Dr. Abraham Nussbaum, MD, MTS, returns to the CPNP Annual Meeting leading an in-depth, pre-meeting workshop entitled "DSM-5: Hands-On Tools for Its Incorporation into Clinical Care and Research." Practical and focused, this workshop will teach participants how to use the DSM-5 assessment tools and rating scales that can help account for cultural differences and degrees of disability, while providing more objective measures of clinical function.
In this feature article, committee member and past Annual Meeting chair Jodie Malhotra, PharmD, conducts an in-depth interview with Dr. Nussbaum. Once you expand the questions/answers below, no doubt you will want to register now for this Sunday, April 27, 2014 learning event.
The greatest gift of DSM-IV was that it introduced evidence-based measures into the psychiatric diagnostic manual while maintaining the basic framework of DSM-III. DSM-III was a categorical model, where people either had or did not have a psychiatric diagnosis based on the presence or absence of certain psychiatric criteria that proved to be a successful way to bring together mental health practitioners. What’s really interesting about DSM-5, is that they wanted to take the strengths of that categorical model, which allowed people with diverse theoretical backgrounds and allow them to talk to each other, and at the same time, move us towards a diagnostic manual that was based fully on the neurosciences.
So one of the big differences about DSM-5 can be easy to miss, namely that it is organized around a sense of why people get ill. Even if a particular diagnosis doesn’t mention why someone develops mental illness, DSM-5, according to where things are in the book, is based on the best available evidence of the putative causes of etiology of why somebody gets ill. So psychotic disorders are placed next to bipolar disorders. So that’s one significant change, that the deep structure of DSM-5 points towards a neurosciences diagnostic manual organized around etiology.
The other thing that’s changed is that DSM was previously divided into disorders that affect children and adolescents versus adult disorders. Now, it’s organized across the lifespan. So illnesses that typically present earlier in life are earlier in the diagnostic manual. Illnesses that present later in life are later in the diagnostic manual. This allows people to not have this artificial distinction between, say, a 17 year old and a 20 year old in trying to figure out where they fit into the diagnostic manual. So those are some of the structural changes.
In addition, the diagnostic manual has tried to remove some of the co-morbidity that plagued DSM-IV. It did so by introducing dimensions. So it allows you, for example, to do things like, say that somebody who has major depressive disorder also experiences panic attacks, but not full blown panic disorder. So the goal is to allow you to rebuild a hierarchy of psychiatric disorders. So that instead of just having a long list of things that people have, you could allow them to prioritize. So, panic is an example; another would be recognizing that people have sleep problems, in the context of another mental illness rather than adding a sleep disorder. Now you can say that somebody has schizophrenia, and they have problems with sleep. Which I think is important because it allows you to distinguish the primary from sort of secondary problems in that.
All of the criteria for each of the disorders have been rewritten. Some disorders have been removed, some have been added. It’s not a fully neuroscientific diagnostic manual, but it points the way towards that, both in its deep structure, its criteria sets, and in the changes it makes to clinical practice and research. It’s an exciting step for psychiatry and mental health services, which I look forward to talking about more when we’re in Arizona.
Anytime you change a diagnostic manual, especially a major revision like DSM-5, it provides an opportunity to discuss what it means to evaluate a person with mental distress and to diagnose them with a mental illness. A mental illness diagnosis serves many functions. It can be a stigmatizing experience, a false start, or the beginning of a life-changing treatment. As mental health practitioners, we have a responsibility to get our diagnoses as accurate as possible. So the success of DSM-5 really comes down to that pragmatic question: does it help us make better diagnoses of the people we meet with mental illness?
On the whole I do think DSM-5 is a step forward. In my experience, your perception of the success of DSM-5 depends a lot on what someone thought was coming out in DSM-5. Many people have reacted to drafts without really diving into the published manual.
One frequent criticism is that DSM-5 was not a big enough change to warrant a new diagnostic manual. And I think there’s some merit to that. I think in a lot of the diagnoses there’s not a big of change as people maybe wanted. Perhaps that is prudent.
