DIAGNOSTIC SYSTEMS
THIS TOPIC IS CONNECTED TO THE RELIABILITY AND VALIDITY OF DIAGNOSING SCHIZOPHRENIA SO MAKE SURE YOU READ THAT AFTER LEARNING ABOUT THE DIAGNOSTIC SYSTEMS.
THE DIAGNOSTIC STATISTICAL MANUAL AND THE INTERNATIONAL CLASSIFICATION OF DISEASE
DSM V AND ICD 11: THE DIAGNOSTIC SYSTEMS
The classification of mental disorders is a key aspect of psychiatry and other mental health professions and an important issue for people who may be diagnosed.
The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) and the International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) both present ways to classify diseases. In the case of DSM-5, it is strictly for mental disorders, which include conditions such as schizophrenia, eating disorders, substance-related disorders, depression, as well as many others. ICD-10-CM includes those same conditions but also includes conditions and diseases related to all other body systems, including genitourinary, respiratory, gastrointestinal, circulatory, and musculoskeletal to name a few.
The ICD-10 criteria are typically used in European countries, while the DSM-V criteria are used in the United States and the rest of the world, and are prevailing in research studies.
Then why is there a need to have both systems you might ask? It would seem that since ICD-10-CM is comprehensive there would be no need for the DSM-5. However, that is not the case. The DSM-5 provides clinicians with the criteria and definitions to accurately diagnose a patient by thoroughly describing disorders. Having a common language facilitates patient care in a more effective manner.
ICD-10-CM provides a code number once the diagnosis has been established, and ICD-10-CM is the HIPAA-approved code set for reporting diagnoses for reimbursement purposes. ICD-10-CM code use also enables statistical compilation and reporting of patient morbidity and mortality.
However, since the DSM-5 and ICD-10-CM are not strictly related, there are disconnects between the two systems. Occasionally, a diagnosis that appears in the DSM-5 has seemingly no direct correlation with ICD-10-CM. For example, dementia is now characterized in DSM-5 as either a major or minor neurocognitive disorder. ICD-10-CM does not list neurocognitive disorder but still has the dementia diagnosis.
In these types of circumstances, it would benefit healthcare organisations to develop an internal coding policy to permit the assignment of, in this case, the dementia diagnosis code when the neurocognitive disorder is documented.
How are patients diagnosed?
Diagnosing schizophrenia is difficult because there is no single symptom that is unique to schizophrenia and there are no definitive blood tests or scans for the disorder. Diagnosing currently requires recognising a constellation of symptoms for at least six months. Seeing a deterioration in the level of functioning of the person with the symptoms, as well as 'ruling out' other possible explanations for the observed disturbance.
A psychiatrist or a specialist nurse will carry out a detailed assessment of symptoms. They will also want to know about personal history and current circumstances.
To make a diagnosis, most mental healthcare professionals use a diagnostic checklist; the ICD-10 (Used in the UK and Europe and written by the World Health Organisation, and DSM-5 (Used in the USA)
Schizophrenia can usually be diagnosed if:
A person has experienced one or more of the following symptoms most of the time for 1-6 months – delusions, hallucinations, hearing voices, incoherent speech or negative symptoms, such as a flattening of emotions
A person’s symptoms have had a significant impact on their ability to work, study or perform daily tasks
All other possible causes, such as recreational drug use or bipolar disorder, have been ruled out
A Brief History of the DSM
The DSM was created to enable mental health professionals to communicate using a common diagnostic language. Its forerunner was published in 1917 and included just 22 diagnoses. The DSM was first published in 1952 when the US armed forces wanted a guide on diagnosing servicemen.
The first version had many concepts and suggestions that would shock today’s mental health professionals. Infamously, homosexuality was listed as a "sociopathic personality disorder" and remained so until 1973. Autistic spectrum disorders were also thought to be a type of childhood schizophrenia. Because our understanding of mental health is evolving, the DSM is periodically updated. In each revision, mental health conditions that are no longer considered valid are removed, while newly defined conditions are added.
