Recommendation for DSM-V: A Proposal for Adding Causal Specifiers to Axis I Diagnoses

| December 27, 2010 | 0 Comments

by Ahmed Aboraya, MD, Dr.PH
Dr. Aboraya is Chief of Psychiatry, William R. Sharpe, Jr. Hospital, Weston, West Virginia; Clinical Professor of Psychiatry, West Virginia School of Osteopathic Medicine, Lewisburg, West Virginia; and Director of World Health Organization (WHO), SCAN Training and Reference Center, West Virginia University, Morgantown, West Virginia.

Psychiatry (Edgemont) 2010;7(12):24–28

Funding: There was no funding for the development and writing of this article.

Financial Disclosures: The author has no conflicts of interest relevant to the content of this article.

Key Words: DSM-V, psychiatric classification, validity criterion, causal specifiers, definite etiopathogenesis (DE), factors contributing to manifestations of mental disorders (FCM_MD)

Abstract: Causal specifiers are certain and possible causes of mental disorders and can be biological, genetic, environmental, developmental, social, psychodynamic, behavioral, cognitive, or personality characteristics.  Depending upon the clinical judgment of the degree of certainty, a causal specifier can be a definite etiopathogenesis or a factor contributing to manifestations of mental disorders. The author recommends adding causal specifiers to Axis I diagnoses in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition to improve communication among clinicians.

Introduction

The current Diagnostic and Statistical Manual for Mental Disorders (DSM) system is descriptive, atheoretical, and depends heavily on counting subjective symptoms.[1–3] One of the important functions of any psychiatric classification system is to improve communication among clinicians,[4–7] and the third edition of the DSM accomplished this. However, in most cases the communication value of the current DSM is limited to diagnostic labels and the number of positive symptoms required to meet the criteria of the disorder. To illustrate this shortcoming of the current DSM system, I present two actual patients I have encountered in my practice. Both cases are simplified to demonstrate the salient points. I will illustrate how to improve the communication value of the current DSM system by adding causal specifiers to Axis I diagnoses.

Case 1. Mr. A was a 45-year-old man who worked in construction for many years, had no psychiatric history prior to age 40, and no family history of psychiatric disorders. At the age of 40, the patient started to have progressive back pain, difficulty performing his work, and eventually lost his job, remaining unemployed for six months. The patient started feeling depressed and was unable to provide for his wife and two sons. His wife joined the work force to make ends meet. A few months later, the patient discovered that his wife had an extramarital affair, and she decided to move out with the children and initiate divorce proceedings. The patient’s financial problems forced him to move in with his mother as he remained unable to work. The patient became more depressed, experienced insomnia, lost interest in social activities, felt worthless, guilty, and hopeless, and started to have suicidal thoughts. At the age of 42, the patient was hospitalized after a suicidal attempt by overdose on his medications. A year later, the patient was hospitalized again after a second suicidal attempt by cutting his wrist. The patient was treated with a selective serotonin reuptake inhibitor (SSRI) and saw his therapist regularly.

Diagnosis according to the current DSM system: The patient was diagnosed with major depressive disorder, severe, recurrent.

Case 2. Mr. B was a 40-year-old associate professor who enjoyed a stable state university job and a stable family life with his wife and two daughters. The patient had a history of depression since the age of 20 and was hospitalized at the age of 24 for a severe depressive episode. At that time, the patient felt very depressed with anhedonia, psychomotor retardation, poor concentration, overeating, over sleeping, and suicidal ideation. The patient was treated successfully with an antidepressant and remained adherent with treatment. The patient had recurrent depressive episodes requiring medication changes. He continued outpatient treatment. The patient had a strong family history of depression (both mother and maternal grandmother had documented history of depression).

Diagnosis according to the current DSM system: The patient was diagnosed with major depressive disorder, severe, recurrent.

Problem with the current DSM system

The two cases described above clearly reflect a major shortcoming of the current DSM system. How can we justify applying the same diagnosis to two cases with different symptoms and signs and different etiological factors? In the event one of these patients moves and sees another doctor, the current DSM diagnosis conveys mainly that the patient has five or more depressive symptoms.

Proposal to improve the current DSM system

To improve the current DSM system, I recommend adding causal specifiers to the current DSM system. Causal specifiers are potential causes of mental disorders and can be biological, genetic, environmental, developmental, social, psychodynamic, behavioral, cognitive, or personality characteristics. Depending on the clinical judgment of the degree of certainty, a causal specifier can be a factor contributing to manifestations of mental disorders (FCM_DM) or a definite etiopathogenesis (DE).[28] Table 1a, Table 1b shows a proposed classification of causal specifiers. The list is obviously simple and incomplete and is designed to illustrate the main categories and their subdivisions. Experts in different areas can revise the categories and their subdivisions.

