Essentials of Psychiatric Diagnosis: Responding to the Challenge of DSM-5®
218
Essentials of Psychiatric Diagnosis: Responding to the Challenge of DSM-5®
218eBookRevised Edition (Revised Edition)
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Overview
Product Details
| ISBN-13: | 9781462513703 |
|---|---|
| Publisher: | Guilford Publications, Inc. |
| Publication date: | 08/08/2013 |
| Sold by: | Barnes & Noble |
| Format: | eBook |
| Pages: | 218 |
| File size: | 2 MB |
About the Author
Allen Frances, MD, is a clinician, educator, researcher, and leading authority on psychiatric diagnosis. He chaired the DSM-IV Task Force, was a member of the Task Force that prepared DSM-III-R, and wrote the final version of the Personality Disorders section in DSM-III. The author of several hundred papers and more than a dozen books, most recently Saving Normal: An Insider's Revolt against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life, Dr. Frances is Professor Emeritus and former Chair of the Department of Psychiatry and Behavioral Sciences at Duke University.
Read an Excerpt
CHAPTER 1
How to Use This Book
This book provides a concise and user-friendly guide to more accurate diagnosis and coding. It offers:
• One or more screening questions for each disorder. (Note that not every mental disorder in DSM-5 is covered in this book; I have omitted a few that do not seem useful.)
• Clear prototypal descriptions of these mental disorders, rather than complex and cumbersome criteria sets that are often ignored.
• The most crucial differential diagnoses that must be ruled out for each disorder.
• Diagnostic tips — everything I have learned through 40 years of seeing patients; supervising trainees; and preparing DSM-III, DSM-III-R, and DSM-IV.
• The required ICD-9-CM codes for each disorder, and ICD-10-CM codes whenever feasible.
• Cautions to reduce diagnostic inflation and counter the influence of fad diagnosing.
• Cautions on questionable aspects of DSM-5.
AUDIENCE
Essentials of Psychiatric Diagnosis is meant for everyone with an interest in psychiatric diagnosis. Practitioners from all the mental health disciplines and at all levels of experience should find valuable tips to aid them in arriving at the right diagnoses and codes. For beginning students and trainees, the book provides a manageable, but fairly comprehensive, introduction to the most important things worth knowing about psychiatric diagnosis. Test takers and board candidates will find it a valuable study guide. Harried primary care doctors (who do 80% of the prescribing of psychiatric medication) will be directed toward an accurate diagnosis in the limited time they have with each patient. Seasoned clinicians may think they already know everything they need to know about diagnosis, but my experience suggests that most do not. I learned a lot in writing this book, and I doubt that there are many mental health workers who will not learn a lot in reading it. Last, but never least, are the patients and families who may find this a useful tool in the process of becoming more informed consumers. Patients have always been my teachers; it is nice to have the chance to return the favor. I have enjoyed writing this book and hope that all of its readers will enjoy using it.
Two notes on my use of pronouns are in order at the outset. First, although I use "you" to refer to "the clinician" in much of what follows, my intent is always to include patients and their families in my audience. Second, in referring to "the patient," I have generally tried to alternate between masculine and feminine pronouns, except in cases where patients with a particular diagnosis are almost all either male or female.
ORGANIZATION OF THE BOOK
Not every mental disorder included in DSM-5 is included in this book; I have omitted a few that simply do not seem useful. I have also not used the names that a few disorders were eventually given in DSM-5. Moreover, the sequence of mental disorders presented here differs sharply from their inconvenient organization in DSM-5. I have based their ordering roughly on their frequency of appearance in an average clinical practice and on the interest typical clinicians and students will have in them. This helps to focus attention on the most important trees in the vast and dense forest of DSM mental disorders, and it highlights the issues that are most interesting and telling in differential diagnosis. A welcome bonus is that the book, so ordered, becomes a much more inviting and useful cover-to-cover read, not just a dry reference. The table of contents indicates the page on which each mental disorder is covered, along with its ICD-CM codes.
