The DSM: Analyzing Strengths and Limitations

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At the heart of every great mystery lies a solution. Just as a good detective may use specific guidelines to gather evidence for a solution, so too might a good psychologist use set criteria to gather evidence for an accurate solution, or diagnosis. Although detectives focus on who is responsible for the problem, psychologists focus on why and how the problem surfaced. To make an accurate diagnosis, psychologists follow set diagnostic criteria outlined in the DSM. As a classification system for diagnosis, the DSM is important in the field, but current literature highlights the fact that, along with its strengths, limitations exist in it for accuracy in client diagnosis.

For this Discussion, consider the classification system of the DSM. Think about the relative strengths and limitations of this classification system in making a diagnosis.

With these thoughts in mind:

Post a brief description of the overall classification system of the DSM in your own words. Then discuss 2 strengths and 2 limitations of the DSM. Be sure to support your answers with specific references using current literature.

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Trends and Implications of Proposed Changes to the DSM-5 for Vulnerable Populations Miller, Raissa;Prosek, Elizabeth A Journal of Counseling and Development : JCD; Jul 2013; 91, 3; ProQuest pg. 359 Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Reproduced with permission of the copyright owner. Further reproduction prohibited without permission. Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 6 Dimensionality Science can describe phenomena using names or numbers. Categories are qualitative, and dimensions are quantitative. Some things in nature, such as the periodic table of elements, neatly fit a categorical paradigm. Others either have fuzzy edges or do not fit into categories at all. This problem has led to debates about the number of planets in the solar system, the hierarchical classification of biological species, the difference between life and nonlife, and the nature of subatomic particles. Most of these disputes depend on where to draw a line to define a category. Many things are better described on a continuum. Yet cognitive science consistently shows that people prefer to think in categories (Rosch & Lloyd, 1978). Medicine has always classified illness in that way. When experienced physicians assess a new patient, they do not go through an extensive checklist of signs and symptoms to make a diagnosis. Instead, they take one look at a patient, ask a few key questions, and rapidly develop a hypothesis and test it through further history taking and examination procedures (Groopman, 2007). Thus, categorical diagnoses correspond to what happens in a clinical encounter. Categories describe typicality in a clinical picture, are the basis of differential diagnosis, are practical for communication, and help determine treatment planning. DSM-5 accepts categories but views them as artificial, proposing scoring procedures, wherever possible, to turn names into numbers. These scores are described as “dimensions,” a geometrical metaphor rooted in a quantitative approach to psychopathology. The uncertainty of psychiatric diagnosis supports a suspicion of categories, given that most consist of a set of symptoms that may or may not 84 EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 6 D i m e n si o n a l i t y | 8 5 correspond to a coherent pathological entity. We sometimes forget that even if diagnoses are useful guideposts, they do not correspond to Platonic reality. Yet categories become reified with time (Hyman, 2010) and are seen as if they were just as real as medical conditions with known biological markers. Major depression is a prominent example—a set of symptoms that may or may not correspond to a coherent diagnostic entity associated with a unique endophenotype. Yet despite teaching psychiatry for many years, I have been unable to convince my students that this diagnosis fails to provide specific guidance for clinical management. For most trainees, major depression closes the case for writing a prescription. Major depression fades imperceptibly into the sadness that everyone feels from time to time (Horwitz & Wakefield, 2007). Using a cutoff, as in DSM’s category of major depression, of five out of nine criteria (as opposed to, for example, seven or eight out of nine) is an arbitrary procedure. That is why this category is so heterogeneous. In addition, patients with subclinical symptoms (less than five) still suffer distress. It is also not clear that patients who have more than five criteria are fundamentally different from those who only barely meet the cutoff. The number 5, chosen because it is more than half of 9, is arbitrary rather than being based on scientific data. Different levels of severity, or even separate disease processes, are obscured by a single category. Despite its ubiquity, major depression is one of the most problematic diagnoses in psychiatry. Categorical classification imposes an artificial order when boundaries between disorders (or between disorders and normality) are fuzzy. Diagnostic categories are always dichotomous, allowing only for a yes or no decision. Those who do not quite meet criteria will be excluded, and patients with different levels of severity can get the same diagnosis. This process leads to a loss of information (Krueger et al., 2011b). Categories are the basis of differential diagnosis, but that procedure makes sense only when disease mechanisms are known. When they are not understood, as is almost always the case in psychiatry, differential diagnosis is little but guesswork. It should be kept EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 86 | Part I Diagn ostic P ri n cip l e s in mind that the most important illness categories in current use, including well-researched diagnoses such as schizophrenia, may or may not meet the test of time. The problems of diagnostic categories in psychiatry are many, including an inadequate scientific base, excessive comorbidity, inadequate coverage, an arbitrary boundary with normality, and heterogeneity among persons sharing the same diagnosis (Kraemer et al., 2004). Comorbidity, when massive, is a good sign that a category is not valid. Inadequate coverage is reflected by the fact many patients do not fit into the categories listed in the system. The “not otherwise specified” (NOS) option (now “other specified” or “unspecified”) introduced in DSM-III was necessary because so many patients do not meet criteria for the specified diagnoses. It is therefore used as a “wastebasket” for patients who do not meet criteria for any category within a group. In personality disorders, 50% of cases could only be fitted into a NOS category in DSM-IV (Zimmerman et al., 2005). Finally, categories obscure clinically important differences between patients meeting criteria for the same diagnosis. These are serious problems requiring a serious solution. An overlap between categories leads patients to meet criteria for multiple diagnoses. This “comorbidity” reflects the absence of hierarchical rules: The DSM-IV-TR system did not generally allow clinicians to determine whether one diagnosis is primary and one secondary. Multiple diagnoses are usually a marker for severity. A community survey in the United Kingdom (Weich et al., 2011) found that those who meet criteria for several mental disorders have more severe levels of dysfunction. The problem with comorbidity is that we have no definite way to determine whether one of two overlapping categories (e.g., mood disorder vs. anxiety disorder, or conduct disorder vs. attention-deficit disorder) should take precedence over the other. If you follow the rules, you are forced to make more than one diagnosis. Comorbidity would be greatly reduced if DSM rewrote diagnostic criteria to minimize overlap. But lacking a clear justification, previous editions of the manual have been reluctant to do this. DSM-5’s view was that comorbidity might be reduced or eliminated by replacing categories with dimensions. EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 6 D i m e n si o n a l i t y | 8 7 A second problem concerns the boundary between pathology and normality. Many clinical symptoms blend into subclinical phenomena that can be seen in large sections of community populations. In other words, most people have periods when they are moody, unhappy, nervous, or show features of addiction. Many have suffered from some of the symptoms of common mental disorders. Even hallucinations sometimes occur in normal people (Stip & Letourneau, 2009). Again, there is no definite cutoff point at which mental disorder can be said to be clearly present. A third issue is that neo-Kraepelinian categories in psychiatry rarely have robust relationships to biological measures, such as genetic markers, hormonal variations, or neuroimaging. By and large, relationships are stronger with dimensional scales that measure traits or score signs and symptoms (Regier et al., 2011)— although even then correlations are not high. The problem with diagnostic categories is that they are dichotomous, allowing only for a yes or no decision. Those who do not quite meet criteria will be excluded, and patients with different levels of severity can receive the same diagnosis. In summary, psychiatric diagnosis has an inadequate scientific base, including massive comorbidity, inadequate coverage leading many patients to fit into only unspecified options, while categories obscure clinically important differences between patients meeting criteria for the same diagnosis (Kraemer et al., 2004). These difficulties have led some to the conclusion that categorical diagnosis in psychiatry should either be scrapped or kept only as a short-term expedient (Kupfer & Regier, 2011). If diagnosis would gradually become dimensional, instead of slotting patients into rigid categories, one could give them a score on one or more dimensions of psychopathology. Rather than packaging pathology within a single category, multiple scores could make overlap disappear. All mental disorders would be seen as lying on one or several spectra reflecting neurobiological variability (Insel et al., 2010). This is the basis of the “research domain criteria” (RDoCs) proposed by the National Institute of Mental