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An essay review of the DSM-5.

As noted by Corcoran and Walsh (2010), social workers have always experienced mixed feelings about using the Diagnostic and Statistical Manual (DSM) of Mental Disorders. Changes from the DSM-IV-TR to the DSM-5 are not difficult to find. They start with the title, which formerly used Roman numerals and now uses Arabic numerals, and go on from there. Addition ally, incremental changes to the new manual will be identified by decimal number (i.e., 5.1) until a completely new version is deemed necessary. This small change is only a hint at the major changes to follow.

The first major change is the discontinuation of the multiaxial sys tem. The DSM-5 combines the first three axes into one list that contains all mental disorders (including personality disorders and intellectual disability) as well as other medical diagnoses (American Psychiatric Association, 2013). Axes IV and V have simply disappeared. Although this change probably follows from psychiatrists' tendency to ignore Axes IV and V, it poses a problem for many social workers. Axis IV offered the only opportunity to discuss psychosocial or environmental factors that caused or contributed to a mental disorder, and Axis V the only opportunity to identify strengths (functioning) of the individual being diagnosed. With out these two axes, the DSM-5 reverts to a biologically driven, deficit based model of mental illness. The Society for Humanistic Psychology (Division 32 of the American Psychological Association) wrote an online open letter about similar concerns and garnered 15,000 individual signatures and the official support of 53 professional associations. Following is an excerpt from the petition

In light of the growing empirical evidence that neurobiology does not fully account for the emergence of mental distress, as well as new longitudinal studies revealing long-term hazards of standard neurobiological (psychotropic) treatment, we believe that these changes pose substantial risks to patients/clients, practitioners, and the mental health professions in general (Society for Humanistic Psychology, 2011).

Ironically, the National Association of Social Workers (NASW) was absent from the list of supporters (Carney, 2012; Francis, 2012). The NASW's official response indicates that the association was clearly aware of the open letter, but decided on a neutral approach NASW is monitoring the DSM-5 process and has not taken an official position regarding the concerns of the Humanistic Psychology Society (National Association of Social Workers, 2012).

How did this change toward psychobiology come about To answer this question, some history is in order. Some of us have been practicing long enough to remember the DSM-III (1980). That edition of the DSM was predicated on the belief that

[each mental disorder] would ultimately be validated by its separation from other disorders, common clinical course, genetic aggregation in families, and further differentiation by future laboratory tests--which would now include anatomical and functional imaging, molecular genetics, pathophysiological variations, and neuropsychological testing (Regier, Narrow, Kuhl, & Kupfer, 2009, p. 645).

Thus, the goal of the DSM-III was to initiate a scientific taxonomy that would be validated by current and future medical procedures. The primary goal of the new DSM-5 is not much different. The committee aimed to produce diagnostic criteria and disorder categories that keep pace with advances in neuroscience (Regier, Narrow, Kuhl, & Kupfer, 2011, p. 21). Clearly absent from this goal is any mention that mental illness is multiply determined or that psychosocial stress has any bearing on functioning. One glaring lack of improvement is that relational problems are still categorized as other conditions that may be a focus of clinical attention. Relegating distress related to parent-child conflict, child mal treatment, and domestic violence to the V-codes will maintain the non reimbursable status of services provided for these problems unless clinicians choose to pathologize one of the persons in the relationship (often the victim). Social workers will want to avoid stigmatizing the injured party in this way and focus on relational issues.

There are two positive features about the reorganization of the DSM-5. First, it is aligned with the Tenth Revision of the International Classification of Disorders (ICD-10), making it easier for clinicians treating immigrants to understand their preexisting conditions. Secondly, it moves adjustment disorders out of the V-codes to the new chapter on trauma and stress-related disorders so that services for transient problems (lasting less than six months) can be reimbursable.

The second major change in the DSM-5 is the addition of dimensional aspects to diagnostic categories. The dimensional approach is a response to the overly optimistic wish that every patient would fit neatly into a clear diagnostic category. (I often tell my students that you can make a round peg fit into a square hole, but you have to do violence to the peg.) In the DSM-III, this led to what Regier (2007) calls a Chinese-menu approach in which the presence of a disorder would be established on the basis of meeting a certain number of criteria (e.g., five out of eight) from a longer list of symptoms. The DSM-III also introduced a hierarchical system that precluded the diagnosis of a lower level disorder if the same client met the criteria for a higher level disorder. Thus, it viewed clients through a reductive lens to preclude the possibility of comorbid disorders. This problem was partly corrected in DSM-IIIR and DSM-IV, but each diagnosis was compartmentalized so that any patient was likely to be labeled with several distinct disorders.

