Thursday, September 6, 2012

DSM-5 Moves Forward With PTSD Diagnosis Revision

English: signs and symptoms ptsd
Signs and symptoms PTSD (Photo credit: Wikipedia)

Anticipating DSM-5...

If you are a psychiatrist, psychologist, a licensed social worker, a researcher, or employed by a health insurance company or a pharmaceutical company, then you are very familiar with the Diagnostic and Statistical Manual of Mental Disorders (DSM). On the other hand, if you suffer from a mental disorder or your loved one has been diagnosed with a mental disorder, then chances are you have no idea how the guidelines or standard criteria set forth in the DSM might impact your particular diagnosis and treatment plan. Currently the DSM is undergoing a review of all new research and is in the process of being revised in anticipation of publishing the DSM-5 in May 2013.  That's right: the DSM is only in its fifth revision since the first edition was published in 1952. To the novice it might seem that the wheels of statistics and diagnosis of mental disorders turn slowly. A treatment professional might argue updating the DSM is a thoughtful and deliberate process seeking to help both professionals and the general public.

The DSM ~ a bit of history...

It might surprise you to know that the DSM's history dates back to the United States 1840 census. At that time the United States decided it was important to collect statistical data regarding mental disorders. Specifically, the US in 1840 wanted to know how many families included members who were being cared for in a public or private institution for the insane and idiotic.  From there the history goes like this:
  • In 1917 the Committee on Statistics, the precursor of the American Psychiatric Association (APA), worked with the National Commission on Mental Hygiene to produce a new guide for mental hospitals which was called the "Statistical Manual for the Use of Institutions for the Insane." It included 22 diagnoses. 
  • During World War II many psychiatrists in the United States were involved in the selection, processing, assessment and treatment of soldiers. Brigadier General William C. Menninger developed a new classification scheme called Medical 203. Medical 203 was issued in 1943.
  • The World Health Organization published the 6th revision of the International Statistical Classification of Diseases (ICD) in 1949. This was the first time that mental disorders were included in the ICD. 
  • In 1950 the APA looked to develop a manual specifically for use in the United States and reviewed the Medical 203.
  • In 1952 the APA issued the DSM-I. The manual was 130 pages and listed 106 mental disorders.
  • DSM-II was published in 1968, with 134 pages, listing 182 disorders.
  • In 1974 the seventh printing of the DSM-II no longer listed homosexuality as a category of disorder. The diagnosis was replaced with a category of "sexual orientation disturbance."
  • While it was decided in 1974 to revise the DSM, it was not until 1980 that DMS-III was published with 494 pages and listing 265 diagnostic categories. Later the revision chairman, Robert Spitzer criticized his work, stating it led to the medicalization of 20-30% of the population who may not have had any serious mental problems.
  • DSM-III was revised in 1987. This revision included 567 pages and 292 diagnoses. It is referred to as DSM-III-R.
  • DSM-IV was published in 1994 growing in length to 886 pages and including 297 disorders. Significantly was the inclusion of a clinical significance criterion requiring that symptoms cause "clinically significant distress or impairment in social, occupational, or other important areas of functioning." DSM-IV-TR was published in 2000, supplying extra information for each diagnosis and some diagnostic codes were updated to be consistent with ICD.
  • DSM-V is a work in progress due to be published in May 2013. Notably, it will be called DSM-5. Here you can review some of the planned updates for DSM-5.

Today's news seems to indicate DSM-5 proposed changes will not significantly affect the number of people who meet the criteria for PTSD

Revisions to the DSM are done carefully; the task force which oversees any revisions looks carefully at new research and statistics. One of the key disorders under review for revisions in the DSM-5 is post traumatic stress disorder (PTSD).

PTSD first appeared in DSM-III in 1980. MedicalXpress' article of September 5, 2012, notes that:

"According to DSM-IV, the criteria for a diagnosis of PTSD include exposure to a traumatic event, persistent re-experiencing of the traumatic event, avoidance and emotional numbing, and persistent hyperarousal and hypervigilance. The proposed revisions for DSM-5 involve clarification regarding what constitutes a traumatic event, the addition symptoms such as self-destructive behavior and distorted blaming of oneself or others for the traumatic event and a reorganization of the diagnostic decision rules for establishing a diagnosis of PTSD."
The question that critics pose regarding this proposed revision is that some of the new symptoms are not unique to PTSD. They raise concerns of potential misdiagnoses, which may artificially increase the number of patients with the disorder. So the task force requested more research be conducted to determine if these criticisms are warranted.

PTSD research results...

To address the critics' concerns mentioned above, researchers led by Mark W. Miller, PhD, associate professor at Boston University School of Medicine and a clinical research psychologist at the National Center for PTSD at the VA Boston Healthcare System, conducted a study to determine if the proposed revisions would affect the number of people diagnosed with PTSD.  They surveyed 2,953 American adults, considered to be a nationally representative sample; additionally, they surveyed a second sample of 345 U.S. military veterans. Again, according to the MedicalXpress news report:

"They found that most of the proposed symptom changes were supported by statistical analysis and did not substantially affect the number of people who would meet criteria for the disorder. Based in part on these findings, the workgroup responsible for the PTSD revisions are now moving forward with the proposed revisions for DSM-5."

Stay tuned...

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