Health (NIMH) EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 88 | Part I Diagn ostic P ri n cip l e s (Insel, 2009). This model overlaps with the point of view of DSM-5, but it pushes the envelope. The basic assumption is that there is no absolute boundary between disorder and normality and that psychopathology is better described by a series of scores. But although RDoCs claims to be a more scientific system, it remains to be seen whether this model corresponds to empirical reality. What Do Dimensions Measure? Despite all their virtues, dimensions cannot untie the Gordian knot of validity in diagnostic classification. The reason is that dimensions suffer from most of the same limitations that afflict categorical systems. They are not based on a fundamental understanding of the etiology and pathogenesis of mental disorders. They are based just as much on clinical observation as on categorical diagnoses. Until we know more about psychopathology, no system can be further advanced than medical diagnosis was in the nineteenth century, prior to the development of blood tests and X-rays. Diagnosis must be rooted in independent markers, most of which will have to be biological. That would be true construct validity. At this point, psychiatry can only aspire to having such measures. Converting clinical observations into dimensional scores will not solve the problem. Dimensions may do a better job of measuring severity. It has been consistently shown that severe effects on functioning provide a better predictor of prognosis than categorization (Krueger & Bezdjian, 2009). However, the scoring of severity in psychiatry is not like the staging of tumors based on imaging and pathological findings. Rather, the procedure is entirely rooted in observation and/or self-report data. If severity ratings are little but a count of signs and symptoms, their introduction could be premature (First, 2005). In short, observable phenomena provide only indirect clues to underlying endophenotypes—the pathological processes that lie behind signs and symptoms. Until psychiatry understands mental illness better, the use of dimensions will only be a rough-and-ready expedient. EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 6 D i m e n si o n a l i t y | 8 9 Dimensions and Clinical Utility A system designed for practitioners as well as researchers has to have clinical utility. If dimensional diagnosis ends up not being used, for lack of clinical utility, adopting it would be pointless (First, 2010). Although taking blood pressure is simple, that is an objective physical measurement using a standard machine. Physicians learn how to perform complex diagnostic procedures (e.g., electrocardiograms) that can make useful predictions about the nature and course of disease. But there is no equivalent procedure in psychiatry. The scoring of symptoms by practitioners, as recommended in DSM-5, has limited utility. Clinicians would need a fair amount of training to make these ratings valid. Busy practitioners are likely to produce unreliable results. This procedure is also different from administering self-report questionnaires, which have been developed over years to establish their psychometric properties and that are the basis of all dimensional research in psychopathology. Such scales do not require reliable rating and can be backed up by systematic testing. Research psychologists like these measures—they are used to deal with data in that way—and have long developed assessment instruments using dimensional approaches. But it is usually impractical to ask patients to fill out questionnaires, even in a waiting room. Even when they do, the answers may not correspond to what clinicians observe. Crucially, although dimensions give an impression of being more “scientific,” they have not been shown to be valid in relation to etiology, pathogenesis, outcome, or choice of treatment. Scores based on symptoms do not measure underlying processes behind disorders. At this point, the whole idea has to be taken on faith. Until more data become available, it seems futile to ask clinicians, who already found DSM-IV to be burdensome, to learn an even more complex system. Most will find dimensional scoring unwieldy. The scoring of symptoms by practitioners requires using a Likert scale (usually rated from 1 to 5) that clinicians need to be EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 90 | Part I Diagn ostic P ri n cip l e s trained to use. But resistance on the part of clinicians to using dimensional scales is not based on habit or laziness (First, 2005). They know that scoring actually tells them no more than what they can readily observe. Why go through a complex procedure when an experienced clinician can know what is wrong in the first 5 minutes? Currently, only a few dimensional measures have been used widely. Although scoring systems have been recommended for personality disorders (Costa & Widiger, 2001), for psychoses (Rosenman et al., 2003), and for depression (Korszun et al., 2004), none of the existing scales has a strong clinical following. No one has been convinced that scoring tells you more about outcome and treatment than a categorical diagnosis. Again, dimensional diagnosis tends to deny the existence of a separation between pathology and normality. Although disorder can sometimes be a matter of degree, if one were to follow dimensionality to its logical conclusion, everyone would merit a score reflecting some level of active or potential condition. Physicians in general medicine do sometimes think in this way, as shown by the widespread measurement of blood lipids in asymptomatic patients. But one need not confuse risk factors with disease. Unless we want to give up diagnosis entirely, we still need to establish cutoff points to distinguish true cases of mental disorder from subclinical or normal variants. Medicine is the study of disease, not a description of normal variation. Dimensions and Research A former director of NIMH (Hyman, 2011) reported that when he was in charge, millions of dollars were spent on genetic studies of DSM categories, but that the money was almost entirely wasted. The reason was that psychiatric diagnoses are not true endophenotypes (Regier et al., 2009). In this way, dimensionalization seems more in accord with modern genetics (Hyman, 2010). EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 6 D i m e n si o n a l i t y | 9 1 Hyman is correct about the danger of reifying categories, but dimensions also lack empirical support. The decision of the current leaders of NIMH to direct funding away from existing DSM categories to a future “brain-based” system (RDoCs; Insel, 2009; Insel et al., 2010; Sanislow et al., 2010) will probably be a failure. Although scoring could be more closely related to endophenotypes, genes, and neural circuits than traditional categories, we do not know how to do this in a valid way. To be fair, RDoCs is an interesting idea that should be researched systematically. But at this point, it has to be considered as a bet that may or may not work out. NIMH has become a center of neuroscience research, and it downplays psychosocial research. The principle that “mental disorders are brain disorders” appeals to those who want to reduce stigma. However, this phrase has become a mantra. It is not a fact but, rather, an ideology used to validate a certain approach to psychiatry. It represents the hope that mental illness can be translated into neuroscience without considering psychology or any of the other social sciences. It has even been suggested that psychiatry should reunite with neurology into one specialty that treats brain diseases (Insel & Quirion, 2005). (A neurological colleague of mine once suggested to me: “We treat the axon and you treat the synapse.”) The question is whether psychiatry can be reduced to the clinical application of neuroscience and whether clinicians should give up talking for prescribing. Needless to say, neuroscience is a valuable tool for our specialty. But studying mental processes on their own terms is an equally valid strategy. Mind is an emergent property of the brain and will never be fully explained on a cellular or molecular level. In other words, complex systems yield phenomena that “emerge” from simpler components but are not fully determined by them. In the simplest example, the properties of water are not explained by the atomic structure of hydrogen or oxygen. Although reducing a system to its components sheds light on what can be directly observed, explanations EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 92 | Part I Diagn ostic P ri n cip l e s of mental disorder should ideally require links between different levels of analysis, from genes and neurons to psychosocial processes (Gold, 2009). Thus, the holy grail of neuroscience may never provide a complete resolution of the problems raised by diagnostic classification. Great advances in research in recent decades have taught us much about the brain. Imaging studies have identified specific functions for many cortical and subcortical structures. We have learned about the alarm system in the amygdala, the memory system in the hippocampus, the reward system in the nucleus accumbens, and the behavioral control system in the prefrontal cortex. At the same time, biochemical and physiological studies have defined synaptic pathways by which neurons communicate, as well as cellular pathways by which proteins are constructed and used within a neuron. Research may eventually specify the genes and proteins that shape all these processes. One can only applaud these scientific advances. However, none of this research has thus far had any clinical application—either to the understanding of disease mechanisms or to the treatment of mental illness. Molecular genetics and neuroimaging have not explained why people become psychotic or severely depressed. It remains possible that future editions of DSM will be guided by helpful neurobiological markers—but not this time around. This gap between basic and clinical science is no accident. Mental processes are too complex to be readily reduced to neuroscience. Moreover, brain mechanisms are only one of several relevant levels of analysis, and a comprehensive theory also needs to include psychological mechanisms. Biological reductionism in psychiatry supports a practice based almost entirely on drug treatment. In the widely cited article by Insel