Diagnosis using the proposed change

In Case 1, factors contributing to depression were mostly social: physical injury (A5B1), unemployment (F3A1), financial (F3B), and divorce (F1C). In Case 2, a contributing factor is genetic (B).

Using the proposed causal specifiers, the diagnoses of the two cases are as follows:

Diagnosis for case #1 according to the proposed DSM change would be major depressive disorder, severe, recurrent; contributing factors are A5B1, F3A1, F3B, F1C.

Diagnosis for Case 2 according to the proposed DSM change would be major depressive disorder, severe, recurrent; contributing factors are B.

Case 1 symptoms are depressed mood, anhedonia, insomnia, worthlessness, guilt, hopelessness, suicidal ideation, and plan. Case 2 symptoms are depression, anhedonia, psychomotor retardation, poor concentration, hypersomnia, hyperphagia, and suicidal ideation.

Advantages of proposed DSM changes include the following:
1.    Improve communication among clinicians
2.    Determination of factors contributing to a certain disorder, which will lead to appropriate treatment decisions
3.    Stimulate thinking and research on causes of disorders.

Future changes with DSM-V

The DSM system is based upon categorical models (also known as the disease model) with the main assumption that psychiatric disorders are separate disease entities.[8] The DSM-V Task Group decided to incorporate a dimensional component in the DSM-V,[8,9] and current field trials are underway to test the reliability and feasibility of proposed dimensional measures. Dimensional models provide a greater amount of information and can measure severity of psychiatric disorders.[10] In addition, dimensional models are more reliable, more valid, and advocated by many researchers.[10–15] Discussions on pros and cons of categorical and dimensional models are explained elsewhere.[8,10,13,14,16–20] To accommodate the new dimensional addition to the DSM-V, Vieta proposed a modular system that may integrate categorical and dimensional issues, laboratory data, medical conditions, psychological assessment, and social issues in a comprehensive and practical approach.[21]

In the course of my clinical research during the past decade, I developed the Standard for Clinicians’ Interview in Psychiatry (SCIP), the only instrument specifically designed for psychiatrists’ needs in the real patient world; whether inpatient or outpatient,[22–27] the SCIP project sample size exceeded 1,000 subjects, making the SCIP project the largest validity and reliability study to date. The SCIP assessment accommodates both categorical and dimensional models of psychiatric diagnoses at the same time (hybrid model). For the categorical model, the SCIP yields diagnoses according to the DSM. For the dimensional models, the SCIP yields scores for obsessions, compulsions, depression, mania, suicide, delusions, hallucination, agitation, disorganized behavior, negative symptoms, catatonia, and drug addiction. Initial analyses of the data show the SCIP to be a valid and reliable instrument. The main publications of the SCIP will ensue soon. As the dimensional model appears on the stage of DSM-V, time will tell which instruments will serve the dimensional addition best: the SCIP or the new dimensional measures proposed by the DSM-V Task Group.

Summary of recommendations

I recommend keeping the descriptive system of the DSM and adding causal specifiers to the diagnosis. The causal specifier can be a contributing factor or a definite etiopathogenesis. As our understanding of causal specifiers improves, causes of mental disorders eventually will be elucidated.

