Recently, Louise co-wrote an article with Jeffrey Wilson, MD, that was published in the IECA’s newsletter, “Special Insights”, April/May 2013. We wanted to share with you that article.
Louise: We would like to thank you for agreeing to update us on the DSM-5. Can I ask how you’ve become familiar with the DSM-5 prior to its publication?
Dr. Wilson: I was a collaborative investigator during the clinical field trials for the new DSM-5 Criteria. The field trials were conducted from 2010-2012 to assess how the diagnoses “worked” in clinical settings. I was involved with applying the diagnoses to my “real life” clinical patients.
Louise: How do the field trials fit into the overall process?
Dr. Wilson: The DSM-5 revision process began in 1997. It continued through 2006 with pre-planning white papers which addressed a wide variety of concerns from expert researchers and clinicians. Since 1994, when the DSM-IV was published, there has been a great deal of research within behavioral health in general. From 2006-2008 a global research agenda was planned, and from 2008-2010 the criteria was publicly available for comment by clinicians, researchers, and consumers. The criteria were then tested in the field trials in carefully selected representative clinical sites and academic research centers. The field trial data was reviewed and the final draft of the DSM-5 was presented to the board of trustees of the American Psychiatric Association in December 2012 for release in May 2013.
Louise: What is the main purpose of the revisions? I thought the purpose of the DSM system was to standardize psychiatric diagnosis so that we are all talking about the same thing – a kind of shorthand for clinicians so that we know what we are talking about when we describe a person as having a particular diagnosis?
Dr. Wilson: Thtat’s a great point. The DSM at any particular time tries to integrate all of the current research in the various fields that make up behavioral health – e.g., psychiatry, psychology, social work, etc. into a manual of diagnosis. Each revision seeks to incorporate the research and clinical knowledge accumulated since the last iteration of the DSM. Because each iteration of the DSM is the best for that time, new research and clinical experience accumulates in between versions and the manual needs to be updated. For example, once upon a time homosexuality was defined as a disorder. It was removed in 1973 with DSM-III because of a necessary shift in the culture and behavioral science. As the field catches up to reality through improved research and clinical practice, changes are necessary to make sure we can best diagnose , treat, and continue to study persons with behavioral health disorders. DSM-IV included research up to 1994, and was already like a couple years behind already just because of the process of committees and manual building. Since 1994, a great deal of research has occurred and the DSM-5 will attempt to include the best thinking in the field related to psychiatric diagnosis at this time.
Louise: What are the general concerns that the DSM-5 tries to address?
Dr. Wilson: Some of the main concerns with the clinical application of the DSM-IV over the past couple of decades have included the lack of dimensional measures, the frequency of “NOS” (not otherwise specified” diagnoses, and the applicability of criteria for adults to children. The categorical approach is useful on many levels but there can be broad variability within particular categories, which emphasizes the need for dimensional approaches. On the other hand, a purely dimensional approach would blur the distinction between normality and pathology or disorder. The DSM-5 will try to add dimensional considerations and there is a plan to review the GAF (global adaptive function) score to make it more useful in practice and research. Another consideration is the frequency of “NOS” diagnoses. These are problematic in research and practice because of the wide variability in which these diagnoses can be applied depending upon the diagnostician’s inclinations toward certain diagnoses. While this may or may not be “right” depending upon your point of view, they make it difficult for an objective observer to determine if we are all talking about the same disorder or category. Theoretically, when the diagnostic criteria are as comprehensive, valid and reliable as possible, there will be fewer “NOS” diagnoses. The presence of high numbers of “NOS” diagnoses suggests that our criteria aren’t as comprehensive, valid, and reliable as they might be. Finally, children and adolescents had historically had fewer studies specific to their respective populations, and developmental considerations that need to be considered in making diagnoses since some behaviors that are age appropriate in childhood are not normative in adults.
Louise: I wonder if you could describe any areas that would be of interest to independent educational consultants.
Dr. Wilson: While there are many areas that have changes to greater and lesser extents, areas of particular interest to independent educational consultants include changes to the way we diagnose autistic spectrum disorders, bipolar, substance abuse and learning disorders.
Louise: I have heard that they removed the diagnosis of Asperger’s Disorder. I know many people are concerned that students with Asperger’s Disorder will not be able to get services. How can we help our students obtain appropriate services for this disorder if it is removed from the diagnostic system?