Regardless, it gives us a chance to talk about these diagnoses and what they mean. They have been debated, researched, and studied. One of the great examples would be major depressive disorder, where the criteria sets did not substantively change. There are some tweaks, including a distinction about bereavement, but no truly significant changes. When they field-tested it, the inter-rater reliability for major depressive disorder was a kappa score of only 0.28, suggesting that is a criteria set that still needs to change.
Some of the more advanced changes that DSM-5 proposed that were really more dimensional models, particularly things like personality disorders, they ultimately moved into the Appendix, or Section C, Section 3, for further study. I found that the personality disorders, the dimensional model they embraced, was difficult to get your head around, but it was really cool, because it allowed you to get a more complex understanding who a person was. Personally, once I understood the model, I was disappointed that they didn’t wind up endorsing it.
So there are some things that are kind of, inside baseball, people who saw earlier drafts of the DSM and were disappointed that some things didn’t make it. I would say that I think the big changes for people who don’t have that perspective, that didn’t happen, some of the criteria sets aren’t sufficiently coordinated with each other. So, for example, there’s a different account of gender in one chapter than in another. Some of the chapters still have diagnostic criteria sets that are really based on a clinical exam, and some of them now require, effectively, some sort of study; particularly the sleep disorder chapters, which really a lot of them require a PSG study.
So I think that the DSM-5 was coordinated to start, and coordinated to finish, but in the middle, I wish that it had been better coordinated across the diagnostic categories. I wish some of the criteria sets, particularly depressive disorder, and personality disorder, had been changed. The changes reflected in the final version of DSM-5 are too modest for those categories.
Sure, so I think the first thing is that when making a diagnosis, there’s a number of different of on-ramps into the DSM-5, avenues, if you will. It’s the first version of the diagnostic manual that has self-screening tools; they’re called Level 1 Tools, that are designs for a patient to administer to himself or herself. There’s also Level 2 Exams, for somebody who is not specialty trained in mental health to kind of screen for a mental health exam. So there are clear pathways into the manual.
That’s one of the ways in which I feel like DSM-5 is really designed for the mental health professional to act as a kind of consultant. There’s a pathway towards referral to a mental health professional, and then once somebody’s at the mental health professionals’ door or office or hospital, or other clinical setting, then the idea would be that mental health professional use the DSM-5 themselves.
And once they do, they’ll find that the DSM-5 is fairly familiar in its arrangement. For people familiar with DSM-IV, they will find that while the criteria sets have been rewritten, their layout is really similar. And again, it’s usually a certain number of, x number of y criteria meet the disorder.
I think what’s different from the mental health professionals’ perspective, are some of the deep structure and some of the things that wound up in Section 3. That’s one of the things I like, for example, there’s a really good rating scale for measuring how severe somebody’s psychosis is. And the advantage of that is that it’s something that can be done by any mental health professional.
There’s a really cool exam called the Cultural Formulation Interview, which again, is designed for any mental health professional to do, which allows somebody to interview somebody who has a mental illness or mental distress but has a different cultural background or practice that you may be familiar with. It helps somebody to do so.
One of the cool things about that, is that it actually has questions. Which is the first time that we’ve had that in DSM-5. That’s also true with the psychosis symptom inventory. In addition, it’s also got another tool called the WHODAS, so the World Health Organization Disabilities Assessment Schedule 2.0, which allows you to carefully characterize disability.
That’s, I think, there’s an on-ramp, then once you’re at the mental health professional’s door, it’s a fairly familiar tool for a mental health professional to use, but then has a number of patient centered interview and assessment tools that I think are helpful for the mental health professional.
Yes. It was a tremendous opportunity that the American Psychiatric Association provided to me. That work began as a curriculum that I taught at the University of Colorado School of Medicine, and drew on my own experiences as a researcher and teacher and interviewer, and in revising that curriculum, I realized I was going to have to revise that curriculum for DSM-5, and approached the APA about turning it into a book. And I was very excited that they embraced that proposal and gave me the opportunity to do so. It’s the first time that the DSM has published with a companion interview guide.
