The Diagnostic and Statistical Manual of Mood Disorders – 5

Standard

The DSM-V       (Diagnostic and Statistical Manual of Mental Disorders) is a standard manual used by psychiatrists in identifying and treating mental illnesses and disorders. V refers to the DSM as being in its 5th edition, revised 4 times. Psychiatrists from around the world assist with the inclusion and definition of various disorders in the manual. A revision can and typically does take years. This edition moves towards a non-axial system. The axial system refers to treating the “whole” person, rather than just the disorder.The manual is just behind the institution of science and is always in a state of revision. The current manual doesn’t include more information than the DSM-IV-TR. Rather, it re-assesses symptoms and disorders based on treatment results and other demographics.

Axis I refers to the major disorder that needs immediate attention; Axis II lists any personality disorder that affects the major disorder   Axis III lists any medical or neurological problems that also affect the major disorder Axis IV codes the major psychosocial stressors such as a divorce or a job loss. Axis V codes the “level of function” the individual has attained at the time of assessment. 

The DSM includes diagnostic criteria (symptoms) and codes. It also lists descriptive text to assist the psychiatrist in making a diagnosis.It makes use of ICD-9 and -10 codes. These codes refer to the  International Statistical Classification of Diseases and Related Health Problems. None of these codes are approved as part of the official DSM-5 diagnoses, but they can provide context for clinical treatment.The manual admits that not every illness or disorder is identifiable. It does so with comments such as “otherwise not specified“.

It formerly used “umbrella” terms – a term that encompassed a wide array of disorders. This system is being slowly eroded in some cases. For instance, the schizophrenia spectrum and other psychotic disorders covered a range of illnesses, including schizophrenia, other psychotic disorders, and schizotypal (personality) disorder and schizoaffective disorder.In the new DSM this approach has changed and there is only one diagnosis, being schizophrenia. The sole exception is catatonia, which now has its own inclusion.

Emerging Methods and Models is another component of the DSM. This section contains tools and techniques to enhance the clinical decision-making process, understand the cultural context. Cultural context is perhaps one of the most challenging aspects of treating a patient. Different nations and races interpret disorders in very different manners. There are still populations that believe in witchcraft and voodoo, for instance, and working with such people makes diagnoses and treatment quite formidable. Of course there are many people who simply do not accept or believe in their diagnoses. This also complicates the treatment process.

Criticism
Criticism unfairly focuses around the use of the DSM. People believe it is used to pathologize normal behaviour. This results partly from the corrections and the very revisions themselves. However revisions are a positive sign. It demonstrates that knowledge of various mental disorders is changing and improving. The same is true of medical illnesses. Insofar as the use of the DSM-V is with DID and MPD however, there is considerable controversy. This will be discussed in other blogs.

Top Ten Revisions in the DSM-V

Axial System – Much of the information gleaned from Axes 1 – 5 are no longer supported by medical research. For instance, there is no medical field that assesses a medical disease then uses Axis III in a treatment plan. Axis IV, psychosocial stressors, is almost never used in diagnostic judgement. Axis 5, the level of function, is used by insurance companies more than for mental health reasons. If the doctor lists the patient as functional, the insurance company will not pay for the patient’s treatment. This runs a huge risk for the patient’s well-being and the doctor may, in turn, have to absorb the cost of treatment.

Elimination of Bereavement Exclusion from Diagnosis of Major Depression
Under the old assessment. the doctor could not diagnose depression in a patient who had lost a loved one for two  months.This implied that people had finished mourning their loved one in two months time. Most people require 1 – 2 years to recover from bereavement and parents whose children die, profess they never recover from bereavement. It also meant the patient had to wait for 2 months for medical intervention.

Elimination of Sub-Types of Schizophrenia
There was paranoid, undifferentiated, disorganized and catatonic. Catatonia is now an independent diagnosis. There is only one diagnosis: schizophrenia, which is a major historical change.

Disruptive Mood Dysregulation Disorder
These are angry and distraught kids in adolescence and the teenage years. Normally these symptoms led to a diagnosis of adolescent bipolar disorder. However these children exhibit a different type of disorder. They aren’t merely angry. They are very distraught, not in mania.

Gambling Addiction
GA appears in substance-related addiction disorders. This diagnosis is surprising since it doesn’t involve the intake of a substance. Then again, neither does shopping or sex addiction whiich is frequently diagnosed by therapists yet isn’t included in the DSM-5.

Gender Identity Dysphoria
A large proportion of the treatment is endocrinological and surgical. This is a controversial diagnosis. In essence it states that there is no “fixing” this patient, ergo, changing reality to align with the patient’s pathological self-perception is the answer. This approach is considered “harm reduction”. However the concern is whether or not this is indeed a reduction of harm, since hormone and surgical therapy drastically alter the shape and function of the mind and body. This encourages the pathology, rather than “curing” it.

No Child/Adolescent Clusters
Many of the disorders diagnosed in children and adolescents persist into adulthood, thus this cluster is misleading.

Hypochondriasis Renamed to Illness Anxiety Disorder
This refers to the decay of the term. The meaning has slowly eroded. When it was first invented it was an honorable term meaning that the origin of the pain was under the ribs – over time it denoted a vague illness with pathological ideology.Using this term about a patient stirred up great resentment since it implies the patient is “faking”. Insurance companies refused to pay for this illness. Of course, the patient is in distress but he or she cannot afford treatment.

Somatic Symptom Disorder
Related to hypochondriasis. This replaces pain disorder and somatization disorder.

No Change in Defining End Point
There is no assessment in defining when mental disorders are cured, if cure is possible. There is no technique as to when the diagnosis criteria is met. Also, when there is remission versus a cure isn’t defined. A good example is trichotillomania (compulsive hair-pulling). “Cure” is a taboo notion. No one knows when cure has been accomplished. Treatment ends when the patient doesn’t want to attend appointments or when s/he requests to be removed from medications. This remains a major problem.

 

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