Table Of Contents-Part 1
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Table Of Contents-Part 1
The DSM, or Diagnostic and Statistical Manual of Mental Disorders, provides standardized criteria to the diagnosis of mental health conditions and has been widely used by mental health practitioners in the U.S. to aid in diagnosing clients since 1952. The previous edition, the DSM-IV, was first issued in 1994 (American Psychiatric Association, 1994) and revised in 2000 (American Psychiatric Association, 2000).
The update of this system, the DSM-5, has been through several stages of review since it was initiated in 1999. (American Psychiatric Association, 2013) It was published after reviews of several decades of scientific research and 10 years of international conferences and deliberation, with the involvement of more than 900 experts from the U.S. and abroad, including clinicians and researchers in psychiatry, psychology, statistics, epidemiology, neurology, pediatrics, social work, and other disciplines and specialties. (Kupfer, 2012)
The payer mandate is to use ICD codes for health care claim purposes. “Since DSM-5 is compatible with the HIPAA-approved ICD-9-CM coding system in use by insurance companies, the revised criteria for mental disorders can be used immediately for diagnosing mental disorders.” (American Psychiatric Association, n. d. b)
The biggest change in the DSM-5 is the elimination of the multi-axial system that clinicians had ingrained in their minds for decades. The new system takes a developmental approach in its organization. It also integrates into the very fabric of the DSM the concept that mental illness is more a spectrum of functioning, from very minimal “normal” levels to more extreme “pathologic” symptoms. Therefore the DSM-5 is moving away from the assumption that some people are fully normal while others are mentally ill, but rather is looking more at a range of human experience.
These changes in the DSM-5 have a significant impact for practitioners who use mental health diagnoses in their work: “Ultimately, this manual and the way in which clinicians apply its guidance impacts every patient treated by the mental health community.” (Gorrindo, 2013) In addition to being a diagnosis resource for healthcare professionals, the DSM also is important for treatment plans, medication choices and protocols, insurance reimbursements, and research agendas.
The DSM guides legal judgments: which criminal defendants are able to stand trial and, in some cases, how they will be sentenced. It creates stigma, and influences personal expectations. The DSM exists in classrooms, libraries, on the Internet, and in the popular imagination. It shapes who receives what treatment, who gets disability, life insurance or workman’s compensation, who gets to pilot a plane, or to adopt a child and which drugs regulators approve. It is also used by public health authorities for compiling and report¬ing morbidity and mortality statistics. School services depend on a psychiatric diagnosis: the manual helps schools decide how to allot special education.
Even seemingly subtle changes to the criteria can have substantial effects on patterns of mental health care because it essentially sets the boundary between who is normal and who is not. These changes could determine how tens of millions of people regard themselves – whether they have a mental disorder or not. Therefore the DSM has become a very important document. (Frances, 2013 d)
This course offers clinicians a comprehensive breakdown of the major aspects of the revisions of the diagnostic categories, both for treatment planning as well as for communicating with colleagues and insurance companies. The course also provides a detailed overview of the debates and controversies accompanying these changes.
Early attempts to classify mental illnesses were based on an evolving understanding of the nature of psychiatric disorders. Historically, countries and individual agencies within these countries had separate approaches to classifying mental illnesses.
Nursing research pioneer, Florence Nightingale, first promoted the use of non-fatal disease classification for morbidity and treatment in 1860 in Europe. By the late 1800s, Kraepelin categorized mental disorders, and his sixth edition of the “Kompendium der Psychiatrie” was widely adopted by both Europeans and Americans. “At a time when naming conditions was in the rudimentary stages, descriptions were identified based on gross departures from predictable, logical, and orderly behavioral patterns.” (Halter et al., 2013 b)
In the United States, the first major attempts to categorize psychiatric disorders occurred during the 1840 U.S. Census (CensusFinder, n. d.). One question, “How many idiotic or insane Whites?” was used to determine the prevalence of mental retardation and mental illness. No definitions of these conditions were provided. The 1880 U.S. Census included more categories of mental illness: mania, melancholia, monomania (impulse control, conduct, and delusional disorders), dementia, and dipsomania (alcohol craving and binge drinking). (Halter et al., 2013 b)
At the beginning of the 20th century more attention was devoted to developing a system that had a more clinical utility. In order to include psychophysiological, personality, and acute disorders of World War II veterans, the U.S. Army and Veterans Administration developed a broader categorization. When the World Health Organization, contemporaneously, included a section for mental disorders for the first time, the new ICD-6 (International Statistical Classification of Diseases) was heavily influenced by the Veteran Administration’s nomenclature.
