830 of 911 people found the following review helpful
on June 14, 2013
There are a few minor and almost no major changes in DSM-5 that the patients and professional need to be aware of.
1. The most remarkable structural change of the Fifth Edition is getting rid of 5-axial system. Good riddance!
The old classification grouped diagnoses down into independent dimensions called axes:
Axis I: all diagnoses except mental retardation and personality disorder
Axis II: personality disorders and mental retardation
Axis III: acute medical conditions
Axis IV: psychosocial and environmental factors making things worse
Axis V: Global Assessment of Functioning (GAF), or a number between 0 and 100 that reflects patients' well-being.
The new classification combines the axes together and let them rate the disorders by severity. In addition the NOS (not otherwise specified) label is changed to NED (not elsewhere defined).
2. The diagnosis Mental Retardation is changed to intellectual disability (intellectual developmental disorder)
3. Autism Spectrum Disorder is the new name and a single category for autistic disorder, Asperger disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (PDD-NOS). Probably a bad idea, in my opinion, as the same diagnosis will be given to a child with mild social deficit and severely autistic, nonverbal, and not functional one. In addition, it would be impossible to find out that there might be more than one disorder in this group, as all of them will carry the same name.
4. Binge Eating Disorder is a newcomer to the group - anorexia nervosa, bulimia nervosa, and eating disorder NOS - three different conditions which ended up in the Eating Disorders group only because they have something to do with food. There does not seems to be a good reason to add another one.
5. Disruptive Mood Dysregulation Disorder (DMDD) is a new category and infact a welcome addition. Moodiness, anger, and emotional outbursts in children have been subject of diagnostic controversy for the last two decades. Unfortunately, the issue was hijacked by some unscrupulous members in academia in tandem with a couple of profit seeking pharmaceutical companies. Previous decade saw forty fold increase in diagnosis of pediatric bipolar disorders. While some children develop bipolar illness as they grow up, overwhelming majority do not. In children, common reason for "manic behavior" is immaturity of the brain, partly responsible for control of emotions (Executive Function Network located mostly, but not exclusively, in pre-frontal area of the brain), while emotions themselves are mild or moderate. By analogy, a car collision might be explained either by revved up engine or failed breaks, but rarely by two failures at a time. Children's "breaks" are commonly weak, while extremes of emotions (frequently diagnosed in adults as Intermittent Explosive Disorder or Mania) are relatively rare. DMDD brings "sanity" into the insane world of pediatric bipolar disorders and redirects our focus on weak inhibition vs. excessive "excitation".
6. New to the DSM-5 is bringing together obsessive-compulsive and other disorders previously found under category of Impulse Control Disorder (OCD, Body Dysmorphic Disorder, trichotillomania - hair pulling, Intermittent Explosive disorder, etc.) into a broader class of disorders. Two new conditions which also include adding excoriation (skin-picking) and hoarding disorder to the group. In my opinion, that was a premature move. Compulsion (an irresistible urge to behave in a certain way) and impulsiveness (acting suddenly on impulse without reflection) are not the same: one can have, the other, both, or neither one. Lumping these distinctly different disorders into one category is premature and unfounded.
7. In personality Disorders category, all 10 original (DSM-IV) disorders remained, but the axes boundaries separating them from other psychiatric disorders were removed. Sharp division between personality disorders has always been seen as artificial, nevertheless, the committee, after long deliberation, left them intact. To my regret, Depressive Personality Disorder (DPD), so common in clinical practice was not resurrected. Originally included in DSM II, DPD was never recognized as a distinct entity in subsequent editions, and only showed up in the Appendix B of DSM-IV TR for consideration for later studies.
8. The new umbrella category, or chapter, in DSM-5 is titled Trauma- and Stressor-Related Disorders and includes posttraumatic stress disorder (PTSD) and a new diagnostic sub-type for pre-school children. The significance and reliability of the new subtype will take time to validate.
