DSM-5 has been finalized... thoughts?

[psychanator]

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I'm always so interested to read people's thoughts on aspects of the field, so I thought I'd start a discussion about the new DSM. For those who don't know, yesterday, changes in the DSM-5 were approved and finalized. There were some very controversial decisions made, and some that people are happy about. What are you thoughts?

(here's an article on the changes. feel free to check on numerous of other great articles on the web: http://psychcentral.com/blog/archiv...approved-by-american-psychiatric-association/)

 

[MBellows]

Removal of bereavement exclusion:

The exclusion criterion in DSM-IV applied to people experiencing depressive symptoms lasting less than two months following the death of a loved one has been removed and replaced by several notes within the text delineating the differences between grief and depression. This reflects the recognition that bereavement is a severe psychosocial stressor that can precipitate a major depressive episode beginning soon after the loss of a loved one.

 

[psychanator]

I couldn't agree more. That's one of my biggest disappointments (to put it lightly!) with the new DSM. Your graphic is right on target.

 

[Doctor Eliza]

I suspect that change is related to insurance reimbursement. Currently, bereavement is a V code (I.e. not reimbursable). This puts clinicians in an awkward spot. Fudge the dx or tell the client they will have to pay out of pocket. If we can make it a disorder, insurance will pay.

But, I'm not saying I'm cool with this....

Best,
Dr. E

 

[compassionate1]

+1

I read an article ( forgot the source. will have to look it up after finals!) defending this change by stating that this is done to benefit clients who would otherwise not receive the help they need.

While I can appreciate this point, I still feel conflicted regarding this change. Even before the new criteria, I felt that bereavement was not given the sufficient respect it merits in this culture. I have lived in three different continents and feel that, unfortunately, in the USA people are given the least permission to mourn their losses or adequately deal with change ( even a positive one such as childbirth). We are just expected to 'follow the program' and move along, whether our internal experience is congruent with it or not. To me this lacks depth and appreciation for individual differences. But then again, there is insurance...

How do we deal with the realistic demands of reimbursement without compromising the integrity of the field? Has the DSM become divorced of its clinical utility?

Compassionate1

I suspect that change is related to insurance reimbursement. Currently, bereavement is a V code (I.e. not reimbursable). This puts clinicians in an awkward spot. Fudge the dx or tell the client they will have to pay out of pocket. If we can make it a disorder, insurance will pay.

But, I'm not saying I'm cool with this....

Best,
Dr. E

 

[Goobernut]

They didn't completely eliminate it, they just rolled it into a new category called "autism spectrum disorder." Which, really doesn't seem all that noteworthy. More like housekeeping. I'm just a layman though 🙂

 

[compassionate1]

For people who have come to view Asperger's as an integral part of their identity, this change is significant, IMHO.

I am working with some clients on the spectrum. I do not know that the change is to their benefit.

Compassionate1

They didn't completely eliminate it, they just rolled it into a new category called "autism spectrum disorder." Which, really doesn't seem all that noteworthy. More like housekeeping. I'm just a layman though 🙂

 

[nicu4leo]

As with any work in progress there will be shortfalls or innovative new conceptions of diagnoses. The DSM has always served as a touchstone for debate, which I think keeps the field moving forward. I personally have been interested in the shifts they making to the Axis II diagnoses... I also wonder (as with the metric system) if we will ever embrace the ICD here in the states? Lastly, an interesting set of articles by Cosgrove was brought to my attention the other week regarding the conflicts between task force members of the DSM and their financial affiliations with the pharmaceutical companies... She argues that their financial investment in the medication business maybe unduly influencing the types of disorders that make it into the manual.I think it brings up discussion points surrounding dual relationships and the realities/challenges to objectivity in research....

See here:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3302834/

http://www.ncbi.nlm.nih.gov/pubmed/16636630

 

[IT514]

They didn't completely eliminate it, they just rolled it into a new category called "autism spectrum disorder." Which, really doesn't seem all that noteworthy. More like housekeeping. I'm just a layman though 🙂

It is noteworthy - there are considerations such as:
1) how will this affect autism insurance/funding mandates in certain states (further overwhelm, drain?), and

2) why are we lumping a group which does not have global cognitive deficits into a group that has mild to severe global cognitive deficits, and

3)note that the type, course, and intensity of treatments differ quite dramatically between autism and aspergers.