The book is really structured to help anybody who is seeing a person with mental distress or mental illness, perform a diagnostic interview exam, focusing on the major categories of mental illness. The book provides sample questions for each of the major illnesses, and for chapter of DSM-5, and along with several of the assessment tools. It also includes a discussion of what it means to examine a person with mental illness or distress and how to build an alliance with them. It’s a short, pragmatic book that’s designed for everyday clinical practice. It’s meant to fit in your pocket, but not stay there.
I’d say the first thing is I’m really grateful for the opportunity to speak to CPNP. I had an opportunity to be there last year in Colorado before the DSM-5 came out. I was grateful for the invitation and grateful for the welcome received there. This year, the embargo is over and we can speak about DSM-5 more frankly. Pharmacists have a critical role to play in the treatment of people’s mental illness and so I’m grateful for that opportunity.
And this year’s workshop will be much more interactive. It’ll be really focused on how pharmacists can take the DSM-5 and use it to improve the lives of persons with mental illness.
I guess my hope would be that, if people use the diagnostic manual well, they’ll help people arrive at a diagnosis sooner, with greater accuracy, and will be able to communicate to other providers more clearly about that. One of the problems we know that psychiatry faces is that people struggle to get a diagnosis. They struggle to see a practitioner, and then once they’re there they struggle to get an accurate diagnose. One of my missions is for people to learn to use the DSM-5 well, so they can speed up that process for somebody.
In the long-term, my hope would be that DSM-5, because of some of the dimensional tools and some of the assessment tools, will help researchers figure out, including pharmacists and researchers, figure out some of the subtypes. We know that many of our mental illnesses are heterogeneous. Most people know that schizophrenia is likely not to prove to be one illness but a number of illnesses that we currently group under the umbrella of schizophrenia. The dimensional tools and assessment tools of DSM-5, when properly used, might help to distinguish different subtypes within something like schizophrenia or major depressive disorder that might lead to changes in treatment for people with mental illness.
So in the short-term, my hope would be that a better diagnostic manual would lead to earlier detection of mental illness, earlier treatment, with more precise diagnoses that don’t change so much over time.
And the long-term, my hope would be that the new diagnostic manual helps us to renew our search for the cause of why people experience mental distress and mental illness, and hopefully better and newer treatments.
Third-party payers are a complicated question. There’s a number of them, and as everybody who reads a paper knows, there’s constant change in the healthcare industry and the insurance industry. If I told you that I could predict the future with all those things, I would be a liar. That being said, most insurers have embraced DSM-5, beginning in January 2014, fully. And so, they are expecting that people use it. So, it’s a skill that people need to use, because third-party payers are using it now. However it’s going to take a while, for some of the EMRs, including in places like the VA, to change over completely.
The good news is that by treaty, the DSM for the last several versions has been tied to the same codes as ICD. So the CPT codes don’t change. And that’s one thing that stays the same. So whenever you make a diagnosis. So, if you did paranoid schizophrenia in DSM-IV or if you do schizophrenia, multiple episodes, currently an acute in DSM-5, it’s going to code, map onto the same CPT code. So that won’t change. That infrastructure is already built.
But in answer to your question, most insurers have switched over. EMRs are coming along on more of a case-to-case basis.
While we’re on the subject, Professor Malhotra, I would also say that, I think one of the things that we meant to talk about but didn’t talk about earlier was this question of how one records a DSM-5 diagnosis. Skilled practitioners will recall, of course, the multi-axial system, the five-axis system. This has been removed in DSM-5. The argument had been that it really introduced a mind-body dualism. So instead you’re going to use a hierarchical problem list as is used in the rest of medicine, where you list the current problems that are affecting treatment. So for example, you might list, if somebody was hospitalized with an acute recurrence of psychosis, you know, schizophrenia, and then the second problem might be medical problems relating to their current system. But you would not be encouraged to list every possible thing that’s ever occurred to someone. So if they’re 47, currently psychotic, but they broke their arm at the age of 15 playing football back in Ohio, but the arm’s healed and is not currently affecting their function, you wouldn’t put that on there. You would just put things that are currently affecting their function.
