DSM-V thoughts?

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perhaps11

perhaps11

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It looks as if the DSM-V is in the final stages of being complete and with various changes (e.g. new/changed diagnoses, adding dimensional assessments in addition to the categorical). That said, I am wondering what you guys think about the changes and how it will effect clinical diagnoses as well as its efficiency in facilitating future research. Some of my clinical professors seem to despise the direction of the DSM while others praise it as a step in the right direction. I'm just wondering where people on here stand on this matter.

For those who do not know, you can view all matters regarding the new DSM at www.dsm5.org
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perhaps11 said:
It looks as if the DSM-V is in the final stages of being complete and with various changes (e.g. new/changed diagnoses, adding dimensional assessments in addition to the categorical). That said, I am wondering what you guys think about the changes and how it will effect clinical diagnoses as well as its efficiency in facilitating future research. Some of my clinical professors seem to despise the direction of the DSM while others praise it as a step in the right direction. I'm just wondering where people on here stand on this matter.
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You'd probably have to look at the diagnoses on a case by case basis. It's hard to make blanket statements about the DSM 5. Then also understand that any diagnostic system is going to be flawed.
 
Pragma said:
You'd probably have to look at the diagnoses on a case by case basis. It's hard to make blanket statements about the DSM 5. Then also understand that any diagnostic system is going to be flawed.
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I guess I just meant for this thread to kind of be a free-for-all kick-starter for some open discussion regarding the changes.
 
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Does anyone know how this will affect neuropsychologists? I kind of recall hearing that Mild Cognitive Impairment and Cognitive Disorder due to do _____ will be in the DSM-V and will require objective neurocognitive data as part of the diagnostic criteria. This could be a good thing....
 
futureapppsy2 said:
I'm guessing more call for neuropsych testing.
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1. Who says npsychs will be the one to do it? It sounds like another procedure that docs/neurologists can do (no doubt inadequately from a psychometric standpoint :rolleyes:) in-house and bill for.

2. Is this really cost efficient for the patient/insurer?
 
erg923 said:
1. Who says npsychs will be the one to do it? It sounds like another procedure that docs can do (no doubt inadequately from a psychometric standpoint :rolleyes:) in-house and bill for.

2. Is this really cost efficient for the patient/insurer?
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1. Well, if we are not effective in proving our worth, maybe. Guess we should maybe do something about it?

2. Again, something we have to demonstrate. Or, just give up now. :rolleyes:
 
Member6523 said:
1. Well, if we are not effective in proving our worth, maybe. Guess we should maybe do something about it?

2. Again, something we have to demonstrate. Or, just give up now. :rolleyes:
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1. I just meant it would be quite naive to think that such a thing would translate into more business.

2. We have not done this thus far. I doubt we will have an extensive lit base on this by the time it comes out either. And I think it interesting to note that I can't really think, of the top of my head, how a npsych eval in your run of the mill MCI patient saves anybody any money in the long run.
 
erg923 said:
1. Who says npsychs will be the one to do it? It sounds like another procedure that docs/neurologists can do (no doubt inadequately from a psychometric standpoint :rolleyes:) in-house and bill for.

2. Is this really cost efficient for the patient/insurer?
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It's still a nudge in the right direction. Nothing compels them to refer to neuropsych currently but many still do.
 
erg923 said:
1. I just meant it would be quite naive to think that such a thing would translate into more business.

2. We have not done this thus far. I doubt we will have an extensive lit base on this by the time it comes out either. And I think it interesting to note that I can't really think, of the top of my head, how a npsych eval in your run of the mill MCI patient saves anybody any money in the long run.
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1. I disagree. It brings the concept of "cognitive impairment" out of the relatively narrow world it lives in. Some physicians will go ahead and try to assess it on their own. Others will refer out. Either way, it will generate more business. Whether or not we neuropsychologists choose to jump onto that business, well, that's up to you. I definitely think the pessimistic ones are not going to be part of that group.