Why the DSM-5 is important for the NHS
Although the NHS uses the World Health Organization system of diagnosing mental health conditions called ICD-10 (International Classification of Diseases), the previous version of DSM, (DSM-IV-TR) has a major influence on how mental health is thought about and treated in this country.
It helps set research agendas, brings conditions into the public eye and influences clinical guidelines. Previous versions of the DSM were arguably responsible for making certain conditions better known in the UK, such as attention deficit hyperactivity disorder and borderline personality disorder.
Pharmaceutical influence on mental health diagnoses
Healthcare in the US is big business. A 2011 report estimated that the total US spending on health during that year was $2.7 trillion. This represents 17.9% of the country's gross domestic product (GDP). In contrast, NHS spending represents just 8.2% of the UK’s GDP. However, treating mental health conditions (including dementia) is the highest area of spending within the NHS.
Links and potential conflicts of interest between the pharmaceutical industry and the DSM-5 task force (the group that revised the manual) are a matter of record. 67% of the task force (18 out of 27 members) had direct links to the pharmaceutical industry.
“Medicalising” mental health
Some proposed diagnoses in DSM-5 were criticised as potentially medicalising patterns of behaviour and mood.
An article entitled DSM 5 Is Guide Not Bible – Ignore its Ten Worst Changes highlighted changes to the manual that were examples of over-medicalisation of mental health. These changes included:
· Asperger’s syndrome
· Disruptive mood dysregulation disorder
· Mild cognitive disorder
· Schizophrenia
· Generalised anxiety disorder
· Major depressive disorder
Major depressive disorder
The most scathing criticism of DSM-5 has been reserved for changes to what constitutes major depressive disorder (MDD). As you would expect, previous definitions described MDD as a persistent low mood, loss of enjoyment and pleasure, and a disruption to everyday activity. However, these definitions also specifically excluded a diagnosis of MDD if the person was recently bereaved. This exception has been removed in DSM-5.
A wide range of individuals and organisations have argued that the DSM-5 is in danger of "medicalising grief". The argument expressed is that grief is a normal, if upsetting, human process that should not require treatment with drugs such as antidepressants.
OLD DSM IV-TR CRITERIA for Schizophrenia
DSM-5 Changes: Schizophrenia & Psychotic Disorders
DSM state that “no single symptom is pathognomonic of [schizophrenia]” and it is a “heterogeneous clinical syndrome”. Two people with people diagnosed with schizophrenia may look and behave nothing like each other.
The new Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) has several changes to schizophrenia and other psychotic disorders. According to the American Psychiatric Association (APA), the publisher of the DSM-5, some of the biggest changes in this chapter were made to better refine the diagnostic criteria based upon the past decade and a half of schizophrenia research.
Schizophrenia: Two changes were made to the primary symptom criteria for schizophrenia. According to the APA, “the first change is the elimination of the special attribution of bizarre delusions and Schneiderian first-rank auditory hallucinations (e.g., two or more voices conversing). In DSM-IV, only one such symptom was needed to meet the diagnostic requirement for Criterion A, instead of two of the other listed symptoms. This special attribution was removed due to the non-specificity of Schneiderian symptoms and the poor reliability in distinguishing bizarre from non-bizarre delusions.
“Therefore, in DSM-5, two Criterion A symptoms are required for any diagnosis of schizophrenia.”
The second change was the requirement for a person to now have at least one of three “positive” symptoms of schizophrenia:
Hallucinations
Delusions
Disorganized speech
The APA believes this helps increase the reliability of a schizophrenia diagnosis.
Schizophrenia subtypes
Schizophrenia subtypes have been dumped in the DSM-5 because of their “limited diagnostic stability, low reliability, and poor validity,” according to the APA. (The old DSM-IV had specified the following schizophrenia subtypes: paranoid, disorganized, catatonic, undifferentiated, and residual type.)
The APA also justified the removal of schizophrenia subtypes from the DSM-5 because they didn’t appear to help with providing better-targeted treatment or predicting treatment response.
