Tuesday, July 2, 2013


I just received my new American Psychiatric Assocation, Diagnostic and Statistical Manual of Mental Disorders - DSM5 - 5th edition.  It's been a long awaited highly controversial text. I've just done the overview and really it's looking overall very good. The devil's in the details but first glance this is a great book.  A whole lot of terrific work.  Well done! 
July3, 2013
I got to read some more of DSM5
PTSD criteria has been broadened over all but has some more specific subcategories. I think it is more in line with the way it has been used clinically though I can see problems arising. Overall it's clear that some serious thinking has gone into this area of trauma related illness and it's well reflected in the clinical thinking inherrent in the changes since DSMIV. This is an area I work alot with and can see myself enjoying using the DSM5 without any overt concerns.
Bipolar Disorder II - the Bipolar Disorder I has remained much the same and hasn't had any controversy attached to it over the years.  Mania is a pretty drastic presentation so it's not one that gets overly misdiagnosed.  Bipolar II however has had serious flaws in diagnostic thinking lacking any real 'exclusion' criteria surrounding the term hypomania.  The idea that 'hypomania is irritability' is where the major crux is. If you're 'irritable' for 4 days now you can be diagnosed with a 'major' mental illness which can reflect on you 'freedom', 'work', 'income' and reputation.  However, a psychiatrist can safely prescribe a wide variety of medications that are likely to improve your mood.  Bipolar II and Bipolar Spectrum Disorders has been where drug companies have had their recent greatest influence as well reported in the book Unhinged, among other sources. That said there's really clear evidence that while the DSM folk might have still been overly influenced by the industry in this regard, there's an attempt to tighten up the diagnosis in specific areas. Therefore I'd say that the prescription pad psychiatrist won't be changed by this but a more concerned clinician with some diagnostic conscience will find this a better diagnosis than was available previously. 
Cyclothymia is well detailed in DSMV.
Substance Abuse - this was a very controversial area and it leaves a lot to be desired.  But it's far from as bad as some of us Addiction Psychiatry/Addiction Medicine sort thought.  It's only about 10years outdated in conceptualization but it's not 50 years out of date or on another planet like some feared.  It's really not changed much from DSMIV on first sight . Again the details will count.  There's some improvement in language. What I do like is that substance use depression is under depression. There was obviously a need for the Substance Use Disorder like this to be categorized under the headings and this has been done with Substance Use Psychotic disorder listed in the grouping for
Schizophrenia and Psychotic Disorders.  When all the chameleon colours of substance abuse disorders was listed separately novice practitioners and especially counsellors routinely misdiagnosed substance abuse psychosis and mood disorder and anxiety disorders because they were not listed under psychosis, mood or anxiety.  This is an improvement I think. The category of substance abuse itself in he desk reference is just fine, broad and specific as needed. Consistent with ICD9and 10 and not much different from DSMIV and probably easier to use clinically in the desk reference because the presentations of this category are often messy and overlapping. The specificity of the previous DSMIV was fairly academic and there's evidence this is more user friendly
The specific substance abuse areas are well documented too
Obviously I'll have more to say about this category when I go through the big book in detail but really it's not as crazy as people feared. I think everyone can work with it but appreciate that Addiction folk feel short changed as the opportunity for DSM5 to reflect the scientific advances in the field, as evidence by MRI, PET, blood urine, end organ damage etc and all the advanced knowleded now available in genetics and neurochemistry isn't clearly evidenced but that's possibly not the job of DSMV. 
Schizophrenia and Psychosis - I think this section is pretty damn good.  It's really well described schizophrenia, brief psychotic episodes, schizophreniform illness, schizoaffective disorder and substance induced psychosis. Can't see anything with first overview I'd disagree with.
 Personality Disorders- I'm really pleased that  the original Jungian categories of essentially odd, extrovert and introvert have been maintained.  There's been major advances in this field which are represented by more dimentionality but frankly I was concerned with clinically having to learn a whole new way of thinking about personality even if it's more scientific. I can see doctors working in this field being very disappointed but again I'm kind of happy it's not going to change the whole Axis II thinking radically. I suspect others that don't work in my areas of interest will like the conservative elements that have influenced DSM5 because while I individually as an addiction psychiatrist who works with trauma have specific concerns I'm pleased when I see that others broad areas have retained their overall basis.  DSM5 is a major undertaiking as much political as scientific, just getting all the doctors with competing agendas to sit at the table.
And this is looking overall like a really worthwhile undertaking.  An amazing contribution like a new encyclopedia Britanica.
The Neurocognitive Domains is a great section that really is an advance and reflects much of the new knowledge in traumatic and degenerative brain changes. Well done DSM5
The Sexual Dysfunction section in DSMIV was really well established and there's more of the same good thinking and work in this DSM5.
Eating disorders seems good too. No surprises, nothing off the wall. Just what we're concerned about clinically.
The Dissociative disorders were highly controversy but seem to be here in a very usable form. 
Somatic Sympton and related disorders seems on first glance to be better conceptualized overall and a very useful set of categories laid out the way clinicians think./
The sleep disorders are well established also with clear definitions and criteria. 

I''m going to say that again with first and second go round at this book, the DSM5 is a truly great work overall with naturally some areas of controversy. It's been a long time coming and a whole lot of very dedicated folk have done an overall amazing job at categorizing mental illness in a way that is clearly going to be useful to clinicians.  Having seen some 10 thousand psychiatric cases over a quarter century or so I think this new DSM5 is going to serve me well.  I'm looking forward to to the courses and controversy and discussions that will flow from this book and result in development of a likely even better DSMV.  It's only too bad that DSMV doesn't have a 'spiritual psychiatry" section.  A V code would have been nice. That would be asking the APA to raise the bar higher than it's usually used too though. Other V codes have been improved on in a major way with the addition of 'suspected and confirmed categories" in the case of 'abuse' which previously was 'assumed true' when indeed it's turned out that there's a real place in the world for the legal term 'alleged' and it's apparent that psychiatric diagnosis are demanding some 'boundaries' in this regard. 

There's a lot of little category changes and additions which will need specific review but again overall it's really an admirable work.

 I know DSMIII is a whole other animal than this DSMV. I'm looking at the advances in my life time a bit like the Star Trek series of enterprises over the centuries of that show and this is only in a matter of decades. The advances made in science and the clinical progression is truly amazing. 

The American Psychiatric Association deserves to be highly applauded for this major and extraordinary contribution to our collective medical knowledge.  Thank you to all involved in the production of DSM5. 

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