9. The new specifier "with mixed features" can be used now with bipolar disorders and Major Depressive disorder (MDD). Mood is divided into predominant (depression, mania, or hypomania) and secondary (subclinical). This development, in my view, will broaden the application of mood disorder diagnosis and will allow flexibility in description of nuances of mood fluctuation. Bereavement exclusion, reserved for depressive symptoms lasting less than 2 months after a loss, has been removed from MDD criteria in DSM-5. Although depression is almost universal and predictable reaction to death of a loved one, it is virtually impossible to separate it from a any other stress induced depressive episode.
10. Substance abuse and substance dependency, separate criteria in the previous edition, were combined in to substance use in DSM-5, each substance use divided into mild, moderate, and severe subtypes.
11. To avoid stigmatizing patients with dementia, DSM-5 introduced neurocognitive disorders in its place. The new edition distinguishes different types of these disorders: Alzheimer disease, Lewy body disease, Parkinson disease, HIV infection, and vascular disease. The disorders are divided into mild and major degree of impairment. I believe it is a move in the right direction. As the population ages, we need better understanding of various types of amnesia, cognitive decline and neuronal degeneration. Studying these diseases will allow better understanding and, prediction of natural course, prevention and treatment.
12. DSM manual, probably in reverence to the psychoanalytical past, always paid excessive attention to sexual perversions, disproportionate to their prevalence and impact. In this edition, while keeping criteria unchanged, the committee advised to discriminate between paraphilic behavior and paraphilic diseases.
13. During the DSM -5 writing other disorders were considered. Among them were Relational disorder, Developmental Trauma Disorder, Parental Alienation Syndrome, Internet Addiction Disorder, Male-to-Eunuch Gender Identity Disorder, Disorders of Extreme Stress, Not Otherwise Specified, etc. Thankfully, they didn't make it.
DSM, despite its new Arabic vs. Roman numeral - 5, is still the same hodge-podge of random symptoms, syndromes, and their clusters with various labels, grouped not by their intrinsic similarities but superficial likeness, e.g. having to do with eating, eliminating, having childhood onset, related to sex, happening soon after "an event", etc. Until the committee and the APA recognize fundamental weakness and confusion of their approach to classification, professionals and patients alike will keep using the document, as Allen Frances, M.D (the chair of the DSM-IV edition) put it, "cautiously, if at all."
In conclusion, I would like share a classification from "certain Chinese Encyclopedia" from Jorge Luis Borges `s The Celestial Emporium of Benevolent Knowledge which, in my opinion, accurately reflects the DSM committee's attempt to organize psychiatric disorders:
"The animals are divided into: those that belong to the Emperor, embalmed, those that trained, suckling pigs, mermaids, fabulous, stray dogs, those that are included in the present classification, those that tremble as if they were mad, innumerable ones, those drawn with a very fine camel hair brush, et cetera, those that have just broken a pitcher, those that from a long way off look like flies."
591 of 684 people found the following review helpful
Ok, I have taken some time to actually read through DSM 5. While DSM has often been scrutinized--both for what it includes, as well as what it doesn't--the back-lash against the newest edition has been particularly pronounced these past few months. Part of this stems from the micro-analysis that happens with many things in our modern world, though we have to admit that ego, resentment, and a misunderstanding of the process also plays a part. In addition, historical debate over DSM typically took place in-house; that is, by clinicians. With DSM 5, this has broadened to people who have little- to no understanding of the diagnostic process, its purpose, and its strengths/limitations. Thus, there has been a lot of negative press about DSM 5 in Huffington Post, NY Times, and other sources, often by people with practically no understanding of mental health.
