Diagnosis
Diagnosis
by Martha Teater, LMFT
There are a lot of changes in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) that have social workers talking. Some of the revisions are seen as positive. However, there are several that are raising concern among clinicians.
I have presented dozens of workshops on the DSM-5 and have trained thousands of clinicians in its use. In these workshops, I've been able to pick up on a few changes that have raised some eyebrows among participants.
People have told me that they are overwhelmed, confused, and even a bit disoriented by all the changes. They have some anxiety with the upcoming conversion to the DSM-5 and the many ways it will affect them as they diagnose people, and the major adjustments that agencies will need to make to adapt.
I'll share with you three of the areas that arouse the most passionate responses from people.
No More Multiaxial System
The change that has been universally upsetting to people in my workshops is the loss of the multiaxial system.
We started using five axes to formulate a diagnosis when the DSM-III-R came out in 1987. Ever since then, we’ve had five main pieces of information that made up our diagnostic impression.
Axis I listed clinical disorders. Axis II included personality disorders and mental retardation. Axis III was where we listed general medical conditions. Axis IV was where we described psychosocial and environmental problems. Axis V was the place to put the Global Assessment of Functioning (the GAF), which summarized how severely a person was affected by his or her mental health condition.
Those five aspects of a diagnosis are no longer going to be listed in the diagnostic description. Instead, diagnoses will just be recorded in a list, with the principle diagnosis being listed first, and others following in order of importance to treatment.
We can reflect contributing factors by using appropriate V codes, and these factors will be reflected in the body of the assessment information (as always), but they will no longer be part of the diagnosis. We will document those factors in our notes, but as one workshop participant lamented, “But nobody reads my assessment!”
Another participant shared her observation, “It seems like we’re losing something important by taking that information away from being front and center in terms of importance. I really like being able to look at the five axes of a diagnosis and being able to get a feel for the person. It’s like seeing a snapshot of the person being treated, and it gives a much fuller picture of someone.”
Let’s look at an example of what a diagnosis would look like now.
Shannon comes in to see you for an initial appointment. She’s 41 years old and reports that she’s been irritable, short-tempered, and tired for the past couple of months. She has been less patient and engaged with her friends and family. She’s not sleeping well, waking up several times at night, and she’s tired when she gets up. She’s gained weight and has stopped exercising. Shannon doesn’t know what’s wrong and has a hard time imagining that she’ll ever feel like herself again.
She has a long history of disrupted relationships, beginning in early adulthood. She often feels that other people aren’t there for her, even though she reports that she is always supportive and there for her friends. She struggles with feeling alone and worries that she’ll be abandoned. She has had several jobs and can’t decide on a direction for her life. Shannon often struggles with her identity and seems to reinvent herself periodically. Sometimes when the stress is too much, she ends up cutting herself, not in a suicide attempt, but to stop her emotional pain.
Unfortunately, Shannon has developed multiple sclerosis. She is still able to be independent, but has balance problems and needs to make some decisions about treatment options.
Along with a recent job loss, her financial situation has gotten desperate. She has been evicted from her apartment because she was so behind in her rent, and she is now staying with various friends.
Here’s how you might write up your diagnosis under DSM-IV:
Axis I: 296.22 Major depressive disorder, single episode, moderate
Axis II: 301.83 Borderline personality disorder
Axis III: 340 Multiple sclerosis
Axis IV: Unemployment, homelessness
Axis V: GAF=40
And here’s how it might look under DSM-5:
296.22 Major depressive disorder, single episode, moderate
301.83 Borderline personality disorder
340 Multiple sclerosis
Asperger’s Disorder Is Gone
By now, most clinicians have heard that Asperger’s disorder is gone from the DSM-5.
There is no diagnosis of Asperger’s disorder in the manual. The term Asperger’s disorder is not even used anywhere in the content. This is now considered high-functioning autism, and will be incorporated as part of autism spectrum disorder.
This change has been one of the most controversial of the whole revision. People with Asperger’s, parents of children with Asperger’s, and advocacy groups have been vocal in their frustration with this omission. They see Asperger's as a different condition from autism, and they disagree with the decision to eliminate it as a separate disorder.
People are apprehensive about the ability of folks with a DSM-IV diagnosis of Asperger’s to retain a diagnosis and continue to qualify for supportive services. The DSM-5 task force has said that most people with a well-established DSM-IV diagnosis of Asperger’s should meet the criteria for autism spectrum disorder in the DSM-5. If they don’t, we are to evaluate them for social (pragmatic) communication disorder.
This has done little to allay the concerns of people with Asperger’s and their advocates. Many feel that their condition, which they may have come to accept, is being replaced with a term that they are less than enthusiastic about.
This is a controversy that I don’t think we’ve heard the end of, although it’s too late to make a change in time for this revision of the manual.
Let’s take a look at how you might assess someone with Asperger’s symptoms:
Noah is a 15-year-old whose parents bring him to see you. They have often wondered why he seems so different from their other two children. Noah has few friends, makes little eye contact, and spends a lot of time alone. He does okay in school and isn’t a behavior problem for his parents or teachers. Noah has a keen interest in movies and superheroes. He can quote long pieces of dialogue from his favorite movies, which he has watched many times. He collects superhero action figures and calls his room his “fortress of solitude,” because he feels peaceful in his room.
To fall asleep at night Noah usually bounces on his bed enough to make the mattress jiggle a bit. His parents sometimes notice that he rocks himself gently, especially when he is feeling a lot of stress.
