DSM is the manual used by clinicians and researchers to diagnose and classify mental disorders. The American Psychological Association (APA) published DSM-5 in 2013, culminating a 14-year revision process.
Why worry about the DSM V in IB Psychology Enhances our knowledge of the concepts of normality and abnormality Highlights problems of validity and reliability of diagnosis. If the manual changes, how certain can we be of its credibility Highlights the role cultural and ethical considerations in diagnosis. Some changes in DSM 5 are societal driven
Why worry about the DSM – 5 Why worry about the DSM – 5? A summary of the changes specific to our IB course move to a nonaxial documentation of diagnosis, combining the former Axes I, II, and III, with separate notations for psychosocial and contextual factors (formerly Axis IV) and disability (formerly Axis V). Changes in the way culture is addressed Changes to classification of PTSD (enhanced position) Changes to consideration of bereavement in Major Depression.
Where did it all start? Diagnostic Classification History Emil Kraeplin (1856-1926) – created a medical model based on symptoms and grouped them based on a pattern of symptoms Realised that the same symptom could occur across disorders abut that different disorders have different patterns of symptoms
Various iterations of DSM
A Short History of the DSM The DSM-1 (1952), 106 disorders across several major categories, reflecting a psychodynamic perspective on etiology DSM II (1968), 182 disorders, similar framework as DSM-1; like DSM-1, it lacked specification of specific symptoms of many disorders; distinguished among disorders at broader levels of neurosis, psychosis, and personality disturbance DSM-III (1980) and DSM-III-R (1987), which focused on standardization of diagnostic categories by categorising illnesses based on symptoms, but to this day does not reflect an understanding of causes. Included 265 diagnoses in DSM-III and 292 in DSM-III-TR
DSM-IV (1994) Effort to develop a consistent worldwide system of classification that would be compatible with the ICD-10 (1993) Huge review of all research on psychopathology to update the classification system Distinction between organically based disorders and psychologically based disorders was eliminated Increased considerations of cultural factors
DSM-IV CLASSIFICATION 1. Disorders usually first diagnosed in infancy, childhood or adolescence 2. Delirium, Dementia & amnestic, & other cognitive disorders 3. Mental disorders due to a general medical condition 4. Substance related disorders 5. Schizophrenia & other psychotic disorders 6. Mood disorders
DSM-IV CLASSIFICATION 7. Anxiety disorders 8. Somatoform disorders 9. Factitious disorders 10. Dissociative disorders 11. Sexual & Gender identity disorders 12. Eating disorders
DSM-IV CLASSIFICATION 13. Sleep disorders 14. Impulse control disorders not elsewhere classified 15. Adjustment disorders 16. Personality disorders 17. Other conditions that may be a focus of clinical attention
Axis I Are features of one or more DSM IV disorders present
Axis II Personality disorders Mental retardation Personality traits & disorders Habitual maladaptive defense mechanisms
Axis III Current general medical conditions that are relevant to understanding and treatment of mental disorder
Axis IV Psychosocial or environmental problem that effects diagnosis, treatment and prognosis of mental disorder: Problems with primary support group Problems related to social environment Educational and occupational problems Housing and other economic problems Problems with access to health care services Problems related to interaction with legal system / crime Other psychosocial and environmental problems
AXIS V: Global assessment of functioning (GAF) Used to plan treatment, measure its impact and predict its outcome GAF= 0 to 100 Only rate with respect to psychological, social and occupational functioning Do not include impairment due to physical or environmental limitations
Limitations of DSM IV Makes unjustified categorical distinctions between disorders, and between normal and abnormal (what about behaviour that falls behind the threshold, is behaviour a continum) Requires judgements can be subjective and open to cultural bias Too many diagnoses? 300 acute stress disorder a natural reaction? Represents increasing medicalization of human nature Relies on a biological model Disease mongering driven by drug companies Demonstrates lack of understanding between causes and illness – focus on treatments Scientific doubt about validity & reliability of diagnostic categories and criteria used
