Critical Evaluation Of Major Changes From DSM IV To DSM V In Bipolar Disorder, Autism Spectrum, And Dementia Reclassification Essay.

Introduction to DSM

Question:

There are several changes from DSM IV to DSM 5 manuals in diagnostic criteria and grouping. Critically evaluate three of these major changes.

Diagnostic and Statistical Manual of Mental Disorders (DSM) is an authoritative guide published by American Psychological Association (APA) used by health care professionals guiding the diagnosis for mental disorders containing symptoms, descriptions and criteria. Many editions of DSM are being modified, reviewed and enlarged when first DSM I was introduced by APA in 1952. New categories of diagnosis were introduced with distinct hierarchy in well-known practice recommending single pathology identification explaining clinical status symptoms (Birgegård, Norring and Clinton 2012). Gradually, the concept of DSM III was abolished and the concept of co-morbidity was introduced confirming DSM IV during 1990s. In 2013, a new version was introduced by APA providing an official list of mental disorders. It guides treatment for mental disorders being the largest change reflecting scientific understanding of the mental issues and its treatment. A lot of modifications took place from DSM IV to DSM V having implications on the understanding and treatment of mental disorders. The modifications took place in seven aspects; autism spectrum, bipolar disorder, ADHD diagnosis, PTSD symptoms, dementia reclassification, intellectual disability and artificial categorization modification (Regier, Kuhl and Kupfer 2013). The following discussion involves the critical evaluation of three major changes from DSM IV to V in terms of bipolar disorder, autism spectrum and dementia reclassification.

The main change occurred in DSM V is that the terminology of “general medical condition” is modified to “another medical condition” relevant for disorders. DSM IV failed to reflect upon the shared symptoms or features of diagnostic groups like bipolar disorders with psychotic disorders, internalizing (depressive, anxiety, somatic) or externalizing disorders (conduct, substance abuse, impulse control) (Cosgrove and Krimsky 2012). On a contrary, DSM V restructured interrelationships, across and within diagnostic chapters. The strength of earlier DSM classification was to diagnose baseline psychiatric diagnosis on the defined and operational criteron that resulted in inter-rater reliability. This was the greatest weakness in DSM IV where patients were formally diagnosed under which only half of the patients were actually treated.  There was lack of operational categorization of subthreshold diagnoses in DSM IV whereas in DSM V, there is high recognition where large number of patients is seeking treatment who were formally under “Not Otherwise Specified” (NOS) group (Kupfer, Kuhl and Regier 2013).

Elimination of bipolar disorder is a major modification from DSM IV to V. DSM IV contains diagnosis of mixed episode, bipolar I disease requires that the person meet the full criteria simultaneously for major depressive episode and mania that is removed in DSM V. There is enhancement in the accuracy for diagnosis and its facilitation at early stage detection in the clinical settings. The criterion A now contains hypomanic and manic episodes including an emphasis on the energy and activity changes and mood in DSM V. This change from IV to V removed the restriction and helpful in diagnosing patients from DSM IV subdiagnostic bipolar syndromes (Grunze et al. 2017).

Restructuring of Diagnosis Categories in DSM V

In the new version, a specific terminology “mixed features” is added applying to episodes of hypomania and mania and previous criteria is removed. In this, depressive features and its episodes in the context of bipolar or depressive disorder are added when hypomania/mania features are present. DSM V also allows the accurate specification of particular conditions that is related to bipolar disorder that includes categorization of individuals with past history of major depressive disorders meeting the criteria for hypomaniac condition except duration criterion of consecutive four days (Swann et al. 2013). The second condition that comprises other specified bipolar related disorder having fewer symptoms of hypomania meeting criteria for full bipolar II syndrome however, duration for four days is sufficient.   

The diagnosis of bipolar disorder in DSM IV has few shortcomings; large proportion of patients who were treated for the bipolar disorders had to be allocated to NOS and vague groups. However, with the introduction of DSM V, bipolar disorders are identified with a new specifier of mixed features applied to hypomania or mania episodes where depressive features are exist. In DSM V, there is also elimination of childhood bipolar disorder as in DSM IV; there was a harmful over-diagnosis and treatment of this condition. However, in DSM V, there was removal of this condition replaced with Disruptive Mood Dysregulation Disorder (DMDD), where all children who were formally diagnosed with bipolar disorder will fall under the category DMDD (Etain et al. 2013). This new category does provide a new way to diagnose this condition more accurately matching set of symptoms characterized by extreme tempered outbursts. Many threshold groups have been added to bipolar disorders, depression and mixed states that are operational in DSM V. The mania and hypomania episodes encountered during treatment of depression under certain conditions are also added under bipolar disorders.  

