, in part because symptom severity fluctuates. Although some contend that a subsyndromal delirium is common and should

ETIOLOGICAL SUBTYPES

In the draft criteria posted on the DSM-5 Web site, we had provided as a prototype the proposed criteria for major and minor NCDs attributable to Alzheimer disease. Our goal was to demonstrate how the syndromic diagnosis would be followed by etiologic subtyping, with criteria specific to each entity. At present, we plan to provide criteria for NCDs with at least the following etiologies: Alzheimer disease, cerebrovascular disease, frontotemporal lobar degeneration, Lewy Body disease, Huntington

ACQUIRED VERSUS DEVELOPMENTAL?

As noted earlier, we agree with the focus of Rabins and Lyketsos² on acquired impairment. However, in recent discussions with the Work Group on neurodevelopmental disorders, it has become apparent that this distinction can be difficult to make in practice. Disorders of children and youth are not necessarily “developmental” in the sense of congenital, but rather can be acquired during the developmental phase. For example, infantile strokes or head trauma during childhood can lead to disorders

BEHAVIORAL MANIFESTATIONS OF NEUROCOGNITIVE DISORDERS

Most of the NCDs have manifestations other than purely cognitive deficits. Apart from changes in “social cognition,” such as the loss of empathy seen in frontotemporal lobar degeneration, behavioral manifestations such as apathy, agitation, delusions, depression, and hallucinations are not only common but are frequently the primary reason that services are sought for the disorder. Two approaches have been suggested.¹⁵ One, which is a continuum of the DSM-IV system, is to provide “fifth digit”

COGNITIVE MANIFESTATIONS OF OTHER BEHAVIORAL DISORDERS

As noted earlier, and also pointed out by Rabins and Lyketsos,² many other mental disorders such as schizophrenia, depression, bipolar disorder, and autism have cognitive manifestations. Despite these very real cognitive deficits, they are not the primary manifestations of the disorders; thus, our strategy has been to exclude them from the NCDs section. This position is also not free of controversy, but we note that DSM-5 as a whole is considering adding a cognitive dimension to all disorders.