Problems with DSM classification: Cultural considerations: Culture determines how a disorder is expressed. May not be reflected in the diagnostic system (e.g. somatic expression of depression) Western-based classification system may have questionable validity in a different cultural context (e.g.neurasthenia) DSM IV has attempted to be more culturally sensitive by: Provides a general framework for evaluating the role of culture and ethnicity Decribes the role of cultural factors and ethnicity for each disorder Lists culture bound syndromes in appendix
Problems with DSM classification: Labelling: Tends to be reductionistic May lead to stigmatization, or person taking on the sick role and identifying with the label Labels are “sticky” Instrument of social control: gives mental health professionals control over people’s lives
LIMITATIONS of DSM DSM demonstrates the link between diagnosis and treatment is relative weak Eg Prozac: Prescribed as anti-depressannt But also helps: Panic disorder OCD Builimia Social phobia
Limitations continued Many patients meet several diagnostic definitions at once Eg adults with clinical depression often fit the definition of an anxiety disorder Patients diagnosed with the same dysfunction aren’t necessarily the same Based on consensus of experts, not scientific evidence
Assessment techniques Behavioural observation Appearance Speech Mood & affect Thought processes Intelligent functioning Sensorium
Assessment techniques Clinical Interview P.88 table
Assessment techniques cont… 2. Psychological Testing Projective testing Use ambiguous stimuli & ask people to describe them e.g. Rorschach Inkbolt, T.A.T, MMPI (personality inventory) Intelligence testing Intelligent quotient (IQ) e.g. WAIS-III, WISC, SSAIS-R
Assessment techniques cont… Physiological Tests Neurological Testing Locates brain dysfunction receptive & expressive language, attention, memory & motor skills More sophisticated technology Computerised Axial Tomography (CAT-Scan) Electroencephalograph (EEG) Magnetic Resonance Imaging (MRI)
Alternative Classification System International Classification of Diseases (ICD 10) Chinese Classification of Mental Disorders (CCMD – 3)
International Classification of Diseases International Statistical Classification of Diseases and Related Health Problems Published by WHO
ICD Gives unique category and code to all diseases Currently in 10th ediction (ICD-10) New edition planned for 2015
Chinese Classification of Mental Disorders CCMD
The Chinese Classification of Mental Disorders (CCMD), published by the Chinese Society of Psychiatry (CSP), is a clinical guide used in China for the diagnosis of mental disorders. It is currently on a third version, the CCMD-3, written in Chinese and English. It is intentionally similar in structure and categorisation to the ICD and DSM, the two most well-known diagnostic manuals, though includes some variations on their main diagnoses and around 40 culturally-related diagnoses. 34
CHINESE CLASSIFICATION OF MENTAL DISORDERS First published by the Chinese Society of Psychiatry, 1979 A clinical guide for diagnosis of mental disorders Currently CCMD-3 Published in Chinese and English Intentionally similar in structure and categories to DSM and ICD Includes some variations on main diagnosis of about 40 culturally related disroders.
Advantages (according to Chinese psychiatrists) Simplicity (Chinese Translation of the ICD- 10 was linguistically complicated) Stability Inclusion of culture-distinctive categories Exclusion of certain Western diagnostic categories
What are the practical and ethical implications of diagnostic classification?
Depression in CCMD-3 Similar to DSM Concept of neurasthenia (nervous system disorder) called ‘shenjing shairu’, which emphaises somatic (bodily) complaints as well as fatigue
Schizophrenia Included Applied readily and broadly in Chinese psychiatry
Diagnoses specific to Chinese or Asian culture Retains ‘ego-systonic homosexuality’ Mental disorder due to Quigong (a Chinese method of mediation/posture/exercise (linked to psychosis) Koro Mental disorders due to superstiion or witchcraft
USE of CCMD-3 in China. used domestically USE of CCMD-3 in China * used domestically. * in international collaborative research use ICD-10 * in research with American colleagues use DSM-IV.
Culture bound syndromes
Classifying Abnormal Behavior Culture and Classification The DSM-IV-TR encourages clinicians to consider the influence of cultural factors in both the expression and recognition of symptoms of mental disorders. People express extreme emotions in ways that are shaped by the traditions of their families and other social groups to which they belong.