DSM V main lines the definition of major depressive disorders basic to DSM IV. Hypomanic and manic episodes are radically revised in this new version impacting on bipolar disorders. Three main changes are being witnessed in DSM V regarding gate questions of hypomania and mania (criterion A), reduction in exclusion criteria and vigorous effort for the operationalization of subthreshold syndromes in bipolar disorder that were earlier diagnosed as NOS (Uher et al. 2014). The mood change that is accompanied by persistent increase energy or activity levels is also included in DSM V. However, this new version is quite strict and restrictive excluding the people who report only one out of three bipolar symptoms and also irritable and elated mood. Apparently, individuals who had been diagnosed with bipolar I or II disorders or manic episodes in DSM IV are now being classified as subthreshold bipolar group under DSM V. On a contrary, the new strict DSM V rule is not data based and there is indeed contradiction of available evidence.

According to Angst (2013) patients receiving treatment for major depressive disorders demonstrated one of the three gate questions clearly and with validity. In addition, Exclusion criteria are one justified and amplified change in DSM V concerning bipolar II disorder diagnosis. DSM IV major change in depression into hypomania was exclusion criteria principle. However, in DSM V, it explained that this condition persists at full level syndrome that is beyond physiological effect of the treatment being explicit bipolar II disorder criterion. DSM V is like DSM IVV allowing scope for clinical judgment to causality. There is also a new formal criterion for medication or substance-induced bipolar related disorder. According to Angst et al. (2012) DSM V will be able to diagnose bipolar II disorder twice as often as bipolar I having a prevalence approach. Bipolar II will be more frequently diagnosed in logical and justified manner explaining a milder condition more prevalent than severe mania. According to Phillips and Kupfer (2013) during the long-term illness, bipolar patients experience milder conditions like minor depression rather than major syndromes.

Elimination of Bipolar Disorder in DSM V

However, despite of the advancement made in the new version, bipolar disorder is still under-recognized in DSM V. The epidemiological studies and its re-analyses demonstrated that major depressive disorder (MDD) is a heterogeneous group with% hidden cases. It requires systematic screening for hypomania in individuals with previous history showing little appreciable impact on hidden bipolarity detection (Koukopoulos and Sani 2014). Concisely, even after DSM V introduction, vast majority of major depressive episodes (MDE) continued to be diagnosed under MDD.

The second modification in DSM IV is autism spectrum diagnostics classification. In DSM IV, pervasive development disorders were also considered under autism spectrum disorders (ASDs). This includes Asperger’s disorder, autistic disorders and pervasive Developmental Disorder Not Otherwise Specified (PDD-NOS). However, with the introduction of DSM V released in 2013, significant modifications have been done in the ASDs categorization. The main reasons for change includes; there was difficulty in applying criteria for PDD subtypes schematically, children diagnosed with AS met the criteria for AD being similar and for controlling the exponential rise in cases (McPartland, Reichow and Volkmar 2012). In DSM V, the four separately classified issues that are very common being unified under ASDs header. The previous categories of DSM IV are no longer in use and separate levels are replaced under one umbrella of ASDs. The severity levels of ASDs are based on support needed for the patients in terms of challenges faced with repetitive behaviours, social communication and restricted interests. The revision suggests that older version was not precise and various clinicians diagnose patients with different disorders and also some changes diagnosis because of same symptoms differing year to year. In the new version, autism is defined by common set of behaviour characterized by single terminology according to severity levels 1, 2 and 3. The removal of PDD-NOS and Asperger’s disorder is the significant change in DSM V and patients who are currently diagnosed with these conditions will be re-diagnosed and evaluated (Grzadzinski, Huerta and Lord 2013). However, this may create confusion among parents of children who are diagnosed with these conditions, adults and children who are strongly identified with these diagnoses.

The new ASDs classification is stricter, thorough as compared to old criteria. In DSM V, more symptoms are required to meet the new criteria within arena of fixated interests or repetitive behaviours. There is also reorganization made in DSM V as DSM IV currently holding domains for ASDs includes impairments in communication, social interaction, restricted interests and repetitive behaviours. In DSM V, social interaction, communication domains have been merged into one entitled, Communication/Social Deficits (Frazier et al. 2012). This is a remarkable change where language development delay is no more necessary for the diagnosis. Although, the modifications are made with a hope to make ASDs diagnosis more reliable, specific and valid, however, there are legitimate concerns raised regarding the impact of people on the spectrum of autism. The biggest concern is that the higher functioning patients will no longer be able to meet the guidelines of strict diagnostic criteria and therefore, will face difficulties in accessing the relevant services. The main question is what will happen to the patients who are currently diagnosed with PDD-NOS or Asperger’s disorder (Kim et al. 2014). There is also growing uncertainty that how the educational and state services, insurance companies will adopt to these modifications.  