Why 5 stars, you might ask? Because my review is based on DSM 5 as a book, not anything else having to do with DSM as a concept or tool. This particular edition 'reads' well, in that the text and lay-out is clear. In contrast to previous editions, the reader will be given more orientation to the book and how to use it. The diagnostic criteria is familiar and through the Table of Contents, Index, and quick-view pages, it is easy to find the diagnosis or category you're looking for. Yes, it's bulky and expensive, but you should have the large edition in your library for now; later, when you're more familiar with the changes, you can buy the quick-reference guide.
As a child psychologist who conducts psychological and neuropsychological evaluations--for social service agencies, schools, the courts, and for families--DSM plays a prominent role in my work. In addition, I have taught a course on DSM to masters-level graduate students for the past 10 years. In my role as a psychologist, I have witnessed first-hand how a DSM diagnosis is formulated, applied, and interpreted. I have also seen the benefits and limitations of assigning a DSM diagnosis to a client. In the end, however, most people are less concerned about the diagnosis, per se, and more about how to facilitate services, treatment or quality of life/education for the individual to whom it is assigned. This will still be the case now that DSM 5 is published.
Through the years, DSM has attempted to reflect our understanding of mental health symptomatology and how it impacts people across the lifespan. This continues to be the case with DSM 5, though admittedly, mental health is a `young' science, and there is much about the human condition we don't fully understand (neither DSM nor any other classification system can help us account for the Sandy Hook shootings; the Cleveland kidnapping case; the Boston bombing; or many other actions our fellow human beings engage in).
With DSM 5, there are some noteworthy modifications to how we code a mental health diagnosis. Thus, users will need to read the introductory chapter in order to make sure their work reflects these changes. In contrast to what has been hyped in the popular media, DSM 5 does not pathologize grief or childhood tantrums. It doesn't randomly lower thresholds, to make it such that more people will now be diagnosed with ADHD, depression, or Bipolar Disorder. And it doesn't eliminate most of the diagnoses that were previously applicable. Rather, DSM 5 reframes some criteria, clarifies various symptom presentations, and tries to shape our perspective on clinical diagnosis. In particular, DSM 5--in contrast to earlier editions--helps to reinforce that we should view most diagnoses from a lifespan perspective, while staying mindful of the fact that its presentation can vary in severity or magnitude. As with previous editions, DSM 5 provides a classification of mental health disorders, but it doesn't make inference about how these should be treated.
In my opinion, DSM is simply one tool we as clinicians use to formulate an understanding of what is happening with a client at any given time. It also serves to provide us with a `common' language, since a diagnosis will be assigned to most of the clients with whom we work. Much of this language, as used in DSM 5, will be familiar, and those of you who have used DSM thus far won't find that the content has changed that much. When you skim the Table of Contents, for example, you won't see a lot of new diagnoses, but you will see a re-working of where some of them are placed (PTSD and OCD, for example, are no longer in the Anxiety Disorders classification).
In particular, I like the expansion we see portrayed in DSM 5 of neurodevelopmental disorders; better clarification for avoiding a mis-diagnosis of Bipolar Disorder with children; the placement of Autism on a spectrum; and distinctions of how PTSD manifests in young children versus adults. What we've previously known as Reactive Attachment Disorder is now split into two separate classifications (to reflect discriminate and indiscriminate manifestations, accordingly). DSM 5 no longer has the classification, `Disorders First Evidenced in Infancy and Early Childhood.' Instead, the classifications are supposedly arranged by manner in which they appear in the lifespan. This rationale doesn't really fit, however, as many of the kids I see in my practice have substance use and/or neurocognitive disorders, which--using this rationale--the authors put later on in the book.
Overall, DSM 5 reflects the evolution we are all involved in, as we try to understand and account for the mental health symptoms
which impact large numbers of the population. People are much more complex than the diagnoses we assign to them, but DSM at least provides us with a place to start. What happens after that depends upon the skill of the clinician; ultimately, isn't that what most of our clients are concerned with?
