Download DSM-5 – The First 17 Pages This is the first of what I am hoping will

DSM-5 – The First 17 Pages
This is the first of what I am hoping will be a series on DSM-5. I will use these summaries to try to get us all up to speed on the changes, nuances, implications, etc., of
this new diagnostic system.
This first chapter (“Introduction”) comprises the first 17 pages of the softback edition published by the American Psychiatric Association. By the third paragraph, it
appears that APA is acknowledging that efforts to improve the reliability of psychiatric diagnoses have not been successful – and admitting that this effort (i.e., DSM-5)
may be only an incremental improvement. “The science of mental disorders continues to evolve”. It is recognized, however, that a rigid adherence to a categorical system does not accurately reflect what we see in our offices, clinics, and hospitals. It is
noted that the scientific/clinical community must find ways to incorporate dimensional approaches to mental disorders – interesting in light of the 11th hour scrapping of proposed sweeping changes to personality disorders along those very lines.
Nonetheless, it appears that the APA is trying hard, albeit awkwardly, to embrace
the idea that “the boundaries between disorders are more porous than originally
perceived.
A very brief history (five sentences) is provided to describe previous editions, and a
more extensive summary of the revision process is offered. A 28-member task force
was developed in 2007 and work groups were formed, beginning in 2008 to set
about proposing revisions over what was described as an “intensive” six-year period.
Draft revisions were guided by the following four principles:
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DSM-5 had to be useful for routine clinical practice
Research evidence should guide any changes
Continuity with previous editions should be maintained if possible
No constraints should limit the degree of change proposed
New diagnoses and disorder subtypes and specifiers would be subject to stipulations involving reliability, clinical utility, and validity. It seems that a high priority
was placed on eliminating the NOS categories, and one aim was to refine the definition of a “mental disorder”. Field trials were described as taking place in two major
types of settings, large medical-academic sites (11 in North America) and in “routine
clinical practices” (via recruitment of individual psychiatrists and other mental
health clinicians – volunteers).
In 2010, the APA developed its Web site to generate public and professional input
into the development of the diagnostic manual. Drafts of changes were posted for a
2-month comment period and more than 8,000 submissions were offered and reviewed initially. Revisions took place, and a second posting was published in 2011 –
feedback was reviewed, and there was a third and final posting in 2012. More than
13,000 comments were received and reviewed and there were “thousands of organized petition signers for and against some proposed revisions . . .”
Apparently, as the actual writing began, the members of 13 work groups collaborated with advisors and reviewers to draft the diagnostic criteria and the text. The text
editor reportedly worked in close collaboration with the work groups under the direction of the task force chairs. A “Scientific Review Committee (SRC)” was established to provide a peer-review process outside of the work groups and to ensure
that the proposed changes could be supported by scientific evidence. All of this
work was submitted to the APA Board of Trustees (the final authority) for consideration.
Another committee was formed – the “Clinical and Public Health Committee” to consider other concerns relating to clinical utility, public health, etc. The APA Council
on Psychiatry and Law reviewed disorders relevant to forensic environments and
forensic experts advised work groups in pertinent areas. Many changes were subject to field trial testing, though there is an admission that “comprehensive testing of
all proposed changes could not be accommodated by such testing because of time
limitations and availability of resources.”
Finally, recommendations from the task force were provided to the Board of Trustees and the APA Assembly’s Committee on DSM-5, made up of a “diverse group of
assembly leaders”. An executive “summit committee” session was held, followed by
a preliminary review by the full Board of Trustees, a vote, and approval for publication in December, 2012. Phew!!!
The next section of the Introduction describes the new organizational structure of
DSM-5. In summary:
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The individual disorder definitions are the core of DSM-5
The classification of the disorders (the grouping) has never been thought of
as significant
It was thought that rethinking the organizational structure might improve
clinical utility and stimulate new clinical perspectives and encourage research
It is recognized that the criteria and their relationships may need to be modified as new evidence is gathered – Personality Disorders are in section II (diagnostic criteria) and Section III (Conditions for Further Study).
DSM-5 had to be in harmony with ICD-11 (International Classification of Diseases – not yet published)
It is important to understand developmental and lifespan considerations that were
used in an effort to improve usefulness. DSM-5 is organized by starting with diagnoses that are thought to reflect developmental processes that manifest early in life
– those with an earlier onset are listed first. A similar approach is used within each
chapter.
