DSM-5 Proposed Draft

[Bob]

At midnight tonight, the American Psychiatric Association (APA) released a proposed draft of the new Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Some notable changes:

-Addition of dimensional assessments
-Addition of standardized way to assess disorder severity
- Binge Eating Disorder added to eating disorders
- Asperger Syndrome removed and folded into the autism spectrum disorder umbrella
-Addition of Nonsuicidal Self-Injury

In addition, there are several proposed changes to 302.85: Gender Identity Disorder in Adolescents or Adults:

* The default wait period for diagnosis-indicative questions has dropped from a year to six months.

* The "distress/impairment" requirement is proposed to be dropped. Also huge. Basically, this means that you can be diagnosed without saying "I am going to die unless something changes."

* It is proposed that the name gender identity disorder (GID) be replaced by "Gender Incongruence" (GI), because "...in a recent survey ... many very clearly indicated their rejection of the GID term because, in their view, it contributes to the stigmatization of their condition."



The APA is seeking public comment from health professionals, consumers of mental health services, and family members of people with mental disorders until April 20, 2010.

The DSM-5 will be published in May 2013.

http://www.dsm5.org/ProposedRevision....aspx?rid=193#
302.85: Gender Identity Disorder in Adolescents or Adults

[Linus]

Unfortunately, not all of it's good. On Pam's House Blend two entries talking about the DSM-V highlight some of those:

http://www.pamshouseblend.com/diary/...sis-added-dsmv

http://www.pamshouseblend.com/diary/...rans-activists

And whether it's called GID or GI, there will still be a stigmatization of the condition by society.

Additionally, I'm not sure why Intersex is now being added to GID as it really shouldn't be classified as a mental health issue. It should be classified as a surgerical mistake. I suspect it goes back to the idea that gender is a social creation only.

[violaine]

i have not really wanted a separation of AS, because in my own experiences with living on the spectrum, i am in fact, all over the spectrum- exceptionally high functioning some areas, as well as medium to low.


Eliminating the Asperger's diagnosis won't mean that people in that category will lose access to services, Grinker says. That's because "almost anybody with an Asperger's diagnosis also could qualify for what is called autistic disorder," he says, adding that the change could make it easier for some parents to get help for a child with Asperger's.

Right now, states including California provide services to children with autism but not those with Asperger's, Grinker says. "So removing Asperger's really removes what is a false barrier to parents getting care for their kids."

http://www.npr.org/templates/story/s...ryId=123527833

[DapperButch]

Originally Posted by violaine

i have not really wanted a separation of AS, because in my own experiences with living on the spectrum, i am in fact, all over the spectrum- exceptionally high functioning some areas, as well as medium to low.


Eliminating the Asperger's diagnosis won't mean that people in that category will lose access to services, Grinker says. That's because "almost anybody with an Asperger's diagnosis also could qualify for what is called autistic disorder," he says, adding that the change could make it easier for some parents to get help for a child with Asperger's.

Right now, states including California provide services to children with autism but not those with Asperger's, Grinker says. "So removing Asperger's really removes what is a false barrier to parents getting care for their kids."

http://www.npr.org/templates/story/s...ryId=123527833

Hi, belle.

When I heard about this potential change at work today, I didn't think about the positive that you mention above (some people not being able to get services). Thanks for that thought.

Instead what I thought about was my concern that those parents who struggle with the idea of accepting that their child has Aspergers will have an even harder time accepting an Autism diagnosis (due to the stigma of that recognizable diagnosis), and that more children will become untreated (that may have been treated) if they had been "labeled" with the "lighter" diagnosis of Aspergers (meaning, parents will be less likely to follow through with treatment if they are told that their child has "autism")

I'd like to hear your thoughts on this.

[violaine]

[QUOTE=DapperButch;48862]Hi, belle.

When I heard about this potential change at work today, I didn't think about the positive that you mention above (some people not being able to get services). Thanks for that thought.

