Supporters Say The DSM-5 Enables Reliable Diagnosis

Those supporting the changes in the DSM-5 have one thing in common, they believe revisions in the new edition have fine-tuned diagnosis capabilities enabling real mental health professionals to reliably diagnose and effectively treat patients affected by psychological problems.

In May 2013, the APA – American Psychiatric Association released the DSM-5, approximately 20 years after the previous revision was released in 1994.

Harriet L Macmillan – A Professor in Dept of Psychiatry and Behavioural Neurosciences discusses some of the positive changes for Trauma-related and Stressor-related Disorders in the DSM-5.

“As a child psychiatrist and pediatrician practicing in the area of family violence, I welcome the increased focus on trauma-related and stressor-related disorders in DSM-5, which is reflected by several important changes. My hope is that these changes, as discussed below, will lead to increased recognition and understanding of the impairment associated with childhood adversities, especially in children. Ideally, this should occur not only among child psychiatrists, but among the full range of clinicians engaged in the assessment and provision of services to children, including family physicians, nurses, pediatricians, and psychologists. This aim is consistent with the view of the DSM-5 Task Force regarding the potential value of the DSM classification system to all professionals concerned with mental health care, not just psychiatrists. I am cautiously optimistic that the DSM-5 will now become more relevant to those of us seeing children and adolescents with stressor-related disorders across disciplines.

The key changes for those of us working in the family violence field are as follows. First, the move of PTSD and acute stress disorder away from Anxiety Disorders to a new stand-alone chapter Trauma- and Stressor-Related Disorders (TSRD) reflects the current deeper understanding of the heterogeneous symptom presentation of stress-related conditions. In addition, the three major PTSD symptom clusters in DSM-IV (re-experiencing, avoidance/numbing, and arousal) have been revised to four clusters: avoidance/numbing is now divided into the two clusters of avoidance and persistent negative changes in both cognition and mood. The latter has been broadened to include negative emotional states. It is increasingly recognized that PTSD symptoms go beyond fear-based anxiety, and include Dysphoria, aggression, guilt, and shame. This is also the case for adjustment disorders, which are now included in the same chapter. Another important difference for the PTSD criteria in DSM-5 is the removal of the subjection reaction (intense fear, helplessness, or horror) of how an individual experienced a traumatic event.

It is encouraging to see the development of a new PTSD sub-type in DSM-5: Post-traumatic Stress Disorder for Children 6 Years and Younger. The DSM-IV PTSD criteria did not take into account the variation in symptom presentation during development, especially in young children. For example, the previous requirement for three avoidance/numbing symptoms in young children, whose capacities to verbally express such experiences are only emerging, led to under-recognition of PTSD in children. The criteria now include one or more symptoms representing either persistent avoidance or negative alterations in cognitions and mood, and presence of one or more intrusive symptoms, in addition to two or more symptoms of alterations in arousal and reactivity.

The inclusion of reactive attachment disorder and a new condition, Disinhibited social engagement disorder, in the TSRD chapter emphasises the recognition of symptoms associated with neglect in childhood. In DSM-IV, reactive attachment disorder had two sub-types, emotionally/withdrawn and indiscriminately social/Disinhibited, but the latter has now become a distinct disorder, based on differences in symptom presentation. Typically classification of stressor-related disorders in childhood has emphasised the impairment associated with abuse in childhood (for example, sexual abuse), rather than neglect. Both types of symptoms and their association with neglect are important to recognise.

The effects that such changes in DSM-5 will have on clinical practice are yet to be determined, but there is the potential for improved assessment of stressor-related conditions in children, now that the criteria are more relevant and appropriate. This is essential, both for identifying stressors such as one or more types of child maltreatment, which can then potentially be stopped from continuing or recurring, and for providing evidence-based interventions to reduce impairment. Increasingly we have approaches such as trauma-focused cognitive behaviour therapy and child–parent psychotherapy which have shown benefits in reduction of PTSD symptoms in children exposed to sexual abuse and intimate partner violence, although additional trials are needed to determine the generalisability of these programs.
Critics of the DSM-5 suggest that lowering the threshold for certain conditions or expanding the symptom criteria may lead to over-diagnosis, that is, identification of conditions that do not necessarily need treatment. In the area of trauma-related and stressor-related disorders, especially in childhood, the problem has been one of under-diagnosis rather than over-diagnosis. Furthermore, the need for both a history of exposure and specific trauma symptoms, as well as association with significant distress or impairment, reduces the likelihood that over-diagnosis will occur in this area.

Perhaps the way in which the DSM-5 changes have the greatest likelihood of improving clinical care for children with stressor-related conditions is through improvement in assessment of outcomes in research evaluating the effectiveness of interventions. A recent comparative effectiveness review of interventions addressing child maltreatment determined that although some programs show promise in improving child well-being and child welfare benefits, the evidence is still very limited. One of the limitations identified in this review was the ‘wide heterogeneity in type and psychometric soundness of outcome measurement across studies.’ Possibly the revised classification in DSM-5 will facilitate better outcome measures of stressor-related conditions that can then be used in ensuring high-quality evaluations of existing and forthcoming interventions.”

Read: 15 New Disorders in the DSM-5

Sources

What’s new in DSM-5 for clinicians working with children exposed to trauma? Harriet L. MacMillan
http://bmcmedicine.biomedcentral.com/articles/10.1186/1741-7015-11-202

DSM overhaul stirs controversy – Kristen Gerencher
http://www.marketwatch.com/story/dsm-overhaul-stirs-controversy-2013-05-22

American Psychiactric Association – DSM-5
http://www.dsm5.org/Pages/Default.aspx

Where to get help

Your GP is the best place to start.
Search for a counsellor near you – www.theaca.net.au
Beyond Blue – Have a list of recommended GPs who are experienced in dealing with mental health issues. You can search one on the website nearest you. Phone 1300 22 4636 https://www.beyondblue.org.au/
Lifeline – A free 24 hour Crisis Counselling service – 13 11 14 www.lifeline.org.au