2. But people are aware of it. Some groups are doing something about it. Our lit base is growing. It's not just pure MCI that neuropsychologists evaluate for, but differentials like dementia, PCS, psychiatric issues, and (rarely) missed neurological causes. MCI is not a clean diagnosis, and so if it achieves more legitimacy and is recognized as something insurance companies should cover, it will require some kind of formal testing to diagnose. Regarding whether neuropsychologists will do that formal testing, well see answer 1.
 
Member6523 said:
1. I disagree. It brings the concept of "cognitive impairment" out of the relatively narrow world it lives in. Some physicians will go ahead and try to assess it on their own. Others will refer out. Either way, it will generate more business. Whether or not we neuropsychologists choose to jump onto that business, well, that's up to you. I definitely think the pessimistic ones are not going to be part of that group.

2. But people are aware of it. Some groups are doing something about it. Our lit base is growing. It's not just pure MCI that neuropsychologists evaluate for, but differentials like dementia, PCS, psychiatric issues, and (rarely) missed neurological causes. MCI is not a clean diagnosis, and so if it achieves more legitimacy and is recognized as something insurance companies should cover, it will require some kind of formal testing to diagnose. Regarding whether neuropsychologists will do that formal testing, well see answer 1.
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The healthcare system is not run by neuropsychologists. They are run by it.

You're approaching it from a clinicians perspective. My arguments/questions/points however, are trying to demonstrate how everyone else in the modern day healthcare system will be approaching the issue.

What say ye?
 
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erg923 said:
The healthcare system is not run by neuropsychologists. They are run by it.

You're approaching it from a clinicians perspective. My arguments/questions/points however, are trying to demonstrate how everyone else in the modern day healthcare system will be approaching the issue.

What say ye?
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I gather that your point is that health insurance companies will try to aim for the cheapest and fastest way possible to diagnose disorders. Well, maybe neuropsychology in general has to go that way and write substandard 2 page reports like the VAs do. Or, we can try to lobby a bit, make it clear why are services are informative. And I believe they are, as they assess current functioning, aid in complex differential diagnoses, and predict outcome.

I'm open to alternatives though. What do you think is going to happen, exactly? Do you think EVERY primary health care provider will attempt to run neurocognitive tests on their own?
 
Regarding your point number to about diff Dx: I would just like to add that it has to be based on if it improves functional outcomes and/or whether it leads to treatments that does so as well (which will save money due to healthcare utilization), not *DIAGNOSIS*

Neuropsychological testing is necessary for *diagnosis* in very few psychiatric or neurological conditions. How many conditions can we name where literature would support NP testing as essential to diagnosis? I'd love to see the list. As far as I am aware, NP testing is unnecessary for *diagnosing* MS, MSA's, PD, HD, mod-severe TBI, stroke and a host of other hard-core neurological diseases and injuries. I assume we get reimbursed for our evals in these populations because we are assessing the IMPACT of an ALREADY DIAGNOSED condition on a person's functioning and quality of life. I assume this saves money somewhere. I would think we should focus on that and quite harping on the Dx issue, which I feel npsychs like to play up to quite self-serving delusional levels...:)
 
erg923 said:
Regarding your point number to about diff Dx: I would just like to add that it has to be based on if it improves functional outcomes and/or whether it leads to treatments that does so as well (which will save money due to healthcare utilization), not *DIAGNOSIS*

Neuropsychological testing is necessary for *diagnosis* in very few psychiatric or neurological conditions. How many conditions can we name where literature would support NP testing as essential to diagnosis? I'd love to see the list. As far as I am aware, NP testing is unnecessary for *diagnosing* MS, MSA's, PD, HD, mod-severe TBI, stroke and a host of other hard-core neurological diseases and injuries. I assume we get reimbursed for our evals in these populations because we are assessing the IMPACT of an ALREADY DIAGNOSED condition on a person's functioning and quality of life.
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Very few, but I dare say MCI is one of those. Obviously major neurological insults/neurodegenerative disorders do not require a neuropsychologist to diagnose.
 
erg923 said:
No. I do not think they will do it at all...
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Thanks for the vague response. I'll ask again. "What do you think is going to happen, exactly?" My whole argument is that if MCI requires documented neurocognitive impairment to diagnose in the DSM-V, and there is a reason to diagnose it, why wouldn't it be something that is referred out for?