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Montreal Cognitive Assessment (MoCA) total scores have been widely used to identify individuals with neurocognitive disorders (NCDs), but the utility of its domain-specific scores have yet to be thoroughly interrogated. This study aimed to validate MoCA's 6 domain-specific scores (ie, Memory, Language, Attention, Executive, Visuospatial, and Orientation) with conventional neuropsychological tests and explore whether MoCA domain scores could discriminate between different etiologies in early NCDs.
Baseline data of a cohort study.
Study included 14,571 participants recruited from Alzheimer's Disease Centers across United States, aged ≥50 years, with global Clinical Dementia Rating of ≤1, and mean age of 71.8 ± 8.9 years.
Participants completed MoCA, conventional neuropsychological tests, and underwent standardized assessments to diagnose various etiologies of NCDs. Partial correlation coefficient was used to examine construct validity between Z scores of neuropsychological tests and MoCA domain scores, whereas multinomial logistic regression examined utility of domain scores to differentiate between etiologies of early NCDs.
MoCA domain scores correlated stronger with equivalent constructs (r = 0.15-0.43, P < .001), and showed divergence from dissimilar constructs on neuropsychological tests. Participants with Alzheimer's disease were associated with greater impairment in Memory, Attention, Visuospatial, and Orientation domains (RRR = 1.13-1.55, P < .001). Participants with Lewy body disease were impaired in Attention and Visuospatial domains (RRR = 1.21-1.47, P < .001); participants with frontotemporal lobar degeneration were impaired in Language, Executive, and Orientation domains (RRR = 1.25-1.75, P < .01); and participants with Vascular disease were impaired in Attention domain (RRR = 1.14, P < .001).
MoCA domain scores approximate well-established neuropsychological tests and can be valuable in discriminating different etiologies of early NCDs. Although MoCA domain scores may not fully substitute neuropsychological tests, especially in the context of diagnostic uncertainties, they can complement MoCA total scores as part of systematic evaluation of early NCDs and conserve the use of neuropsychological tests to patients who are more likely to require further assessments.
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Ref. [22] is particularly targeted at Alzheimer’s disease. In addition, the term “Mild Cognitive Impairment” (MCI) is in use from the past decade, describing a state intermediate in severity between normal aging and dementia (mostly Alzheimer’s type), and frequently a precursor to it [39]. References [21,24,26] are targeted at mild cognitive impairment.
To determine whether smart conversational agents can be used for detection of neuropsychiatric disorders. Therefore, we reviewed the technologies used, targeted mental disorders and validation procedures of relevant proposals in this field.
We searched Scopus, PubMed, Pro-Quest, IEEE Xplore, Web of Science, CINAHL and the Cochrane Library using a predefined search strategy. Studies were included if they focused on neuropsychiatric disorders and involved conversational data for detection and diagnosis. They were assessed for eligibility by independent reviewers and ultimately included if a consensus was reached about their relevance.
2356 references were initially retrieved. Eventually, 17 articles – referring 9 smart conversational agents – met the inclusion criteria. Out of the selected studies, 7 are targeted at neurocognitive disorders, 7 at depression and 3 at other conditions. They apply diverse technological solutions and analysis techniques (82.4% use Artificial Intelligence), and they usually rely on gold standard tests for criterion validity assessment. Acceptability, reliability and other aspects of validity were rarely addressed.
The use of smart conversational agents for the detection of neuropsychiatric disorders is an emerging and promising field of research, with a broad coverage of mental disorders and extended use of AI. However, the few published studies did not undergo robust psychometric validation processes. Future research in this field would benefit from more rigorous validation mechanisms and standardized software and hardware platforms.
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For example, is it really possible to separate complex attention, a term used to describe processes such as selectively paying attention only to relevant stimuli in our environments, from executive functioning, a term used to describe processes that prevent interference from distracting stimuli? Such issues were recognised by the APA task force who developed the new criteria [49], but the consensus was to retain these categories for diagnostic purposes. Not only are there difficulties in delineating precise definitions of each domain, but many of the tasks that can be used to measure neurocognitive performance tap into multiple domains.
Early detection is the key to successfully tackling dementia, a neurocognitive condition common among the elderly. Therefore, screening using technological platforms such as mobile applications (apps) may provide an important opportunity to speed up the diagnosis process and improve accessibility. Due to the lack of research into dementia diagnosis and screening tools based on mobile apps, this systematic review aims to identify the available mobile-based dementia and mild cognitive impairment (MCI) apps using specific inclusion and exclusion criteria. More importantly, we critically analyse these tools in terms of their comprehensiveness, validity, performance, and the use of artificial intelligence (AI) techniques. The research findings suggest diagnosticians in a clinical setting use dementia screening apps such as ALZ and CognitiveExams since they cover most of the domains for the diagnosis of neurocognitive disorders. Further, apps such as Cognity and ACE-Mobile have great potential as they use machine learning (ML) and AI techniques, thus improving the accuracy of the outcome and the efficiency of the screening process. Lastly, there was overlapping among the dementia screening apps in terms of activities and questions they contain therefore mapping these apps to the designated cognitive domains is a challenging task, which has been done in this research.
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Approximately 25% of individuals who are diagnosed with amnestic mild cognitive impairment (aMCI) revert to normal cognition (NC) rather than progressing to Alzheimer disease (AD). However, the prevalence of progression and reversion among older people in Asia remains unclear.
A prospective cohort study.
A community in Japan.
A total of 4153 individuals without dementia aged ≥65 years were classified as having NC, aMCI single domain (aMCIs), non-aMCI single domain (naMCIs), aMCI multiple domain (aMCIm), non-aMCI multiple domain (naMCIm), or global cognitive impairment (GCI).
The National Center for Geriatrics and Gerontology-Functional Assessment Tool and the Mini-Mental State Examination were used to conduct cognitive screening. The participants completed baseline (August 2011 to June 2012) and follow-up (August 2015 to June 2016) assessments. We followed up monthly for newly incident AD, as recorded by the Japanese National Health Insurance and Later-Stage Medical Care systems. Multiple imputation was used to adjust for selection bias and loss of information.
At 4-year follow-up, the reversion rates to NC in aMCIs, naMCIs, aMCIm, naMCIm, and GCI were 38.7%, 57.0%, 25.7%, 20.9%, and 43.7%, respectively. Of the participants with NC, aMCIs, naMCIs, aMCIm, naMCIm, and GCI at baseline, 4.7%, 4.5%, 13.1%, 20.6%, 21.6%, and 14.3%, respectively, were subsequently diagnosed with AD. We found significant associations between incident AD and naMCIs [hazard ratio (HR) compared to NC: 2.18, 95% confidence interval (CI): 1.45-3.26], and between AD and aMCIm (HR: 4.39, 95% CI: 2.06-9.39) and between AD and naMCIm (HR: 3.60, 95% CI: 2.13-6.08). However, the association between incident AD and aMCIs and between AD and GCI did not reach significance.
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EditorialClassification of Neurocognitive Disorders in DSM-5: A Work in Progress

Section snippets

SCOPE OF THE MANDATE

NAMING THE BROAD CATEGORY

IDENTIFYING THE DOMAINS

DIAGNOSTIC THRESHOLDS AND THE ROLE OF FUNCTIONAL IMPAIRMENT

LEVELS OF COGNITIVE IMPAIRMENT AND SUBTYPES OF NEUROCOGNITIVE DISORDERS

DEMENTIA

THE CASE OF DELIRIUM

ETIOLOGICAL SUBTYPES

ACQUIRED VERSUS DEVELOPMENTAL?

BEHAVIORAL MANIFESTATIONS OF NEUROCOGNITIVE DISORDERS

COGNITIVE MANIFESTATIONS OF OTHER BEHAVIORAL DISORDERS

Am J Geriatr Psychiatry

Lancet Neurol

J Psychosom Res

Am J Geriatr Psychiatry

Am J Geriatr Psychiatry

DSM-IV-TR: Diagnostic and Statistical Manual of Mental Disorders

The evolution of the cognitive model of depression and its neurobiological correlates

Am J Psychiatry

Walking the walk while talking. Cognitive therapy for mobility in dementia?

Neurology

Editorial
Classification of Neurocognitive Disorders in DSM-5: A Work in Progress