Classifying Abnormal Behavior Culture and Classification (continued) The diagnostic manual attempts to sensitize clinicians to cultural issues by including a glossary of culture-bound syndromes. These are patterns of erratic or unusual thinking and behavior that have been identified in diverse societies around the world and do not fit easily into the other diagnostic categories that are listed in the main body of DSM-IV-TR.
Classifying Abnormal Behavior Culture and Classification (continued) Culture-bound syndromes have also been called idioms of distress. In other words, they represent a manner of expressing negative emotion that is unique to a particular culture and cannot be easily translated or understood in terms of its individual parts.
Classifying Abnormal Behavior Culture and Classification (continued) These dimensions include: emotional expressions (an explosion of screaming and crying, coupled with overwhelming feelings of anxiety, depression, and anger), bodily sensations (including trembling, heart palpitations, weakness, fatigue, headache, and convulsions), actions and behaviors (dramatic, forceful gestures that include aggression toward others, suicidal thoughts or gestures, and trouble eating or sleeping), and alterations in consciousness (marked feelings of “not being one’s usual self,” accompanied by fainting, loss of consciousness, dizziness, and feelings of being outside of one’s body).
Some important general facts on DSM 5 DSM 5 (not V) to allow for numbering of revisions (5.1, 5.2, etc). Was targeted for 2009, then 2011, finally May, 2013. 2-year grace period for implementation. Complete interface with ICD-11; codes in parentheses. DZ
Some key changes Elimination of multiaxial system and GAF Establishes 20 diagnostic classes or categories of mental disorders Introduction of new diagnostic category of Neurodevelopmental Disorders to include Autism Spectrum Disorder and ADHD and other disorders reflecting abnormal brain development Removes obsessive-compulsive disorder from category of Anxiety Disorders and places it in new category of Obsessive-Compulsive and Related Disorders: More on that later!!!
The 20 diagnostic categories of the DSM - 5
Diagnostic Categories Diagnostic Category Examples of Specific Disorders Neurodevelopmental Disorders Autism Spectrum Disorder Specific Learning Disorder Communication Disorders ADHD, Motor Disorders, etc. Schizophrenia Spectrum and Other Psychotic Disorders Schizophrenia Schizophreniform Disorder Schizoaffective Disorder Delusional Disorder Schizotypal Personality Disorder Bipolar and Related Disorders Bipolar I Disorder, Bipolar II Disorder Cyclothymic Disorder Depressive Disorders Disruptive Mood Dysregulation Disorder Major Depressive Disorder Persistent Depressive Disorder Premenstrual Dysphoric Disorder
Diagnostic Categories Diagnostic Category Examples of Specific Disorders Anxiety Disorders Specific Phobia Social Anxiety Disorder (Social Phobia) Panic Disorder Agoraphobia Generalized Anxiety Disorder Separation Anxiety Disorder Selective Mutism Obsessive-Compulsive and Related Disorders Obsessive-Compulsive Disorder Body Dysmorphic Disorder Hoarding Disorder Hair-Pulling Disorder (Trichotillomania) Excoriation (Skin-Picking) Disorder Trauma and Stressor Related Disorders Adjustment Disorders Acute Stress Disorder Posttraumatic Stress Disorder Reactive Attachment Disorder Disinhibited Social Engagement Disorder
Diagnostic Categories Diagnostic Category Examples of Specific Disorders Dissociative Disorders Dissociative Identity Disorder Dissociative Amnesia Depersonalization/Derealization Disorder Somatic Symptom and Related Disorders Somatic Symptom Disorder Illness Anxiety Disorder Conversion Disorder (Functional Neurological Symptom Disorder) Factitious Disorder Feeding and Eating Disorders Anorexia Nervosa Bulimia Nervosa Binge Eating Disorder Pica, Rumination Disorder Avoidant/Restrictive Food Intake Disorder Elimination Disorders Enuresis Encopresis
