As I interact with colleagues I sense an incredible, almost exuberant, level of excitement and anticipation for the DSM-V. “It will change psychiatry”, “it will answer the questions”, “it will abandon categories”, etc, etc, etc. The expectations are so great and in so many directions, that I can’t help but to think that the DSM-V will inevitably disappoint most. Some will complain that it went too far, some will say it did not go far enough. Most likely, as one of the DSM-V committee members recently said, the “DSM-V will be an awkward transitional instrument” because the goals are too great, the changes too drastic, for all of it to be completed in a single sitting; even if the sitting took 17 years.

So today I want to touch on a topic raised by renowned child psychologist Dr. Thomas Achenbach in a recent issue of the journal Psychology Clinical Science and Practice. This topic, the role of “functional impairment” as a component of the diagnostic process, will likely become the elephant in the room, and a source of much tension and debate.

There are many extensive resources about the history of the DSM and the process of the DSM-V (I invite readers to visit the DSM-V official page). So here I provide you a very simplistic background of the issues:

In 1980, the American Psychiatric Association, published the DSM-III, which at the time represented a paradigm shift in Psychiatry. The system was based on the basic concept that psychiatric disorders, just like other medical disorders, where organized in discrete categories. You had depression or you didn’t. You had schizophrenia or you didn’t. The decision as to whether you had or did not have a disorder was based on a threshold consensus of how many symptoms you experienced: 4 symptoms? You have the disorder. 3 symptoms? You don’t have the disorder. etc, etc, etc. This system was kept relatively intact in the next version of the DSM (DSM-IV) published in 1994.

So for almost 30 years our field has followed a categorical diagnostic classification system. But the problem is that such a system is actually not well supported by the science in at least in two key issues: 1) Research has consistently shown that there is significant fluidity between diagnostic categories. That is, the line between depression and anxiety, for example, is more of an imaginary line than an actual wall. So clinical phenomena (depression, anxiety, phobias, delusions, compulsions, etc) occur on integrated dimensions that are not as easily separated as the DSM-IV categorical system suggests. And 2) Research is also consistent in showing that the degree of severity of each symptom and each overall condition also fall on a continuum or dimension. Unlike the assumption of the categorical system, we don’t really have an “all or nothing” situation, a “you have it or you don’t”. Instead, the story is much more complex. Therefore, as clinical phenomena occur in a continuum, clinical decisions should also occur in a continuum. Thus, a dimensional view of these clinical conditions may facilitate research on how different thresholds may lead to more effective clinical decisions (for example, at what level of depression is hospitalization the best option, or at what level does SSRI is recommended?).

Now, when I talk to colleagues about these issues, some mistakenly believe that the change in DSM-V is mostly about adopting a dimensional approach to functional impairment. This is due to the erroneous view that severity of a disorder = severity of impairment. In the Psychology Clinical Science and Practice article, Dr. Achenbach argues that impairment should be separated from diagnoses. He states:

Although impairment should certainly be considered when deciding whether to treat, how to treat, and with what dose level, inclusion of impairment criteria for diagnoses implies that disorders are present only when they cause significant impairment. If impairment were required for diagnoses such as HIV and cancer, epidemiological studies would exclude many people who have the diseases but are not yet impaired. Worse yet, treatment could not be justified until impairment occurred, when it may be too late. Quantification of the number and/or severity of symptoms could help us evaluate the certainty and severity of disorders without confusing the existence of disorders with the important but separate issue of impairment.

Why do I think this is the big elephant in the room? Because for many decades the concept of impairment has been embedded into our conceptualization of disorders, and, with a few rare exceptions, all DSM-IV diagnostic criteria require the presence of impairment. Impairment has been central to the field’s attempt to deal with issues of culture, normalcy, and the notion of disease vs. disorder. Yet, Dr. Achembach presents what some could argue to be a medical model that separates impairment as an implicit requirement of the diagnostic process.

Does a person with asthma only have the condition when he or she is functionally impaired? What about diabetes, infections, viruses, tumors… do they require the person to be functionally impaired before they are illegible to receive a diagnosis and treatment? Then why would schizophrenia, depression, and anxiety be any different? Why would a person with depression need to wait until the depression affects her work, personal life, and/or education before he/she is able to receive treatment and a proper diagnosis?

UPDATE: In my original post I incorrectly mentioned Asperger’s as one disorder that does not have an explicit requirement of impairment in the current DSM-IV-TR.  One of our readers correctly mentioned that it is autism, not asperger’s, that doesn’t include the explicit impairment requirement. I deleted the example from the main post as it was not directly related to the core issues I wanted to discuss but I’m including this update to provide context to some of the comments below.

Achenbach, T. (2009). Some Needed Changes in DSM-V: But What About Children? Clinical Psychology: Science and Practice, 16 (1), 50-53 DOI: 10.1111/j.1468-2850.2009.01142.xResearchBlogging.org

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10 Responses to DSM-V, dimensions, categories, and the elephant of impairment

  1. Socrates says:

    This is a debate that needs a much wider audience – and I think, is particularly relevant to Pervasive Developmental Disorders.

    It is also reflected in the growing use of the phrase, Autistic Spectrum Condition, instead of Autistic Spectrum Disorder.

  2. To seperate impairment is an interesting notion, but I am curious how “impairment” might be defined?

    …and particularly interested that Asperger’s syndrome is brought out as a shining light of “non-impairment” when it can very much impair or impede a person, just not intellectually.

    It is entirely possible for some persons with Asperger’s, depression or bipolar disorder etc to function in the world and to *appear* unimpaired. However each person probably pays high price for this appearance of normality: by restrictions on their life or other methods. Would such a person be considered clinically “impaired”?