Every disorder has its story to tell, and each illustrates the fascinating variety of human behavior in sickness and in health. Each chapter begins with a list of the disorders it covers. Within the chapters, the ICD-9-CM code (and, whenever feasible, the ICD-10-CM code) is given with each disorder's main entry. The ICD-9-CM code is presented in heavier gray type, followed by a slash (/) and the ICD-10-CM code, presented in lighter type. By international treaty, all countries in the world use the codes of the International Classification of Diseases (ICD). Countries other than the United States have been using the ICD-10-CM coding system for some time. In DSM-IV, the Diagnostic and Statistical Manual of Mental Disorders codes were the ICD-9-CM codes, but DSM-5 presents both the ICD-9-CM and ICD-10-CM codes. Because the ICD-10-CM system is far more complex than ICD-9-CM, not every ICD-10-CM code for every disorder is given in the table of contents or text, to keep this book brief and user-friendly. More ICD-10-CM codes are provided in the Crosswalk to ICD-10-CM Codes (p. 193), and the Resources for Codes page (p. 218) provides links to several crosswalk/conversion websites.
Diagnostic Prototype versus Criteria for Diagnosis
The entry for each of the mental disorders begins with a screening question and a brief prototypal description. DSM-5 is such a large book in part because it contains sets of very detailed diagnostic criteria that define each diagnosis. The introduction of this method when DSM-III was published in 1980 was a great advance in the history of psychiatry because the careful use of criteria (especially in research and forensic environments) can lead to greatly enhanced reliability. Without criteria, psychiatric research would be impossible, and our field would lose credibility. But there is a hitch: Criteria sets are so cumbersome that most clinicians simply don't use them. Many say that they have committed the criteria sets to memory, but I know this is impossible. There are so many criteria for so many disorders that no one can possibly remember them. I have tested many very experienced and presumably expert diagnosticians on their recall of the specific items included in various criteria sets. They routinely fail, usually quite badly. Given the vicissitudes of memory, proper practice would be to look up the pertinent DSM sections before making a diagnosis, or to use a DSM checklist, but most busy clinicians do neither.
So I have taken an alternative approach in this book. Instead of offering diagnostic criteria that people won't remember, I provide a descriptive prototype for each diagnosis that captures its essence, hopefully in a more memorable way. This "prototypal method" is useful and convenient, and is the method almost all clinicians use anyway. But it also has clear limitations. More precise diagnosis (using explicit and detailed diagnostic criteria, and perhaps semistructured interviews) is clearly preferable for situations where more time is available and when establishing reliability is of paramount importance — for example, in research studies, in forensic proceedings, in disability determinations, when the diagnosis is particularly unclear, or when treatment based on a prior diagnosis has failed.
Differential Diagnosis and Diagnostic Tips
Following each prototypic description, there is a comprehensive differential diagnosis listing the conditions that need to be ruled out. Diagnostic tips specific to each diagnosis are provided. Whenever the differential diagnosis is difficult, you will find it useful to go back and forth between the likely contenders as you consider where your patient fits best. If there is insufficient information to permit you to choose between them, or if neither really fits well, feel comfortable being tentative with the best "Unspecified" choice (see below).
Crosswalk to ICD-10-CM Codes and Resources for Codes
An Appendix (Crosswalk to ICD-10-CM Codes, p. 193) provides a quick reference for converting ICD-9-CM codes to ICD-10-CM, and additional detail on ICD-10-CM codes where appropriate. The Resources for Codes page (p. 218) provides URLs for several crosswalk/conversion websites. These materials are also provided on the publisher's website (www.guilford.com/frances_updates), together with an alternative version of the Crosswalk in which disorders are listed alphabetically.
Index of Disorders by Symptoms
The Index of Disorders by Symptoms allows you to determine which mental disorders should be considered for each presenting symptom. Checking this is a useful way to ensure that you are not missing any of the possibilities.
CONTAINING DIAGNOSTIC INFLATION AND AVOIDING FADS
Retrospective epidemiological studies report that 20% of the general population qualifies for a current psychiatric diagnosis and 50% for a lifetime one. Prospective epidemiological studies double these rates and suggest that mental disorder is becoming virtually ubiquitous. During the past 20 years, we have experienced three unanticipated fads partly precipitated by DSM-IV: a 20-fold increase in Autism Spectrum Disorder, a tripling of Attention-Deficit/Hyperactivity Disorder (ADHD), and a doubling of Bipolar Disorders. The most dangerous fad is a 40-fold increase in childhood Bipolar Disorders, stimulated, not by DSM-IV, but instead by reckless and misleading drug company marketing. Twenty percent of the U.S. population is taking a psychotropic drug; 7% is addicted to one; and overdoses with legal drugs now cause more emergency room visits than overdoses with illegal drugs.