Diagnostic Categories Diagnostic Category Examples of Specific Disorders Sleep-Wake Disorders Insomnia Disorder Hypersomnolence Disorder Narcolepsy Breathing-Related Sleep Disorders Circadian Rhythm Sleep-Wake Disorders Parasomnias: Sleepwalking, Sleep Terrors, Nightmare Disorder, Rapid Eye Movement Sleep Behavior Disorder Restless Legs Syndrome Sexual Dysfunctions Delayed Ejaculation Erectile Disorder Female Orgasmic Disorder Female Sexual Interest/Arousal Disorder Genito-Pelvic Pain/Penetration Disorder Male Hypoactive Sexual Desire Disorder Premature (Early) Ejaculation
Diagnostic Categories Diagnostic Category Examples of Specific Disorder Gender Dysphoria Disruptive, Impulse-Control, and Conduct Disorders Oppositional Defiant Disorder Intermittent Explosive Disorder Conduct Disorder Antisocial Personality Disorder Pyromania Kleptomania Substance-Related and Addictive Disorders Substance Use Disorders Substance-Induced Disorders Gambling Disorder Neurocognitive Disorders Delirium Major & Mild Neurocognitive Disorders
Diagnostic Categories Diagnostic Category Examples of Specific Disorders Personality Disorders Paranoid Personality Disorder Schizoid Personality Disorder Schizotypal Personality Disorder Antisocial Personality Disorder Borderline Personality Disorder Histrionic Personality Disorder Narcissistic Personality Disorder Avoidant Personality Disorder Dependent Personality Disorder Obsessive-Compulsive Personality Disorder
Diagnostic Categories Diagnostic Category Examples of Specific Disorders Paraphilic Disorders Voyeuristic Disorder Exhibitionistic Disorder Frotteuristic Disorder Sexual Masochism Disorder Sexual Sadism Disorder Pedophilic Disorder Fetishistic Disorder Transvestic Disorder Other Mental Disorders Other Specified Mental Disorder due to Another Medical Condition
The (Dearly?)Departed: Dropped or Consolidated Diagnoses from DSM-5 Somatization Disorder (gone) Amnestic Disorders (amnesia now a feature of neurocognitive disorders) Dissociative Fugue (now a subtype of dissociative amnesia) Pain Disorder (gone) Hypochondriasis (cases now divided between Somatic Symptom Disorder and Illness Anxiety Disorder depending on severity of physical symptoms) Asperger’s Disorder (may now be diagnosed as ASD) Childhood Disintegrative Disorder (may now be diagnosed as ASD) Pervasive Developmental Disorder NOS (may now be diagnosed as ASD) Vaginismus and Dyspareunia (now Genito-Pelvic Pain/Penetration Disorder) Gender Identity Disorder (now Gender Dysphoria) Sexual Aversion Disorder (dropped, most cases reclassifiable as specific phobia)
Disorders that have graduated out of the Appendix Binge Eating Disorder Premenstrual Dysphoric Mood Disorder Mild Neurocognitive Disorder Caffeine Withdrawal Factitious Disorder by Proxy (now called factitious disorder imposed on another)
Name Changes Was (DSM-IV) Will Now Be (DSM-5) Gender Identity Disorder Gender Dysphoria Sleep Disorders Sleep-Wake Disorders Dysthymic Disorder Persistent Depressive Disorder (Dysthymia) Learning Disorders Specific Learning Disorder Stuttering Child Onset Fluency Disorder (Stuttering) Phonological Disorder Speech Sound Disorder Mental Retardation Intellectual Disability (Intellectual Developmental Disorder) Depersonalization Disorder Depersonalization/Derealization Disorder Hypersomnia Hypersomnolence Disorder
Name Changes (continued) Was (DSM-IV) Will Now Be (DSM-5) Circadian Rhythm Sleep Disorder Circadian Rhythm Sleep-Wake Disorder Breathing-Related Sleep Disorder Obstructive Sleep Apnea Hypopnea Syndrome, Central Sleep Apnea, or Sleep-Related Hypoventilation Primary Insomnia Insomnia Disorder Male Orgasmic Disorder Delayed Ejaculation Premature Ejaculation Premature (Early) Ejaculation Male Erectile Disorder Erectile Disorder Female Sexual Arousal Disorder Female Sexual Interest/Arousal Disorder Hypoactive Sexual Desire Disorder Now either Male Hypoactive Sexual Desire Disorder or Female Sexual Interest/Arousal Disorder
Name Changes (continued) Was (DSM-IV) Will Now Be (DSM-5) Sleepwalking Disorder, Sleep Terror Disorder Non-Rapid Eye Movement Sleep Arousal Disorders: Sleepwalking, Sleep Terrors Social Phobia Social Anxiety Disorder (Social Phobia) Autistic Disorder Autism Spectrum Disorder