 

[shumshum81]

Going out on internship (hopefully) next year, I will feel somewhat at a loss that I will be the last class to leave my academic training without coursework that teaches the new hybrid system of diagnosing personality disorders. I think that the new PD classification system will be more clinically useful to psychologists communicating with one another, but I doubt that the medical field will take the time to conceptualize patients in the way that we do. Can't tell if this is a blessing or a curse.

 

[Doctor Eliza]

It is noteworthy - there are considerations such as:
1) how will this affect autism insurance/funding mandates in certain states (further overwhelm, drain?), and

2) why are we lumping a group which does not have global cognitive deficits into a group that has mild to severe global cognitive deficits, and

3)note that the type, course, and intensity of treatments differ quite dramatically between autism and aspergers.

Agreed with the above. It is a misconception that Aspergers is the same as High Functioning Autism. There is a body of literature to support this. I'd love to pass along some citations, but I don't do a ton of work in this area and I don't know them off the top of my head. Sorry!

Best,
Dr. E

 

[Maedothin]

Going out on internship (hopefully) next year, I will feel somewhat at a loss that I will be the last class to leave my academic training without coursework that teaches the new hybrid system of diagnosing personality disorders.

In the same boat as you. We would be wise to put some energy into self-study / training ops to be fluent with the DSM5's diagnostic system before internship interviews.

 

[becomethelight]

As with any work in progress there will be shortfalls or innovative new conceptions of diagnoses. The DSM has always served as a touchstone for debate, which I think keeps the field moving forward. I personally have been interested in the shifts they making to the Axis II diagnoses... I also wonder (as with the metric system) if we will ever embrace the ICD here in the states? Lastly, an interesting set of articles by Cosgrove was brought to my attention the other week regarding the conflicts between task force members of the DSM and their financial affiliations with the pharmaceutical companies... She argues that their financial investment in the medication business maybe unduly influencing the types of disorders that make it into the manual.I think it brings up discussion points surrounding dual relationships and the realities/challenges to objectivity in research....

See here:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3302834/

http://www.ncbi.nlm.nih.gov/pubmed/16636630

Biggest problem by far with new DSM.

 

[FadedC]

This is a fairly common misconception about asperger's and autism. The only difference, according to the DSM IV, between a diagnosis of asperger's and autism, is the presence of an early language delay/deficit. The presence or absence of cognitive deficits is not part of the diagnosis for either, and can be present for individual's with asperger's or not present for individual's with autism.

The general confusion and lack of understanding about the difference between autism and asperger's, even among professionals, is probably a big reason for asperger's being removed. That and the tendency for people to completely ignore the actual diagnostic criteria when making a classification.

2) why are we lumping a group which does not have global cognitive deficits into a group that has mild to severe global cognitive deficits, and
.

 

[psypsypsy]

This is a fairly common misconception about asperger's and autism. The only difference, according to the DSM IV, between a diagnosis of asperger's and autism, is the presence of an early language delay/deficit. The presence or absence of cognitive deficits is not part of the diagnosis for either, and can be present for individual's with asperger's or not present for individual's with autism.

The general confusion and lack of understanding about the difference between autism and asperger's, even among professionals, is probably a big reason for asperger's being removed. That and the tendency for people to completely ignore the actual diagnostic criteria when making a classification.

Exactly. I think there are pros and cons of lumping everything together, particularly for those with more severe impairment, but that being the sole difference between the two disorders is one of the more confusing aspects for both parents and clinicians. Particularly because you may see two children who now look identical with zero language impairment. However, since one had an early language delay and the other did not, they get two different diagnoses.

 

[EmotRegulation]

I went to a DSM-5 Personality Disorders talk at ABCT a few weeks ago and its wild to me that after 8 years of work on a hybrid categorical/dimensional model which was *requested by the DSM-V task force,* the Board of Directors rejected it in favor of the DSM-IV categories we have now. Even though some of them have horrible reliability and validity and decades of research suggests a dimensional model is more appropriate. So the PD section will be an exact replica of DSM-IV with the new stuff in the provisional "Section 3." Ridiculous.

 

[AcronymAllergy]

It might've already been linked (although I don't see it yet), but here's a response in Psychology Today:

http://www.psychologytoday.com/blog/dsm5-in-distress/201212/dsm-5-is-guide-not-bible-ignore-its-ten-worst-changes

I particularly agree with points 1 (especially), 2, and 3. I haven't checked the new criteria for ADHD, so I can't speak to #4; what I will say is that if the concern is regarding the dropping of the age-of-onset criteria, then I think it's unfounded, as it was an entirely arbitrary age to begin with that the DSM-IV's own task force data indicated reduced diagnostic accuracy.