and Quirion (2005), the word “psychological” does not even appear. This mindless approach to psychiatry, supported by both DSM-5 and NIMH, has real consequences for practice. It supports the current tendency for psychiatry to abandon psychosocial models and to restrict itself to neuroscience. EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 6 D i m e n si o n a l i t y | 9 3 Dimensionalizing by Scoring Symptoms DSM-5 could be used to dimensionalize diagnoses depending on severity by scoring the number of symptoms present in any patient. Thus, if there are nine criteria for a diagnosis and each is rated simply “yes,” “maybe,” or “no,” one would immediately have a scale ranging from 0 to 27. Alternatively, clinicians could score each criterion on a 4-point scale (e.g., not at all, some, a fair amount, or a lot). These procedures could be applied to any diagnosis. Again, it should be kept in mind that severity scores do not produce dimensions in the same way as scores on a test. There is no way of knowing how to weigh each criterion. Psychometric analysis of questionnaires requires that a large number of items be analyzed to ensure that the instrument as a whole produces a reliable result. Scales have to be smoothly continuous, not bumpy. Reaching that goal usually requires years of research. For this reason, scoring existing diagnostic criteria creates a chimerical beast that is neither fully categorical nor properly dimensional. Although the criteria in the manual can be useful in the aggregate, hardly any of them have validity on their own. Many reflect symptoms that resemble each other and that often occur together. This is why even sophisticated statistical methods (e.g., factor analysis) cannot “carve nature at its joints.” Ideally, a valid dimensional scale would need to be created de novo and be based on sources of external validity, not on existing criteria. DSM-5 does not have the evidence to support such a procedure or the time to develop it. Diagnostic Spectra Overlapping diagnoses that reflect different aspects of the same pathological process may fall within spectra, a range of disorders rooted in common mechanisms. The oldest and best supported is the schizophrenia spectrum (Siever & Davis, 1991). This concept EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 94 | Part I Diagn ostic P ri n cip l e s includes conditions ranging from severe psychosis (schizophrenia itself) and milder psychoses (brief psychotic episodes and delusional disorder) to diagnoses in which formal delusions and hallucinations are absent (schizotypal personality disorder). The validity of this concept is supported by family studies, in which spectrum disorders show a stronger pattern of inheritance than schizophrenia alone (Kendler et al., 1994). It has also long been known that schizotypal personality shares biological markers with overt schizophrenia, even if they are not specific enough to be used for diagnosis (Siever, 2007). The concept of a mood spectrum also has a degree of validity. Decades ago, the American psychiatrist George Winokur suggested that depression and alcoholism might reflect the same disease process—with the former being more common in women and the latter being more common in men (Winokur et al., 1975). Later, the Swiss psychiatrist Jules Angst proposed a more restricted spectrum, including classical depression and its subclinical variants, as well as conditions sharing the same endophenotype, particularly anxiety disorders (Angst & Merikangas, 1997). Other spectra have been proposed for panic/agoraphobia, substance use, psychosis as a whole, anorexia–bulimia, an obsessive– compulsive domain, and social anxiety (Frank et al., 2011). A bipolar spectrum (discussed in Chapter 9) would bring together all disorders in psychiatry in which mood instability is prominent (Ghaemi et al., 2002). Another concept is an impulsive spectrum (Zanarini, 1993), based on evidence that impulsive traits—present in substance abuse, eating disorders, and personality disorders—run in the same families. Spectra could be used to search for endophenotypes (biological pathways) that lie behind symptoms (Gottesman & Gould, 2003). But like dimensions, they all still depend on phenomenological observation. In the absence of biological markers, disorders may not fall within the same spectrum just because they resemble each other. Also, disorders may be based on multiple endophenotypes, in which case basing spectra on clinical features alone oversimplifies a complex problem. EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 6 D i m e n si o n a l i t y | 9 5 How many diagnostic spectra would we need to describe most of the disorders listed in the DSM manual? A seminal study using factor analysis (Krueger, 1999) suggested that most of the territory could be covered by just two factors—internalizing and externalizing disorders. However, these dimensions do not describe cognitive impairment, a central issue for psychiatry. Kotov et al. (2011) suggested that five dimensions would do the trick: internalizing, externalizing, cognitive, somatoform, and antagonism. Thus, internalizing dimensions would describe most anxiety and mood disorders; externalizing would describe substance use and impulsive disorders; cognitive would describe schizophrenia, neurodevelopmental disorders, and neurocognitive disorders; somatoform would describe somatic symptom disorders; and antagonism would account for many personality disorders. There may be something useful to be garnered from these factor analyses. But keep in mind that they only describe symptomatic resemblances, and they tell you nothing about etiology or pathogenesis. Dimensional Assessments in DSM-5 Several dimensional assessment measures can be found in Section III of the manual. One consists of a set of disorder-specific measures of severity, with details provided concerning “Clinician-Rated Dimensions of Psychosis Symptom Severity.” Finally, DSM-5 has a series of “cross-cutting” symptom assessments that describe psychopathology dimensionally. They have 13 domains, including standard clinical problems such as substance use, suicidal ideation, and psychosis, each scored by severity. These scales have not been the focus of much research. However, their reliability was tested in field trials, and kappas were better than most of those proposed for common categories (Regier et al., 2013), probably because it is easier to determine whether a patient falls within a symptom spectrum than to make a precise diagnosis. These spectra need much more work and should be thought of as a work in progress. EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 96 | Part I Diagn ostic P ri n cip l e s At one point, it was proposed that DSM-5 should have its own scale for predicting suicide. For some very good reasons, this cannot be found in the final version of the manual. Every clinician is trained to assess suicide risk using a melange of indicators, such as stated intent, past suicidal behavior, psychosocial status, the presence of substance abuse, family history, and clinical diagnosis (Bongar, 1992). However, the prediction of suicide has mostly been marked by failure (Paris, 2006). Empirical studies show, at best, a small relationship between predictors and outcome. Large-scale research using algorithms based on commonly applied clinical judgment failed to predict a single case (Goldstein et al., 1991). The sober fact is that psychiatrists are unable to determine which patients are at risk for taking their own lives. If they could, they might be in a position to prevent suicide. Why is this so? The reason is that although suicidal ideation is very common, and attempts are not infrequent, completed suicide is relatively rare. Because of this “base rate” problem, most methods of predicting suicide turn up an enormous number of false positives. Even the most successful predictors, such as the Suicide Intent Scale (Beck et al., 1974), can only predict completion with statistical significance (Suominen et al., 2004). Even if one sees relationships in large samples, the scale will be wrong most of the time in practice. This is why scores based on statistical data are not accurate enough to be useful in making clinical decisions. Although long-term follow-up studies have found that scales can have some predictive value, most people who score high on them never commit suicide (Goldstein et al., 1991). Thus, in the vast majority of cases, completion is not predictable. The failure of prediction has an important corollary. Most people who are admitted to the hospital as suicide risks are unlikely to kill themselves (Paris, 2006). Also, those who carry the most risk may never present clinically. The vast majority of completed suicides occur on the very first attempt and involve guns or hanging (Beautrais, 2001). The proposal for DSM-5, responding understandably to clinical need, was a scale assessing some standard risk factors (previous EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 6 D i m e n si o n a l i t y | 9 7 attempt, aggressivity, social isolation, recent losses, chronic pain, diagnosis of severe mental disorder, substance abuse, suicidal plans, and hopelessness). Yet it only had face validity, mirroring what psychiatrists have long been taught about the assessment of suicide risk and not providing scientific justification for clinical prediction. It did not belong in a diagnostic manual. Functioning and Impairment Diagnosis is a meaningful cluster of symptoms but does not always reflect functioning. We need a separate measure. Axis V in DSM-III and DSM-IV was a failure. It mixed apples and oranges. It tried to take into account symptom severity, ability to work, and the quality of intimate relationships—all in one number! The results were predictably unreliable and misleading. Thus, the history of Axis V is an instructive failure. Introduced in DSM-III, it was based on a measure developed years before by Luborsky (1962)—the Health–Sickness Rating Scale (HSRS)— and later adapted into a Global Assessment Scale (GAS; Endicott et al., 1976). The GAS was renamed in DSM-III-R as the Global Assessment of Functioning (GAF). The concept was to score functioning on a scale from 0 to 100. In case of a discrepancy between different areas of functioning (as one often sees), the score should reflect the lowest common denominator so that the most dysfunctional area would determine the final