211 of 248 people found the following review helpful
on May 30, 2013
Nearly all of the media criticisms of DSM-5 are fairly wide off the mark. The main critique is that psychiatry is trying to pathologize increasing amounts of normal human behavior with the DSM-5. The new diagnoses in DSM-5 are modest, evidence-based, and are ways of better describing the types of problems that people come into psychiatrists' and psychologists' offices asking for help with.
For example, the diagnosis of Body Dysmorphic Disorder makes a distinction from "dysmorphic concern" (which is largely normative) and requires that the preoccupation interferes with social or occupational functioning, or causes clinically significant distress. That means: it is already a problem for the person, whether or not anyone makes it a diagnosis.
The main problem with the manual is actually that the changes were not bold enough, not forward thinking enough, and have resulted in very few improvements considering the huge amount of effort put into the enterprise.
There was a goal to improve certain diagnoses, and address problems such as the rampant overuse of bipolar diagnosis in youth. Certain problems are significant in the execution of the goal. First, the diagnosis of Disruptive Mood Dysregulation Disorder is actually very narrow, and contains to specifiers that make it not apply to many of the kids that have been incorrectly diagnosed "bipolar". It requires irritable or angry mood most of the day, nearly every day. Many of the kids, if not most, that are engaging in rages actually have a mood that is fine whenever you are giving them whatever they want, or things are going their way. The disturbance has to be in 2 settings, and sometimes kids are able to suppress rages outside the home. The disturbance must also be enduring for 3 months. So, what do you diagnose if they are the narrow criteria aren't met? Mood Disorder NOS is no longer available, so then do you do depression NOS? That hardly seems descriptive to what is occurring. Intermittent explosive disorder accurately describes the raging of these youth, but misses the mood reactivity that we commonly see, and the text asserts that IED (those are initials that should have been terrible/stigmatizing enough to cause a name change) is rare in youth. Data? The diagnosis of DMDD also moves in the opposite direction of the rest of the DSM, which is allowing coding of ADHD in Autism, etc., and not shooting for complete syndromes, but more "modules" of behavioral problems that can be put together to describe a person. For DMDD, ODD and Conduct Disorder are not allowed-- which leads me to the conclusion that what we see in the DMDD diagnosis is the result of an inter-committee turf war. The DMDD decision, and placing it within depressive disorders and suppressing clinically meaningful comorbidities of ODD and CD, suggests that the child mood people have a lot of sway in the APA. This disorder of mood regulation does have real relationships to depression, but it also is not dominated by the typical depressed mood, and is not episodic and tempermental. The construct of Severe Mood Dysregulation seems to be a lot more serviceable, and the rationale for preferring DMDD is not convincing. The Deficient Emotional Self-Regulation concept, that came-out of the Achenbach (I believe) also may be a better foundation. The syndrome does have validity, but it is not encompassing of all (or in narrow definition, most) of the kids with rages and mood reactivity/dysphoria. And... there is not a category like Mood NOS to capture them.
Other problems with the DSM are indicative of some of the compromises it was trying to achieve, such as integration with ICD-10/11. For opioid withdrawal, it says that the disorder cannot be coded with a mildopioid use disorder, "refelcting the _fact_ that opioid withdrawal can occur only in teh presence of a moderate or severe opioid use disorder". This demonstrably false statement (opioid withdrawal can take place in pain patients that _don't even have a disorder) might have escaped my attention if it didn't say the word "fact". How this got past such a large committee reviewing for so many years is beyond me (the severity of the disorder is not based on the pharmacologic definition, but on the behavioral one) and it shows the committee may have been over-eager to pursue ICD-10 synthesis-- when they should have just focused on the already very difficult job of classifying reality. Cannabis-induced anxiety disorder is not allowed with onset during withdrawal, despite numerous case reports and data from the data on cannabis withdrawal. Although, cannabis-induced sleep disorders was appropriately added.
Of course, much of the criticism has been placed on using the "judgmental" term addiction-- but the word addiction is not going to disappear for treatment centers because some people might get their feelings hurt-- and recovering from addiction requires facing-down some uncomfortable concepts.