Clinicians can now add dimensions or aspects to diagnoses such as attention deficit/hyperactivity disorder (ADHD), major depression, or schizophrenia. The dimensional approach in the DSM-5 is an attempt to avoid the reductionism of a single diagnosis for a complex problem, as well as to avoid the problems of multiple diagnoses. For example, the following dimensions may now be added to widely divergent diagnoses symptom severity, duration (acute or chronic), symptoms outside of the primary diagnosis (e.g., anxious distress, catatonia, or suicidality), changes in sleeping or eating habits, cognitive factors, substance use, psychosis, relationship history, and degree of insight. For social workers, the dimensional specifiers allow the addition of some color to the otherwise black and-white categories as well as an opportunity to identify client strengths.

The third major change in the DSM-5 is the elimination of the not otherwise specified (NOS) categories. This is accomplished in three ways. First, this reduction is accomplished by combining diagnoses. For example, the new autism spectrum disorder (ASD) now encompasses the previous DSM-IV autistic disorder (autism), Asperger's disorder, child hood disintegrative disorder, and pervasive developmental disorder not otherwise specified. Likewise, specific learning disorder combines the DSM-IV diagnoses of reading disorder, mathematics disorder, disorder of written expression, and learning disorder not otherwise specified. Sec ondly, this reduction is accomplished by creating new diagnoses. For example, the DSM-5 now includes hoarding disorder, excoriation (skin picking) disorder, disruptive mood dysregulation disorder, and disinhibited social engagement disorder. The increase in child-related disorders, however, has some professionals worried. The Society for Humanistic Psychology (2011) states that it is gravely concerned about the introduction of disorder categories that risk misuse in particularly vulnerable populations and explicitly mentions disruptive mood dysregulation disorder for children as a case in point. The final method for reducing NOS diagnoses is to replace them with two options other specified disorder and unspecified disorder. The first allows a practitioner to specify the reason that the criteria for a disorder are not met; the second allows a practitioner the option to forgo any specificity.

The fourth major change in the DSM-5 is the reduction of the bereavement exclusion. Although the DSM-5 explicitly rejects the idea that bereavement typically lasts only two months (as in the DSM-IV), it now allows the diagnosis of major depression after only two weeks. Addition ally, the DSM-5 sees bereavement as a severe psychosocial stressor that can precipitate a major depressive episode in a vulnerable individual. It also argues that bereavement-related major depression is most likely to occur in individuals with past personal and family histories of mood disorders. Finally, it argues that bereavement-related depression responds to the same psychosocial and medication treatments as depression. Social work professor Joanne Cacciatore (2012), who works with parents who have lost a child, disagrees, however, with the premise that bereavement does not need to be cured. (As part of full disclosure, I must admit that I am writing this a month after my father's death.) The loss of a child is certainly the most heart-wrenching pain any parent can imagine. What can any professional do to heal this hurt Many people simply cannot tolerate being present while another grieves--they want to say or do the right thing, and psychiatrists are no different. What is intolerable is turning normal sorrow into a psychiatric disorder (Horwitz & Wakefield, 2007). The medical establishment, however, views death as the enemy and pain as bad. Anyone who needs to embrace death as part of life must be viewed as sick or mentally ill. The real problem is society's dis-ease with death and pain, and this discomfort demands quick fixes in the form of medication, evidently a solution that psychiatry is only too happy to apply.

The fifth major change in the DSM-5 is to eliminate the DSM-IV chapter that included all diagnoses usually first made in infancy, childhood, or adolescence. All of these disorders have been redistributed into other clusters, reflective of a new lifespan approach to mental disorders. This reorganization not only makes the diagnoses for children and adolescents more difficult to locate, but it also subtly suggests that these disorders will continue into adulthood. Perhaps this is because two-thirds of children with a mental disorder do not get the help they need; the one third who do receive help get it through their local school, most likely from a school social worker (Raines, 2008). The assumption, however, that mental disorders are lifelong is a very pessimistic prognosis about the possibility for improvement.

Social workers are by far the largest constituency of mental health professionals, with over 100,000 potential users of the DSM-5 (Bureau of Labor Statistics, 2013; Manderscheid & Berry, 2006). By contrast there are only 33,000 psychiatrists. According to John Oldham (2011), president of the American Psychiatric Association (APA), however, of the 160 professionals who served on 13 different DSM-5 committees, there was only one social worker, but there were ninety-seven psychiatrists. This means that social work representation was 0.6 percent, whereas psychiatric representation was 60 percent! Yet Oldham makes the amazing claim that there was sufficient variety to achieve a diversity of opinion (p. 2). If the APA were organizing a multiracial gathering, we would call this tokenism. Clearly, social workers were marginalized and given minimal input into the final product.