score. DSM-III also asked clinicians, as a way of assessing change, to record a score for the highest level in the past year, which could then be compared to the current GAF. For more than 30 years, I taught residents to write clinical reports that include a GAF score. They almost never got it right. The main reason is that the number is a composite. A patient could be unemployed and isolated but only have mild symptoms, whereas another patient could have severe symptoms despite a good job and a loving family: Both could receive the same GAF score. In practice, the GAF functions not as a 100-point scale but, rather, a 30-point EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 98 | Part I Diagn ostic P ri n cip l e s scale. Any score greater than 80 would be Utopia, and I do not think I have ever felt that good for more than a week. Patients who score between 70 and 80 are having expectable reactions to situations, a level that defines them as mentally healthy. We do not see patients like that either. Those with real mental disorders always score less than 70. Thus, patients with only mild dysfunction would fall between 60 and 70, those with moderate problems between 50 and 60, and those with severe dysfunction less than 50. This leaves a very narrow range. Finally, the GAF scale lacked clinical utility. Almost none of my colleagues (including those who used to be my students) could follow its complex procedures. So I am not unhappy to see it go. But I am not yet convinced that DSM-5 has come up with anything better. One scale was intended to follow the guidelines of a National Institutes of Health initiative called Patient-Reported Outcomes Measurement Information System (PROMIS; Anatchkova & Bjorner, 2010). It might be used as a measure of both functioning and disability (Narrow et al., 2009; Narrow & Kuhl, 2011), but its scientific basis is uncertain. It is much more complicated than GAF, virtually guaranteeing that it will never be used in clinical practice. A much better choice, now formally recommended by DSM-5, is the World Health Organization Disability Assessment Schedule or WHO-DAS 2.0. Along with a guide to its use, this instrument is available online at http://www.who.int/classifications/icf/whodasii/en. It has self-report and clinician-report versions. The WHO-DAS is a generic assessment instrument for health and disability that can be used for all diseases, including mental, neurological, and addictive disorders. It has been applied in both clinical and general population settings, produces standardized disability levels and profiles, and is applicable across cultures and for all adult populations. The WHO-DAS is a self-report measure that is short, simple, and can be administered in 5–20 minutes. It is commonly used for insurance assessments that require a formal and quantitative measure of disability. It is also likely to be used in research. However, it is unlikely to become a routine part of EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 6 D i m e n si o n a l i t y | 9 9 diagnostic procedures in practice. Busy clinicians will not want to take the time to do complex scoring when they can directly observe severity. The point to remember is that functioning is only partly driven by categorical diagnosis. Some people with serious mental disorders manage surprisingly well, whereas some patients with mild to moderate mental disorders function at a low level. Even in schizophrenia, 10–20% of patients are employed, depending on the job market (Marwaha & Johnson, 2004). Nearly one-fourth of men with schizophrenia (and approximately half of women) will eventually marry and have families (Saugstad, 1989). At the same time, patients with common mental disorders (anxiety and depression) can be unemployed and socially isolated. Rating psychosocial functioning is a complex business. Un­packing the mixed bag of Axis V requires clinicians to make multiple ratings, which they will not have time to do. In any case, any scale used to determine whether patients will receive money from insurance companies or governments is not going to be fully objective. Abolishing the Five-Axis System Axis V was part of a larger assessment procedure that was considered innovative when DSM-III was introduced. It offered a way to be “biopsychosocial” by considering personality, medical illness, stressors, and functional levels on top of diagnosis. Some of my colleagues became very attached to the five axes and continue to use them even though they are not in DSM-5. My own conclusion is that the system never worked properly. Almost everyone focused on Axis I—the traditional way of making categorical diagnoses. Most clinical reports stopped there. Axis II (personality disorders and intellectual disability) became a second-class citizen, mostly ignored or, at best, “deferred.” Including these diagnoses in the same axis as every other category avoids this kind of stigmatization. Regarding Axis III, medical diagnoses are EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 100 | Part I Diagn ostic P ri n cip l e s of interest, but they can usually be found in a full report. Axis IV depended on a vague rating stressor that was not validated and difficult to score. As already noted, Axis V was an amalgam of symptoms and psychosocial functioning. My view is that the five axes will not be missed, and they will gradually die out. What was cutting-edge 30 years ago turned out to be problematic in practice. One can only wonder whether the same judgment will be made about some of the innovations of DSM-5 when DSM-6 is ready for publication. Dimensionalization as a Vision The American journalist Lincoln Steffens, who visited the Soviet Union soon after the Russian Revolution, famously concluded, “I have been over into the future, and it works.” It took decades for everyone to realize just how wrong he was. Similarly, the editors of DSM-5 had a visionary view of psychiatric diagnosis. They knew where psychiatry was going, and they wanted to help it get there more rapidly. Dimensionalization was a major factor in their ideology. Only time will tell whether it works for or against clinical practice. First (2010) nicely summarizes these issues: For there to be any chance that the DSM-5 dimensions will fare better than their DSM-IV predecessors, significant efforts must be made to establish their reliability, sensitivity to change, and clinical utility. Fundamental to this effort is empirical evidence establishing not only that clinicians find such measures “feasible” or “acceptable,” but also that the use of such measures improve clinical outcomes. Otherwise it is unlikely that clinicians will be motivated to spend the time and effort required to put the measures into routine clinical use. (p. 698) The situation would be different if dimensions had the scientific status of blood pressure. As it stands, the only practical issue for EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 6 D i m e n si o n a l i t y | 1 0 1 practitioners is whether a disorder is mild, moderate, or severe. But severity does not define the boundaries of disorders, and there is also no established benefit to a scoring system that simply counts criteria. Clinicians who want to communicate about their patients can do just as well by continuing to use categories. And this is exactly what they will do. EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 7 Clinical Utility DSM-5 is designed to be practical. Busy practitioners do not use diagnostic classification in the same way as researchers. The success of the new edition will stand or fall on how clinicians apply it in daily practice. Practitioners like familiar diagnoses. Whatever problems there are with the boundaries of mental disorders, typical cases of well-established categories, such as schizophrenia or bipolar illness, immediately convey a great deal of information. Every psychiatry and psychology student learns about these diagnoses and knows more or less what a case looks like. That is why some prefer prototypes, even if diagnosis during the past 30 years has made them comfortable with algorithms. Eventually, research may provide us with sufficient reasons to abandon some of the most familiar categories. Major depression, conduct disorder, and schizophrenia could turn out to be a group of disorders rather than one. When the evidence is strong enough, we can replace the old with the new. But until we have that kind of data, traditional concepts remain valuable. DSM-5 was too keen to be innovative, even when data were not yet in. Making it more difficult to reach a diagnosis undermines recognition of disorders. If a system is too complicated to use, practitioners cannot reach accurate conclusions. For that reason, a lack of clinical utility is also bad for patients, who may end up receiving useless or harmful treatment. All the potential advantages of creating a new edition of DSM could be lost. Consider an example of how clinicians use manuals in the real world: the familiar category of major depressive disorder. Research 102 EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 7 Clinical Utility | 103 shows that only a minority follow DSM rules when making this diagnosis (Zimmerman & Galiano, 2010). Instead, practitioners depend on a global impression or “prototype,” and they may not quite remember what the manual states. Few take the time to count to determine if five of nine criteria are met. Psychologists have long known that the most anyone can remember from a list of any kind is seven items (which is why we have to write down telephone numbers). So who can remember nine criteria? You could use an acronym of capital letters to jog your memory, but you would still have to remember the acronym. Because clinicians do not have the time to go through algorithmic procedures, they reach conclusions based on immediate impressions. This is what Kahneman (2011) calls “thinking fast.” The problem with impressionistic diagnosis is that it is particularly prone to cognitive error, such as coming up with the first diagnosis that comes to mind. Kahneman describes that as an “availability heuristic.” All editions of DSM have clearly stated that they are not intended to be guides to treatment. But that is not what happens in practice. Clinicians go directly from diagnosis to treatment. Moreover, they prefer diagnoses that lead to a specific treatment of some kind, even when they are wrong. For