The ICD-6 was considered unacceptable by most countries, including the U.S., because of its heavy reliance on unproven etiological concepts (First, Tasman, 2004). To lessen the confusion, APA’s (American Psychiatric Association) Committee on Nomenclature and Statistics began work on the first edition of the DSM. The final version of the DSM-I, which assigned 3 categories based on lists of symptoms, and established 106 diagnoses, was approved by a vote of the APA membership and published in 1952.
It was the first official manual of mental disorders in the United States that focused on clinical utility. “The use of the term reaction throughout DSM-I reflected the influence of Adolf Meyer’s psychobiological view that mental disorders represent reactions of the personality to psychological, social, and biological factors.” (American Psychiatric Association, 2000, p. xxv).
The DSM-II with 11 major categories, 185 diagnoses, and 92 pages was published in 1968 to further facilitate communication among professionals. Like the DSM-I, it retained many etiological concepts but eliminated the term reaction. Both of these editions were strongly influenced by a psychodynamic approach, and therefore provided no sharp distinction between normal and abnormal conditions. Mental disorders were considered reactions to environmental events, as they exist on a continuum of behavior.
Consequently, everyone is more or less abnormal. A person with more severe abnormalities has more severe difficulties with functioning. The classificatory structure in these two editions of the DSM was rooted in a distinction between two poles of mental disorder, psychosis and neurosis. A psychosis was a severe mental disorder characterized by a disconnection from reality (hallucinations and delusions). A neurosis, however, was a milder mental disorder characterized by distortions of reality, but not a complete break with reality (anxiety and depression).
The DSM-I and the DSM-II were widely criticized for their lack of empirical basis, reliability, validity, and detailed description. (Blashfield, 1998; Kirk & Kutchins, 1994). Many psychiatrists were concerned about the implicit medical model, stating that it was inappropriate because the cause of most disorders was unknown. Among the most noted examples of controversial diagnoses was the classification of homosexuality as a mental disorder. This diagnosis was removed by a vote of the APA in 1973 after various gay activists groups demonstrated at APA meetings for three years.
After reviewing the early drafts of the ICD-9, the APA decided to publish the DSM-III (American Psychiatric Association, 1980) in 1980 because of concerns that the international nature of the ICD-9 might result in inconsistent terminology and definitions and that the sub-typing was inadequate for clinical and research use. Largely because the primary function of the ICD-9 was to facilitate health statistics, it did not include diagnostic criteria or a multiaxial system. The DSM was intended for use by mental health professionals, third party payers, and for research and administration. On 482 pages the DSM-III now contained 265 diagnoses.
This edition presented a major paradigm shift from the psychodynamic view and the etiologically-based frameworks of the DSM-I and the DSM-II, moving to a bio-psychological model as the primary approach. This methodological innovation introduced a clear distinction between normal and abnormal. Disorders were defined by the use of explicit diagnostic criteria, and separated by developmental and personality disorders (Axis II), physical disorders (Axis III), stressors (Axis IV), and level of adaptive functioning (Axis V) from the presenting diagnosis (Axis I). The DSM became atheoretical since it had no preferred etiology for mental disorders. The new descriptive approach was meant to facilitate communication among mental health professionals operating from various theoretical orientations. (First, Tasman 2004).
Because of several inconsistencies in the system and a number of instances in which criteria were not entirely clear, the DSM-III-R (R for revision – American Psychiatric Association, 1987) was published in 1987 with substantive corrections and revisions and 297 diagnoses. Six new categories were deleted while others, such as Trichotillomania, were added.
The DSM-IV (American Psychiatric Association, 1994) was timed for publication in 1994. The most significant change in this issue was the process in which the DSM-III-R was revised to produce the DSM-IV (Widiger et al., 1991). Prior revisions were mostly guided by expert consensus. Their decisions were subject to potential biases. “In contrast, whenever possible, DSM-IV decisions were based on systematic review of the then current empirical database.” (First & Tasman, 2004, p. 6) The method used to establish an empirical basis was divided into three stages:
A summary of the results of this review process, as well as the rationale for the changes in the DSM-IV, was published in the four-volume DSM-IV Sourcebook (Widiger et al. 1994, 1996, 1997, 1998). On 886 pages with 365 diagnoses, the DSM-IV offered detailed information about each disorder, including essential and associated features; presence, course, and familial pattern; differential diagnosis; and age, gender, and culture.