I think that the current substance use disorder classifications also miss a very important group-- that is adolescents who are using at _considerable_ risks to themselves, but may not be on an addiction continuum. The significant risks involve OD, DUI, and being victim of sexual assault-- and high-risk adolescent users may not be making significant progress on the addiction continuum, but might kill themselves before they ever get there. This is what they were going for with the Abuse/Dependence distinction, but it was found that most people progressed through all of the symptoms of both disorders on one dimensional line-- but high-risk use in adolescence may be a different class. This group may still have some concerning addiction pathology, but it is the amplification of adolescent risk-taking that is most concerning. The lumping of NMDA antagonists with other hallucinogens does not make a lot of sense, due to the mechanism of action being different, and calling verything phencyclidine without mentioning ketamine or dextromethorphan may confuse some. A better job was done separating nitrous from volatile hydrocarbon "inhalants". The manual was so slow in development, that there is no mention of synthetic cannabinoids. Finally, the use of "mild" as a descriptor of Substance Use Disorder pathology is not a wise choice in words for a disease that features rationalization and lack of insight as part of its phenomonology.
Binge-eating disorder was also criticized, but if we are talking about 3000 calorie-binges once a week with a sense of lack of control, eating rapidly, alone, until uncomfortable, and when not hungry really seems like a problem to me. Criticism is sure to come that more people will be seen as having a psychiatric diagnosis because of this, but we are a culture whose availability of food and other changes may be leading to more people with disordered behavior. So, an increase in prevalence doesn't increase a power-grab by psychiatry, just as the rise in obesity doesn't mean that the rest of medicine is inappropriately expanding its range-- the problem is just increasing.
The merger of Asperger's and Autism into Autism Spectrum really does go against some of the utility of having a diagnostic manual, in the first place. Studies have found the two to not be genetically distinguishable (most of the time), but that doesn't mean there is no distinction, because the data could just be noisy. The DSM committee admitted there were significant differences, but said these were mainly accounted for differences in IQ scores and subscores. Okay, that shows there is a difference-- so why lump them together? Possibly the answer is politics, and the pragmatics of getting FDA drug approval-- if you can lump the Aspergers and Autistic kids together in one group, then an FDA indication has broader reach. The politics comes-in with parents complaining their Aspeger kids have been denied services provided to autistic individuals, but that is probably did not sway the committee. One sad answer may be that they followed flawed data over the cliff of clinical significance. The distinction works for clinicians and parents-- and there are different treatments for Asperger's and even high-functioning autistic kids.
The lack of a go-live on the bold classification of personality disorders is sad-- but was probably necessary due to the manual's biggest short-coming: the lack of progress in dimensional/biologically-based/empirical classification of the other Axis I disorders. This is what the NIMH director was complaining about. The idea that we should junk DSM in favor of Research Domain Criteria is almost as laughable for research as it is for clinical science, but I understand the impulse- as remarkably little has been done, despite the explosion of knowledge in neuroscience. Efforts were made to make the diagnoses more biological, and the ADHD work-group initially was looking at incorporating brain-imaging into the diagnosis of ADHD, but found they just could not make it work. The same problem will probably befall the Research Domain Criteria, as we may have difficulty finding all the endophenotypes that make-up the clinical reality of a disorder. Researchers frustration may not be due to DSM, but are probably due to the reality of psychiatric illnesses-- the complexity of the brain means that these are subtle disorders, affected by differential expressions and interactions between multiple genes, all of small effect-- leading to an large number of underlying conditions that do seem to lead to some final common pathways.
The overuse of medications may be due to the fact that we do not have enough diagnoses in the manual, rather than too many. When you think everything is a nail, you are likely to use a lot of the hammer. The medication overuse is most likely related to the other problem of psychiatry-- the lack of evidence-based therapy-based interactions that are rewarded by government and insurers.