New Kids on the Block in DSM - 5: The newly Diagnosed Disorders Disruptive Mood Dysregulation Disorder Somatic Symptom Disorder Illness Anxiety Disorder Hoarding Disorder Excoriation (Skin-Picking Disorder) Hoarding disorder Disinhibited Social Engagement Disorder Avoidant/Restrictive Food Intake Disorder Social (Pragmatic) Communication Disorder Restless Leg Syndrome Rapid Eye Movement Sleep Behavior Disorder Hoarding disorder added due to the ongoing popularity of a TV show “Hoarders” Demonstrates the relevance of popular culture in diagnosis
DSM – 5 encompasses many changes The following slides deal only with those which may be relevant to IB Psychology
The DSM IV – TR Axis system eliminated The Axis system from DSM-IV-TR:
The “axis” diagnostic system Elimination of the five "axis” diagnostic system previously in use that required clinicians to rate each client according to criteria other than their main psychological disorder. no one truly could define the word “axis” (it was roughly a dimension), the previous DSM’s included a rather strange combination of personality disorders and and “mental retardation” into one grouping. All other disorders were placed elsewhere. In addition, a collection of unrelated disorders that “originated in childhood” (but not “mental retardation”) were strung together in one section (ie Axis II) regardless of what the symptoms were.
Culture in the DSM IV In medicine and medical anthropogy, a culture-bound syndrome, culture-specific syndrome or folk illness is a combination of psychiatric and somatic symptoms that are considered to be a recognizable disease only within a specific society or culture. the term culture-bound syndrome was included in the DSM – IV, which also included a list (in appendix) of the most common culture-bound conditions
The Impact of Cultural Differences Different cultures and communities exhibit or explain symptoms in various ways. it is important for clinicians to be aware of relevant contextual information stemming from a patient’s culture, race, ethnicity, religion or geographical origin. For example, uncontrollable crying and headaches are symptoms of panic attacks in some cultures, while difficulty breathing may be the primary symptom in other cultures. Understanding such distinctions will help clinicians more accurately diagnose problems as well as more effectively treat them.
Cultural developments in DSM-5 incorporates a greater cultural sensitivity throughout the manual. Rather than a simple list of culture-bound syndromes, DSM-5 updates criteria to reflect cross-cultural variations in presentations, gives more detailed and structured information about cultural concepts of distress, and includes a clinical interview tool to facilitate comprehensive, person-centered assessments. specific diagnostic criteria were changed to better apply across diverse cultures. For example, the criteria for social anxiety disorder now include the fear of “offending others” to reflect the Japanese concept in which avoiding harm to others is emphasized rather than harm to oneself.
Incorporation of cultural concepts of distress in DSM 5 details ways in which different cultures describe symptoms. In the Appendix, they are described through cultural syndromes, idioms of distress, and explanations. These concepts assist clinicians in recognizing how people in different cultures think and talk about psychological problems. Incorporation of a cultural formulation interview guide to help clinicians to assess cultural factors influencing patients’ perspectives of their symptoms and treatment options. Includes questions about: patients’ background in terms of their culture, race, ethnicity, religion or geographical origin. The interview provides an opportunity for individuals to define their distress in their own words and then relate this to how others, who may not share their culture, see their problems. This gives the clinician a more comprehensive foundation on which to base both diagnosis and care.
