DSM in general, and in child psych

[nancysinatra]

I was just wondering--does every psychiatrist in the US use the DSM? Is there an official requirement that psychiatrists use the DSM? If not, how did its use become so ubiquitous?

I was recently doing a rotation in child psychiatry, where I found it very confusing to try to apply DSM criteria to some of the patients. From what I could tell, they often do not "endorse" symptoms in the same way adults might be expected to. But then when you observe them and try to figure things out that way, they don't LOOK like adult patients either. Then a lot of the time there's a family component to their problem, which makes any collateral information suspect as well. And to top it all off, there's no Axis II to help explain anything either. Nonetheless, patients have to have something written on their discharge summary. This is where I got to feeling like the DSM was not helping me much. There were times when I could just as easily have thrown "lupus" or "lyme disease" into the differential as any DSM code--it was that vague and confusing to me. There were other times where a code did make sense, however--but those were mostly patients with the disorders unique to childhood. (And I must admit I have not memorized the DSM, and was just borrowing the unit copy. It's possible I am not fully appreciating all that the DSM has to offer yet.)

Getting back to my original question--what alternatives are there to the DSM? There's an international equivalent, isn't there? Does each country have its own individual guide? What would happen if I wanted to practice psychiatry overseas in a country with a different language and culture--would I have to bring the DSM and use it because that's how I was trained, or would I have to follow some other book, or would I have to learn a whole different specialty altogether?

And what do Freudian psychoanalysts do? Is there a DSM code for "unconscious conflict?"

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[Doc Samson]

I was just wondering--does every psychiatrist in the US use the DSM? Is there an official requirement that psychiatrists use the DSM? If not, how did its use become so ubiquitous?

I was recently doing a rotation in child psychiatry, where I found it very confusing to try to apply DSM criteria to some of the patients. From what I could tell, they often do not "endorse" symptoms in the same way adults might be expected to. But then when you observe them and try to figure things out that way, they don't LOOK like adult patients either. Then a lot of the time there's a family component to their problem, which makes any collateral information suspect as well. And to top it all off, there's no Axis II to help explain anything either. Nonetheless, patients have to have something written on their discharge summary. This is where I got to feeling like the DSM was not helping me much. There were times when I could just as easily have thrown "lupus" or "lyme disease" into the differential as any DSM code--it was that vague and confusing to me. There were other times where a code did make sense, however--but those were mostly patients with the disorders unique to childhood. (And I must admit I have not memorized the DSM, and was just borrowing the unit copy. It's possible I am not fully appreciating all that the DSM has to offer yet.)

Getting back to my original question--what alternatives are there to the DSM? There's an international equivalent, isn't there? Does each country have its own individual guide? What would happen if I wanted to practice psychiatry overseas in a country with a different language and culture--would I have to bring the DSM and use it because that's how I was trained, or would I have to follow some other book, or would I have to learn a whole different specialty altogether?

And what do Freudian psychoanalysts do? Is there a DSM code for "unconscious conflict?"

If you want to bill insurance, you need a DSM diagnosis. However you formulate the case treatment-wise is up to you, but the note and the insurance submission needs a 5 digit code. The rest of the world uses the ICD-10. Freudian psychoanalysts are, of course, private pay only.

 

[michaelrack]

If you are doing inpatient psychiatry, you pretty much have to use Dsm 4- most psych wards/hospitals have rules that require a psychiatrist to use DSM 4.

For outpatient psychiatry, it varies from insurance company to insurance company. If you avoid mental health carve-outs, you can generally avoid using DSM 4 on an outpt basis- just bill the ICD 9 codes.

 

[erg923]

It's tricky because alot of DSM diagnosis have age and temporal specifiers that make it difficult or even impossible to diagnose children with some disorders. However, the DSM is embedded with caveats that state "In children symptoms may be expressed as more as "blank", rather than "blank." Irritability in depression rather than subjective patient report of "low" or "depressed" mood is one for example. Bipolar DO is another one that is tricky for adolescents. The only thing that can really help in your situation is the continued development of more sophisticated clincial judgment by seeing a variety of disorders in children and learning how symptoms are differentially expressed in this population. Bottom line is that diagnostic system in general is just something we haven't figured out completely, especially with regards to children.

And yes, hardcore Freudians use the ICD-10, although the DSM provides opportunities to plug in Psychoanalytic terms that might help inform the clincial picture (i.e., "frequent use of projection" can be plugged in on axis II in adults).

 

[Therapist4Chnge]

There is also the PDM, but it isn't mainstream. I haven't gone through it thoroughly yet, but I do like their approach to some of the Dx's, as the DSM leaves a bit to be desired.