What changes will affect school-age children the most Listed below are a number of major changes

a. For ADHD diagnoses, there have been five significant changes

1. The cross-situational requirement has been strengthened to several symptoms in each setting.

2. The onset criterion has been changed to several inattentive or hyperactive impulsive symptoms were present prior to age 12 [versus age 7].

3. Subtypes have been replaced with presentation specifiers.

4. The threshold of symptoms has been lowered from six to five for older adolescents.

5. A comorbid diagnosis with autism spectrum disorder is now allowed. Before diagnosing older children with ADHD, social workers should rule out other possible causes such as anxiety disorders, depressive disorders, stress disorders, or psychotic disorders.

In DSM-5, autism spectrum disorder combines the previously separate diagnoses mentioned above. Instead of three types of symptoms (social impairment, communication impairment, and repetitive/restricted behaviors), two domains are used social communication impairment and restricted interests/repetitive behaviors. Within the latter domain, a new symptom is included hyper- or hypo-reactivity to sensory input or unusual interests in sensory aspects of the environment (e.g., adverse reactions to specific textures). Given the distinct clinical presentations and treatment protocols of the previous diagnostic categories, this change has caused widespread concern by parent groups, such as AutismSpeaks.org.

b. Communication disorders now include language disorder (which combines expressive and mixed receptive-expressive language disorders), speech sound disorder (a new name for phonological disorder), and childhood onset fluency disorder (a new name for stuttering). Also, social (pragmatic) communication disorder (often found in Asperger's disorder) has been added.

c. Intellectual disability is now, according to a 2010 federal statute in the United States (Rosa's Law, 2010), the required term that replaces all references to mental retardation in federal law. Most importantly, the DSM-5 criteria move away from relying exclusively on IQ scores and toward using additional measures of adaptive functioning. The DSM-IV criteria required an IQ score of 70 as the cutoff for diagnosis. The new criteria only recommend IQ testing and the use of deficits in adaptive functioning as the primary means to determine if an individual has failed to meet standards for personal independence and social responsibility (Raines, 2009).

d. Motor disorders include developmental coordination disorder, stereotypic movement disorder, Tourette's disorder, persistent (chronic) motor or vocal tic disorder, provisional tic disorder, other specified tic disorder, and unspecified tic disorder.

e. Post-traumatic stress disorder (PTSD) diagnoses no longer require that the client must have direct experience with an unusually severe stressor. This was obviously meant to help those who experience secondary trauma as part of their jobs (e.g., child protective services workers), but it opens such a wide door that many people may be overdiagnosed with PTSD. Thus, social workers would be wise to remember that flashbacks are only a symptom that may be ascribed to multiple syndromes including bipolar disorder, psychotic disorder, substance abuse, or traumatic brain injury.

f. Reactive attachment disorder in the DSM-IV had two subtypes emotionally with drawn inhibited and indiscriminately social disinhibited. In DSM-5, these subtypes are now distinct disorders reactive attachment disorder and disinhibited social engagement disorder. Reactive attachment disorder more closely resembles internalizing disorders; it is essentially equivalent to a lack of or incompletely formed attachments to caregiving adults.

g. Separation anxiety disorder is now classified as an anxiety disorder. The wording of the criteria has been modified to represent the expression of separation anxiety symptoms in adulthood. The diagnostic criteria no longer specify that age at onset must be less than eighteen years.

h. Selective mutism is now classified as an anxiety disorder, given that a large majority of children with selective mutism are anxious.

School social workers in some states are required to use the DSM sys tem to diagnose children. For example, the Illinois standards state that [the competent school social worker] makes accurate mental health diagnoses based on the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (1994), published by the American Psychiatric Association, 1400 K St., N.W., Washington DC 20005; no later amendments to or editions of these standards are incorporated by this Section (Illinois State Board of Education, 2002, p. 341).

What can social workers do about the new changes There are at least three options. The first and easiest option will be to follow the NASW and acquiesce to the new status quo by adopting the new manual by October 1, 2014, when many of the insurance companies will move to the new system (Coleman, 2013). A second option is to revolt against the psychiatric hegemony. This is the approach recommended by Allen Francis, former chair of the DSM-IV task force. He writes, DSM-5 has changed the landscape by being so closed in its process, flawed in its execution, unrealistically ambitious in its hopes, and dangerous in its product that many mental health professionals may choose not to use it (Francis, 2013). In conclusion, he recommends, don't buy DSM 5, don't use it, don't teach it. Jack Carney (2012) concurs
   [Social workers'] acquiescence to the DSM5 as currently composed
   signifies for me an abandonment of core principles--service to
   others; pursuit of social justice; respect for the worth of the
   persons being served; the importance of human relationships; and
   the salience of integrity and competence in social work practice.