Overall, there is a much increased emphasis on multicultural Guidelies Overall, there is a much increased emphasis on multicultural Guidelies. Emphasis is on how social, cultural, political, and historical contexts manifest in clinical presentations.
Changes to Anxiety Disorders, and specifically PTSD Removes PTSD from Anxiety Disorders and places it in new category of Trauma and Stressor-Related Disorders Groups all stress-related psychological disorders under the same umbrella; Adjustment Disorders may now be coded in context of traumatic stressors
Trauma- & Stressor-Related Exposure to traumatic or stressful event. New grouping of disorders from various places in DSM Adjustment Disorder. Acute Stress Disorder. PTSD. 4 clusters of symptoms: Intrusion, Avoidance, Negative mood/cognitions, Arousal & reactivity. Children: expanded definition; section for < 6 yo. Specifiers: (a) dissociative sxs (depersonalization or derealization); (b) delayed expression. Attachment disorders (next slide).
Trauma- & Stressor-Related Attachment related disorders: Common etiology: Absence of adequate caregiving during childhood. Reactive Attachment Disorder: Internalizing disorder: depression, withdrawal. New criteria (4/5 sxs; onset between 9 mos. & 5 yrs.) Disinhibited Social Engagement: (NEW). Externalizing disorder: disinhibition, externalizing behavior. 2/4 sxs; onset > 9 mos.
Implications for PTSD It is no longer an “anxiety disorder” Described as a disorder of reactivity, along with specific & social phobia, rather than a syndrome. Anxiety is present in most psychiatric disorders A number of symptoms of PTSD such as numbing, alienation, detachment are frequent depressive symptoms Suggestion that PTSD is more than simply an anxiety disorder
Key change to Major Depression Elimination of bereavement exclusion from major depression Recognizes that a major depressive episode may overlay a normal reaction to loss; critics claim it may pathologize bereavement
Bereavement Exclusion dropped in Major depressive episode DSM IV had exclusion for a major depressive episode that was applied to depressive symptoms lasting less than 2 months following the death of a love one. Exclusion omitted in DSM-5: Removes impication that bereavement only lasts 2 months Bereavement is recognized as a severe psychosocial stressor that can preciptiate major depressive episode Most likely to occur if there are past personal and family histories of major depressive episodes The depressive symptoms associated with bereavement related depression respond to the same psychosocial and medication treatments as non-bereavement related depression.
Some key criticisms of DSM - 5 little consensus on the extent to which psychiatric disorders or syndromes are universal or the extent to which they differ on their core definitions and constellation of symptoms as a result of cultural or contextual factors. controversy continues due to the lack of biological markers, imprecise measurement and the lack of a gold standard for validating most psychiatric conditions NIH (in US) has disavowed the DSM -5 as a successful diagnostic standard.
Creates new diagnostic category of Substance-Related and Addictive Disorders (Now includes Gambling Disorder (previously Pathological Gambling) but other forms of nonchemical addiction, such as compulsive Internet use and compulsive shopping, don’t make it into the manual and remain under study)
Controversies in DSM - 5 Expansion of diagnosable disorders Net result of diagnostic inflation may be to greatly expand the numbers of people labeled as suffering from a mental disorder or mental illness; e.g., Mild Neurocognitive Disorder may pathologize mild cognitive changes or everyday forgetting in older adults; e.g., Disruptive Mood Dysregulation Disorder may pathologize repeated temper tantrums in children
Controversies in DSM - 5 Changes in classification of mental disorders Critics question whether changes in classification are justified and might lead to greater diagnostic confusion; parents of Asperger’s children are concerned their children may not qualify for the new ASD diagnosis and associated treatment benefits
Controversies in DSM - 5 Changes in diagnostic criteria for particular disorders Critics contend that many of the changes in the diagnostic criteria have not been sufficiently validated. Particular concerns are raised about the substantial changes made in the set of symptoms used to diagnose Autism Spectrum Disorders, which may have profound effects on the numbers of children identified as suffering from these disorders
DSM-IV-TR DSM 5 Autism Overlap Aspergers Social Communication Disorder Autism Spectrum Disorder RO
Key criticisms of DSM - 5 Critics claim development of the DSM-5 was: shrouded in secrecy, failed to incorporate input from many leading researchers and scholars in the field changes to the diagnostic manual were not clearly documented based on an adequate body of empirical research
So what does the DSM 5 show Diagnosis is controversial The concept of abnormality changes between culture and across time The concept of abnormality is influenced by the dominant culture’s definition of normalcy
What are the practical and ethical implications of diagnostic classification?
