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.x
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