Instead what I thought about was my concern that those parents who struggle with the idea of accepting that their child has Aspergers will have an even harder time accepting an Autism diagnosis (due to the stigma of that recognizable diagnosis), and that more children will become untreated (that may have been treated) if they had been "labeled" with the "lighter" diagnosis of Aspergers (meaning, parents will be less likely to follow through with treatment if they are told that their child has "autism")

I'd like to hear your thoughts on this.

thank you for responding to my post, and interest in further communication regarding the elimination of asperger's dx to the DSM V.

i have seen the parents in support groups- yes - they do often struggle with the 'A' word. sometimes, it appears to be more about what NT parents want AT kids to do/be, instead of who the person on the spectrum wishes to be, and i cannot help thinking about NT hard wiring connected to peer pressure - many times there's perceived such strengths in achieving lots of socialisation/fitting in, et c.

asperger's is not necessary 'lighter' in all areas- that's what i mean- it manifests for everyone differently. because someone is more verbal, can operate a computer, and hold a job- does not automatically assume the aspie is free of depression, anxiety, melt.down, & insomnia. what if a person has no family support, friendships, & social skills? although a 'lighter' dx is given, there's huge missing pieces.

if parents view asperger's as an easier road, that could set the child/teen/adult up for as much failure as choosing to eliminate very real needs a person on the spectrum has in place for coping skills- just because the parent forces 'normalisation' either from denial or embarrassment.

acceptace is gold- education is great- it's up to the parents to educate themselves instead of being in denial, embarrassed, or forcing an AT to be NT

best,
belle

[violaine]

http://wamu.org/programs/dr/10/02/16.php


The Latest on Aspergers and Autism
A move to include Aspergers within the definition of autism has raised concerns of families, physicians, educators and insurance companies. The latest on our understanding of Aspergers syndrome.

Guests
Dr. Fred Volkmar, professor of child psychiatry and director of the Yale University Child Study Center at Yale University School of Medicine and an international authority on autism spectrum disorders. Coauthor of A Practical Guide to Autism with his wife Lisa Wiesner.

Gardiner Harris, science reporter for "The New York Times"

Dr. Edwin Cook, an autism researcher at the University of Illinois Chicago and member of the American Psychiatric Association's work group proposing the changes to their diagnostic manual.

[DapperButch]

[QUOTE=violaine;49341][QUOTE=DapperButch;48862]Hi, belle.

When I heard about this potential change at work today, I didn't think about the positive that you mention above (some people not being able to get services). Thanks for that thought.

Instead what I thought about was my concern that those parents who struggle with the idea of accepting that their child has Aspergers will have an even harder time accepting an Autism diagnosis (due to the stigma of that recognizable diagnosis), and that more children will become untreated (that may have been treated) if they had been "labeled" with the "lighter" diagnosis of Aspergers (meaning, parents will be less likely to follow through with treatment if they are told that their child has "autism")

I'd like to hear your thoughts on this.

[COLOR="DarkOrchid"]thank you for responding to my post, and interest in further communication regarding the elimination of asperger's dx to the DSM V.

i have seen the parents in support groups- yes - they do often struggle with the 'A' word. sometimes, it appears to be more about what NT parents want AT kids to do/be, instead of who the person on the spectrum wishes to be, and i cannot help thinking about NT hard wiring connected to peer pressure - many times there's perceived such strengths in achieving lots of socialisation/fitting in, et c.
asperger's is not necessary 'lighter' in all areas- that's what i mean- it manifests for everyone differently. because someone is more verbal, can operate a computer, and hold a job- does not automatically assume the aspie is free of depression, anxiety, melt.down, & insomnia. what if a person has no family support, friendships, & social skills? although a 'lighter' dx is given, there's huge missing pieces.

if parents view asperger's as an easier road, that could set the child/teen/adult up for as much failure as choosing to eliminate very real needs a person on the spectrum has in place for coping skills- just because the parent forces 'normalisation' either from denial or embarrassment.

acceptace is gold- education is great- it's up to the parents to educate themselves instead of being in denial, embarrassed, or forcing an AT to be NT

best,
belle

I absolutely agree with you across the board, belle. Thank you for your thoughts.