The APA proposes that clinicians instead use a “dimensional approach to rating severity for the core symptoms of schizophrenia is included in Section III to capture the important heterogeneity in symptom type and severity expressed across individuals with psychotic disorders.” Section III is the new section in the DSM-5 that includes assessments, as well as diagnoses needing further research.
The former DSM-IV category is called Schizophrenia and Other Psychotic Disorders. The DSM-5 has added the word, “spectrum” to the title. The same basic diagnoses are still available in the DSM-5. Some symptom criteria were changed to make the diagnosis more accurate and precise. Additionally, catatonia has been reconceptualised as a separate diagnostic feature that cuts across several broad categories of disorders. The distinction between bizarre and non-bizarre delusions is no longer diagnostically significant.
DSM note that if symptoms of schizophrenia begin in childhood or adolescence, “the expected level of function is not attained. Comparing the individual with unaffected siblings may be helpful.” This must only amplify sibling rivalry.
The authors also comment that “individuals who had been socially active may become withdrawn from previous routines. Such behaviours are often the first sign of a disorder.” In the past few years, some studies have argued for treating people who are at high risk of developing schizophrenia, even though they have not yet met diagnostic criteria.
This is controversial because we cannot predict who will develop schizophrenia. Some treatments, such as antipsychotic medication, are not benign. This statement seems to permit more assertive treatment of youths who present with “prodromal” symptoms of schizophrenia.
Criterion C discusses the six-month duration that distinguishes “schizophrenia” from “schizophreniform disorder” (one to six months) and “brief psychotic disorder” (one day to six months).
Criterion E asks the reader to please rule out psychosis due to drugs or a medical condition.
The authors also explicitly comment about “decrements” in cognitive function in people with schizophrenia, which frames the condition as a brain disease. Similarly, there’s a note that “unawareness of [schizophrenia in the patient] is typically a symptom of schizophrenia itself rather than a coping strategy.” It’s not a psychodynamic defence mechanism of denial.
“It should be noted that the vast majority of persons with schizophrenia are not aggressive and are more frequently victimized than are individuals in the general population.”
The rest of the chapter discusses demographics, course of illness, etc. Here are some things I found noteworthy:
“Late-onset cases (i.e., onset after age 40 years) are overrepresented by females, who may have married.” Why is that last part there? Is this meant as a consolation prize to their husbands?
DSM-5 officially concedes that “some minority ethnic groups” are more likely to be diagnosed with schizophrenia.
Substance-related disorders are high (over 50% smoke cigarettes regularly). They are also more likely to experience weight gain, diabetes, metabolic syndrome, and cardiovascular and pulmonary disease. People with schizophrenia are at high risk for suicide: 5-6% die by suicide, and 20% attempt suicide. The combination of these factors may explain why people with schizophrenia die early compared to the general population.
International Classification of Disease (ICD-10) Criteria for Schizophrenia:
Either at least one of the syndromes, symptoms and signs listed below under (1) or at least two of the symptoms and signs listed under (2) would have been present for most of the time during an episode of psychotic illness lasting for at least one month.
1. At least ONE of the following:
· Thought echo, thought insertion or withdrawal and thought broadcasting.
· Delusions of control, influence or passivity, clearly referred to body or limb movements or specific thoughts, actions or sensations, and delusional perception.
· Hallucinatory voices giving a running commentary on the patient's behaviour or discussing him/her between themselves or other types of hallucinatory voices coming from some part of the body.
· Persistent delusions of other kinds that are culturally inappropriate or implausible, such as religious or political identity, superhuman powers and ability etc.
2. At least TWO of the following:
· Persistent hallucinations in any modality, when accompanied by either fleeting or half-formed delusions without clear affective content or by persistent over-valued ideas or when occurring every day for weeks or months on end.
· Breaks of interpolations in the train of thought, resulting in incoherence or irrelevant speech or neologisms.
· Catatonic behaviour, such as excitement, posturing or waxy flexibility, negativism, mutism and stupor.
