Dear Editor:
Almost as soon as the DSM-IV was published in 1994, discussions began about revisions for the DSM-V. The extremes are perhaps best illustrated by the articles, “Dump the DSM!” and “The DSM: Not Perfect, but Better than the Alternative.”1 Although the former makes a number of hyperbolic statements (“The DSM IV…deters medical students from entering psychiatry”), the DSM-IV does include a great deal of arbitrary and frustrating criteria, such as “more-than-2-weeks-but-less-than-6-months.” Some basic suggestions to consider:
Simplification. The original DSM (1952) was 144 pages. Today's DSM-IV-TR has 992 pages and an entire library of accompanying publications to help clinicians understand it.2 But expansion in size and detail has provided no more diagnostic precision, hence the continuing discussions. Simplifying the next iteration of this text would be beneficial, in order to promote accuracy and consistency.
Lumping versus splitting: The DSM-IV includes 17 major classifications and over 300 specific disorders. Nowhere is this tendency for “splitting” more apparent than in the Substance Abuse diagnoses. There are 16 possible choices for Sedative-, Hypnotic- or Anxiolytic-Induced Disorders. That presupposes one knows which substance induced the delirium, dementia, anxiety, etc. Often it is not certain. To simplify the diagnoses, one might consider the following: A patient who only uses cannabis and alcohol if available, but craves cocaine, might be diagnosed as follows:
Substance abuse—cannabis, alcohol.
Substance dependence—cocaine.
The “intoxication” and “withdrawal” qualifications are not legitimately psychiatric. They denote temporary, acute medical conditions. A patient may have an admitting diagnosis of Alcohol Intoxication, but once detoxed and transferred to psychiatry, the diagnosis becomes Alcohol Dependence or Alcohol Abuse.
Unspecified, Not Otherwise Specified (NOS), and Not Elsewhere Classified (NEC). Unspecified, NOS, and NEC diagnoses offer a distinction without a difference and no clarification whatsoever. If anything, they serve only to muddy the waters. In Personality Disorders, for example, the DSM-IV denotes NOS “for [personality] disorders that do not meet criteria for any specific personality disorder,” or “a specific personality disorder that is not included, e.g., passive aggressive personality.”3 Why, then, is passive-aggressive personality not included? NEC/NOS designations suggest that we have no clear idea what the diagnosis is and tend to impact negatively the image of psychiatry as a science.
“Childhood” versus “Adulthood.” These designations can impede diagnostic accuracy. Attention deficit disorder is often missed in adult patients, because it is linked to childhood in our minds.4 Likewise, “adult” diagnoses, Personality Disorders, for example, could be diagnosed in children.5
The axes. Is it really helpful to separate the “major psychiatric” and personality disorders into two separate axes? Many personality types are as dysfunctional as major Axis I disorders. “Cluster placement” adds nothing to diagnostic clarity, and chips away at confidence in psychiatric nosology.
Axis III is helpful since psychiatrists are wont to overlook medical conditions or give them short shrift. But stress can contribute to virtually any medical illness,6 so attempting to determine a clear correlation is immaterial. Listing all medical problems under Axis III would assist all providers in designing effective treatment plans.
Axis IV contains information that belongs in the History of the Present Illness, and should be reconsidered or eliminated.
Axis V is unfortunately used for purposes other than diagnostic accuracy. For example, some youth facilities have a “ceiling GAF” of 40, and psychiatrists will “diagnose below” that ceiling in order to justify an admission. Moreover, the 10-point spread within each GAF level strains credulity. Can anyone legitimately differentiate between a GAF of 54 and 55?
In summary, simplification is the keyword. Clarity, rationality, and consistency of diagnosis should be the focus of the DSM-V.
With regards,
Lorraine S. Roth, MD
Department of Veterans Affairs Department of Psychiatry North Chicago, Illinois lorraine.roth@med.va.gov
References
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