The proposed organization of chapters after the neurodevelopmental disorders is
based on groups of internalizing (that is, those with prominent anxiety, depressive,
and somatic symptoms), externalizing (that is, those with prominent impulsive, disruptive conduct, and substance use symptoms), and other disorders. It is hoped that
this will encourage further study of underlying pathophysiological processes that
underlie diagnostic comorbidity and symptom heterogeneity. Related to these recommendations were “scientific validators” that served to inform how the disorders
would group together based on 11 indicators:
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Shared neural substrates
Family traits
Genetic risk factors
Specific environmental risk factors
Biomarkers
Temperamental antecedents
Abnormalities of emotional or cognitive processing
Symptom similarity
Course of illness
High comorbidity
Shared treatment response
It is hoped that this organizational structure will serve as a convenient transition to
new diagnostic approaches, without disrupting current clinical practice. APA seems
to recognize that alternative definitions for many disorders will be necessary, leading to a model focusing on dimensional, rather than categorical descriptions, but it
was thought that such profound changes were premature and too disruptive. “Such
a reformulation of research goals should also keep DSM-5 central to the development of dimensional approaches to diagnosis that will likely supplement or supersede current categorical approaches in coming years” (p. 13).
The influence of cultural concerns and gender differences is discussed as well. It is
noted that Section III contains tools for an extensive cultural assessment, and the
Appendix contains a “Glossary of Cultural Concepts of Distress”. Three concempts
are described that outline the recommended approach to culture-bound syndomes:
1. Cultural syndrome – A group of unchanging symptoms found in a specific cultural group. Community, or context – not recognized as an illness within the
culture, but recognizable by an outside observer
2. Cultural idiom of distress – a way of talking about suffering among individuals within a group. This is not associated with specific symptoms or perceived causes, and may convey a wide range of discomfort
3. Cultural explanations or perceived cause – an explanatory model that provides a culturally determined etiology.
It is noted that sex and gender differences are established for a number of mental
disorders, and revisions include reviews of potential differences between men and
women in illness expression. Sex differences are attributable to reproductive organs and the individual’s genetic complement, while gender differences result from
biological sex as well as the person’s self-representation. Gender can influence illness in several ways:
1. Exclusive determination of whether someone is at risk for a disorder (e.g.,
premenstrual dysphoric disorder).
2. Moderate the overall risk for the development of a disorder
3. Gender may influence the likelihood that particular symptoms are experienced
DSM-5 includes information on gender at multiple levels. Gender-specific symptoms are added to diagnostic criteria. A gender-related specifier is provided to offer
additional information on gender and diagnosis. Additionally, a section labeled
“Gender-Related Diagnostic Issues” outlines other concerns that are pertinent.
The APA was clear in it’s intent to do away with NOS designations, pointing out that
they were being overused and they led to lack of specificity. Two options were proposed and ultimately implemented:
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Other Specified Disorder – Allows the clinician to describe the specific reason
that person does not meet the criteria for any specific category within a diagnostic class.
o Record the name of the category, followed by the specific reason – for
example: “other specified depressive disorder, depressive episode
with insufficient symptoms”
Unspecified Disorder – Used when the clinician chooses to not specify the reason the criteria are not met. Example: “unspecified depressive disorder”
The Multiaxial System
It’s gone. Separate notations for important psychosocial and contextual factors (IV)
and disability (V) are to be outlined separately. Axis III has been combined with Axes I and II – clinicians should continue to list medical conditions that are important
to the understanding of the person’s mental disorder(s). It was decided that ICD-9
CM V codes ICD-10 Z codes could be used to describe relevant psychosocial and environmental problems. GAF was dropped for several reasons with the WHODAS
(World Health Organization Disability Assessment Schedule) suggested for further
study.
Finally, online enhancements are discussed. Only the most relevant clinical rating
scales and measures are included in the print edition. Additional measures used in
field trials are available online (www.psychiatry.org/dsm5), linked to the relevant
disorders. The Cultural Formulation Interview, Cultural Formulation Interview –
Informant Version, and other elements of the interview are available online at the
same address. It is noted that PsychiatryOnline.org provides an online subscription
service that enhances the printed text. Also available are supportive references and
additional information. DSM-5 does not tell you this, but the annual fee for this service is presently $420.00 – information can be found at this address:
http://www.appi.org/SearchCenter/Pages/SearchDetail.aspx?ItemId=POLIND