If neuropsychologists (and psychologists in general, and doctors, and so forth) can make a stance for why MCI is worth documenting (like LD and ADHD), as for example, in worker's comp cases, then the system will accept us. That equals more jobs, more revenue, more business. I see it as a positive thing.
 
erg923 said:
No. I do not think they will do it at all...
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I don't picture any GPs or most neurologists picking up a DSM. That being said, I could see word getting out among referrers that the criteria for "mild neurocognitive disorder" encourages (but doesn't require) formal testing. It could encourage some clinicians to start referring for testing. I don't see how including formal testing related language/criteria would reduce neuropsych use.

It's probably naive to assume this will create sudden massive demand , but I think it's reasonable to think demand could take small ticks up over the years as the new DSM language spreads through current referral sources.
 
roubs said:
I don't picture any GPs or most neurologists picking up a DSM. That being said, I could see word getting out among referrers that the criteria for "mild neurocognitive disorder" encourages (but doesn't require) formal testing. It could encourage some clinicians to start referring for testing. I don't see how including formal testing related language/criteria would reduce neuropsych use.

It's probably naive to assume this will create sudden massive demand , but I think it's reasonable to think demand could take small ticks up over the years as the new DSM language spreads through current referral sources.
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I agree with this. There won't be any sort of explosion. But I think we will survive, and grow as a field. Maybe we'll evolve in unexpected ways, but we'll be around, unless some kind of apocalypse occurs. In that case, us psychologists will probably be the first to go...
 
Member6523 said:
I agree with this. There won't be any sort of explosion. But I think we will survive, and grow as a field. Maybe we'll evolve in unexpected ways, but we'll be around, unless some kind of apocalypse occurs. In that case, us psychologists will probably be the first to go...
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I mean really it's a DSM revision. I don't think anyone expects large changes but it's still worth discussing which trends will this encourage/discourage.
 
I'm not in this part of the field but a recent NYT magazine story made me look up the change from gender identity disorder to gender dysphoria. I think the name change itself is a positive step toward reducing stigma. You could argue that placing gender dysphoria among a list of mental disorders is evidence that gender nonconforming remains stigmatized, but for the foreseeable future parents are going to be asking themselves "what do I do?" when they have a gender nonconforming child--and they are going to bring this question to doctors and psychologists so we will need a name for this issue and I think it's better that the name doesn't include the word "disorder"
 
Member6523 said:
Thanks for the vague response. I'll ask again. "What do you think is going to happen, exactly?" My whole argument is that if MCI requires documented neurocognitive impairment to diagnose in the DSM-V, and there is a reason to diagnose it, why wouldn't it be something that is referred out for?

If neuropsychologists (and psychologists in general, and doctors, and so forth) can make a stance for why MCI is worth documenting (like LD and ADHD), as for example, in worker's comp cases, then the system will accept us. That equals more jobs, more revenue, more business. I see it as a positive thing.
Click to expand...

Because, its the DSM and other professions will either a.) not know about it. b.) not care since its not in ICD.

I think many neurologists will do a one size fits all screening, likely on a computer, to keep the billing and money in-house. And, so save the patient the time and expense.
 
erg923 said:
Because, its the DSM and other professions will either a.) not know about it. b.) not care since its not in ICD.

I think many neurologists will do a one size fits all screening, likely on a computer, to keep the billing and money in-house. And, so save the patient the time and expense.
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Fair enough. I still think this is a positive move for reasons stated above. Neuropsychologists are such a minority right now, our role in the bigger healthcare system is going to be minute regardless. Right now we need to work together to protect what we do, inform MDs what we do, and integrate our services in a way that is flexible with the current milieu. Anything that legitimizes us further, like the DSM-V, can only help.
 
roubs said:
You could argue that placing gender dysphoria among a list of mental disorders is evidence that gender nonconforming remains stigmatized....
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Or evidence that it IS a disorder. Of course, unless you believe that the people behind DSM-V do not make decisions based on scientific evidence, or that they always do except in this case.
 
