The DSM and the ICD

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We hear so much about the Diagnostic and Statistical Manual of Mental Disorders, we tend to forget that it is not the only “bible” or set of guidelines in use. The other major guide, the International Classification of Diseases and Related Health Problems, is produced by the World Health Organization (WHO).

A far-reaching study asked mental health professionals from everywhere to compare the current edition of that manual, familiarly known as ICD-10, with the 4th edition of DSM (since DSM-5 had not been published yet). This was in preparation for ICD’s 11th revision, expected to be finalized in 2017.

Each is a DCS

There is one more acronym central to this discussion: DCS, or Diagnostic Classification System. A diagnostic classification system needs to be simple, reliable, easy to use, and helpful toward making treatment and management decisions. A classification’s value is measured by its clinical utility, and most clinicians favor a system with fewer categories of disorder.

Classifications are needed so that medical professionals in different specialties, and from different countries, can communicate with each other regarding a patient or a disease. In some places, they are used to allot resources and support. Of course, when a patient is covered by insurance, the official diagnosis must always be selected from the available DCS choices and plugged into the paperwork. Additionally, within each category, there is plenty of room for disagreement over such matters as “whether or how to incorporate dimensional classification, functional impairment, and severity.”

Who Likes What?

Clinicians who primarily use either ICD or DSM were asked about what kinds of cases they saw most frequently. The most commonly seen problems are mood and anxiety disorders, along with stress-related and childhood disorders. Interestingly, the less frequently encountered conditions included “substance-related disorders, psychotic disorders, and eating disorders.” It should also be noted that a significant proportion of psychologists rarely or never use a diagnostic classification system. Prof. Graham Davey explains:

We should be clear that diagnostic systems are not a necessary requirement for helping people with mental health problems to recover, and many clinical psychologists prefer not to use diagnostic systems such as DSM-5, but instead prefer to treat each client as someone with a unique mental health problem that can best be described and treated using other means such as case formulation.

Around the world, 60% of psychologists use a formal classification system, with 51% routinely consulting ICD and 44% favoring DSM. In many places, mental health professionals are turned off by what they perceive as a cultural bias that gives more weight to the American and European way of doing things. Psychopathy is not seen in exactly the same way every in all parts of the world. There are “culturebound syndromes” and local differences in the delivery of mental health services.

When it comes to diagnostic and treatment guidelines, crosscultural applicability is, understandably, a significant issue. But some critics are not even satisfied with that goal – they want a national classification system relevant to their particular country, and this feeling is strongest in Latin America, Africa, and the Eastern Mediterranean. Both psychiatrists and psychologists vastly prefer flexible diagnostic guidelines, and that preference is equally true of those who mainly use either ICD or DSM. Traditionally, and quite logically, ICD has offered more leeway for cultural variation and clinical judgment.

Why Flexibility?

Flexibility matters because some basic assumptions are not universally shared. For instance, there is disagreement over the diagnosis of depression. If incidents in a patient’s life are clearly so horrific as to warrant major depression, is it fair to label that person as having a mental disorder? Of the professionals polled, a slight minority said no. Conversely, slightly more than half favor going with the depression diagnosis, even if the person’s distress is a “proportionate response to adverse life events” – in other words, if the depression has been earned by experiencing dreadful real-world horrors.

Your responses and feedback are welcome!

Source: “Psychologists’ perspectives on the diagnostic classification of mental disorders: Results from the WHO-IUPsyS Global Survey,” tandfonline.com, 06/10/13
Source: “Changes in DSM-5,” Blogspot.com, 02/13/13
Image by Premnath Thirumalaisamy

 

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