DSM-IV

“DSM-IV is a classification of mental disorders that was developed for use in clinical, educational, and research settings.” What the DSM attempts to do is have specific criteria for specific disorders, but at the same time, not have the manual be used in a “cookbook” fashion. Meaning that the specific diagnostic criteria in the DSM are meant to serve as guidelines concurrently with clinical judgment. As we all know, each disorder included in the DSM has a set of diagnostic criteria that signify what symptoms must be present in order to meet the criteria for a diagnosis. Conversely, there are some disorders where there are symptoms that must not be present in order for an individual to be eligible for the diagnosis. A strong point of this particular set-up of the DSM manual makes finding the disorder and its diagnostic criteria easier because of its conciseness. The use of the DSM diagnostic criteria to diagnose has been shown to increase diagnostic reliability.

As noted above, the DSM-IV is a manual that helps outline mental disorders. A major strength is that healthcare professionals such as physicians, psychologist, psychiatrists, and others combined their resources and knowledge to create a universal manual (Well in the US anyways). Also, the DSM is used for appropriate coding for billing and insurance purposes which, for most psychologists, is imperative in order to receive reimbursement for treatment. DSM IV allows researchers anywhere to gather together a group of patients who meet the described criteria for the disorder, try different treatments, and compare the results. The diagnosis is universal. Thus, a given percentage of patients with social phobia might be helped by placebo, and if a greater number will be helped by paroxetine, or gabapentin, or cognitive behavioral therapy, or whatever the treatment in the research design might be, then these treatments can be designated effective if statistical significance is reached. “Evidence based treatment” appeals to the FDA and, more importantly, seemingly appeals to common sense. Empirical data is usually far more valuable than theories and controversy that cannot be backed up by a test of the facts. In recent years “evidence based medicine” has become a rallying cause. Pressures are exerted for it to become the standard of care. The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the standard classification of mental disorders used by mental health professionals in the United States. It is intended to be applicable in a wide array of contexts and used by clinicians and researchers of many different orientations (e.g., biological, psychodynamic, cognitive, behavioral, interpersonal, family/systems). DSM-IV has been designed for use across settings, inpatient, outpatient, partial hospital, consultation-liaison, clinic, private practice, and primary care, and with community populations and by psychiatrists, psychologists, social workers, nurses, occupational and rehabilitation therapists, counselors, and other health and mental health professionals. It is also a necessary tool for collecting and communicating accurate public health statistics. The DSM consists of three major components: the diagnostic classification, the diagnostic criteria sets, and the descriptive text.

They have again missed the opportunity to note that although terms such as neurosis, hysteria and neurasthenia are not disorders in the DSM system, they are widely used throughout the rest of the world; none of these three terms is given an entry in the general index to the volume. This is a particularly unfortunate omission with regard to neurasthenia, since it means that the claim about taking notice of recent research cannot be taken very seriously. ? One of the weaknesses of the DSM system has always been the frequently available option of including the social effects of disorders in the criteria by which the same disorders are identified.

The DSM-IV is a categorical classification system. The categories are prototypes, and a patient with a close approximation to the prototype is said to have that disorder. DSM-IV states, “there is no assumption each category of mental disorder is a completely discrete entity with absolute boundaries…” but isolated, low-grade and noncriterion (unlisted for a given disorder) symptoms are not given importance.[18] Qualifiers are sometimes used, for example mild, moderate or severe forms of a disorder. For nearly half the disorders, symptoms must be sufficient to cause “clinically significant distress or impairment in social, occupational, or other important areas of functioning”, although DSM-IV-TR removed the distress criterion from tic disorders and several of the paraphilias. Each category of disorder has a numeric code taken from the ICD coding system, used for health service (including insurance) administrative purposes.

Despite caveats in the introduction to the DSM, it has long been argued that its system of classification makes unjustified categorical distinctions between disorders, and uses arbitrary cut-offs between normal and abnormal. A 2009 psychiatric review noted that attempts to demonstrate natural boundaries between related DSM syndromes, or between a common DSM syndrome and normality, have failed.[4] Some argue that rather than a categorical approach, a fully dimensional, spectrum or complaint-oriented approach would better reflect the evidence.[38][39][40][41]

In addition, it is argued that the current approach based on exceeding a threshold of symptoms does not adequately take into account the context in which a person is living, and to what extent there is internal disorder of an individual versus a psychological response to adverse situations.[42][43] The DSM does include a step (“Axis IV”) for outlining “Psychosocial and environmental factors contributing to the disorder” once someone is diagnosed with that particular disorder.

Because an individual’s degree of impairment is often not correlated with symptom counts, and can stem from various individual and social factors, the DSM’s standard of distress or disability can often produce false positives.[44] On the other hand, individuals who don’t meet symptom counts may nevertheless experience comparable distress or disability in their life.

Despite doubts about arbitrary cut-offs, yes/no decisions often need to be made (e.g. whether a person will be provided a treatment) and the rest of medicine is committed to categories, so it is thought unlikely that any formal national or international classification will adopt a fully dimensional format.[4]

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