example, patients who say they are depressed and have some accompanying symptoms, such as insomnia and fatigue, tend to be diagnosed with major depression, followed by a routine drug prescription. The overdiagnosis of major depression, based on its overly broad definition, is one of the most serious problems in contemporary psychiatry. Although some patients meeting these criteria benefit from antidepressants, results are far from consistent, as shown by placebo-controlled trials (Kirsch et al., 2008) and by effectiveness research (Valenstein, 2006). Most categories in DSM-5 are syndromes, not diseases. Because DSM criteria are little but lists of symptoms, clinicians who use the manual end up treating symptoms rather than diseases. The reification of diagnosis gives the impression that a category such as “major depression” is a specific medical illness that responds to specific methods of treatment. EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 104 | Part I Diagn ostic P ri n cip l e s Diagnosis as Communication The most important function of diagnosis is communication—to other practitioners, to patients, to families, and to health care system administrators (First et al., 2004). Yet if clinicians find DSM-5 categories unwieldy, they will not be used effectively. Diagnosis also provides important information for people suffering from mental disorders. There was a time when psychiatrists were reluctant to share diagnoses with patients. I was taught to practice that way. It was also a time when physicians were much more authoritarian than they are now, and the idea of educating patients to participate in their own treatment had not been developed. Moreover, because the diagnostic system used when I was in training (DSM-II) was flawed, we did not think patients were missing much. Some of my teachers believed that communicating a diagnosis could actually interfere with treatment by pigeonholing patients into categories that failed to acknowledge unique life stories. My supervisors told me that the best answer to the question, “What’s my diagnosis, doctor?” should be “I don’t think about your problems in that way.” That answer was not quite honest, but my teachers, sympathetic to psychoanalysis, were afraid that diagnosis could become the only way to understand a patient. (Although they were wrong about many other things, they were correct to point out this danger.) Like most psychiatrists, I gradually changed my ways. For the first time in the history of psychiatry, diagnosis made a real difference in the choice of treatment. The best example is bipolar disorder. In the early 1970s, with the introduction of lithium, it became crucially important to distinguish bipolarity from schizophrenia. One also needed to educate bipolar patients about their disorder to help them to be compliant with treatment. Although some did not want to hear about their diagnosis (particularly when in a manic mood), psychoeducation can be useful when bipolar patients are euthymic (Scott et al., 2006). Each diagnosis in psychiatry presents unique challenges for patient education. Schizophrenia, which interferes with insight, EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 7 Clinical Utility | 105 presents particular difficulties. I often tried to explain this diagnosis to patients, with very limited success. Only in recent years have formal cognitive therapy programs been developed that make use of more sophisticated psychoeducational methods (Rummel-Kluge & Kissling, 2008). It is now widely accepted that treatment benefits from informing patients about their diagnosis. I am familiar with its use in my own area of subspecialization, borderline personality disorder (BPD). This is a disabling condition marked by unstable mood, impulsivity, and unstable relationships (Paris, 2008b). In pioneer research on the management of these patients, Linehan (1993) described how the first step of her treatment method (dialectical behavior therapy) was to show a slide of the DSM criteria, explain the diagnosis in detail, and use the criteria as guideposts for planning treatment. My experience confirms the value of these procedures. I have found that explaining the diagnosis brings most patients relief, as they realize that their problems are known to psychiatry and that research on treatment can guide their recovery. I encourage patients to look up the diagnosis and to discuss with me which features they have and which ones they do not. In modern medical practice, patients are no longer passive consumers of services. Many read about their illness on the Internet. Some arrive in the office armed with printouts. Patients need to know—and deserve to know—their diagnosis. Moreover, each major disorder now has support groups devoted to explaining the nature of the problem to patients and to their families. All these developments make it even more important that DSM-5 diagnoses be user-friendly. However, it is not clear how easily clinicians can explain complex diagnoses, particularly if they are based on scoring procedures. Making Diagnosis User-Friendly DSM-III demanded more of clinicians than did its predecessors. Because the manual was extremely popular and came to dominate the mental health field, everyone was expected to use it. Moreover, EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 106 | Part I Diagn ostic P ri n cip l e s clinicians became familiar with its specific criteria, even if few went through the procedure of counting them. Academics and researchers went a step further, using structured interviews that were much more reliable than clinical diagnosis (i.e., based on DSM criteria but forcing clinicians to go through an algorithm thoroughly and systematically). There was little formal research about how previous editions of DSM were actually used. Jampala et al. (1992) surveyed psychiatric educators and residents, with results (unsurprisingly) showing that the manuals were consulted by almost everyone. For example, psychiatric social workers routinely make DSM diagnoses, largely because insurance companies require them to do so (Frazer et al., 2009). What these surveys fail to show is how diagnostic decisions are reached or whether the specific procedures required in the manual were followed. My experience, in line with the findings of Zimmerman and Galiano (2010), has been that only a few clinicians are systematic and make algorithmic diagnoses in the way described by the manual. They have a general picture in their minds of what constitutes a major depression, a manic episode, or a panic attack, and they make a diagnosis if the patient’s symptoms approximate that picture. Thus, many clinicians still prefer to diagnose by prototype. DSM may have expected too much of its users by asking them to follow algorithms. Clinicians are pressed for time, and they need to cut corners. They read the manual while in training, and they rarely consult it later. In discussing diagnostic dilemmas with colleagues, I almost never hear how many criteria for a disorder a patient met or what precisely were the observations on which each criterion was scored. I am much more likely to hear about one particular symptom believed to be characteristic of a diagnosis. The more complicated a diagnostic system, the less likely clinicians are to use it. That is why the five-axis system introduced in DSM-III, and continued in DSM-IV, was a failure. The concept of multiple perspectives on diagnosis was well intentioned and appeared to be good in theory. Who could argue with the need for a EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 7 Clinical Utility | 107 broader perspective? Yet in practice, only Axis I was used with any consistency. Most reports stopped there, with the other axes either given short shrift or left blank. To my chagrin, assessment of Axis II never really caught on. Many reports I read simply fudged the issue by writing “Axis II, deferred.” This system was too complicated for clinical utility. Dropping the multi-axis system in DSM-5 was the correct decision, but it offers other ways to make things difficult. If you apply the assessment tools in Section III, DSM-5 will be even more complicated than its predecessors. Practitioners will rebel if they now not only have to observe criteria but also have to count and score them. Rating scales, however beloved by research psychologists, will be completed only if they provide a practical link to treatment—as in oncology, in which staging of cancers is important in planning therapy. But if scales are added only as a way of being “more scientific,” then clinicians get no help from them at all. In the more than 30 years that I taught DSM-III and DSM-IV to residents, I was unable to get them to use the multi-axial system with real accuracy. Most found it cumbersome and burdensome. Any system that devotes too many precious minutes to thought without concrete clinical value is a recipe for leaving tasks undone. Once, when I challenged a colleague in one of the workgroups about the complexity of the proposed DSM-5 criteria for personality disorders, he replied, “Don’t physicians learn how to read electrocardiograms?” But that is a false analogy. There can be no comparison between the measurement of electrical waves and ratings of clinical observations. Psychiatry is many decades away from developing a classification based on etiology and pathogenesis (First, 2010; Hyman, 2007). Unfortunately, this has not led to humility among the experts involved with DSM-5. In the early stages of the process, I found the tone of the leadership to be one of undeserved self-congratulation. But by the end, they were admitting that they had done the best they could considering how little is known about mental illness. EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 108 | Part I Diagn ostic P ri n cip l e s Clinicians have to use this system for years to come, but they must accept that it is provisional. Instead of introducing quasi-scientific ratings, we should aim to make DSM-5 user-friendly. We need to be patient and wait until we know enough to come up with something better. EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 5 Diagnostic Validity “Validity” refers to whether or not an instrument accurately assesses what it sets out to measure. It is an essential element of medical diagnosis. Valid diagnoses should not be the creations of enthusiastic clinicians but, rather, be based on empirical