To provide continuity and educational value, changes to the text were made on the basis of a comprehensive review of the literature relevant to the categories that were published since 1992. These changes manifested in the DSM-IV-TR (TR for Text Revision), which was published in 2000 with 374 diagnoses. Some factual errors were also corrected. DSM-IV-TR diagnostic codes were selected by perusing the ICD system and picking the ICD codes that best correspond to each DSM-IV-TR categories. (American Psychiatric Association, 2000)
The following list summarizes some historical information (Peele, n. d.):
DSM-I: 1952 [129 pages] (Raines)
DSM-II: 1968 [134 pages] (Gruenberg)
DSM-III: 1980 [474 pages] (Spitzer)
DSM-IIIR: 1987 [567 pages] (Spitzer)
DSM-IV: 1994 [968 pages] (Frances, Pincus, and First)
DSM-IV-TR: 2000 [988 pages] (First and Pincus)
DSM-5: May 17, 2013 [947 pages] (Kupfer and Regier)
ICD-9-CM: International Classification of Diseases, Clinical Modification (ICD-9-CM) is an adaption created by the U.S. National Center for Health Statistics [NCHS] and used in assigning diagnostic and procedural codes with inpatient, outpatient, and physician office utilization in the United States. It is updated annually on October 1.
ICD-10-CM: Due to be implemented in the U.S. on October 1. 2014.
“The development of DSM-5 began with an unprecedented process of research evaluation.” (Gray, 2013) Originally, a research–planning process was initiated to stimulate research and devise a research agenda that would facilitate the integration of findings from animal studies, genetics, neuroscience, epidemiology, clinical research, and cross-cultural and clinical services research (Regier et al., 2002).
Beginning in 1999, the APA engaged almost 400 international scientists and clinicians at 13 international conferences. A series of monographs and peer-reviewed journal articles were produced. “The final manual includes contributions from more than 1,500 experts in psychiatry, psychology, social work, psychiatric nursing, pediatrics, neurology, and other fields from 39 countries.” (American Psychiatric Association, 2012 a) The DSM-5 was developed in several phases.
During the first phase of the DSM-5 planning process, a series of “white papers” were commissioned in order to stimulate research and discussion in the field in preparation for the eventual start of the DSM-5 revision process. An important goal of these papers was to encourage a research agenda that goes beyond the current diagnostic paradigm in the DSM-IV-TR in order to integrate information from a wide variety of sources and technologies. For this reason, these white papers focus on cross-cutting issues by covering the following areas: 1) Basic Nomenclature Issues; 2) Neuroscience; 3) Developmental Science; 4) Personality Disorders and Relational Disorders; 5) Mental Disorders and Disability; and 6) Culture and Psychiatric Diagnosis. (First, 2007) Three additional white papers are subsequently being developed. They focus on gender issues, on diagnostic issues in the geriatric population, and on mental disorders in infants and young children. (First, et al., 2007)
The second phase of the DSM-5 planning process consisted of reviewing the literature reviews and data generated as part of the 10 research planning conferences (The Future of Psychiatric Diagnosis: Refining the Research Agenda). These conferences for the most part focused on specific diagnostic topics. They were to stimulate the empirical research necessary to allow informed decision making regarding crucial diagnostic deficiencies identified in DSM-IV-TR and ICD-10 and to promote international collaboration in order to increase the likelihood of developing a future unified DSM/ICD. (First, et al., 2007)
The third phase started in 2007 and 2008. Work group members were reviewed for potential conflicts of interest and approved by the APA Board. Nominees were widely viewed to be the leading experts in their field.
The DSM-5 Task Force and Work Groups, made up of more than 160 world-renowned clinicians and researchers, were tasked with building on the previous seven years of scientific reviews, conducting additional focused reviews, and garnering input from a breadth of advisors as the basis for proposing draft criteria. Each work group has met regularly, in person and on conference calls. They began by reviewing DSM-IV’s strengths and problems, from which research questions and hypotheses were developed, followed by thorough investigations of literature reviews and analyses of existing data. Based on their comprehensive review of scientific advancements, targeted research analyses, and clinical expertise, the work groups have developed the DSM-5 diagnostic criteria.
The fourth phase began in the spring of 2010. The APA publicly requested feedback on the DSM-5 draft diagnostic categories. Ultimately, psychiatrists, psychologists, licensed clinical social workers, advanced practice psychiatric nurses, mental health nurses, licensed counselors, and licensed marriage and family therapists helped shape diagnostic criteria and proposed dimensional measures for the new manual. (American Psychiatric Association, 2012 d) This independent review lasted for 18 months. The findings are not available to the public. (Gray, 2012)
The last phase of the manual’s development began in late June 2012 at the end of a last, six-week open-comment period for health professionals, patients and families, advocates and others.