Dr. Wilson: The child committee recommended that Asperger’s Disorder be included in a new entity called “Autistic Spectrum Disorder”. This recommendation was based upon similarities in outcome between persons with “PDD NOS” and “High Functioning Autism.” In other words, these youths with Asperger’s did not differ from them when their socio emotional deficits were considered. The severity of their socio emotional deficits is what determined their prognosis, regardless of category (i.e. Asperger’s vs. PDD NOS vs. Autistic Disorder).
Louise: Aren’t there substantial differences between Asperger’s Disorder and Autistic Spectrum Disorder?
Dr. Wilson: By definition, the only difference between Asperger’s Disorder and Autistic Spectrum Disorder is the lack of language delay in the former. It may be that over time, milder language deficits may attenuate and the significance of language delay before five may decrease prognostically. Clearly, the most severely impaired autistic persons with language delay appear categorically different. However, the past couple of decades have seen an enormous increase in persons diagnosed with higher functioning autism, and the needs of these persons are not terribly different from youths with Asperger’s disorder. In fact, clinically we often refer such youths to Asperger’s groups because these families struggle to relate to lower functioning autistic persons. As a result of this clinical reality, the committee sought rather to include all youths in a single category of “autistic spectrum” disorder.
Louise: How are differences between these DSM-IV categories of PDD addressed in DSM-5?
Dr. Wilson: In order to address the heterogeneity of this broad spectrum disorder, a severity specifier was added. There are three general levels, all of which cause some degree of adaptive impairment and hence, would meet criteria a a disability. As far as I understand, the committee’s decision making, the goal was to expand access to care for all youths within this spectrum. It should also be noted that they will no longer be categorized as “pervasive developmental disorders” and all of these disorders will be included in the general spectrum of autistic disorder. Also of interest to providers for youth with autistic spectrum disorders is the removal of the exclusion criterion for an ADHD diagnosis. In the DSM-IV youths with any type of PDD were excluded from the diagnosis of ADHD. Although many of the criterion have been removed from the Website, if you are an interested reader, there is additional information on the dsm5.org website, e.g., www.dsm5.org/Documents/12-15%20DSM%20Commentary_Autism.pdf
Louise: Understanding these new distinctions will be critical as we try to place students and get the proper services for them. Moving on, I understand there has been a dramatic increase in the diagnosis and treatment of children and adolescents with bipolar disorder.
Dr. Wilson: In the 1990s there were increased awareness of bipolar disorders in children and adolescents and there was a dramatic change in the field with the increased identification of bipolarity in this age group. This indubitably helped many youths who were previously not treated; however, non-episodic irritability was increasingly diagnosed and treated as a prodrome to bipolar disorder. However, non-episodic irritability can be caused by a variety of problems in youths, including borderline personality disorder, oppositional defiant disorder, ADHD, conduct disorder, PTSD, and even unipolar depression. In fact, recent studies have suggested that the prodromal child/adolescent state of non-episodic irritability is more predictive of depression and anxiety disorders in adulthood than bipolar disorders. Making things more complicated, symptoms of ADHD, ODD, cluster B personality disorders (e.g., antisocial, borderline, histronic, narcissistic), and even the grandiosity of childhood itself are sometimes difficult to discern from mania per se in youths. It seems to use that in a more and more restrictive economical environment for healthcare, less and less time is allowed for diagnostic assessment, and there is an economic incentive to rapid diagnosis and treatment. However, it is rarely more critical than when considering life-long treatment with complex and sometimes toxic treatments for bipolar disorder, which themselves can aggravate undiagnosed ADHD or depression when misdiagnosed in youths as bipolar disorder. On the other hand, failing to diagnose prodromal or the early onset of bipolar disorder can also be devastating to families.
Louise: Does the DSM-5 address this bipolar disorder controversy?
Dr. Wilson: Unfortunately, this important controversy will not be resolved presently. What the DSM-5 attempts to do is to better identify this group of youth who don’t meet narrow criteria for bipolar disorder, i.e., youths with severe mood dysregulation who have not had manic episodes. The main way that the DSM-5 addresses no episodic irritability is what has been called severe mood dysregulation by some child researchers is to allow for a diagnosis of “disruptive mood dysregulation disorder”. This was originally called disruptive tempter dysregulation disorder, but there was an outcry against making temper tantrums the main focus. The reasoning for the definition of disruptive mood dysregulation disorder is in the depresseive disorders section is for two reasons: 1.) 90% of youths who meet criteria for this disorder also meet criteria for ODD, a disruptive behavior disorder, and 2.) depressive irritability appears to be a key part of the syndrome.
