Two years on from publication of the DSM-5
In part one I considered the DSM-5 in light of the problems inherent in diagnostic classification. In part two I reflect on how changes to the DSM-5 have affected my clinical practice.
In Victoria’s mental health system we use the World Health Organisation’s International Classification of Diseases to record diagnoses in health record systems, but clinical discussions almost always refer to the DSM. [It is interesting to consider the reasons for the DSM’s much wider clinical adoption. One reason is that the better funded DSM tends to lead changes to diagnostic criteria, with the ICD then following suit.] The changes in DSM-5 have been minor, and have had only subtle effects on my clinical work. That they should have any effect at all is perhaps surprising: but inevitably the DSM influences the information that patients access about their diagnoses and thus the conversations we have about them.
I mainly see patients with severe depression, which is often comorbid with personality disorders, substance use disorders, and autism spectrum disorders. The only patients in the clinic who don’t have depression have severe OCD. There was really only one significant change to the criteria for major depressive disorder in DSM-5: patients who were grieving were no longer to be excluded from the diagnosis. This caused much wringing of hands — it fed into the pathologising normal theme — but has had no effect on my clinical practice. Partly because it is uncommon that I see a young person who is experiencing acute grief, but mostly because differentiating grief from depression — and more importantly, determining the need for psychiatric intervention — is a matter of common sense. If you are suffering from severe insomnia and dark thoughts following the sudden death of your mother I will understand that as part of the grieving process: if you then try to kill yourself I will consider that something beyond grief is going on. Naturally there are degrees between these poles and differentiating between the states requires judgement. But I don’t think sensible clinicians will be inserting themselves into the grieving process when they don’t need to.
When I reflect on the DSM-5 changes that have made a difference, I can think of only two. Both have affected the discussions I have with patients rather than the management of their illnesses. The first is the consolidation of the various autism-related disorders — autistic disorder, Asperger’s disorder, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified — into one of autism spectrum disorder. This is a change that makes clear how diagnoses have cultural meanings as well as clinical ones. Many people with Asperger’s have felt they have lost an important part of their identity with the elimination of the diagnosis: they are no longer officially (as per the DSM) “Aspies”, and some actually don’t meet the criteria for the new autism spectrum disorder, stripping them of any diagnosis. The change does reflect, though, the way the diagnoses were already being discussed in the clinic. To invoke a spectrum reflects clinical reality, and invites useful discussion with patients irrespective of whether they meet diagnostic criteria. “There is a spectrum between severe autism and ‘normality’, and your symptoms suggest you sit …”
The other change that has affected clinical discussions is to the criteria for obsessive compulsive disorder. OCD has also moved chapters: in DSM-IV it sat with the anxiety disorders, but in DSM-5 forms its own chapter alongside hoarding disorder, trichotillomania, and body dysmorphic disorder. Patients with OCD are intensely preoccupied by obsessional beliefs and rituals (“I must wash my hands after touching the bottom of my shoe, otherwise my mother will contract a fatal illness”), but most can acknowledge, on reflection, the irrationality of them. A small portion of patients with OCD cannot. They are completely convinced that their beliefs are grounded in truth — with an intensity that is delusional. [In my experience the beliefs often have a religious flavour, and often in someone who hasn’t been religious. “If I don’t tap my shoulders in repeating patterns of three alternating taps then my soul will be damned to hell”.] DSM-5 now acknowledges that OCD can include beliefs that are delusional in intensity — we can discuss with patients that they have, in the DSM-5 framework, one illness (OCD with delusional beliefs) rather than two (OCD and a psychotic disorder such as schizophrenia). Of course we could always do that. But now what the patients read about their diagnosis accords with what we are discussing with them.
So despite the flurry of commentary that greeted the fifth edition’s publication — almost all of it negative — I can appreciate some improvements. Small ones, perhaps, but for me DSM-5 seems an improvement on DSM-IV. The changes are really just tinkering with a compromised document, but one we have to live with for now while we await psychiatry’s periodic table.