References

1.    Dittman V. Modern psychiatric classification in research and clinical practice. Archives Suisses de Neurologie et Psychiatrie. 1991;142(4):341–353.
2.    Spitzer RL. Values and assumptions in the development of DSM-III and DSM-III-R: an insider’s perspective and a belated response to Sadler, Hulgus, and Agich’s “On values in recent American psychiatric classification.” J Nerv Ment Dis. 2001;189(6):351–359.
3.    Clark LA. Temperament as a unifying basis for personality and psychopathology. J Abnorm Psychol. 2005;114(4):505–521.
4.    First MB, Pincus HA, Levine JB, et al. Clinical utility as a criterion for revising psychiatric diagnoses. Am J Psychiatry. 2004;161(6):946–954.
5.    Andreasen NC, Black DW. Introductory Textbook of Psychiatry. Washington, DC: American Psychiatric Press, Inc.; 2001.
6.    Spitzer RL, Fleiss JL. A re-analysis of the reliability of psychiatric diagnosis. Br J Psychiatry. 1974;125(0):341–347.
7.    Sokal RR. Classification: purposes, principles, progress, prospects. Science. 1974;185(4157):1115–1123.
8.    Helzer JE, Kraemer HC, Krueger RF, et al. Dimensional Appoaches in Diagnostic Classification: Refining the Research Agenda for DSM-V. Arlington, Virginia: American Psychiatric Press Inc.; 2008.
9.    Regier DA, Narrow WE, Kuhl EA, Kupfer DJ. The conceptual development of DSM-V. Am J Psychiatry. 2009;166(6):645–650.
10.    Watson D. Rethinking the mood and anxiety disorders: a quantitative hierarchical model for DSM-V. J Abnorm Psychol. 2005;114(4):522–536.
11.    Widiger TA, Clark LA. Toward DSM-V and the classification of psychopathology. Psychol Bull. 2000;126(6):946–963.
12.    Widiger TA, Samuel DB. Diagnostic categories or dimensions? A question for the Diagnostic And Statistical Manual Of Mental Disorders–fifth edition. J Abnorm Psychol. 2005;114(4):494–504.
13.    van OJ, Gilvarry C, Bale R, van HE, et al. A comparison of the utility of dimensional and categorical representations of psychosis. UK700 Group. Psychol Med. 1999;29(3):595–606.
14.    Kraemer HC. DSM categories and dimensions in clinical and research contexts. Int J Methods Psychiatr Res. 2007;16(Suppl 1):S8–S15.
15.    Peralta V, Cuesta MJ, Giraldo C, Cardenas A, Gonzalez F. Classifying psychotic disorders: issues regarding categorial vs. dimensional approaches and time frame to assess symptoms. Eur Arch Psychiatry Clin Neurosci. 2002;252(1):12–18.
16.    Sprock J. Dimensional versus categorical classification of prototypic and nonprototypic cases of personality disorder. J Clin Psychol. 2003;59(9):991–1014.
17.    Peralta V, Cuesta MJ, Giraldo C, Gardenas A, Gonzalez F. Classifying psychotic disorders: issues regarding categorical vs. dimensional approaches and time frame to assess symptoms. Eur Arch Psychiatry Clin Neurosci. 2002;252:12–18.
18.    Milton T. Classification in psychopathology: rationale, alternatives, and standards. J Abn Psychol. 1991;100(3):245-61.
19.    Kraemer HC, Noda A, O’Hara R. Categorical versus dimensional approaches to diagnosis: methodological challenges. J Psychiatr Res. 2004;38(1):17–25.
20.    Shear MK, Bjelland I, Beesdo K, Gloster AT, Wittchen HU. Supplementary dimensional assessment in anxiety disorders. Int J Methods Psychiatr Res. 2007;16(Suppl 1):S52–S64.
21.    Vieta E, Phillips ML. Deconstructing bipolar disorder: a critical review of its diagnostic validity and a proposal for DSM-V and ICD-11. Schizophr Bull. 2007;33(4):886–892.
22.    Aboraya A. The Arabic version of the Schedules for Clinicians’ Interview in Psychiatry. Proceeding of 3rd Ain Shams International Congress on Psychiatry. Luxor,  Egypt; 2007.
23.    Aboraya A. The computer version of the Schedules for Clinicians Interview in Psychiatry (SCIP): a new instrument for psychiatrists with dual function: clinical management and research. Proceeding of Fourth Ain Shams International Congress on Psychiatry. Hurghada, Egypt; 2009.
24.    Aboraya A. The Schedules for Clinicians Interview in Psychiatry (SCIP): a new instrument with categorical and dimensional models for substance use disorders. Proceeding of 10th Annual Meeting for International Society of Addiction Medicine. Cape Town, South Africa; 2009.
25.    Aboraya A, Rankin E, France C, et al. The reliability of psychiatric diagnosis revisited: the clinician’s guide to improve the reliability of psychiatric diagnosis. Psychiatry (Edgemont). 2006;3(1):41–50.
26.    Aboraya A, Tien A. Schedules for Clinicians Interviews in Psychiatry (SCIP): work in progress. eCOMMUNITY: Int J Ment Health Addict. 2004.
27.    Aboraya A, Zheng W. The Schedules for Clinicians Interview in Psychiatry (SCIP): a new innovative educational tool with dual funtion: clinical management and research. Proceeding of Association For Academic Psychiatry Annual Meeting. Boston, MA; 2007.
28.    Aboraya A. Scientific forum on the Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition (DSM-V): an invitation. Psychiatry (Edgemont). 2010;7(11):32–36.

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