The best thing about DSM-5 is that the use of Arabic numerals allows the easier modification of criteria-- that means many of the problems may be corrected in DSM 5.1. And, possibly the monumental size of this task lead to a compressed period of evaluation and synthesis of data-- and the future evolution of the manual will need to take place continuously, one module at a time, so there is continuous forward progress. This will keep psychiatry from getting 20 years out-of-date with its diagnostic systems, and allow the DSM to more strongly guide clinical care.
34 of 37 people found the following review helpful
on February 25, 2014
I ordered this book, and the book I received had about 40 pages that were upside down. This was disappointing. I would not recommend.
Here is a picture of the book I received: [...]
42 of 48 people found the following review helpful
on July 30, 2013
I don't get the hate for this book. There are a lot of personal issues being taken out on a technical manual. I disagree with some things, sure. There are some parts that are a result of public pressure and campaigning. The world of Mental Health is not black and white, but no medical discipline is, in fact no science is clear only shades of gray. Yes, it is a science, a behavioral science. There is no blood test for Autism, ADHD, or Depression. You identify disorders through symptoms. To make relevant psychological diagnosis, to research and study current diagnosis in the academic setting, and to communicate with your peers, you'll need this book. To hate this book would be like a carpenter hating the necessity of hammers and nails. It's simply illogical.
Get the hardback, My previous one lasted for 15 years of heavy use. From experience, the paperback will fall apart. Yes, I look forward to a kindle version but I always go back to the hard copy.
17 of 18 people found the following review helpful
on April 16, 2014
The book was missing essential pages and had duplicate pages. They changed book companies at the last minute from the original book company I order with. The entire process has been frustrating . And because I needed the book and couldn't send it back the only gave me half of a refund. This company sucks and it's sad that amazon allows them to operate through their website
17 of 19 people found the following review helpful
on August 2, 2013
As one reviewer said, in a way it doesn't matter whether you like DSM-V, since it will probably become the standard for psychiatric diagnosis in the US therefore, if you are a practitioner making diagnoses or a consumer seeking to understand them, then understanding DSM-V will be a necessity.
Some things not to like: it seems APA kept changing the manual (including in major ways) right up until its release. I'm afraid it represents an unprecedented amount of controversy and indecision within the major psychiatric organization itself, as to whether the changes were helpful or not. For example, there was consideration of dropping 4 out of 10 "personality disorders" but in the end they were all retained. There was serious thought to replacing the categorical diagnosis of a personality disorder (because of the amount of overlap between some of them) with several dimensional axes of personality traits, to more accurately reflect diversity of personality, but in the end this was relegated to a section for further study (personally, I'm glad about that)
For some trenchant criticisms of the DSM-V process you might search for articles by Allen Frances MD, former chairperson of the DSM-IV task group. He felt the process was too secretive, that it had the potential of further "medicalizing" essentially normal behavior, and that it really got ahead of the advances in scientific understanding. Some have criticized APA for releasing an updated diagnostic manual simply as a way to generate revenue (the process does generate a lot) or at least to recoup the millions of dollars already spent on a new diagnostic manual, even if it wasn't a significant enough advance over the prior version.
Good things about DSM-V: most clinicians applauded doing away with the 5-Axis system as being too cumbersome and arbitrary in practice. In my own opinion, adding a physical diagnosis was a good idea mainly if it was felt to have a major contribution (in one way or another) to the psychiatric condition. The Axis V (global assessment of function) was often felt to be a poorly-defined mix of quite different types of dysfunction which tended to make it arbitrary, and some clinicians simply "gamed" the ratings, either to justify admission, discharge, or insurance benefits. I guess I am glad about doing away with the distinction between Axis I and Axis II for at least 3 reasons: 1. Some Axis II were likely milder forms of Axis I disorders. 2. Axis II was often felt to be pejorative (even within the mental health community) and 3. Some patients with Axis II disorders really were more impaired than some patients with Axis I disorders.