They’ve also encouraged people to systematize the psychosocial problems that were previous listed as an open-ended narrative on Axis IV, by using ICD Z-codes, which are provided both in the DSM-5 itself and in the back of the pocket guide, my book that we’ll be sharing with people who come to the workshop at CPNP.
How do you see research being impacted by the DSM-5 including past research that uses the diagnoses that may have been removed? Going forward, are researchers going to start using the new diagnostic criteria?
Yeah. It’s fascinating. Ever since DSM-III, which was really redesigned to move psychiatry and mental health back into the university setting, this question of how to use the diagnostic manual for research has been an important and pressing one. With both DSM-III and DSM-IV, there was an embrace of the diagnostic manual by the research community. DSM-5 has been interesting of course. People are very aware of the public debate between the NIMH and Dr. Insel and the American Psychiatric Association.
Dr. Insel has publicly declared that he believes that the current version of DSM-5 is inadequate for research, and that he is going to develop what he calls the RDoC, or Research Domain Criteria, for use, for research. And he encourages people applying for NIMH research grants to work across DSM-5 diagnostic categories.
So then, sometimes people ask me, well, “Why don’t we just use the RDoC?” And the answer is, because the RDoC doesn’t exist. The RDoC is a proposal. It’s something that NIMH and Dr. Insel are actively pursuing, but it doesn’t exist today. So, one could not use it as a diagnostic manual even if one wanted to. However, the assumption of the RDoC, which is that mental illness is caused by dysfunctions in neurocircuits, is an interesting hypothesis and will likely be the future of the diagnostic manual. However, to get there, I think we need to the intermediate step of something like DSM-5.
So the hope would be that researchers would use DSM-5 and using that they would be able to identify subtypes of currently heterogeneous diagnoses, as in the case of somebody with schizophrenia, and also be able to identify dimensional aspects of other illnesses. So for example, people who have depression, with and without panic attacks, to push forward research agendas as we clarify the etiology of mental illness.
However, ultimately, the question about how any diagnostic manual is used really depends on how it’s adopted in clinical practice and by the research community as well.
You mentioned the question, too, about what to do with diagnoses that are currently in or out of the DSM, and it’s a very astute question, of course, Professor Malhotra. Some diagnoses have been removed and some have been added back by DSM-5. Part of what’s always interesting about the DSM process is that as people generate more evidence, the diagnostic manual changes. The DSM-5 is very much a pragmatic manual for clinical practice. So, something like premenstrual dysphoric disorder is pulled back into the main text of DSM-5 after being in the Appendix C for DSM-IV.
I think it should give hope to any researcher who’s got a diagnosis that they really care about, but it’s not in the diagnostic manual now, that that can change, as DSM changes. And it should also be an opportunity for further study, because, part of what I like about this version of the DSM is that in the third section, emerging measures and models, they really talk about some conditions for further study that I think are good places for researchers to consider.
Particularly, we know that the way that they structured the addictions chapter, really is meant to expand for people to look at other things that people can be addicted to. Internet gaming disorder, Caffeine Use Disorder are both in Section 3, but will likely eventually be in the main text. I think, addictive disorders are a fertile territory for researchers who want to see something added to the diagnostic manual.
We also know that the DSM-5 Committee really struggled with this question of how to account for people who commit acts of self-harm and several of those criteria have wound up in Section 3. I think that those are good places for researches to focus on if they want to change the diagnostic manual.
So, the best answer is that by sitting with and learning from persons with mental illness and distress, and from talking about them, about their own experience, and using the DSM-5 in their clinical practice. You know, one of my hopes is that the clinical tool I’ve designed, the Pocket Guide to the DSM-5 Diagnostic Interview will prove helpful to people.
And I look forward to being in Arizona and speaking with the committed professionals of the CPNP and teaching them, and learning from them, in our interactive workshop at the Grand Arizona Hotel in Phoenix. It will be a great workshop. I learn from the CPNP every year, and look forward to seeing you all in the desert.