I don't think we are experiencing a real epidemic of increased mental disorders; instead, we are in the midst of an epidemic of careless diagnosis and loose prescription habits. Very small changes in how disorders are defined and in how the diagnostic criteria are applied can result in enormous changes in the reported rates of disorders and in the use of medications. Part of my goal in this book is to help correct diagnostic inflation and curtail or prevent fads. Whenever appropriate, I provide cautions and recommendations on how to avoid the loose diagnostic practice that leads to overdiagnosis. The wise clinician is always cautious and goes against fads rather than joining them. If everyone suddenly seems to have a diagnosis du jour, most probably don't.
PROBLEMS WITH DSM-5
DSM-5 suffers from the unfortunate combination of unrealistically lofty ambitions and sloppy methodology. Its optimistic hope was to create a paradigm-shifting advance in psychiatry; instead, the sad result is a manual that is not safe and not scientifically sound. For example, it has introduced three new disorders that are at the fuzzy boundary with normality: Binge-Eating Disorder, Mild Neurocognitive Disorder, and Disruptive Mood Dysregulation Disorder. Unless these diagnoses are used with restraint, millions of essentially normal people will be mislabeled and subjected to potentially harmful treatment and unnecessary stigma. DSM-5 has also lowered the requirements for diagnosing existing disorders. For example, 2 weeks of normal grief have been turned into Major Depressive Disorder. The criteria for adult ADHD have been loosened, making it easily confused with normal distractibility and facilitating the illegal misuse of prescription stimulants for performance enhancement or recreational purposes. DSM-5 has collapsed early Substance Abuse and end-stage Substance Dependence (addiction) into one category, confusing their very different courses and treatment needs and creating unnecessary stigma.
None of these changes was based on a solid scientific foundation; none has been tested sufficiently; none has any proven relation to effective treatment; and all are subject to grave misuse. For example, Disruptive Mood Dysregulation Disorder is included in DSM-5, despite its having been studied by just one research group for only 6 years. A petition by 51 mental health associations that the DSM-5 changes be reviewed by independent experts in evidence-based medicine was rejected without explanation. DSM-5 has thus opened the floodgates to worsened diagnostic inflation and to excessive medication use.
CAUTION Boxes
My advice is to beware of changes introduced by DSM-5 that encourage diagnostic inflation. To aid clinicians in avoiding such inflation, I have discussed problematic DSM-5 disorders in Caution boxes within relevant sections. The boxes include explanations of why I think these specific diagnoses should be used rarely, if at all. Caution boxes also appear following the diagnostic prototypes for those established disorders most likely to be misdiagnosed if the lowered DSM-5 thresholds are used.
Be mindful that not all symptoms and problems in living are caused by mental disorders, and that mislabeling can be extremely harmful to those mislabeled. In judgment call situations, it is always much safer and more accurate to underdiagnose than to overdiagnose. It is easy enough to add a diagnosis when time and experience prove it to be appropriate, but once a misdiagnosis is made, it takes on a life of its own and is very hard to unmake. In the rest of this chapter, I offer clinicians some practical guidelines for reaching accurate diagnoses.
THE DIAGNOSTIC INTERVIEW
The Relationship Comes First
An accurate diagnosis comes from a collaborative effort with a patient. It is both the product of that good relationship and one of the best ways of promoting it. The first interview is a challenging moment, risky but potentially magical. Great things can happen if a good relationship is forged and the right diagnosis is made. But if you fail to hit it off well in the first visit, the person may never come back for a second. And the patient doesn't always make it easy. It is likely that you are meeting him on one of the worst days of his life. People often wait until their suffering is so desperate that it finally outweighs the fear, mistrust, or embarrassment that previously prevented them from seeking help. For you, a new patient may be just the eighth patient you see in a long and hectic work day. For this patient, the encounter is often freighted with expectations that are exaggerated for good or for bad. Every diagnostic evaluation is important for the patient, and it should be for you too. The focus, first and always, should be on the patient's need to be heard and understood; this must trump all else.