roubs said:
I'm not in this part of the field but a recent NYT magazine story made me look up the change from gender identity disorder to gender dysphoria. I think the name change itself is a positive step toward reducing stigma. You could argue that placing gender dysphoria among a list of mental disorders is evidence that gender nonconforming remains stigmatized, but for the foreseeable future parents are going to be asking themselves "what do I do?" when they have a gender nonconforming child--and they are going to bring this question to doctors and psychologists so we will need a name for this issue and I think it's better that the name doesn't include the word "disorder"
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I was wondering whether this would come up if I kept my big clam shut. I know queer/trans communities have been unhappy with Kenneth Zucker being assigned to the working group on this because of his work on "reparative therapies."
 
wigflip said:
I was wondering whether this would come up if I kept my big clam shut. I know queer/trans communities have been unhappy with Kenneth Zucker being assigned to the working group on this because of his work on "reparative therapies"
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First off, I assume you mean SOME people in queer/trans community are unhappy with this guy. It's a pet peeve of mine when I hear people make this kind of generalization, the kind you hear in politics (e.g. Arab world is angry about X, or the Chinese are unhappy with Y) as if there are no other opinions there. Of course, unless someone has done a very comprehensive high quality study and asked everybody's opinion and 99% are of a certain opinion. Second, so he's worked on "reparative therapies," so what? He's also done hundred other things too, and he's an exceptionally competent scientist, psychologist, and sexologist. Good scientists do not refuse to try something only because it's politically incorrect. They let the truth, the scientific method, and ethics guide them. That's how they learn what works and what doesn't. Science behind the study of gender identity should not differ from study of anxiety. I think he's more than competent in making decisions based on the science available.

http://www.dsm5.org/MeetUs/Documents/Task Force 2011/Zucker 4-28-11.pdf
 
Iwillheal said:
Or evidence that it IS a disorder. Of course, unless you believe that the people behind DSM-V do not make decisions based on scientific evidence, or that they always do except in this case.
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I'm not exactly sure what you mean?
 
Iwillheal said:
They let the truth, the scientific method, and ethics guide them. That's how they learn what works and what doesn't. Science behind the study of gender identity should not differ from study of anxiety. I think he's more than competent in making decisions based on the science available.

http://www.dsm5.org/MeetUs/Documents/Task Force 2011/Zucker 4-28-11.pdf
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I disagree that his line of research is ethical. I think whether research is ethical also relates to how it will likely be used.

I also think he makes very strong statements as a result of his "research." I read a quote from him stating that he encourages assigning infants with ambiguous genitalia to being raised as females. Unless he has a 100 years of data with a large number of subjects supporting that conclusion (we all know he doesn't) it sure seems to me that he has a huge gender conformity agenda.

Dr. E
 
Shifting for a moment back to neuropsych testing: one thing I'd like to mention about diagnosis is that just the process of diagnosing something can save the patient (and the system) money, as it then hopefully prevents that person from seeking additional (and possibly very expensive) testing in the future to figure out what's going on.

Also, I'm personally of the belief that just "knowing what's wrong with me" can be very reassuring in some ways in its own right. Plus, at the same time, and as we all know, one of the first steps in developing and prescribing appropriate treatments is to be able to adequately identify the disorders themselves. With many neurological disorders, I feel as though one of the reasons we're doing such a currently-crappy job of coming up with decent treatments is that our diagnostic system and understanding of the disorders themselves is limited.

Not that either of the above points is particularly earth-shattering, of course, or that they hadn't occurred to anyone else. Just thought they were worth pointing out.
 
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Doctor Eliza said:
Unless he has a 100 years of data with a large number of subjects supporting that conclusion (we all know he doesn't) it sure seems to me that he has a huge gender conformity agenda.

Dr. E
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Indeed. In this case, he would be blatantly ignoring evidence that this is not best practice. Admittedly, the evidence mostly comes from case studies. However, I think that's perfectly understandable given that the population of intersex youth raised female is relatively small.
 
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