data and multiple indicators. As in medicine, psychiatric diagnoses need support that is independent of clinical observation. That is why biological markers should eventually become a crucial element. But currently, validity is only a long-term goal. Even the most modest proposals are unattainable ideals. The reason is that not enough is known about the causes and nature of mental disorders. Most categories in DSM are syndromes of uncertain validity. Some, particularly the psychoses, have more data behind them than others. But even categories as widely used as major depression, or attention-deficit hyperactivity disorder, reflect more about expert consensus than science. And consensus is based on compromise, not on fact. Reliability and Validity As every psychology student is taught, reliability comes before validity. Measurements cannot be reliable unless raters agree on them—at least most of the time. In principle, reliability has been supported by DSM’s algorithmic procedures. Clinicians are guided to a conclusion by criteria rooted in clinical observation and asked to count how many of them are present. But getting observers to agree on whether specific symptoms are present or absent, or whether they are clinically significant, is not simple. Some are 70 EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 5 D i a g n o st i c Va l i d i t y | 7 1 obvious (delusions and hallucinations). Others are subtle (mood instability and impulsive behavior patterns). Although the reliability of diagnosis in psychiatry is better than it was prior to 1980, it is far from satisfactory. In the field trials of DSM-III, reliability was not very high. The standard is a statistic called kappa: “fair” if kappa lies between. 41 and. 60, “good” between. 60 and. 74, and excellent if. 75 or higher. But even for a category as basic as major depression, reliability is only fair to good (Keller et al., 1995). In the DSM-5 field trials, some numbers were even lower, occasionally no better than. 20 (Kraemer et al., 2012). Clinicians are not generally aware of this problem. If they were, they would be less likely to believe that psychiatric diagnoses are written in stone. The reliability problem was not solved by the field trials for DSM-5. Even if kappas were as good (or as bad) as in previous editions, there is no assurance that they translate into reliability in the real world of clinical practice. Moreover, field trials are only a first step. Worryingly, the task force suggested that low kappas were “good enough” reliability for DSM-5 (Kraemer et al., 2012), noting that any medical diagnoses based entirely on clinical observation often do no better. However, psychiatry, which does not have access to confirming laboratory tests, needs to set the bar higher, not lower. Why is reliability so problematic and where do the problems lie? In a large sample of outpatients, Brown et al. (2001) reported on what produced disagreement in the diagnosis of anxiety and mood disorders. The issue was not so much the presence or absence of clinical symptoms. Rather, reliability was compromised by “boundary problems”—that is, determining whether symptoms are clinically significant. At what point can we say that a symptom causes dysfunction or is disabling? This is why boundary problems bedevil most diagnostic procedures in psychiatry. They are linked to the question of what is, and what is not, a mental disorder. Another problem affecting reliability is widespread comorbidity. The term “comorbidity” is a confusing misnomer that implies that a patient has two or more disorders. The overlap we see in practice EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 72 | Part I Diagn ostic P ri n cip l e s might be more usefully called “co-occurrence.” Multiple diagnoses are an artifact of a system structured to produce them. Given that so many categories have overlapping criteria, this result is inevitable. High levels of comorbidity, as in anxiety and mood disorders, could suggest that disorders arise from a common matrix (Goldberg & Goodyer, 2005. Most of the time, diagnosis of more than one disorder adds little to our understanding, so clinicians choose the one they consider most important. This is actually perfectly logical because the DSM system is based on symptoms that are present in multiple diagnoses. The more symptoms you have, the more diagnostic criteria you will meet. But that does not make comorbidity a meaningful concept, and it should not be used to justify treating every symptom as if it were a separate disorder. A few diagnoses are genuinely comorbid. The best example occurs when substance abuse complicates a mood disorder. In such cases, making two diagnoses is logical because addiction has its own trajectory and requires separate treatment (Compton et al., 2007). With this in mind, clinicians correctly speak of patients with drug and alcohol problems as having a “dual diagnosis.” Criteria for Validity The criteria for validity in psychology and medicine have been defined in various ways, but they can be boiled down to a few basic concepts (Strauss & Smith, 2009). Descriptive validity (whether or not methods of measurement are accurate) is the most fundamental principle. Face validity (whether a measure seems, on the face of it, to describe a phenomenon) is not so useful because indirect measures can be as good as, if not better than, criteria that seem intuitively “right.” Predictive validity (whether a measure predicts outcomes such as clinical course or treatment response) is particularly important. The type of predictive validity that psychological assessment has always emphasized is construct validity—that is, whether internal measures correlate with external measures. In other words, you EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 5 D i a g n o st i c Va l i d i t y | 7 3 need to show that different methods of assessment come to the same conclusion. Cronbach and Meehl (1951), in one of the most highly cited papers in the history of psychology, applied this principle to psychological testing. Construct validity is equally important for diagnosis. Again, that is why psychiatry needs to discover biological markers. These principles were the basis of the well-known Robins–Guze (1970) criteria for valid diagnosis. These authors described five criteria that are still invoked, largely because they place psychiatry in the same frame as internal medicine. The first, precise clinical description, is the basis of the DSM system. Signs and symptoms need to be observable, with features that can be described reliably. Immeasurable concepts (e.g., mental conflict, as in DSM-II) are discarded. The spirit of the DSM system eschews armchair theories of any kind. Even so, clinical descriptions do not always produce reliable measurement and therefore fail to shed light on validity. DSM-5 proposed quantifying these fuzzy clinical descriptions through scoring procedures. In the words of the nineteenth-century British physicist Lord Kelvin (1889), “when you can measure what you are speaking about, and express it in numbers, you know something about it; but when you cannot measure it, when you cannot express it in numbers, your knowledge is of a meager and unsatisfactory kind.” Even so, it remains to be seen whether scores based on clinical observation can improve diagnostic validity. The second Robins–Guze criterion was another form of construct validity: laboratory studies to identify biological markers. When physicians observe jaundice, and liver function tests are also abnormal, they have an independent source of validity. This possibility is alluded to in the DSM-5 definition of mental disorder. Unfortunately, because biological markers remain unknown in psychiatry, this source of validity remains out of reach. The third Robins–Guze criterion is clear delineation from other disorders. In this respect, the DSM system has been a notable failure: Overlap is the rule, not the exception. Disorders frequently co-occur, and a decision to remove hierarchical rules EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 74 | Part I Diagn ostic P ri n cip l e s for diagnosis in DSM-III-R only made the situation worse. The idea was that if no one knows which one is primary and which is secondary, the presence of one diagnosis should not exclude another. In practice, very few patients can be described by a single category. But massive comorbidity reflects a serious lack of validity in the entire system. In a widely quoted article, Kendell and Jablensky (2003) suggested diagnosticians should look for “zones of rarity” between disorders. But no one has, thus far, been able to find them—not for severe disorders such as schizophrenia or bipolar disorder, nor for common problems such as depression and anxiety. The fourth Robins–Guze criterion is another form of construct validity: a characteristic outcome in follow-up studies. Kraepelin (1921) distinguished schizophrenia from bipolar illness on this basis (schizophrenia tends to deteriorate without full remission, whereas bipolar disorder tends to be intermittent). Yet such distinctions are far from absolute. Increasingly more evidence has been accumulating pointing to overlap between the major psychoses (McDonald, 2004). Severity of illness tends to be a better predictor of outcome than categorical diagnosis. The fifth Robins–Guze criterion, another source of construct validity, is a genetic pattern in family history studies. Family history is an indicator of heritability that can be much more easily measured than genes. But up to now, this line of investigation has not been very fruitful. What seems to run in families are not categories but, rather, broader dimensions of psychopathology—tendencies to psychosis, to moodiness, or to impulsive behavior. Because these diagnostic spectra are not confined to single categories, they undermine the validity of a neo-Kraepelinian system. In summary, after more than 40 years, the Robins–Guze criteria remain visionary; we are in no position to apply them, and they may also be wrong. It could be 50 or 100 years before we know enough to reach a final conclusion. Meanwhile, DSM-5 took a different approach, downplaying neo-Kraepelinian assumptions in favor of a dimensional neurobiological model. EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 5 D i a g n o st i c Va l i d i t y | 7 5 Semi-Structured Interviews and Self-Report Measures Clinicians rely