Make Diagnosis a Team Effort
Make the search for the diagnosis a joint project that displays your empathy, not a dry affair that feels invasive — and always provide information and education. The patient should walk out feeling both understood and enlightened. Never forget that this evaluation may be a crucial tipping point that can change the patient's entire future.
Maintain Balance in the First Moments
There are two opposite types of risk that occur in the first moments of the first interview. Many clinicians prematurely jump to diagnostic conclusions based on very limited data and stay stuck on incorrect first impressions, blinded to subsequent contradictory facts. At the other extreme are those who focus too slowly, missing the amazingly rich information that immediately pours forth on the first meeting with a patient. Patients come in primed to convey a great deal to you, intentionally and unintentionally, through words and demeanor. Maintain balance — be extra alert in those first few minutes, but don't jump quickly to diagnostic conclusions.
Balance Open-Ended with Checklist Questions
Until DSM-III, training in interviewing skills emphasized the importance of giving the patient the widest freedom of expression. This was extremely useful in bringing out what was most individual in each person's presentation, but the lack of structure and specific questioning led to very poor diagnostic reliability. Clinicians can agree on diagnosis only if they gather equivalent information and are working off the same database. The desire to achieve reliability and efficiency has led clinicians at some centers to go very far in the opposite direction: They do closed-ended, "laundry list" interviews focused only on getting yes–no answers to questions exclusively based on DSM criteria. Carried to extremes, both approaches lose the patient — the former to idiosyncratic free form, the latter to narrow reductionism. Let your patients reveal themselves spontaneously, but also manage to ask the questions that need to be asked.
Use Screening Questions to Hone in on the Diagnosis
The surest way toward a reliable, accurate, and comprehensive diagnosis is a semistructured interview that combines a wide range of open-ended and closed-ended questions. However, this takes hours to perform and is possible only in highly specialized research or forensic situations, where time is no object and reliability is all-important. The everyday clinical interview necessarily requires shortcuts; you can't ask every question about every disorder. After listening carefully to the patient's presenting problems, you must select which branch of the diagnostic tree to climb first. Place the symptoms among the most pertinent of the broad categories (e.g., Depressive Disorders, Bipolar Disorders, Anxiety Disorders, Obsessive–Compulsive Disorder [OCD], Psychotic Disorders, Substance-Related Disorders, etc.). Then ask screening questions (provided for each disorder) to start narrowing down to the particular diagnostic prototype that best fits the patient. Before feeling comfortable with your diagnosis, make sure you explore with the patient the alternative possibilities covered in the differential diagnosis section for that disorder. I'll be giving diagnostic tips that will help you along the way. Always check for the role of medicines, other substances, and medical illnesses in everyone you evaluate.
(Continues…)
Excerpted from "Essentials of Psychiatric Diagnosis, Revised Edition"
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Copyright © 2013 The Guilford Press.
Excerpted by permission of The Guilford Press.
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Table of Contents
1. How to Use This Book2. Disorders Usually First Diagnosed in Childhood and Adolescence
3. Depressive Disorders
4. Bipolar Disorders
5. Anxiety Disorders
6. Obsessive-Compulsive and Related Disorders
7. Trauma- and Stressor-Related Disorders
8. Schizophrenia Spectrum and Other Psychotic Disorders
9. Substance-Related Disorders and Behavioral Addictions
10. Neurocognitive Disorders
11. Personality Disorders
12. Impulse Control Disorders
13. Eating Disorders
14. Sleep-Wake Disorders
15. Sexual and Gender Issues
16. Disorders Related to Physical Symptoms
17. Dissociative Disorders
18. Codes for Conditions That May Be a Focus of Clinical Attention but Are Not Mental Disorders
Appendix. Crosswalk to ICD-10 Codes
Resources for Codes
Interviews
Psychiatrists, clinical psychologists, clinical social workers, psychiatric nurses, and counselors working with adults and children; graduate students and trainees. Also of interest to primary care physicians. May serve as a supplemental text in graduate-level courses.