    I suppose my question is at what point would a diagnosis and/or help be extended to such a person, both now and under DSM-V.

    It brings to mind the concept of the functional alcoholic, who may retain a job and home/relationships for many years, and for whom all around will *know* there is a problem, but will not -in general- act, until something serious happens (DUI conviction, accident, job loss …whatever)

    A similar example seems to be true now in the mental health field. Can latent mental health issues be screened and found earlier? If so, would that represent a potential problem for the now rebranded “mentally ill” individual, who is nonetheless functioning in the community? I am thinking of employment, insurance, child custody and other rights which could potentially be impacted for some individuals under the wrong circumstances.

    It’s an interesting can of worms, to be sure.

    The same seems true now of latent mental health
    it is a very interesting hot

    • Repost: I went to edit this reply and instead i deleted it. So here it is again.

      “interesting can of worms” It is for sure. As to how impairment would be define, I assume that it will not change much from today’s definition. Does the condition lead to aversive consequences in the occupational, educational, or personal domains, such as the ability to keep a job, get an education, maintain meaningful relationships, etc

      Yes, the issue is much more complex than that and I think the discussion should move towards an understanding of the interplay between impairment and the condition. For example… impairment may not be observed during early stages of a condition even when the condition is truly present. Impairment can also be minimized or completely eliminated with treatment, but this may or may not reflect that the condition is no longer present. In some cases there is no impairment because the condition is not present (for example a person who is no longer clinically depressed) – while in some other cases there is no impairment because the condition is present but controlled (such as a person holding a job while on medications for schizophrenia). And of course all of this touches on our conceptualization of disorder and disease- what does it mean to be ‘no longer depressed’ or to have schizophrenia…
      Nestor.

  3. In fact the current DSM-IV-TR requires “clinically significant impairment” in Asperger’s as an additional mandatory criterion (apart from the listed impairment in the social domain). See C in the Asperger’s criteria.

    This additional mandatory requirement is not in the autism criteria, where there is only “delays or abnormal functioning” as an additional mandatory criterion.

    This anomaly has been noted with some incredulity by some researchers (I do not have time to look them up, sorry).

    Also, one of the changes in the DSM-IV-TR was to remove the requirement for “significant distress or impairment” from the criteria for Tic Disorders (e.g., Tourette’s). The reason given for this change (Appendix D) was that this requirement was inconsistent with clinical experience and had distorted research.

    • Thank you Michelle, you are completely correct. I remembered the very strange omission of impairment in the autism criteria and the lack of coffee got to me this morning. Thanks for bringing this to our attention.

  4. Just for clarity (and in case new arrivals wonder what on earth I was going on about), the statements by Dr Lopez-Duran (about Asperger syndrome not being an impairment in the DSM-IV) that I was responding to have now all been removed by him, both from his original post and from his comments.

    • Thanks for the clarification Michelle. Yes, some people may be confused. I did not feel I needed to leave the error with an added clarification since that error was immaterial to the focus of the post. I used Asperger’s as an example when I should have used autism. There was no need for the example since this post was not about ASDs – so I deleted it.

      I also just added an update with the clarification. Thanks. Nestor.

  5. RAJ says:

    Here is the current recommendations for changes to DSM-V:

    http://www.psych.org/MainMenu/Research/DSMIV/DSMV/DSMRevisionActivities/DSM-V-Work-Group-Reports/Neurodevelopmental-Disorders-Work-Group-Report.aspx

    If implemented Autistic Disorder, PDD/NOS and Asperger Syndrome will be removed and replaced by a sliding scale of severity of impairment. Two new categories will be added, consistent with a concept of autism being on a continuum from profoundly handicapped to normal.

    The category of Atypical ASD would incorporate many cases who do not qualify for an ASD diagnosis under current criteria including mentally retarded, learning disabled, communication impairmed, ADHD, any child whose behaviors include varying degree of social-communicative problems.

    The sub-category of normal ASD, no impairment but who are socially isolated or ‘awkward’ would place 25% of the general population at risk for being given a neuropsychiatric diagnosis of an ASD.

    Many studies have shown that app. 25% of the general population would fall into the introverted personality type with 75% falling into the extroverted personality type.

    At what point does the fashionable label of ASD become so prevalent that the entire concept of ‘autism’ become useless.

    If implemented, prevalence rates would continue to expand at rates that make current prevalence estimates pale by comparison.

  6. Ian MacGregor says:

    A person must have a finger tip cutoff, another person must lose all four limbs. Both are amputees whose condition is worse?

    A person gets the flu and needs to stay home for a couple of days, another gets the flu and is hospitalized but recovers, a third dies from it. Which one had the worse case of the flu?

    How condition impacts a person is important. It does not mean that person who is not gravely affected does not have the condition and does not deserve treatment. But the lives of the people who are greatly impaired by autism and those who are not is great.

    My daughter has low-functioning autism. Like most people I have some autistic tendencies, but unlike her, I am not autistic. Perhaps though, under the new rules, I’d qualify.

    • Hi Ian, no one currently know what the final new system will look like (including those in the working groups). So it is difficult to say which clinical profiles would meet diagnostic criteria and which will not. The non-inclusion of impairment in the classification system does not necessarily mean that a person with tendencies or traits of a condition would qualify as having the condition. This would depend upon whether such traits (their nature, severity, frequencies, etc) are indicative of the syndrome as defined in the new classification system. But again, we can only speculate as to the future definition and criteria of these conditions.

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