Many insurers and providers tended (somewhat arbitrarily) to agree to treat Axis I disorders (or most Axis I) but not Axis II. Now that they are combined, agencies will need to look more carefully at degree of impairment and the degree of treatability, rather than on what "Axis" a disorder lies.
There was also an effort to put out DSM-V to better coordinate with the next International Classification of Diseases (how successful that was, I can't say just yet but it was a decent goal)
I am not a "conspiracy theorist" that the diagnostic manual for mental disorders is merely a "stalking horse" for Big Pharma and a way for them to push more drugs (although I cannot argue that way before DSM-V, many Americans have been way over-medicated, both with psychiatric and with other medications). Nor do I accept that the DSM defines (not typically, anyhow) variants of "normal" behavior as pathology. There are certain substantial controversies in psychiatry (such as the growing "incidence" of autism and of ADHD) some of which DSM-V attempts to address, although the success will not be clear until it has been used for awhile (or until its first text revision!!!)
In summary there are some changes in DSM-V I very much support, others which I do not, and others about which I haven't yet formulated an opinion. Nevertheless it will be an important text for anyone working in the field of mental health. Please read my review along with some of the "most popular" reviews as it is somewhat supplementary.
Speaking of which I can't resist a comment about one popular review: the section clumping together OCD and several other disorders does not merely conjoin "compulsive and impulsive" disorders. The most bizarre change there was the inclusion of "Body Dysmorphic Disorder" which in itself is neither a compulsion nor an impulsive disorder, but a major disorder in self-perception...
Lastly for those who bemoan lack of a better scientific foundation for psychiatry: through no fault of our own we are somewhat like medical doctors of 100 years or so ago who used to diagnose "rusty sputum pneumonia", "green sputum pneumonia", "dry pneumonia" and the like. That is, we simply don't yet understand enough about the brain and its disorders to have a better understanding of the basic pathophysiology. For one, the brain is vastly more complex than any other organ. Secondly, it is easy to do a skin biopsy or even a lung or liver biopsy, but most patients do not want to sign up for a brain biopsy (nor would it be as useful anyhow...) The brain is simply way more complex and can develop problems in quite a few different, not always well-understood ways.
14 of 15 people found the following review helpful
on December 10, 2013
I ordered 22 of these for our agency.. There are missing codes and information.. that does not appear until the second printing which occurred in June.. I am extremely displeased with the publication.
15 of 17 people found the following review helpful
on November 11, 2013
If you had to pick out the most serious issues with not just the DSM-IV, but the entire DSM in all of its editions, what do you think the most important parts to address were?
I don't know what you think, but I'm of the school of thought that says the categorical system for illnesses, which has *never* been a useful diagnostic guide due to the astounding frequency of overlapping of symptoms, has been almost completely useless as any sort of diagnostic tool, or, most importantly, a way to assist treatment.
That's where the DSM has proven itself to totally fall apart the most. There are lots of other issues worth noting, sure. Clinicians are still very arbitrary in their definitions of what constitutes a "symptom" (in no small part due to the astonishing amount of pressure on doctors due to insurance entities and HMOs that virtually *require* a diagnosis in one single session of first meeting the patient), and the more keen of the field, very notably the renowned child psychiatrist Dr. Jefferson Prince, often choose to totally ignore diagnosis in favor of the patient's symptomology.
The DSM's major failing is its categorical structure, which, in itself, has absolutely nothing to do with treating mental illness. It can't even accurately be used as a diagnostic tool. In fact, it's shown itself to be potentially dangerous, as patients and their loved ones are often desperate for an explanation for the person in question's behavior.
But that's just not feasible in the completely impractical approach the DSM has continued to push repeatedly in every edition. It's obviously natural for people to want a specific name for an illness, something with which they can directly identify and personally research, to put in perspective the patient's major issues.