Louise: That’s a very high degree of co-occurance. If it’s disruptive, why label is as depressive?
Dr. Wilson: Exactly. One caveat is that there is overlap in the definitions: temper tantrums are a part of the diagnosis of ODD, which may contribute to the high co-occurrence. The child committee felt strongly that the mood component needed to be emphasized but distinct from the bipolarity per se. Interestingly, the underlying diagnosis for these youths appears to be more (unipolar) depression than bipolarity, as judged by prognostic studies of youths with severe mood dysregulation which did not show most of these kids going on to have bipolar disorder. Most of these kids go on to have depression and anxiety according to the scientific literature. Relatively little research is known in this newly defined category of youths, who are predominantly characterized by temper tantrums and co-occuring oppositional defiant disorder. The vision for the future is to begin to systematically diagnoses, treat, and follow these youths to determine the most effective treatments. In my opinion, it is critical not to take sides in this controversy. Consider the differential and determine the most appropriate diagnosis most likely to help the child in front of you. If everything or conversely nothing is bipolar disorder, you can’t help but fit the child into your preconceived notions. In my mind there is no question that bipolar disorder is over-diagnosed and overly treated, but that doesn’t mean it doesn’t exist and that youths properly diagnosed can’t be helped by valid diagnosis of bipolar disorder. Given what is known about co-occuring disorders in children, the full differential needs to be considered in each case, since they are likely to have a wide variety of presentations and co-occuruing disorders.
Louise: What can you say about the changes to substance abuse disorders?
Dr. Wilson: There are a number of minor changes, but I will focus on the most significant change. The basic criteria for substance abuse disorders have been retained, but the well known “substance abuse” and “substance dependence” have been removed. This is because the distinctions between the two have proved invalid. The theory was that the abuse distinction represented an intermediate step between use and dependence, but little evidence was found epidemiologically to support a two step process. Some youths met one or two criteria for dependence and no criteria for abuse and hence did not meet the DSM-IV standard for either diagnosis. These so-called diagnostic orphans when studied prognostically did not differ from those meeting criteria for dependence. Severity measures simply by the number of symptoms in either category proved more importance in terms of outcome than the categories of abuse or dependence. Based on these scientific observations the committee for SUDs suggested a single category of SUD with a severity specifier based upon the symptom count. The individual criteria from the two categories are reliable and valid except for the legal problems criterion, which is removed in DSM-5. The addition of a severity dimension will add to the clinical information provided in a SUD diagnosis.
Louise: I have heard there was a change in the reclassification of ADHD. Can you tell us about that?
Dr. Wilson: To be clear, there are a lot of changes, some of major significance, some less so. There have been a few structural changes. First, there is no longer a category of “disorders first diagnosed in childhood and adolescence.” Instead, there is a category called “neurodevelopmental disorders” and this includes autism, ADHD, learning disorders, communication disorders, and motor disorders. It is generally thought that ADHD is neurodevelopmental whereas ODD and CD are more behavioral, and the latter are classified in the “disruptive behavior disorders” category, and ADHD has been removed and placed in the neurodevelopmental category.
Louise: What are the changes to the category of learning disorders?
Dr. Wilson: The main focus of the changes to the category of learning disorders include a restructuring to “specific learning disorder” rather than the discrete categories of dyslexia, dyscalculia, disorder of written expression. Instead, the specific learning disorder will be described. The committee felt that this would provide more useful information as to the type of learning disorder and broaden services available, recognizing that children may have a variety of learning disorders which may interfere with their functioning. Because of the explicit definition of learning disorder within the DSM-IV some states reject applications for individualized educational plans based on a concrete definition of discrepancy between aptitude and achievement. The new definition emphasizes the complete use of neuropsychological profiles in an integrated fashion based upon the youth’s individual developmental needs. Hence, the definition of specific learning disorder is made by a clinical synthesis of the individual’s history, psycho educational reports of test scores and observations, and response to intervention.
Dr. Wilson served as a collaborative investigator during the DSM-5 field trials. He is a distinguished fellow of the American Academy of Child and Adolescent Psychiatry and is currently the medical director at the Aspen Institute for Behavioral Assessment in Salt Lake City.