T3 - Therapy Basics: The DSM

One thing all therapists, psychologists, licensed clinical social workers, psychiatrists and whoever else might provide mental health services has in common is the DSM. (Oh, and health insurance and pharmaceutical companies, too.)

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (or DSM-IV-TR for short) is called the therapist's "bible," although I'm not thrilled with that association. (I've only got ONE Bible, thank you.) It's put out by the American Psychiatric Association (APA) and the list price of it is about $89, but you can get it from Amazon for $72.

The DSM lists the criteria for mental disorders. Each disorder is given a specific code (i.e. 301.13) and this code is recognized by health professionals everywhere in the US. (Like, I know 301.13 is Cyclothymic Disorder).

In addition to the criteria (list of symptoms to look for in a patient), the DSM provides a lot of other helpful information about each disorder. (Psychiatric terms in bold italics)

1. Diagnostic Features - this is the criteria written out in paragraph form, often with illustrative examples
2. Subtypes and/or Specifiers - gives whether there are different types of a disorder (like there are several types of schizophrenia); specifiers simply give more specifics on the disorder, like when the onset was, or if a certain feature is more prevalent over another
3. Associated Features and Disorders - this gives clinical features that are frequently associated with the disorder, but aren't required to make a diagnosis, as well as associated medical and physical examination findings (i.e., people with an eating disorder are likely to have dental erosion or alcoholics typically can have cirrhosis of the liver)
   
4. Specific Culture, Age, and Gender Features - sometimes people present a disorder in a way that doesn't completely add up with the description on the page, and the reason could be one of the above listed, i.e., their developmental stage or cultural setting
5. Prevalence - the section gives known information for prevalence, incidence and lifetime risk; when it's known, this information includes different settings - community, primary care, outpatient mental health clinics and inpatient psychiatric settings
6. Course - gives the typical lifetime patterns of the disorder: how it's presented, how it evolves, typical age of onset, mode of onset (was it abrupt like PTSD or gradual like Alzheimer's?), whether it's in episodes (episodic) or a continuous course, a single episode v. recurrent, the duration of the disorder, as well as the typical length of the illness and it's progression over time (stable, worsening, improving)
7. Familial Pattern - looks at the frequency of the disorder among first-degree biological relatives compared with the general population
8. Differential Diagnosis - probably one of my most favorite sections, as it gives possible other diagnoses that might be similar as far as presentation and then how to differentiate between the two (or three or five)
   

Not every disorder will include all of this information. Sometimes the information isn't known, and it might be included in the next version of the DSM (to come out in 2012, tentatively). Many times this information changes from publication to publication, as data is gathered from ongoing studies. New diagnoses emerge and some diagnoses get the chopping block or get absorbed into others.

There is talk of including internet addiction, compulsive shopping, or premenstrual dysphoric disorder--that's right, ladies. The real name for PMS, and it's not actually a diagnosis right now!--as well as getting rid of schizoaffective disorder and possible gender identity disorder to reflect the changing times. Major changes within editions usually make the news, the biggest being in 1974 when the APA took out homosexuality as a disorder. As you can imagine, new editions cause LOTS of controversy between professionals in the field as well as political and religious leaders.

But one thing remains the same: this is the therapist's manual. I never see a client when I don't break out this really large book of almost 1000 pages. You can see how this would be helpful in writing, right?

Q4U: Which of the eight sections do you think would be most helpful when writing?

Join me next Thursday as I discuss the multi-axial format of the DSM and why this is extremely useful.