[AtLast]

The DSM has been fraught with politics since its inception. The APA's development of diagnostic criteria for it has a long standing economic history of how do we (clinicians) get reimbursement? From private health care insurance carriers as well as public health care programs. Then, there are the internal politics of the APA and just who gets on the panels & committees to revise it. You won't find a lot of mental health professionals without medical degrees or PhD’s or one's that are not from Ivy League schools. These committees are very white and male.

It should be nothing more than a diagnostic tool that is simply part of an array of diagnostic tools to aid mental health professionals develop treatment plans. What it has become is a huge book of codes that satisfies reimbursement requirements. It can be a very helpful tool, but it also aids in over pathologizing and stigmatizing people.

Clinicians often get put in the position of having to use a more pathological diagnosis via the DSM in order for their patients to be able to utilize many services and actually receive benefits from their insurance carriers. For example, someone dealing with transgender issues could be seeking therapy for nothing more than how to deal with what is coming up for them within their family and how to handle this. They have made their own decisions about transitioning and that is just not what they are seeking to deal with in treatment. But, in order for them to utilize their insurance (or utilize a publicly funded program), the therapist is put in the position of using a diagnosis of GID ( ya know with the word disorder in it) in stead of v. codes/adjustment diagnoses.

Also, something that has always ticked me off as a clinician is the gate-keeping role therapists are put in with medical interventions (i.e., hormone treatment, surgeries) and transitioning. From my point of view, this experience is nothing more than CYA medicine for surgeons and other physicians (endocrinologists, for example). So often, these medical practitioners simply want to make certain a person has a DSM diagnosis given by a mental health clinician so that if something goes wrong with the transitioning process and the patient sues, their ass is covered! Even when all the treatment is elective! They can counter-sue the mental health professional based upon a faulty diagnosis. . Its the deep-pocket theory of law at it’s finest. Most people (based upon legal advise) will sue the deeper pocket, which is the surgeon or other medical doc (think about the cost comparison of mal-practice insurance between let's say, a licensed clinical social worker and a plastic surgeon. So, after the surgeon gets sued, they go after the mental health professional.

I am only using the GID example because it is relevant to our community- this scenario can be found throughout the medical/mental health systems and mal-practice law.

This is really a crazy-making situation when you think about the fact that a therapist (that is trained to do just that, therapy, not be a gate-keeper) is put in the position of having to code someone with a disorder (including at times a very serious diagnosis of a personality disorder) or even psychosis in order for a patient to be able get treatment about things that we all deal with in life!

I finally stopped doing any insurance work in my practice by the time I retired from it because of these kinds of things. And that didn't always feel great, either because I still felt like patients were put in a financial position that is just unfair. Also, in CA, changes in what used to be sacred
in terms of patient confidentiality became open-season for insurance companies and lawyers. Presently, patient/client records just do not have the scope of security they used to and laws were enacted that took clinician's legal safeguards away in protecting patient records in the mental health field. At one time, refusing to give any portion of a patient's therapy record was one in which a therapist could stand on without threat of legal action (with some exceptions). One could protect patient confidentiality. This is no longer true. Other changes in CA law have led to strict recording rules requiring a diagnosis be part of patient records. A diagnosis from the DSM. Consequently, if records are ordered to be turned over, and do not have all of the legally components in them, the therapist can be held negligent.

OK... my rant is over.... the DSM and how it is utilized today as well as how it is politically maneuvered, is directly contradictory in many ways to one’s training as a therapist. And look what position its miss-use can do to people just trying to get some help!

