JRB said:
Actually, the DSM was developed with a priority on its usefulness in guiding clinical practice. But, as you stated, it's limitations are in the fact that it is not designed to individualize patients who very often don't "fit" into the diagnostic criteria. The DSMs usefulness for research purposes was a secondary goal in its development.
Criterions B, C, and D may be important depending upon what form of treatment is recommended and/or selected; and how these criteria impact the individual person.
The DSM, diagnostically, accounts for people who don't meet full criteria for disorders... such as ADHD NOS.
Not disagreeing with you, just trying to be technically accurate.
JRB
Ok, so, regarding technical accuracy...
I should point out that the original (pre-DSM) standardized psych nosology -- containing 22 disorders -- was in fact written by the American Medico-Psychological Association in 1918 with the express purpose of collecting uniform statistics on patients in institutions. While DSM-I and II might have focused a bit more on clinical utility, DSM-III and subsequent editions were designed simply to give explicit, descriptive diagnostic criteria for mental disorders. Per Kaplan & Sadock's "bible," The Comprehensive Textbook of Psychiatry, 7th ed., p. 824: "Extensive efforts to correct this perception [of psychiatric classifications seeming "less scientific"] resulted in a paradigmatic shift from hermeneutic to empirically based approaches, and the development of a nosology intended to increase diagnostic reliability and facilitate research efforts."
Basically, the DSM was never designed with a priority on its usefulness in guiding clinical practice, any more than the ICD manuals were designed to be useful in guiding medical practice. It was designed to make sure that everyone used the same name (diagnosis) when they looked at a person with a specific set of symptoms. As a secondary benefit, the research that has been done using these specific criteria has had clinical utility. Nonetheless, the DSM was never designed to aid clinical practice, except for ensuring consistent diagnoses.
As for ADHD NOS, yes, it does exist in the DSM. Unfortunately, just about any person, mentally ill or not, can be put into an "NOS" category in the DSM -- just look at Mood disorder NOS, or Personality disorder NOS. My point was simply that no one should diagnose themselves or rule out diagnoses based on the DSM criteria for anything. In real life, NOS diagnoses are rarely used. Diagnosing someone as ADHD NOS instead of ADHD (inattentive, hyperactive, or combined) may mean that the patient does not get mental health coverage, because it's not an official parity diagnosis in that state; or that ADHD medications are not covered, because they're not approved for that diagnosis. Guess how most psychiatrists diagnose their technically-NOS patients?
Finally, regarding B, C, and D, well, I stand by my statement that they are "basically not important." Treatment is pretty much directed by symptoms, not by age of onset or which spheres of life it effects. So, if someone meets criteria A and E, I will treat them the same regardless of B, C, and D. Once they've met A and E, the only other thing I need to know clinically is, "Is the patient bothered by it?" If they are, I treat it. If they're not, I don't treat it. Mind you, if I do ever come across literature that suggests that different medications work better for childhood-onset vs. late-onset, I might change my mind. But as far as I know, while that's always interesting to learn, it doesn't change treatment.
OK, off my soapbox. Sorry. I should have warned you not to get me started on the DSM.........