Except it doesn't work like that. With the unbelievable amount of room for interpretation, combined with "practical" diagnoses (e.g., diagnosing one illness instead of another due to stigma and complication associated with a particular one), diagnoses as a whole are almost totally useless in treatment. The most proficient doctors care for *symptoms*, NOT disorders. This is where the idea of categorical diagnoses that have a multitude of necessary symptoms for a diagnosis clash with a practical treatment plan. Diagnoses, by themselves, are in no way a guide to treatment. With the absurd amount of co-morbid conditions often associated with almost any disorder, along with the ever-complicating similarity between disorders, the entire point of the DSM becomes moot.
Nowhere is this more obvious than in the nature of "X number of symptoms, listed below, qualify for a diagnosis." In practice, this type of categorization is utterly pointless, as the vast majority of patients suffer from a multitude of psychological symptoms, and if taken as a whole, virtually never point to one, single disease.
In practice with clinicians, this becomes a total diagnostic nightmare in which absolutely no one can agree. I have witnessed an astonishing number of clinicians who clearly tend to interpret symptoms differently than another with a second opinion. The gap between interpretations is so absurd, this typically is nothing more than a roulette of clinicians to decide on a treatment plan. All too often, treatment for one disease turns out to be either worthless or, at the worst, destructive to someone who simply had different issues than the ones immediately presented. Someone being treated for depression, for instance, might have something entirely more the trouble, even if it isn't a reactive illness.
In reality, the DSM takes a backseat to the problematic overlapping symptomology of its categorical method and near-universal co-morbidity that those in need of treatment for mental illness offers no guide whatsoever. I believe it should be taken as a given by now that the extremely flawed nature of the categorically-based method of the DSM and its diagnoses is in a major scientific crisis. Because symptoms tend to lean toward a dimensional approach, and treatment is often based in those dimensions of symptoms and their respective severities, the categorical method of placing a patient in "this, that, or probably both" diagnosis is totally worthless to practice.
I'd like to close this rant on the failure of the DSM-5 to make a real difference with an actual discussion that happened within the APA. When a presenter was asked about the usefulness of having schizoaffective disorder as its own unique diagnosis, the presenter wryly responded with, "While there is little evidence that schizoaffective disorder as its own entity provides little, if any, useful distinction between treatment plans, I believe it is absolutely critical to clinical practice." The audience laughed, as this shows that even the APA realizes how utterly banal the DSM really is for information, but it does have some implicit perks for clinical practice as merely a tool to placate those who can benefit from its methods at all.
96 of 124 people found the following review helpful
on June 7, 2013
For a book that was two decades in the making, the presence of so many coding errors in the first printing is simply unacceptable. If you own the first printing see: http://www.dsm5.org/Documents/IMPORTANT%20CODING%20CORRECTIONS%20FOR%20DSM-5%206-5-13rev.pdf for the corrections you absolutely must make. Seriously, make those changes right now if you own this book. You cannot afford not to - fellow clinicians, insurance companies, auditors, even hapless bystanders will send all sorts of hate your way if you use the wrong code.
The debate over diagnostic changes has been hashed over enough so I won't bore you with my own soapbox speech on whether or not a particular diagnosis should have been altered or changes. Of course it is criminal that this version of the DSM has ignored completely the devastating effects of cheese addiction and related illnesses, but I'm pretty sure you know that already.
The opportunity to contribute $160 to the American Psychiatric Association and their quest for world domination was not overlooked, however I believe I deserved a free copy. I feel it obvious that myself and my genetic lineage were surely the inspiration for this book from the get-go, it is rather disappointing that there was no mention, not even a thank you, for our efforts. A simple picture on the back cover with dedication was all I would have asked for.
As for the positives: the purple cover is rather pretty, and the hardcover version with gold lettering is well worth the extra money. Especially since this is a book you will have on your desk with loathing for the next two decades.