I don’t support our not having to be accountable with diagnostic criteria as that could very well hurt patients, too (with treatment options). But, the reimbursement regulations requiring that reimbursement be based upon more characterlogical and pathological diagnosing does nothing more than promote social stigma that in itself causes more problems for people dealing with some tough things already.

I should have been a gardener….

[DapperButch]

Hey, AtLastHome, I really enjoyed your post.

Originally Posted by AtLastHome

The DSM has been fraught with politics since its inception. The APA's development of diagnostic criteria for it has a long standing economic history of how do we (clinicians) get reimbursement? From private health care insurance carriers as well as public health care programs. Then, there are the internal politics of the APA and just who gets on the panels & committees to revise it. You won't find a lot of mental health professionals without medical degrees or PhD’s or one's that are not from Ivy League schools. These committees are very white and male.

It should be nothing more than a diagnostic tool that is simply part of an array of diagnostic tools to aid mental health professionals develop treatment plans. What it has become is a huge book of codes that satisfies reimbursement requirements. It can be a very helpful tool, but it also aids in over pathologizing and stigmatizing people.

Clinicians often get put in the position of having to use a more pathological diagnosis via the DSM in order for their patients to be able to utilize many services and actually receive benefits from their insurance carriers. For example, someone dealing with transgender issues could be seeking therapy for nothing more than how to deal with what is coming up for them within their family and how to handle this. They have made their own decisions about transitioning and that is just not what they are seeking to deal with in treatment. But, in order for them to utilize their insurance (or utilize a publicly funded program), the therapist is put in the position of using a diagnosis of GID ( ya know with the word disorder in it) in stead of v. codes/adjustment diagnoses.
Also, something that has always ticked me off as a clinician is the gate-keeping role therapists are put in with medical interventions (i.e., hormone treatment, surgeries) and transitioning. From my point of view, this experience is nothing more than CYA medicine for surgeons and other physicians (endocrinologists, for example). So often, these medical practitioners simply want to make certain a person has a DSM diagnosis given by a mental health clinician so that if something goes wrong with the transitioning process and the patient sues, their ass is covered! Even when all the treatment is elective! They can counter-sue the mental health professional based upon a faulty diagnosis. . Its the deep-pocket theory of law at it’s finest. Most people (based upon legal advise) will sue the deeper pocket, which is the surgeon or other medical doc (think about the cost comparison of mal-practice insurance between let's say, a licensed clinical social worker and a plastic surgeon. So, after the surgeon gets sued, they go after the mental health professional.

I am only using the GID example because it is relevant to our community- this scenario can be found throughout the medical/mental health systems and mal-practice law.

This is really a crazy-making situation when you think about the fact that a therapist (that is trained to do just that, therapy, not be a gate-keeper) is put in the position of having to code someone with a disorder (including at times a very serious diagnosis of a personality disorder) or even psychosis in order for a patient to be able get treatment about things that we all deal with in life! I finally stopped doing any insurance work in my practice by the time I retired from it because of these kinds of things. And that didn't always feel great, either because I still felt like patients were put in a financial position that is just unfair. Also, in CA, changes in what used to be sacredin terms of patient confidentiality became open-season for insurance companies and lawyers. Presently, patient/client records just do not have the scope of security they used to and laws were enacted that took clinician's legal safeguards away in protecting patient records in the mental health field. At one time, refusing to give any portion of a patient's therapy record was one in which a therapist could stand on without threat of legal action (with some exceptions). One could protect patient confidentiality. This is no longer true. Other changes in CA law have led to strict recording rules requiring a diagnosis be part of patient records. A diagnosis from the DSM. Consequently, if records are ordered to be turned over, and do not have all of the legally components in them, the therapist can be held negligent.

OK... my rant is over.... the DSM and how it is utilized today as well as how it is politically maneuvered, is directly contradictory in many ways to one’s training as a therapist. And look what position its miss-use can do to people just trying to get some help!