Noah likes to write stories about superheroes that he creates, and he is interested in clocks and lamps.
You may be thinking that Noah might fit a diagnosis of Asperger’s disorder, and you’d be right. But with implementation of the DSM-5, you won’t have that as an option. You would diagnosis him with autism spectrum disorder, and you would indicate the severity of that.
For autism spectrum disorder, you would gauge severity in two different areas: social/communication deficits and restrictive, repetitive behaviors (RRBs). For each of those domains, you can select a severity level of 1, 2, or 3, indicating the level of support that’s needed. Most people with an Asperger’s-looking presentation will end up with both severity indicators being a level 1.
Dramatic Changes in Substance Use Disorders
There are a lot of revisions to the substance use disorders category that have people talking. Some practitioners are complaining that the symptom threshold is too low, and it will be too easy to tag someone with a diagnosis. Others don’t like the loss of the abuse and dependence distinctions. Some people don’t like the fact that gambling is the only behavioral addiction in the manual.
Let’s start with the change in the symptom threshold. Substance use disorders have 11 symptoms to choose from. Severity is determined by the number of symptoms that are endorsed: mild is two to three symptoms, moderate is four to five symptoms, and severe is six or more symptoms being endorsed.
Someone could have two symptoms and end up with a substance use disorder. Some clinicians fear that this could too easily burden a person with a substance use disorder diagnosis prematurely.
I’ve been asked whether or not insurance companies will pay for treatment for a mild substance use disorder. I haven’t heard anything definitive about that, but I suppose payers could decide not to cover such disorders if they want to save reimbursement for people who have moderate or severe substance use disorders.
There are some practitioners who like the descriptors of abuse or dependence to define the extent of a person’s substance use. Those terms are gone from the manual, replaced by the severity scale related to each substance that a person uses problematically.
One question comes up at every training I’ve done on the DSM-5. A participant will raise a hand and ask where sexual addiction is listed. Someone else may then ask about pornography addiction. People are usually surprised and disappointed to learn that there are no behavioral addictions or compulsive behaviors in the manual other than gambling.
The task force maintains that the body of research doesn’t yet support inclusion of those compulsive behaviors in the manual. The research evidence appears stronger for gambling, so it’s still in the manual. Problem gambling is now grouped in the substance use and addictive disorders category. It’s no longer in the disruptive, impulse control, and conduct disorders section.
Here’s an example of one person’s presentation with a substance use disorder:
Ron is 37 years old and was referred to you by the court system following a recent DUI conviction. He says he was at a friend’s birthday party and thought he could safely drive home after drinking “a few” beers. He’s really upset about the DUI and feels a lot of embarrassment. He’s worried about the financial expense and loss of his license for a year. He’s had a hard time sleeping because of the worry and depressed reaction he’s experienced since the DUI.
Upon further investigation, you find that Ron drinks “several” beers most nights of the week. He estimates that he drinks 6-8 beers a day, “sometimes more, sometimes less.” He has tried to cut back, but has been unsuccessful in those efforts. He used to “feel a buzz” after drinking 3-4 beers, but now it takes 6-8 to get the same feeling.
He smokes pot with his work friends, but doesn’t like to do that regularly because of his fear of failing a random drug test at work. He smokes pot 3-4 times monthly. When he tries to cut back, he finds himself feeling strong urges to smoke pot.
He is a cigarette smoker, smoking about a pack a day.
If you were going to diagnose Ron, it might look something like this:
309.0 Adjustment disorder with mixed anxiety and depressed mood
305.00 Alcohol use disorder, mild
305.20 Cannibas use disorder, mild
305.1 Tobacco use disorder, mild
More to Think About
I do want to emphasize that not all of the changes in the new manual are causing angst and woe among clinicians. I’ve highlighted the top three modifications that people are finding frustrating.
There are some changes that people are feeling good about. They seem to like the severity scales being specifically tailored to many different diagnoses. For example, anorexia severity is determined by a person’s BMI (body mass index). Bulimia severity is based on the number of inappropriate compensatory behaviors weekly (vomiting, laxative use, over-exercising, and so forth). Oppositional defiant disorder severity is based on the number of settings in which symptoms are present.
People also seem excited about the new symptom cluster for PTSD, which is negative alterations in mood and cognitions. They feel that these cognitive changes reflect ways that people with PTSD often feel most affected by their trauma exposure.
A couple of things that leave folks scratching their heads are some of the changes in gender dysphoria and caffeine-related issues. These issues don’t seem to get a resounding positive or negative reaction, but they are causing people to think.
Changes in the language of gender dysphoria include wording that indicates that we are now looking at gender as being on a spectrum, not just as the two choices of either male or female, but some alternative gender. This is a departure from the way most people have conceptualized gender until this point.
The confusion in the area of caffeine use comes from the fact that we have choices of caffeine intoxication or caffeine withdrawal, but there is no option of caffeine use disorder. People have wondered why we have intoxication and withdrawal, but not a use disorder.
You’ve asked a good question, and now’s the time to become familiar with the changes that are part of the DSM-5. I encourage you to read up on the revisions and prepare yourself well for this dramatically different way to diagnose people.
Martha Teater is a licensed marriage and family therapist in Waynesville, NC. She was a collaborating clinical investigator for the DSM-5 field trials for routine clinical practice. She can be contacted at martha@marthateater.com or http://www.marthateater.com.