· Negative symptoms such as marked apathy, paucity of speech and blunting or incongruity of emotional responses (these usually result in social withdrawal and lowering of social performance). It must be clear that these are not due to depression or neuroleptic medication.
· A significant and consistent change in the overall quality of some aspects of personal behaviour, manifest as loss of interest, aimlessness, idleness, a self-absorbed attitude, and social withdrawal.
Exclusion Criteria: The ICD-10 criteria specify that schizophrenia should not be diagnosed if the symptoms are better accounted for by a mood disorder, 'overt brain disease' or drug intoxication or withdrawal.
Differences between DSM and ICD in classifying Schizophrenia
Subtypes: The DSM-V contains NO sub-classifications of schizophrenia
ICD 10 recognises seven subtypes.
Paranoid, Hebephrenic, Catatonic, Undifferentiated, Residual, Simple Schizophrenia and Post-schizophrenic depression
Post-schizophrenic depression: A depressive episode arising in the aftermath of a schizophrenic illness where some low-level schizophrenic symptoms may still be present.
Simple schizophrenia: Insidious and progressive development of prominent negative symptoms with no history of psychotic episodes. (ICD code F20.6)
The ICD-10 is not as widely used as the DSM-V but may be used in some cases to make a clinical diagnosis of schizophrenia.
Other differences between ICD and DSM
DSM recognises Schizoaffective disorder, acute and transient psychosis and Schizophreniform, delusional disorder as part of Schizophrenia, whilst ICD sees them as separate disorders (mood disorders).
The duration criteria differ markedly: ICD-10 requires at least one month with the ... whereas DSM-V requires continuous disturbance for at least six months, with an active period of one month.
DSM-5 AND ICD 10CM IN BRIEF
DSM-5
· Diagnostic and Statistical Manual of Mental Disorders
· Created and Maintained by the American Psychiatric Association
· Released in May 2013
· The standard classification of mental disorders used by mental health professionals
· A listing of diagnostic criteria for every psychiatric disorder recognised by the U.S. healthcare system
· Required by most licensing boards (What is the Relationship?)
· Clinicians use DSM Methodology to identify the diagnoses
· Decision Trees based on Symptomology lead the clinician to the appropriate Diagnoses
· The diagnoses are then Coded using ICD-10-CM
The ICD-10 CM
· International Classifications of Diseases, Tenth Revision, Clinical Modifications
· Created and Maintained by the World Health Organization
· Released on January 1, 1999
· Being used by every country except the United States
· Mandated for use for all claiming activities by the Centres for Medicare and Medicaid services beginning October 1, 2015 (Oh – that’s today!)
· Each region or country can “customize” ICD-10 to meet their cultural needs
· ICD-10-CM is the Clinical Modifications approved for use in the U.S.
· Future History:
· ICD-11 has now been delayed until 2018 – four years later than originally planned
The 11th Revision of the International Classification of Diseases (ICD-11) is due in 2018!
Differences between ICD and DSM - Schizophrenia
· The DSM-5 manual contains 20+ pages
· Includes a list of specific sets of symptoms to reference
· For example, two or more Delusions, Hallucinations, Disorganized Speech, Disorganized or Catatonic behaviour, diminished emotional expression, diminished levels of life functioning, etc.
· Is very specific: “At least 2 Criterion A symptoms must be present for a significant portion of time…” and “Schizophrenia involves impairment in one or more major areas of functioning
· Differences - Schizophrenia
· The ICD-10 “Bluebook” only has one page
· It states: “The clinical picture is dominated by relatively stable, often paranoid, delusions, usually accompanied by hallucinations, particularly of the auditory variety…”
· It only lists 3 “common” symptoms – Delusions of persecution, hallucinatory voices, hallucinations of smell or taste
Classification of schizophrenia ESSAY NOTES.
Reliability and validity in diagnosis and classification of schizophrenia, including reference to co-morbidity, culture and gender bias and symptom overlap.