I don’t support our not having to be accountable with diagnostic criteria as that could very well hurt patients, too (with treatment options). But, the reimbursement regulations requiring that reimbursement be based upon more characterlogical and pathological diagnosing does nothing more than promote social stigma that in itself causes more problems for people dealing with some tough things already.

I should have been a gardener….

As a clinician, I get what you are saying throughout this whole post and have felt all of the same things. I wanted to highlight a couple of things that you said and comment. The colors match the responses:

What I have always done is unless the person is seeking surgery and needs the GID diagnosis, I just diagnose them with the correct code (but, yes, of course this sometimes means giving them an adjustment diagnosis since v. codes aren't accepted by insurance companies.). I never use the GID diagnosis unless the person needs it. I suppose I just happen to "miss" that someone meets the criteria of a "diagnosis" that the establishment deems a mental illness.


Fortunately, I have never been faced with this situation where a client's records had to be handed over to someone my client did not want the records to go to. However, this is the reason why I document as little information as possible about my client. I document only what is necessary.


Yes, and now that insurance companies have the whole parity vs. nonparity diagnoses, with clients receiving more visits per year if they have a "parity diagnosis" (i.e. a diagnosis indicating having more severe difficulties than some other diagnoses), some clinicians may be more apt to give a client this type of diagnosis (if the person's symptoms could qualify for either type of dx), just so that the client can get the number of visits they need in order to get better. I have actually said to a client once or twice, "Hey, your symptoms fit under a "Major Depression" diagnosis, but typically I would "diagnose" you with the "lighter" diagnosis of "Depressive Disorder, Nonspecific" (I always send the "lightest diagnosis" that I can feel ethically comfortable with, to the insurance company). You get 20 visits a year for the second diagnosis, but would get unlimited visits for the more "serious" diagnosis. Which would you prefer I send to your insurance company?" I present them with this since my diagnosis impacts their treatment and my usual, "give them the lightest diagnosis I can get away with ethically", actually works AGAINST them in this situation. The whole thing just SUCKS.

[Darth Denkay]

For those of you who want to actively voice your opinion on what is going on with GID in the upcoming DSM edition, here is a link you might find useful.

http://professionals.gidreform.org/

[AtLast]

Originally Posted by Darth Denkay

For those of you who want to actively voice your opinion on what is going on with GID in the upcoming DSM edition, here is a link you might find useful.

http://professionals.gidreform.org/

Thanks! it really is an important time to make opinions to the APA about this. There are several diagnostic categories that need our attention!

[moxie]

Originally Posted by DapperButch

Hey, AtLastHome, I really enjoyed your post.



As a clinician, I get what you are saying throughout this whole post and have felt all of the same things. I wanted to highlight a couple of things that you said and comment. The colors match the responses:

What I have always done is unless the person is seeking surgery and needs the GID diagnosis, I just diagnose them with the correct code (but, yes, of course this sometimes means giving them an adjustment diagnosis since v. codes aren't accepted by insurance companies.). I never use the GID diagnosis unless the person needs it. I suppose I just happen to "miss" that someone meets the criteria of a "diagnosis" that the establishment deems a mental illness.


Fortunately, I have never been faced with this situation where a client's records had to be handed over to someone my client did not want the records to go to. However, this is the reason why I document as little information as possible about my client. I document only what is necessary.


Yes, and now that insurance companies have the whole parity vs. nonparity diagnoses, with clients receiving more visits per year if they have a "parity diagnosis" (i.e. a diagnosis indicating having more severe difficulties than some other diagnoses), some clinicians may be more apt to give a client this type of diagnosis (if the person's symptoms could qualify for either type of dx), just so that the client can get the number of visits they need in order to get better. I have actually said to a client once or twice, "Hey, your symptoms fit under a "Major Depression" diagnosis, but typically I would "diagnose" you with the "lighter" diagnosis of "Depressive Disorder, Nonspecific" (I always send the "lightest diagnosis" that I can feel ethically comfortable with, to the insurance company). You get 20 visits a year for the second diagnosis, but would get unlimited visits for the more "serious" diagnosis. Which would you prefer I send to your insurance company?" I present them with this since my diagnosis impacts their treatment and my usual, "give them the lightest diagnosis I can get away with ethically", actually works AGAINST them in this situation. The whole thing just SUCKS.