Throughout a total of three open-comment periods, which began in 2010, the APA has received more than 13,000 comments and more than 12,000 emails and letters. This has been an unprecedented approach. (American Psychiatric Association, n. d. a)
8,600 comments submitted in response to the draft of the DSM-5 helped spur changes in the draft. “Because of the Internet and the ‘Web 2.0′ movement – where there is an inherent expectation of the ability to engage in a two-way dialogue about content found online – the DSM-5 has done something never done before. It has encouraged a two-way dialogue with the workgroups responsible for making changes and edits.” Grohol, J.M. (n. d. b)
Every previous revision of the DSM caused controversy. But never has the process provoked warfare so brutal, with attacks coming from within the profession during the DSM-5 revision process. (Greenberg, 2013)
While some see the many statements of concern as squabbling and feel that mental health professionals merely use the DSM-5 as a reference guide tool for diagnosis, others feel that the changes have a detrimental effect on mental health care. Critics claim: though conducted with volunteers, the revision process has been somewhat secretive and did not sufficiently consider objections to what the manual contains. Some call the changes in the new manual flawed, unsafe, scientifically unsound, and costly to our society. (Gray, 2013)
All the critics seem to agree on one thing, which is that the DSM-5 extends the reach of psychiatry further into daily life. The new manual makes many more individuals eligible for psychiatric diagnoses, resulting in more prescriptions for medication (more than 10% of American adults already take antidepressants). (Greenberg, 2013) They warn that the DSM-5 is likely to create “false-positive” epidemics – the diagnosis and consequent treatment of individuals who by many criteria are neither ill nor experiencing distress at levels beyond that experienced during normal everyday living (Frances, 2012 b). The American Psychiatric Association dismissed DSM-5 opponents as overly alarmed (Gray, 2013).
Allen Frances, the most vociferous critic of the DSM-5, concluded that the revised manual will worsen the already existing “misallocation of resources by recklessly introducing new and untested diagnoses and reducing the thresholds for existing ones. People who don’t need diagnosis and treatment will get it, while people in desperate need will be frozen out; and drug companies will laugh all the way to the bank.” (Frances, 2013 k)
It is likely that expanded public awareness and media interest in the DSM-5 were a product of electronic communication and exponentially-increased instantaneous discussion and debate about the manual. This may be one of the reasons why the DSM-5 revisions resulted in greater controversy than earlier editions. (Halter et al., 2013)
“Drafting new diagnostic criteria more strongly rooted in biology was a major goal of the leaders of the DSM-5 when they began their work more than a decade ago. At the time, cognitive neuroscience was exploding, the human genome was soon to be in hand, and it seemed reasonable to hope that a revolutionary new manual based on science would be possible. Instead of checking off lists of symptoms, psychiatrists would soon be using genetic tests and brain scans to diagnose their patients. That turned out to be premature.” (Miller, 2013)
The world’s largest mental health research institute, the National Institute for Mental Health (NIMH), set off a firestorm by distancing itself from the DSM-5 just weeks before the its publication. NIMH director Thomas Insel complained about the manual’s lack of validity, saying “mental health patients deserve better than that”. The research of the NIMH, which invests $1.5 billion a year into mental health research, will be re-orientated away from the DSM categories, which are not grounded solidly in biology. The NIMH plans to classify psychopathology based on observable behavior and neurobiological measures. (Insel, 2013)
“The DSM-5 Task Force spent years and untold amounts of money chasing the same dream Insel has, to no avail.” (Gever, 2013) The co-chair of the DSM-5 task force, David Kupfer, insisted that – while genetic and other biological tests would be the ultimate holy grail of diagnosis – there’s no sign that such foolproof methods will be available anytime soon. (Kupfer, 2013) Therefore, supporters of the manual stated: “With little research producing reliable biomarkers or laboratory tests for mental disorders, the DSM-5 remains the most reliable diagnostic system that is empirically-based.” (Grohol, 2013)
The Board of Trustees of the American Psychiatric Association approved the product of this extensive discussion and debate, the DSM-5, on December 1, 2012. They officially released the new manual on May 18, 2013 at their annual meeting in San Francisco, with an electronic version of the manual to appear in late 2013. (American Psychiatric Association, 2013 c) A group of “Occupy Psychiatry” protesters responded by demonstrating for an overhaul of the diagnostic system in front of the conference building a couple of days later. (Swan, 2013)
For Extended Bibliography and References, click here.