on observation to make diagnoses. Yet there are ways to make the assessment of signs and symptoms more precise. One can try to ensure that everyone is observing the same thing. For example, although interviewing is a skill, not every interviewer can be counted on to ask the same questions. Clinicians go about things in their own way, and they rarely use the DSM in a systematic way. That is the reason for the development of a series of semistructured interviews, whose content is defined by specified areas of inquiry that must be covered. (The “semi” part means that raters can ask questions naturally, in their own words, rather than follow a script). Semi-structured interviews became a cottage industry after the publication of DSM-III. They have the potential to make diagnosis more reliable (Garb, 2005; Mullins-Sweatt & Widiger, 2009), but not all interviews are created equal. Some of the most widely used instruments are directly derived from DSM criteria and follow them closely. These measures ensure that all key questions are asked so that sufficient information has been collected to rate criteria (Rettew et al., 2009). If DSM definitions are not gold standards, this approach is obviously limited. Thus, validity is ultimately no better and no worse than DSM categories. The best-known instrument has been the Structured Clinical Interview for DSM Disorders (SCID)—the SCID-1 for Axis I, supplemented by the SCID-II for Axis II (Spitzer et al., 1992). Developed for DSM-III, these interviews replaced a Schedule for Affective Disorders and Schizophrenia (SADS; Endicott & Spitzer, 1978), based on “research diagnostic criteria” developed by the group at Washington University. The SCIDs were revised as the manual itself went through several revisions, and reliability studies were conducted on the DSM-III-R version (Williams et al., 1992). (We will need a new set for DSM-5.) The K-SADS, a widely used interview in child psychiatry, also follows DSM-IV criteria (Hersen, 2003). Semi-structured diagnostic interviews that are not based on the DSM system apply similar principles. The Present State Examination EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 76 | Part I Diagn ostic P ri n cip l e s (Wing, 2009), originally designed for epidemiological studies by the World Health Organization, is based on ICD criteria. It has been used in Europe for both clinical and research purposes. Some interviews are designed for specific disorders. At times, researchers have developed a measure because DSM is seen as deficient. The broader the diagnosis, the more likely it is to lack specificity and overlap with other categories. For example, in borderline personality disorder, the Diagnostic Interview for Borderlines, Revised (DIB-R; Zanarini et al., 1989) defines this category more narrowly (and more precisely) than DSM-IV. The problem is that anyone who wants to develop an interview can do so—and give it an acronym that carries a scientific gloss. In one case, researchers studying the dubious group of dissociative disorders (see Chapter 15) were interested in appropriating the “SCID” brand, and they convinced Robert Spitzer to allow them to call an interview the “SCID-D” (Steinberg & Hall, 1997). The association with a standard acronym gave the impression that this measure was empirically grounded. Actually, all it did was guide clinicians to apply the DSM criteria when interviewing patients. Semi-structured interviews are valuable tools in research. Few journal articles are published today that do not use them. But their application requires training, which is why research papers usually have to report inter-rater reliability. Given the time to administer them, and the need to train clinicians in their use, these instruments are not suitable for practice. There are also clinician-administered ratings, such as the Brief Psychiatric Rating Scale (BPRS; Overall & Gorham, 1962) and the Clinical Global Impression (CGI; Guy, 1976). These scales have been widely used in research (Leucht et al., 2005), and because they are simple to score, they are sometimes applied in clinical settings. The most widely used measures are the Hamilton Scales for anxiety and depression [HAM-A (Hamilton, 1960) and HAM-D (Hamilton, 1959)]. Even after 50 years, these scales retain a niche. They should be revised (the HAM-D is heavily loaded with insomnia questions), but they have been used for so long and are so familiar that nobody EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 5 D i a g n o st i c Va l i d i t y | 7 7 wants to give them up. Moreover, checklists are easy to score and only take a few minutes of clinician time. Psychiatry has always emphasized interviewing skills, but useful information can also be gleaned by administering self-report questionnaires. The Symptom Checklist-90 (SCL-90-R; Derogaitis, 1975) is one of the most widely used general measures of psychopathology. The Beck Depression Inventory (BDI; Beck et al., 1996) is a popular self-report measure used to score the intensity of depression. There is also a widely used self-report measure for alcoholism: the Michigan Alcohol Screening Test (MAST; Shields et al., 2007). These measures do not need training to establish inter-rater reliability, as is the case for interviews. The problem is that self-reports do not always measure the same phenomena that clinicians are interested in. Self-report measures are particularly useful in research because they are standardized and because subjects will put up with only a limited number of interviews. Clinicians need not use them because most of the same information can be obtained in a few minutes of evaluation. Although questionnaires could be administered in a waiting room, they would require time for scoring and interpretation. Clinicians are therefore perfectly right to continue to depend on their own interviews to make diagnoses. The main role of self-report instruments and semi-structured interviews is in research studies, in which one has to be sure that different observers are measuring the same thing. Checklists are no substitute, however, for the clinical diagnosis of mental disorders. Effects of Age, Gender, and Culture DSM-5 has expressed interest in taking into account the effects of age, gender, and culture on diagnosis. To this end, it set up workgroups to examine these issues. The following factors can have an effect on the validity of diagnosis: if disorders present differently at different ages, differently in men than in women, or differently in one culture than in another (Narrow et al., 2007). EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 78 | Part I Diagn ostic P ri n cip l e s Age: While DSM-5 has avoided defining a separate group of childhood disorders, psychopathology often presents differently early in life than it does after puberty. For example, children are rarely psychotic, although they can develop symptoms that are precursors to psychotic illness later in life (Erlenmeyer-Kirling et al., 2000). It used to be thought that children do not develop clinical depression either, but they do—they just do not talk about feelings in the same way as adults (Cytryn & McKew, 1996). Other diagnoses, such as antisocial personality disorder or attention-deficit hyperactivity disorder, clearly start in childhood and are made in adults who have not remitted from earlier symptoms. By and large, the earlier the onset of a mental disorder, the more severe and chronic will be its course (Paris, 1999). That is because temperamental, rather than environmental, factors are predominant in early onset disorders. This principle is most clearly established for diagnoses that first appear in childhood, such as disruptive behavior disorders. Severe patterns of misbehavior can meet criteria for conduct disorder (CD). But when CD begins in the preschool years, the syndrome is most likely to continue into adulthood as antisocial personality disorder (Zoccolillo et al., 1992). On the other hand, when problems begin only in adolescence, they usually remit by young adulthood (Moffitt, 1993). Most clinically important mental disorders begin after puberty. There is also a relationship between onset and prognosis. In schizophrenia, early onset is associated with a poor outcome as well as cognitive deficits and negative symptoms (Engqvist & Rydelius, 2008; Rajji et al., 2009). In bipolar disorder, an early onset is associated with severity and chronicity (Perlis et al., 2009). An early onset of unipolar depression predicts a more chronic course (Coryell et al., 2009). Adolescence is also a common age of onset for anxiety disorders, substance abuse, eating disorders, and personality disorders. This may reflect hormonal changes that influence how mental symptoms develop. Another explanation could be that brain circuits are pruned and modified during adolescence. Another possibility is that the psychological challenges of this stage are stressors in vulnerable adolescents. EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 5 D i a g n o st i c Va l i d i t y | 7 9 When a disorder begins later in development, prognosis tends to be better because some life tasks will already have been successfully carried out. A young adult who has never worked and has not finished an education will have more difficulty recovering from mental symptoms than a middle-aged person who is established in life. Moreover, the disorder itself may look different. For example, there are not as many negative symptoms following an episode of late-onset schizophrenia (Gottesman, 1992). Yet these distinctions are not always consistent. For example, whereas DSM-III stated that schizophrenia cannot be diagnosed if the first onset occurs after age 45 years, later research showed that late-onset cases are clinically indistinguishable from early onset cases (Gottesman, 1992). In the absence of markers to explain why the process begins in late middle age, the restriction was dropped in DSM-IV and has not reappeared in DSM-5. By and large, age of onset is more useful in determining prognosis than in defining disorders. Finally, mental disorders do not always remain the same over time. Diagnoses can change, and several of the major disorders become less severe or are no longer diagnosable by middle age. Gender: It has long been known that many mental disorders vary in prevalence between males and females (Narrow et al., 2007). For example, schizophrenia is somewhat more