Last May when the American Psychiatric Association (APA) published its latest version of the diagnostic and statistical manual, the DSM-5, I was dreading having to learn the new system. While many of you are already using it, we are holding off until October 1, 2014 when the new edition of the International Classification of Disease is adopted as the nation’s standard medical coding system. The proliferation of ICD codes is staggering, indeed. A recent webinar I attended generated a lot of anxiety over the DSM-5. Strangely enough it was more fiscal then clinical, as the phrase "diagnosis creep" was over shadowed by "revenue cycle interruption".
This new manual is a far cry from the slim amber-covered booklet that I was given when I first started working in the field of mental health in the early 1970’s. The Diagnostic and Statistical Manual of Mental Disorders-II (DSM-II) I used then was just the second revision of this best-selling manual and it was published in 1968. It contained a list of all the common psychiatric diagnoses along with a very short paragraph describing each one. These descriptions were very general and loaded with the current Freudian terminology and theoretical references. My favorite diagnosis back then was something called “Inadequate Personality”. I was told that this diagnosis, which is now long-gone, was used to describe people who no matter how hard they try, just can’t seem to succeed. These were folks like Charlie Brown, in the Charles Schultz comic strip Peanuts who seem to have “endless determination and hope, but who are ultimately dominated by his insecurities and a permanent case of bad luck".
While the DSM-5 changes have riled up a lot of protest it seems more like DSM-IV-TR than different. The promise of a real neuroscience based system, or even a workable dimension systems for personality disorders, still seems as far away as Freud's Project for a Scientific Psychology or a detailed description of the inner workings of Skinner's black ever where. I have completed some on-line training and attended a workshop and have spent a lot of time pouring through the new volume, along with some critical books and articles.
First of all, I miss Allen J. Frances and Thomas Widiger. I'm glad to see the GAF bite the dust and I'm not sure I ever saw a Rett's or Childhood distintegerative diagnosis actually ever used. Most alarming, however, is that the Autistism Spectrum Disorder (ASD) criteria seems to be living up to the early expressed concerns that it would reduce the number of diagnosed cases by up to 30%. I'm especially anxious to see how all the specifiers are going to be programmed into our EMR.
I am concerned about the increasing pathologizing of everyday life and the intrusion of big pharama, which seems to be ever increasing. Paradoxically this is occurring at the same time as folks are earnestly arguing things like ADS should be considered neurodiversity, rather than pathology.
Pardon the cliché but it is what it is. Try your hand at my brief quiz below. The answers are in the book or in one of France's cogent criticism. E-mail me if you get stumped (firstname.lastname@example.org).
DSM-5 Quiz for Beginners
1. What five disorders combined to form Autism Spectrum Disorder?
2. What two Personality Disorders are also listed in two diagnostic chapters.