Revisiting Limitations of DSM IV (as these still apply) Makes unjustified categorical distinctions between disorders, and between normal and abnormal (what about behaviour that falls behind the threshold, is behaviour a continum) Requires judgements can be subjective and open to cultural bias Too many diagnoses? 300 acute stress disorder a natural reaction? Represents increasing medicalization of human nature Relies on a biological model Disease mongering driven by drug companies Demonstrates lack of understanding between causes and illness – focus on treatments Scientific doubt about validity & reliability of diagnostic categories and criteria used
Problems with DSM classification: Labelling: Tends to be reductionistic May lead to stigmatization, or person taking on the sick role and identifying with the label Labels are “sticky” Instrument of social control: gives mental health professionals control over people’s lives
.......... DSM-5 still leaves the stigma of diagnosis
Problems with DSM classification: Cultural considerations: Culture determines how a disorder is expressed. May not be reflected in the diagnostic system (e.g. somatic expression of depression) Western-based classification system may have questionable validity in a different cultural context DSM 5 has attempted to be more culturally sensitive
Ongoing Limitations of DSM Represents increasing medicalization of human nature Relies on a biological model Disease mongering driven by drug companies Demonstrates lack of understanding between causes and illness – focus on treatments Scientific doubt about validity & reliability of diagnostic categories and criteria used
Limitations continued Many patients meet several diagnostic definitions at once Eg adults with clinical depression often fit the definition of an anxiety disorder Patients diagnosed with the same dysfunction aren’t necessarily the same DSM makes unjustified categorical distinctions between disorders, and between normal and abnormal Based on consensus of experts, not scientific evidence
Some more recent criticisms, specific to DSM - 5 Suggestion that the American Psychiatric Association is giving way to big pharmaceutical companies who see the new manual as helping feather their own quite lavish nests. Bad press may discourage those with psychiatic disorder from seeking treament
A cynic’s perspective!
So where does this leave us as Psych students in 2013 the purpose of having diagnoses is to allow mental health professionals to use a common language when working on behalf of their clients. without diagnoses, researchers would not be able to compare their results from study to study. Research in psychiatry and abnormal psychology consistently specifies the nature of the diagnoses of the people who participate in research, and without these diagnoses they wouldn’t know how to compare their findings. in the world of managed care, not to mention the Affordable Healthcare Act, diagnoses are unavoidable. The authors of the DSM-5 weighed the disadvantages of labeling clients with a diagnosis against the advantages to them of receiving healthcare coverage.
Still need to consider Reliability of diagnostic systems Reliability: the degree to which a measurement is consistent The extent to which different clinicians agree in identifying a disorder
Still need to consider Validity of diagnostic systems: Validity: the degree to which the system measures what it seeks to measure Construct validity: whether the symptoms chosen as criteria for a disorder are consistently associated with the disorder Predictive validity: The extent to which a diagnosis is able to predict the course of the disorder and the likely effect of treatment. Content validity: the extend to which a diagnosis reflect what experts in that field think of a diagnosis
Supporting Research Nothing of substance relating to DSM -5 published yet! SO, continue to use: Rosenhan (1973) Beck et al. (1962) – investigating classification Cooper et al. (1972) – cross cultural classification issues Di Nardo et al. (1993) – inconsistencies in DSM diagnoses Lipton and Simon (1985) – inconsistencies in DSM diagnoses Nicholls et al (2001) – DSM IV, ICD-10m GOS – inter-rater reliability