What are the three most important things you learned this week?
What questions remain uppermost in your mind?
Is there anything you did not understand?
Complete these answer based off of powerpoint,
NURS 521
DSM and Psychiatric Diagnosis
Week of Feb 4
DSM HISTORY
Robert Spitzer
Why was the DSM created?
Common language for clinicians
Research and public health purposes
Progression from DSM to DSM 5 – in simplistic terms reflects the transition from a more psychodynamic to a (marginally) more biological approach
Now moving towards DSM 5-TR
Reflects both research based knowledge and societal influences
Developed by panels of experts
Categorical (vs. dimensional)
SYMPTOM BASED VS. DIAGNOSIS BASED
Galenic approach (prior to 1900s)
Symptom based
Emphasis is on biological theory and biological speculation
Hippocratic approach (since 1900s)
Disease based
Emphasis is on clinical and research observation
Note: Hippocrates actually wrote “Practice two things with disease: Help, or at least do no harm”
He did not say ”First, do no harm”
Neither approach is particularly well implemented in the DSM
Ghaemi, 2019
EMIL KRAEPELIN
1856-1926
Often thought to be highly brain based
Had more of a pragmatic clinical perspective – symptoms and course of illness
Problems with this approach, “fever” analogy
Observed patients living in “insane asylums” – reviewed records
Developed conceptual model of what we would now diagnose as schizophrenia, bipolar disorder, and neurosyphilis
Dementia praecox (deteriorating) and manic-depressive insanity (non-deteriorating)
Some contemporaries critiqued his approach
Is his approach still relevant?
EUGENE BLEULER
Swiss psychiatrist
Coined terms schizophrenia, schizoid, and autism
“Schizo” = split, “phrene” = mind
Directly observed patients
Emphasized psychological disturbance over biological
SIGMUND FREUD
Originally was a neurologist
Founder of psychoanalysis
Believed psychiatric symptoms were related to unresolved unconscious conflicts and childhood experiences
Concepts of id, ego, and superego
How is his work relevant today?
UNITING THESE APPROACHES
Mental illnesses have neurobiological correlates and observable behaviors/symptoms
Current knowledge of neurobiology has challenged earlier concepts
Consider genetic predisposition and epigenetics, environmental influences
DSM BRIEF OVERVIEW
DSM-I -1952 – designed to classify and report cases, based primarily on psychodynamic explanation plus some “organic” disorders
DSM-II – 1968 – continued psychodynamic approach
DSM-III – 1980 – explicit criteria for each disorder, dropped psychodynamic explanations, dropped neurosis, multiaxial system
DSM-III-R – 1987 – removed hierarchies based on exclusion criteria
DSM-IV – 1994 – dropped “organic mental disorders”, required some research support for diagnoses
DSM-IV-TR – 2000 – minor updates
DSM-5 – 2013 – removed axes, disorders grouped developmentally, removed NOS, added “unspecified”, reorganized other diagnostic clusters
DSM-5-TR – 2022 –
DSM-I -1952 – designed to classify and report cases, based primarily on psychodynamic explanation plus some “organic” disorders
DSM-II – 1968 – continued psychodynamic approach
DSM-III – 1980 – explicit criteria for each disorder, dropped psychodynamic explanations, dropped neurosis, multiaxial system
DSM-III-R – 1987 – removed hierarchies based on exclusion criteria
DSM-IV – 1994 – dropped “organic mental disorders”, required some research support for diagnoses
DSM-IV-TR – 2000 – minor updates
DSM-5 – 2013 – removed axes, disorders grouped developmentally, removed NOS, added “unspecified”, reorganized other diagnostic clusters
DSM-5-TR – 2022 – updates to terminology and diagnostic criteria for some disorders
B-SNIP STUDY (2014)
933 participants with schizophrenia, schizoaffective disorder, or psychotic bipolar disorder
Collected data related to phenotype, clinical characteristics, cognitive functioning, social functioning, genetic markers, fMRI, EEG, and other brain scans
Overall there was more similarity than difference across diagnostic categories on the majority of these measures
Takeaway – the symptom based diagnostic categories of the DSM are likely inaccurate based on neuroscience findings
How to apply these findings – we don’t really know yet!
RDOC APPROACH
Research Domain Criteria Initiative from NIMH
Research framework – not a diagnostic guide
Categorizes cognitive and affective brain function by neural circuits
Meant to provide info about basic biological and cognitive processes relevant to mental health and illness
DSM 5 DEFINITION OF MENTAL DISORDER
“A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities.”
WHAT’S IMPORTANT HERE?
“A mental disorder is a syndrome characterized by clinically significant disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually associated with significant distress or disability in social, occupational, or other important activities.”
How do we define syndrome vs. disease vs. diagnosis vs. disorder?
HETEROGENEITY IN DSM DIAGNOSTIC CATEGORIES (ALLSOP ET AL, 2019)
Standards to which symptoms are compared (ex. MDD, mania, delusions and hallucinations)
Comparison with prior experience, socially expected responses, no comparators
Duration of symptoms (ex. MDD vs unspecified vs dysthymia)
Minimum duration, no duration, discrete episodes
Identifiers of severity (ex. manic episode)
Perspective from which distress is assessed (self, others, clinician, ambiguous)
Symptom overlap across categories (ex. anxiety)
Role of trauma –trauma and stressor related disorders includes etiological requirement, other categories don’t mention trauma
PSYCHIATRY BEYOND THE CURRENT PARADIGM (BRACKEN ET AL, 2012)
Technological paradigm (reductionistic)
Mental health problems are related to abnormal processes within the individual
These processes are causal
Technological interventions are most important and context independent
Evidence that non-technological interventions improve mental health conditions
Over reliance on psychopharmacology
Emphasis on therapeutic alliance
Recovery approach
Collaboration with consumer movement
ICD-10
ICD – International Classification of Diseases and Related Health Problems
Used throughout the world for psychiatric disorders but in the US only for billing purposes
DSM 5 lists ICD-9 codes first, then ICD-10 codes in parentheses
Currently using ICD-10, will convert to ICD-11 at some point
Key Points
The history of the DSM is reflective of societal trends
The DSM is an important tool but is not perfect
Psychiatric diagnoses contain overlapping symptom clusters and are often not clear cut
Learn and follow the diagnostic criteria while in school, but understand that the DSM does not always reflect the real world and real patients
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