Delirium in the Spanish version of the DSM-5: More confusion?

Dear Editor:

In May 2013 the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was published, involving changes in some diagnostic criteria with respect to the previous edition, some more profound than others.¹ The most important modifications in relation to delirium were the following:

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  Focusing Criterion A on attention/awareness, which is the most important core characteristic of the disorder according to empirical data.² For this purpose, the complex term “consciousness” used in Criterion A in the DSM-IV-TR was abandoned.

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  Including a specific criterion on differential diagnosis with other neurocognitive disorders such as Alzheimer's or with a state of severely reduced level of arousal (e.g., coma).

Experts in America and Europe received these changes positively, especially those related to Criterion A.³ The other 3 criteria, which involve the presence of alterations in other cognitive functions (e.g., in memory), the acute-fluctuating onset of symptoms and the need to identify possible aetiologies, were only slightly modified.

In the Spanish version of these new criteria for the diagnosis of delirium (2014),⁴ the word “awareness” (present in the new Criterion A) is translated as «conciencia» [consciousness/awareness/conscience]; this word had been translated as «atención al entorno» [attention to the surroundings] in previous versions of the manual, thus preserving the authors’ intention. The erroneous use of the complex and operationally weak term «conciencia» for “awareness” in the main item of the new criteria could reduce concordance between examiners and hinder therapeutic decisions. In addition, it may reduce the international validity of studies carried out using the Spanish version of the DSM-5.

The DSM-5 in Spanish also disconcerts by calling the disorder «síndrome confusional» [confusional syndrome]. This designation is related to the 19th-century French concept, Confusion Mentale Primitive (which had to do with the consolidation of the current construct of the syndrome).⁵ However, most Spanish speakers prefer the term delirium.⁶ This expression was salvaged from the first specific operative criteria published in the DSM-III, looking to preserve historical coherence with the term introduced by Celsus (c. 25 BCE–c. 50 CE).⁷ Delirium is also the designation used in the other current Spanish classification, the 10th version of the International Classification of Diseases. Such lack of consensus in the name used for a disorder involving professionals from various areas makes communication more difficult. It could also lead to situations in which the different specialists think that they are facing various diagnoses instead of only one.

The editors of the Revista de Psiquiatría y Salud Mental informed us that the DSM-5 translation team received a glossary of terms in Spanish from the American Psychiatric Association that they were to use. This instruction meant that the version of several diagnostic criteria in our language is not as well adapted to the linguistic characteristics as the team would have wished. Consequently, refining these criteria in a new revision is of great interest.

Reed and Ayuso-Mateos,⁸ in reference to the forthcoming 11th edition of the International Classification of Diseases, argue that during the development of any diagnostic classification, the characteristics of the different languages in which the classification is to be published should be considered, to optimize its usefulness. Along these lines, Tohen⁹ indicates that every effort must be made so that the language, as the backbone of psychiatry, facilitates collaboration among Spanish-speaking professionals.

In our opinion, when the DSM-5 in Spanish is used to diagnose delirium, it should be remembered that Criterion A of the original in English refers to alterations in attention.³ Another point is that delirium is the current designation and the one most accepted everywhere for the syndrome in question.⁶ That is why we advocate its use instead of other expressions that proliferate among diverse specialists.