DISCLAIMER: I don't deal with private insurance. I have always worked in community mental health with it's own billing department that deals with all the approvals/billing stuff. For the past 3 years our agency has not accepted private insurance (unless it is in conjunction with Medicaid, then when the private insurance kicks it we send it to Medicaid) due to the excessive need for services and lack of providers for those with Medicaid along with those without insurance. Medicaid has it's own headaches that I won't get into when it comes to billing and recordkeeping.

I go to court with every single client of mine while I am open for services with them and sometimes I get subpoenaed to testify because it changes what I can and cannot say in court. When I don't testify because I am no longer involved with the client they use my records. There is SO much stuff that I don't put in my notes. I put enough in to satisfy Medicaid standards for my treatment plan goals and objectives and for other practitioners to understand what is going on with the client and skills/techniques I use and teach and that is it. I have seen fellow clinicians put things in records like incessant amounts of dialogue that don't need to be there and has been used in court for the abusive parent to get custody of the kids.

I don't have to deal with the diagnosis correlating with the number of sessions. The insurance stuff is one of the reasons I won't go into private practice. I ALWAYS go with the least-stigmatizing diagnosis and I am very fortunate to be able to do that due to not dealing with the private insurance industry. I used to work in conjunction with a state-run inpatient psychiatric facility as a liason and I can't tell you how many times personality disorder diagnoses would be given while the client was hospitalized for 3 days with no access to previous records or hospitalizations. Three days?!?! Diagnoses follow people around and sometimes people don't remember that. I am fortunate to be able to use V-codes and adjustment disorder diagnoses and change diagnoses as needed. Nowadays Bipolar Disorder and ADHD are the diagnoses du jour.

Okay, back to the DSM. More personality disorders are being added, including passive-aggressive (negativistic) personality disorder. This bothers me because I see them used way too often and I fear that with more being added that it will give practitioners even more reason to use them. I see Borderline Personality Disorder diagnosed way too much and way to soon. I see the stigma associated with diagnoses daily. You walk into a room and talk about a client that has been diagnosed with a personality disorder and people cringe and don't want them as a client. The diagnostic criteria for Personality Disorders have been proposed to be changed also and I am not quite sure yet what to think about it.

Adjustment disorders are also being changed with the addition of PTSD-Like or ASD-Like symptoms, which I think could be beneficial.

They are also adding some diagnoses and specifiers to the Schizophrenia and other Psychotic Disorders category. These changes include removing subtypes with schizophrenia...all I have to say is wow. Schizophrenia exhibits itself in different ways with people and they are wanting to remove the specifiers. I need to find some literature as to why they are proposing this because I am just dumbfounded.

[AtLast]

Originally Posted by puregrrl

They are also adding some diagnoses and specifiers to the Schizophrenia and other Psychotic Disorders category. These changes include removing subtypes with schizophrenia...all I have to say is wow. Schizophrenia exhibits itself in different ways with people and they are wanting to remove the specifiers. I need to find some literature as to why they are proposing this because I am just dumbfounded.

By the time I retired my practice, I had stopped accepting insurance, just went to a sliding scale.

I so agree with you about the removal of subtypes with schizophrenia! I am looking for some literature also. What I hope I don't find is influence by the health-care insurance carriers or major pharmaceutical companies over the APA. Wouldn't be the first time, however.....

Frankly, the passage of health-care reform could end up playing a major role with the DSM revisions. I wish I wasn’t so cynical about how revisions to the DSM are so blatantly political and economic, but, I remain feeling this way. If there ever are changes in the very classist /political structure of how and why the APA forms the revision committees, I may have a change of heart.