frequent in men (Thorup et al., 2007). In bipolar disorder, overall prevalence is equal, although men tend to have an earlier onset (Kennedy et al., 2005). In major depression, a 2:1 or 3:1 ratio in favor of women is seen throughout the world—a finding that has been much discussed and is still in search of an explanation (Culbertson, 1997). It is unlikely that these differences are entirely cultural (Weissman & Klerman, 1985). But severe depression in men is associated with a higher suicide rate in almost all countries, whereas women attempt more but use less lethal means (Beautrais, 2001). The tendency for depression to be more frequent in females is open to several interpretations. It might reflect social disadvantage, hormonal influences specific to women, or genetic predispositions that differentially affect the genders. It is possible that EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 80 | Part I Diagn ostic P ri n cip l e s all three factors play a role. However, because gender differences are seen in many different cultures, their effects on prevalence are unlikely to be due to social disadvantage alone (Weissman & Olfson, 1995). Alcoholism and substance use disorders are a mirror image of depression in that in all countries in which surveys have been conducted, ratios strongly favor men (Wilsnack et al., 2009). But women can be addicted to other behaviors, as witness the strong female predominance in eating disorders (Hudson et al., 2007). The tendency of substance use disorders to be more frequent in males, although consistent (Office of Applied Studies, 2004), is open to several explanations. Perhaps men drown their sorrows in drink rather than get depressed. There could be a common endophenotype for mood and substance use disorders, expressed differently in each gender (Winokur, 1979). But it is also possible that men carry a genetic risk for substance use that women do not. Finally, cultural factors can affect prevalence, such as the tendency of men to bond with each other through drinking. Personality disorders also show gender differences. Antisocial personality disorder (ASPD) is more common in men (Coid et al., 2006; Lenzenweger et al., 2007). Criminality, one of the main features of this diagnosis, is also much more frequent in males (Hagan, 2008). Borderline personality disorder (BPD) is a mirror image of ASPD in that most clinical cases are female (Zimmerman et al., 2005). Even so, epidemiological studies in the United States (Lenzenweger et al., 2007) and in the United Kingdom (Coid et al., 2006) have found that BPD (contrary to ASPD) affects as many men as women in the community. The difference in clinical populations reflects help-seeking behavior and the fact that women with BPD are more likely to show suicidality than criminality (Paris, 1997). Most of the completed suicides in young people found on psychological autopsy to have had a diagnosis of BPD occur in males (Lesage et al., 1994; McGirr et al., 2007), consistent with the overall higher rate of suicide in men. Differences between males and females in eating disorders can be largely attributed to cultural forces. Women in modern societies are EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 5 D i a g n o st i c Va l i d i t y | 8 1 much more concerned about remaining thin than are men—a preoccupation that emerges only in societies in which food is abundant (Garner & Garfinkel, 1980). In general, attractiveness in women is linked to physical attributes that suggest fertility, whereas in men attractiveness depends less on appearance and more on access to resources (Buss, 2007). Some differences in prevalence might also be attributed to men being more aggressive than women, which is one of the most consistent findings in all gender research (Krahe, 2007). Men are more physically aggressive and tend to do more harm to others than to themselves. But when men fail in life, they are more likely than women to kill themselves (Beautrais, 2001). In summary, gender differences in mental disorders are real. They should not be regarded as social constructs or as attempts to marginalize one gender or another. Such differences do not in any way undermine the validity of mental disorders or affect their classification in DSM-5. Culture: The prevalence of mental disorders is greatly affected by culture, by history, and by social context (Gone & Kirmayer, 2010). One does not to have to search far to see these relationships. Culture shapes mental disorders in three ways. First, social forces influence how vulnerabilities to psychopathology (i.e., endophenotypes) express themselves in symptoms. Shorter (1994) described a “symptom pool” in which distressed patients can show distress in different ways at different times that are shaped by culture. For example, patients in the nineteenth century were more likely to present somatic complaints of various kinds (“classical hysteria”), whereas 100 years later patients were more likely to come to treatment with psychological complaints such as anxiety and depression. Another example is the clinical presentation of eating disorders during the past few decades (Nasser et al., 2001). Whereas anorexia nervosa has been described in the medical literature for approximately 200 years, bulimia nervosa is a new syndrome that has now become common, largely through social contagion (Crandall, 1988). Thus, bulimic patients express their EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 82 | Part I Diagn ostic P ri n cip l e s distress through abnormal eating behavior, and the pattern has become a social epidemic. The second way in which culture can shape mental disorders is by adding social stress to preexisting biological vulnerabilities. This mechanism has been shown to apply to depression (Kendler, 2005) but may also apply to psychoses, long considered to be primarily biological disorders. Studies of immigrants have established that social disadvantage plays a role in its pathogenesis of schizophrenia (Dutta & Murray, 2010). The exact mechanism is not clear, but West Indian immigrants to the United Kingdom have a much higher rate of schizophrenia than those who remain in their native country, indicating that some form of social causation must be involved. The third mechanism is that social forces can shape unique disorders that are seen only in one culture or a group of cultures—in which case the syndrome is described as “culture-bound” (Prince & Tseng-Laroche, 1990). Anorexia nervosa is unknown in societies in which food is scarce and obesity is an advantage, and it develops only in societies in which there is an excess of food and obesity is a social disadvantage (Garner & Garfinkel,1980). The question has been raised as to which mental disorders are universal. The answer is that by and large, the most severe conditions are seen in societies throughout the world—an observation that applies to schizophrenia (Jablensky et al., 1992) as well as bipolar disorder and melancholic depression (Weissman et al., 1996). However, prevalence can vary from one country to another as well as between different ethnic groups within the same country. As noted previously, the rate of schizophrenia in immigrants is unusually high—much greater than in their countries of origin (Cantor-Graae & Selten, 2005). In summary, culture plays an important role in the phenomenology and prognosis of mental disorder, and in some cases it is an etiological factor. DSM-5 recognizes these principles, and one can find a Cultural Formulation Interview consisting of 14 questions in the manual. We do not know much about the validity of this instrument or whether it is likely to be used in practice. EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost Copyright @ 2015. Oxford University Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. 5 D i a g n o st i c Va l i d i t y | 8 3 Treatment Response as a Source of Validity Diagnosis can sometimes be validated by the application of a specific therapy. It is gratifying when the identification of a disease process leads logically to an effective treatment. This scenario is most obvious in infectious diseases, but it also applies to a number of other diagnoses, from essential hypertension to cancer. Of course, some therapies, such as steroids or anti-inflammatory agents, have nonspecific effects on many disease processes. Yet even in conditions in which the etiology of certain illnesses is entirely unknown (e.g., cancer), treatment can be standardized. The situation in psychiatry is more complex. Most diagnoses in the DSM manual cannot be used to prescribe definitive or consistent therapy. By and large, clinicians treat symptoms rather than disorders. Some therapies (e.g., antipsychotics and lithium) seem to target underlying neurobiological processes, even if we do not understand the mechanism. Many interventions control specific symptoms without reversing a disease process. Even in schizophrenia, drugs have more effects on positive than on negative symptoms, and although they can prevent relapses, they have limited effects on the ultimate progression of the disorder. Similarly, although a great breakthrough, lithium controls symptoms effectively but does not reverse the long-term course of bipolar disorder. Frances and Egger (1999) summarized the strengths and limitations of DSM-IV in light of research. Their conclusion was sobering: “We are at the epicycle stage of psychiatry where astronomy was before Copernicus and biology before Darwin.” There seems to be no reason to change that assessment with the publication of DSM-5. EBSCO : eBook Collection (EBSCOhost) - printed on 6/5/2018 9:27 AM via WALDEN UNIV AN: 939818 ; Paris, Joel.; The Intelligent Clinician's Guide to the DSM-5? Account: s6527200.main.ehost
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Running head: STRENGTHS AND WEAKNESSES OF DSM

Strengths and Weaknesses of DSM
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STRENGTHS AND WEAKNESSES OF DSM

Introduction
Diagnostic Statistical Manual (DSM) is the standard mode of classification for
diagnosing mental illness in people. It consists five classifications, which are known as labels,
used by therapists to develop a treatment plan for mental disorders. In other words, it acts as a
guideline or a tool that physicians use to conceptualize unique cases of mental illness on clients
based on each of ...


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