Bret S. Stetka, MD; Christoph U. Correll, MD


May 21, 2013

In This Article

Neurocognitive Disorder

The Change

At the DSM-5 press conference, Dr. Dilip Jeste -- at that point still APA president -- referred to the movement among some psychiatrists to retire the term "dementia" for stigmatic reasons, the literal Latin translation being "without mind." Jeste pointed out that not only does the term hold negative connotations, but it is also simply inaccurate; many patients with diagnosed "dementia" maintain faculties, awareness, and haven't actually "lost" their mind. However, because of the term's long medical history and its familiarity among clinicians and patients, the new DSM recognizes "dementia" as an acceptable alternative for the newly preferred and more scientific term "neurocognitive disorder."

This new diagnosis includes both the dementia and amnestic disorder diagnoses from DSM-IV. Furthermore, DSM-5 recognizes specific etiologic subtypes of neurocognitive dysfunction, such as Alzheimer disease, Parkinson disease, HIV infection, Lewy body disease, and vascular disease. Each subgroup can be further divided into mild or major degrees of cognitive impairment on the basis of cognitive decline, especially the inability to perform functions of daily living independently. In addition, a subspecifier "with" or "without behavioral disturbances" is available.

The Implications

The nosologic distinctions between varying dementia etiologies should prove helpful in determining prognosis and therapeutic course. Moreover, clinicians will be able to more clearly determine whether the cognitive decline alone should be the focus of concern and intervention, or whether behavioral disturbances should also be considered and addressed.

The addition of a mild degree of cognitive impairment is consistent with recent research suggesting that treatments for declining cognition may be phase-specific, with certain medications and approaches possibly only working early in the disease course. Although distinguishing mild from major impairment may, in some cases, rely on clinician judgement, DSM-5 does attempt an objective distinction. Mild neurocognitive disorder requires "modest" cognitive decline which does not interfere with "capacity for independence in everyday activities" like paying bills or taking medications correctly. Cognitive decline meets the "major" criteria when "significant" impairment is evident or reported and when it does interfere with a patient's independence to the point that assistance is required. In other words, the diagnostic distinction relies heavily on observable behaviors.

Hopefully, this new classification system will stimulate research in the area of prevention and early intervention of neurocognitive disorders.