A third, more nuanced approach is to use the DSM-5 critically. Reject its simplistic biomedical explanations for behavior, beware of its lowered thresholds for certain disorders, accept its changes only when they are supported by solid empirical evidence, cautiously use the new diagnostic codes when they benefit the clients you serve, and advocate for true representation and needed changes in the next iteration of the DSM. Finally, if you do decide to buy it, get the $69 pocket desk reference (ISBN 978-0-89042-556-5) or the mobile app, not the $199 full-size version.

References

American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC American Psychiatric Association

Bureau of Labor Statistics, U.S. Department of Labor (2013). Occupational employment and wages, May 2012. 21-1023 Mental Health and Substance Abuse Social Workers. Retrieved July 4, 2013, from http://www.bls.gov/oes/current/oes211023.htm

Cacciatore, J. (2012, March 1). DSM5 and ethical relativism [web log post]. Retrieved May 23, 2013, from http://drjoanne.blogspot .com/2012/03relativity-applies-to-physics-not.html

Carney, J. (2012, March 27). 1984 & DSM-5, revisited Where are the social workers [Web log post] Retrieved June 14, 2013, from http://www.madinamerica.com/2012/03/1984-dsm5 revisited-where-are-the-social-workers

Coleman, M. (2013, May 10). DSM-5 is coming. Practice Alert. Retrieved May 19, 2013, from http://www.socialworkers.org/practice/ clinical/2013/05/1013.asp

Corcoran, J., & Walsh, J. (2010). Social work and the DSM Person-in environment vs. the medical model. In Clinical assessment and diagnosis in social work practice (2nd ed., pp. 11-33). New York, NY Oxford University Press.

Francis, A. (2012, April 2012). Why social workers should oppose the DSM-5. Psychology Today. Retrieved May 19, 2013, from http://www.psychologytoday.com/blog/dsm5-in-distress/ 201204/why-social-workers-should-oppose-dsm-5

Francis, A. (2013, June 7). Should social workers use DSM-5 Retrieved June 14, 2013, from http://www.socialworkhelper.com/2013/ 06/07/should-social-workers-use-dsm-5

Horwitz, A. V, & Wakefield, J. (2007). The loss of sadness How psychiatry transformed normal sorrow into depressive disorder. New York, NY Oxford University Press.

Illinois State Board of Education (2002). Standards for the school social worker. Springfield, IL Author.

Manderscheid, R. W., & Berry, J. T. (Eds.). (2006). Mental health, United States, 2004. Rockville, MD U.S. Department of Health and Human Services. Retrieved from http://store.samhsa.govshin/ content//SMA06-4195SMA06-4195.pdf

National Association of Social Workers (2012, January 20). DSM-5 sign-on letter. Retrieved May 19, 2013, from http://www.social workers.org/practice/clinical/2012/01/2012.asp

Oldham, J. (2011, November 21). Letter to Don W. Locke, Ed.D., president of the American Counseling Association. Retrieved July 4, 2013, from http://www.dsm5.org/DocumentsDOC001.pdf

Raines, J. C. (2008). Evidence-based practice in school mental health A primer for school social workers, psychologists, and counselors. New York Oxford University Press.

Raines, J. C. (2009). The screening and assessment of adaptive behavior. In C. R. Massat, R. Constable, S. McDonald, & J. P. Flynn (Eds.), School social work Practice, policy and research (7th ed., pp. 431-451). Chicago, IL Lyceum Books.

Regier, D. A. (2007). Dimensional approaches to psychiatric classification Refining the research agenda for DSM-V An introduction. International Journal of Methods in Psychiatric Research, 16(Suppl. 1), S1-S5.

Regier, D. A., Narrow, W. E., Kuhl, E. A., & Kupfer, D. J. (2009). The conceptual development of DSM-V. American Journal of Psychiatry, 166(6), 645-650.

Regier, D. A., Narrow, W. E., Kuhl, E. A., & Kupfer, D. J. (2011). The conceptual evolution of DSM-5. Arlington, VA American Psychiatric Publishing.

Rosa's Law. (2010). Pub. L. No. 111-256, 124 Stat. 2643. Society for Humanistic Psychology, Division 32 of the American Psychological Association (2011, October 22). Open letter to the DSM-5. Retrieved May 19, 2013, from http://www .ipetitions.competitiondsm5

James C. Raines, PhD, LCSW, is department chair, Health, Human Services & Public Policy, California State University, Monterey Bay.
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Author:Raines, James C.
Publication:School Social Work Journal
Article Type:Essay
Geographic Code:1USA
Date:Jun 1, 2014
Words:3276
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