Point 6 addresses ASD and the effects it will have on diagnoses. I agree with the spirit of the reply that if it increases diagnostic accuracy, even at the expense of some individuals currently receiving services, then I'd likely support it overall. However, I haven't looked into the changes enough as of yet to form an educated opinion as to whether or not I actually agree with them.

 

[weeblewobble]

+1

I read an article ( forgot the source. will have to look it up after finals!) defending this change by stating that this is done to benefit clients who would otherwise not receive the help they need.

While I can appreciate this point, I still feel conflicted regarding this change. Even before the new criteria, I felt that bereavement was not given the sufficient respect it merits in this culture. I have lived in three different continents and feel that, unfortunately, in the USA people are given the least permission to mourn their losses or adequately deal with change ( even a positive one such as childbirth). We are just expected to 'follow the program' and move along, whether our internal experience is congruent with it or not. To me this lacks depth and appreciation for individual differences. But then again, there is insurance...

How do we deal with the realistic demands of reimbursement without compromising the integrity of the field? Has the DSM become divorced of its clinical utility?

Compassionate1

Agreed. There's a great book, "The Loss of Sadness," that talks about this. It's so unfortunate that bereavement and sadness in general has been pathologized to this extent. I wish that APA and apa would normalize negative emotional reactions to negative life events, psychosocial stressors, and loss. There has to be an approach that allows for this experience and offers help (therapy, not drugs) and other resources for those who want it but doesn't pathologize people experiencing normal reactions.

I agree with all of the responders noting that this DSM seems to be primarily a response to big pharma's needs and reimbursement needs rather than an attempt to clarify diagnoses for clinical or research purposes. I wish we could adopt ICD-10 or create a unbiased (unfunded!!) board with psychologists, psychiatrists, and social workers to determine changes.

 

[IT514]

Good points - my #2 above was not accurate if referring only to the DSM-IV criteria. I will say that one group tends to have more global impairments while the other is less likely to have them. Same goes for rates of comorbid seizure disorder between the two. Yes, I am aware that there are kids who meet aspergers criteria who also have seizures. What I'm trying to get across is that there are distinct differences between LFA, HFA, and Aspergers. See the MIND lab at UC Davis, genetic studies at the Cold Springs lab, etc. I think it muddies the waters and there are plenty of ways to distinguish the two groups in a proper assessment. Also, Is dysthymia still called dysthymia and not depression in the DSM-V? Is OCD distinct from GAD? I understand that most things exist on a spectrum, but there is a place for more specified diagnoses.

 

[FadedC]

That kind of gets into the whole problem though of what is a "proper assessment". The DSM IV is supposed to list the criteria for an assessment or diagnosis, but so many people completely ignore DSM IV criteria for the distinction between Autism and Asperger's. These leads to the problem where everyone is using their own definitions to diagnose the disorder, which is entirely the type of thing that the DSM is supposed to minimize. This creates extremely muddy waters as it is, as I never know whether someone classified with Asperger's has the DSM version, a version defined by a different assessment, or a version defined by someone's touchy feely vision of what Asperger's "should" look like.

Good points - my #2 above was not accurate if referring only to the DSM-IV criteria. I will say that one group tends to have more global impairments while the other is less likely to have them. Same goes for rates of comorbid seizure disorder between the two. Yes, I am aware that there are kids who meet aspergers criteria who also have seizures. What I'm trying to get across is that there are distinct differences between LFA, HFA, and Aspergers. See the MIND lab at UC Davis, genetic studies at the Cold Springs lab, etc. I think it muddies the waters and there are plenty of ways to distinguish the two groups in a proper assessment.

 

[mewtoo]

Here's an article about how it affect PDs: http://www.newscientist.com/article/dn22563-personality-disorder-revamp-ends-in-horrible-waste.html

 

[IT514]

That kind of gets into the whole problem though of what is a "proper assessment". The DSM IV is supposed to list the criteria for an assessment or diagnosis, but so many people completely ignore DSM IV criteria for the distinction between Autism and Asperger's. These leads to the problem where everyone is using their own definitions to diagnose the disorder, which is entirely the type of thing that the DSM is supposed to minimize. This creates extremely muddy waters as it is, as I never know whether someone classified with Asperger's has the DSM version, a version defined by a different assessment, or a version defined by someone's touchy feely vision of what Asperger's "should" look like.

I use an actuarial approach to assessment.I dont see how lumping kids with aspergers and kids with childhood disintigrative disorder into the same diagnosis is clearing things up.