“In retrospect: The five lives of the psychiatry manual
Roy Richard Grinker describes the military origins of the key reference work for diagnosing mental illness.
Diagnostic and Statistical Manual: Mental Disorders American Psychiatric Association First published 1952
My grandfather, the pioneering psychiatrist Roy Grinker (1900–93), said that “to know schizophrenia is to know psychiatry”. Indeed, psychiatry in the nineteenth and early twentieth centuries was largely an effort to understand psychosis, the majority of practitioners being employed in public mental-health institutions. The field broadened in the mid-twentieth century when psychiatrists became aware of a spectrum of mental disorders — not in hospitals, but in wars.
The Second World War led to major attempts to classify psychiatric conditions in the United States. Of the 11 million men and women who served in the US military between 1941 and 1945, 1 million were diagnosed with ill-defined ‘neuropsychiatric’ disorders. The inadequacy of clinical terminology at the time meant that a soldier with ordinary anxiety might be assigned a ‘psychopathic personality that clearly did not apply. Yet these wartime syndromes were responsive to brief psychotherapy, often as simple as allowing the soldiers to talk about their experiences in a safe and restful environment. Psychiatrists’ understanding of mental disorders and interventions expanded rapidly as a result.
Psychiatrists redefined many mental disorders after seeing the Second World War’s effects on soldiers. Credit: J. DOMINIS/TIME LIFE PICTURES/GETTY
In 1948, eager to advertise that psychiatry could treat more than psychoses, the Office of the Surgeon General published Medical 203, the US Army’s classification manual for mental-health conditions. The volume was revised four years later by a committee of the American Psychiatric Association (APA), chaired by Captain George Raines of the US Navy, and published as the Diagnostic and Statistical Manual: Mental Disorders — now known as DSM-I. Released during the Korean War, DSM-I was a surprisingly harmonious marriage of military experience and psychoanalytical theory.
Mental disorders were seen at the time as maladaptive neurotic reactions to the environment, and most included ‘reaction’ in their name. Disorders were classified in terms of the physical symptoms, the organ system involved (such as skin or cardiovascular) and whether the cause was known, secondary or unknown. A schizophrenic reaction, for example, was assumed to result from the individual’s struggle to adapt to internal or external stressors.
Overreaction
The second edition, DSM-II (1968), retained the psychoanalytical focus on neurosis and adaptation. But it eliminated the use of ‘reaction’ in response to pressure put on psychiatrists to diagnose actual diseases, as other medical professionals did. ‘Schizophrenic reaction’ thus became ‘schizophrenia’.
The 9 types of schizophrenia recorded in DSM-I were divided into 15 in DSM-II in order to capture a wide range of symptoms associated with the disorder — including some that appeared in other conditions, such as manic-depressive illness, depression and even bacterial infections. These 15 types included autism — then considered a feature of childhood-onset and paranoid schizophrenia rather than a distinct diagnosis — as well as subtypes that are no longer valid, such as ‘latent type’, which described early-onset symptoms. However, the revision did little to standardize diagnosis. In a 1971 study, Robert E. Kendell and his colleagues showed that in cases in which the majority of US psychiatrists diagnosed a patient with schizophrenia, the majority of British psychiatrists diagnosed the same patient with manic-depressive illness.
A decade later, DSM-III (1980) revolutionized psychiatry, especially clinical trials and psychiatric epidemiology, by making it more evidence-based. Accepting that the physical origins of most psychiatric disorders were unknown (as they still are), the DSM-III authors eschewed psychoanalytical theory and hypothetical causes in order to establish diagnostic reliability and validity. Psychoanalysts were consequently outraged at what they considered to be a backwards step.
The standards in DSM-III were also aligned with the World Health Organization’s International Classification of Diseases (ICD) manual, used in Europe. For scientists, these changes opened up new avenues for collaboration: researchers now shared the same language. For clinicians, the scientific criteria were a defence against the attacks on psychiatry as the subjective and dehumanizing profession represented in films such as One Flew Over the Cuckoo’s Nest (1975). For patients, DSM-III promised more precision in diagnosis and treatment, especially for individuals who had rejoined their communities when many US public mental-health institutions were closed in the 1970s.