Changes in DSM V regarding Autism and Dementia

In DSM V, to fulfil ASD criteria, symptoms must be present during childhood manifesting social demands exceeding capacities having a marked effect on the functional ability and level of severity specified. Apart from removal of separate Asperger’s and autism categories to ADSs, there is also removal of criteria including; cognitive and language delay, lack of imaginative or varied play. The levels are also well specified under DSM V. Level 3 comprises of categorization requiring highly substantial support measuring severe deficits in non-verbal and verbal communication, very limited response and initiation as compared to others. Level 2 requires substantial support having marked deficits in communication, abnormal response and limited initiation speaking few words. Lastly, level 1 category requires support having deficits in social communication, unsuccessful overtures and deficits in response and initiation (Mahjouri and Lord 2012).

The new diagnosis for autism in DSM V is purely based on behaviours and no differentiation of Asperger syndrome, PDD-NOS and Childhood Disintegrative Disorder. There is no definition for aetiology within ASD with simplified approach and fewer ways for a person to meet criterion in two domains. The social communication domain also recognizes the social function of communication being some of the advantages of DSM V ASD (Lai et al. 2013). It is evident that ASD changes will be going to affect people and families currently diagnosed with ASD and pose challenge to clinicians on how they are going to use this new criterion for the evaluation of children and its impact on availability of resources.  

Reclassification of dementia is another modification from DSM IV to V. In the new version, dementia and learning or memory difficulties categories called amnestic disorders are subsumed into a new category of major neuro-cognitive disorder (NCD) (Tay et al. 2015). This new criteria splits the disorder into broad severities of major and minor for encouraging early detection, treatment of the issues. The terminology, dementia in etiological subtypes is not precluded from application where this term is standard. In DSM V, cognitive impairment at less severe level, a new disorder permitting diagnosis of less disabling syndromes, mild NCD, nonetheless might be the focus of treatment and concern. The diagnostic criteria in DSM IV comprises of memory impairment (category A1) and fulfilling of one or more symptoms like apraxia, aphasia, agnosia and executive functioning disturbance (category A2). Category B- the cognitive deficits in A2, A1 causing significant impairment in occupational or social functioning representing significant decline in functioning level. Category C defines that cognitive deficits does not occur exclusively during course of delirium (Sachdev et al. 2014).

DSM V criteria (previously dementia) is now NCD providing evidence for cognitive decline from decreased performance level in one or more domains of cognitive functioning like language, memory and learning, complex attention, executive function, social cognition and perceptual-motor being category A with no sub classification (Strydom et al. 2013). Category B defining cognitive deficits interfering with independence and assistance required for activities of daily living (ADL) classified under NCD. Category C defines that cognitive deficits is not exclusive in delirium and a new category D is introduced defining that cognitive deficits not explained by other mental disorders like schizophrenia and major depressive disorder. The new version focuses on the decline from level of functioning rather than cognitive deficits and term “NCD” removed the stigmatization that people have about older term “dementia”.

Changes in DSM V regarding Hypomania and Mania

There is potential fallout in this change as healthcare professionals have to spend considerable amount of time in understanding and transitioning to new system learning the differences between minor and major NCDs and explanation of significance and differences to the patients and family members. This new system can confuse older individuals about dementia as they consider it as Alzheimer failing to comprehend between the two conditions. Another challenge is lack of recognition regarding the minor condition as patients may not be serious about the progression to major condition (Carpenter and Tandon 2013). Using DSM V, clinician will diagnose major or minor condition due to Alzheimer and MCI will be diagnosed as mild NCD due to Alzheimer leaving the end result confusing for the clinician, patient and family members.  The concept needs to be explained to the population with correct guidance for eliminating the confusion.

From the above discussion, it can be concluded that DSM V is a strict, advanced and restrictive form than DSM IV. DSM IV is a statistical and diagnostic manual adopted by APA in correlation with ICD-10 Classification of Mental and Behavioural Disorders by World Health Organization (WHO). DSM IV was used as an axial system grouping disorders into broad categories like personality disorders, mental retardation, and all psychological categories except personality disorder and mental retardation. In contrast, DSM V provides better classification of dementia, autism and bipolar disorder. Asperger’s disorder and pervasive disorder are put under category of ASD, bipolar disorder falling under DMDD and reclassification of dementia. In this, amnestic disorders are subsumed into new category NCD splitting into broad categories. DSM V has controversial issues like Asperger’s disorder removal and inclusion within Autism much to dismay of current patients with this disorder. However, DSM V is a right step towards acknowledging new terms and mixed groups in bipolar disorder. In addition, it created confusion among the clinicians and require consideration in learning and explaining the new version to the patients. It causes potential fallout for the patients who are currently being diagnosed or treated for the conditions that are being removed or merged. Therefore, DSM V provide significant changes from DSM IV providing tightened up definitions, adding rating levels of severity and elimination or grouping of specific disorders. The diagnostic criteria are clarified and provide changes for the clinicians outlining more valid diagnoses.

References

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Exclusion Criteria Principle in DSM V

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