 

[cara susanna]

I agree that the DSM IV PDs section needs an overhaul, but I didn't like the continuum/trait system that was being developed. So I have mixed feelings.

I agree that removing bereavement is a bad idea, as is lumping Asperger's with autism. I also still have bad feelings about disruptive dysregulation disorder (or whatever it's called).

And, yes, I think most of the DSM V changes are not motivated by science but more by pharmaceutical funding.

 

[FadedC]

I'm not really sure what an actuarial approach to assessment is. But if your saying that you don't use the DSM criteria for assessment, then your kind of making my point for why it's being removed.

I use an actuarial approach to assessment.I dont see how lumping kids with aspergers and kids with childhood disintigrative disorder into the same diagnosis is clearing things up.

 

[mixolyd]

I'm surprised no one is talking about the most drastic change in the DSM V. They are getting rid of the multiaxial system.

Also, as clinical psychologists, we are allowed to not use the DSM, correct? I heard that the ICD is being used more and more now.

 

[MBellows]

I suspect that change is related to insurance reimbursement. Currently, bereavement is a V code (I.e. not reimbursable). This puts clinicians in an awkward spot. Fudge the dx or tell the client they will have to pay out of pocket. If we can make it a disorder, insurance will pay.

But, I'm not saying I'm cool with this....

Best,
Dr. E

We could avoid this mess entirely by treating specific symptoms and causes rather than making questionably valid assumptions about individuals based on a diagnosis code when two people with the same dx could have completely different symptoms within the criterion with completely different causes/triggers. But then insurance companies would whine because they would have one less reason to deny people what they paid for.

 

[Neuropsych2be]

The DSM-III, DSM-III-R, DSM-IV and the DSM-IV TR are not worth the paper they are printed on. The diagnostic categories utterly lack reliability let alone validity. I have no hopes that the DSM-V will be any different. After all we are talking psychiatrists putting this chimera together here not psychologists. Psychologists have the need for reliability and validity pounded into our heads at every opportunity. At best the various iterations of the DSM give us a common nomenclature.

 

[Pragma]

I'm surprised no one is talking about the most drastic change in the DSM V. They are getting rid of the multiaxial system.

Can I still use my GAF dart board? 😀

 

[AcronymAllergy]

Can I still use my GAF dart board? 😀

😀

In all seriousness, I think the DSM-5 is keeping Axes IV and V, so the almighty GAF is safe for the time being. At least that's my understanding; I honestly haven't kept up with this very much of late.

 

[paramour]

Can I still use my GAF dart board? 😀

Ooooh, I need one of those.

Perhaps a random number generator would work just as well? 😀

 

[MBellows]

Ooooh, I need one of those.

Perhaps a random number generator would work just as well? 😀

You could just use the ICF...

 

[Pragma]

Ooooh, I need one of those.

Perhaps a random number generator would work just as well? 😀

In a different thread we were just discussing how assessment tools maybe be migrating to computerized formats. But clearly my dartboard is more reliable than some random number generator 🙂

 

[cara susanna]

Can I still use my GAF dart board? 😀

Haha!

 

[Doctor Eliza]

Some thoughts published on Medscape:

http://www.medscape.com/viewarticle/775526?src=mpnews

 

[Goobernut]

The DSM-III, DSM-III-R, DSM-IV and the DSM-IV TR are not worth the paper they are printed on. The diagnostic categories utterly lack reliability let alone validity. I have no hopes that the DSM-V will be any different. After all we are talking psychiatrists putting this chimera together here not psychologists. Psychologists have the need for reliability and validity pounded into our heads at every opportunity. At best the various iterations of the DSM give us a common nomenclature.

I think this is a really good point. On the practical side of it, quite a few MD's don't really care what the ICD/CPT says, they just want to know what they need to put down to get paid. In fact, a lot of them will put down whatever diagnosis they want, and it's the coder's job to address it and to make sure the code picked will fit with the procedures. As a surgical coder, I coded from op reports. MD's aren't really expected to know or understand diagnosis coding. They just say, Patient is blah blah, and the coder makes it fit to the procedure or vice versa (and the particular insurance rules). OR the coder has to do the research in the medical record to fine tune the code (diabetes springs immediately to mind). Unless you happen to have a knowledgeable doc. As I medical coder I always felt like what I was really doing was translating -- Medical terminology into billing practices.

I can imagine a plethora of reasons that it would be different in clinical psych - sometimes the consequences of a psychological diagnosis are much farther reaching than a medical DX. So for those clinicians out there, do you code yourself, or just write down your diagnosis? Is this a practice that varies by office, or is it the profession?