In the process of gathering evidence and aligning standards, subtypes lacking validity were collapsed. The schizophrenias dropped to five variants. And two main symptom domains for the disorder were established: the positive, which included hallucinations and delusions, and the negative, which noted impaired cognitive, emotional and social functions. The negative domain was especially beneficial because DSM-III could now capture individuals with schizophrenia who were not actively psychotic, or whose symptoms had changed over time.
Without the structure of underlying explanations, the manual became a list of symptoms for an expanding list of diseases, from a few dozen disorders in the first edition to well over 200. As psychologist Arthur Houts wrote, DSM-III showed how “a psychiatric nomenclature cut adrift from any theory became a nomenclature unconstrained”.
For DSM-IV in 1994, the authors worked closely with authors of the ICD to make the two manuals congruent, clinically relevant, grounded in the most recent empirical research and more sensitive to how patients might interpret diagnosis. For example, in the updated DSM-IV-TR published in 2000, the writers eliminated language that might create stigma, replacing ‘schizophrenic’ — which implied that the disorder was an identity — with ‘individual with schizophrenia.
Back to the future
Scientists now hope to integrate the classification of mental disorders with recent advances in genetics and neuroscience. Research suggests that many conditions, including schizophrenia, autism, bipolar disorder and depression, do not have distinct causes but arise during the brain’s development, owing to shared genetic variations and relationships between behaviour and neural circuitry. The Research Domain Criteria (RDoC) project, launched by the US National Institute of Mental Health in 2009, is encouraging the study of mechanisms that are common to multiple disorders. Such approaches hark back to the causality on which DSM-I speculated.
Reconnecting our fragmented picture of mental illness is at the heart of DSM-5 (Arabic numerals now replace the Roman), due to be released in 2013. Recognizing that narrow diagnostic categories do not help us to understand the way a person will develop over time, DSM-5 will use symptom-severity scales instead of yes-or-no checklists to better reflect the range and dynamics of patients’ experiences. In another echo of DSM-I, special attention will be paid to context, in no small part caused by intense scientific and public interest in the mental-health problems associated with military personnel deployed in wars.
The number of possible diagnoses may contract in DSM-5. In the case of schizophrenia, the APA proposes removing all previous subtypes. The major debate is whether to add a category for psychosis risk syndrome, not unlike the ‘latent type’ within DSM-II. Some argue that because schizophrenia is a developmental disorder, with attenuated symptoms that can appear before psychotic episodes, a risk designation might aid early treatment and improve prognosis. Others note that most ‘at-risk’ individuals ultimately do not develop psychosis, and fear that the designation might turn normal human differences into pathologies or be motivated by pharmaceutical interests.
Each new edition of the DSM is considered a marker of progress, but we should be careful not to assume that psychiatric classification today is better than it was. Social scientists have widely criticized all releases of the DSM for making arbitrary distinctions between health and disease. They challenge the manual’s power to dictate how the human mind is viewed across the public arena, in schools, hospitals and courts of law. Clinicians note that mental disorders are more heterogeneous than the DSM suggests, and question whether changes in classification have yielded better outcomes for patients.
Shifts in classification occur for many reasons — such as the influence of war, changes in the insurance industry or public attitudes towards mental illness — that have little to do with scientific progress and much to do with society and history. A disorder, even one with a clear cause or biomarker, is only a disorder when a society construes it as such. For example, Asperger’s disorder is scheduled for elimination from the DSM, but this does not mean the category was wrong. It was useful when a non-stigmatizing term was needed for people with the disorder, but is becoming obsolete now that autism is accepted as a broad-spectrum illness without clear-cut subtypes. The possible collapse of schizophrenia classifications similarly reflects a more nuanced and connected picture of mental illness.
Nearly six decades after breaking ground with DSM-I, and three decades after DSM-III was radically reappraised, psychiatrists are braced for another diagnostic revolution”
