Best Practices and the Continuing Relevance of DSM IV TR in Contemporary Clinical Practice
Best Practices and the Continuing Relevance of DSM IV TR in Contemporary Clinical Practice
US Psychiatry 2007;1:46-8
It has been more than seven years since the publication of the Diagnostic and Statistical Manual of Mental Disorders 4th Edition Text Revision (DSM IV TR).1 Is there anything left to be said about it? This article focuses on how DSM IV TR can be still be made relevant and useful to contemporary clinical practices of the mental health professions (psychiatry, psychology, and clinical social work). In recent years, DSM IV TR has been arguably relegated to classifying syndromes into codified diagnosis for the purpose of insurance reimbursements and chart-keeping practices for regulatory bodies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
It has also been used to describe and classify syndromes in research. Its active use in clinical practice—such as in daily rounds of hospitalized patients, re-examination of the accuracy of diagnosis, and the important area of prognosis—are the major thrusts of this article, arguing that the regular use of DSM IV TR may help to improve practice. Case studies will be presented to highlight salient points. Finally, we will visit the emerging idea of ‘best practice’ as it comes to prominence with the increasing demand for evidence-based clinical management.
Diagnostic Precision
In psychiatry, the traditional or so-called ‘gold standard’ of diagnostic assessment is the clinical interview, in which the only requirement is education and experience on the part of the assessing clinician. In this interview, signs and symptoms are elicited through questions and answers. Based on how these elements fit into known syndromic clusters, diagnostic impressions are then formulated. This method has been the subject of critical scrutiny. Compared with computer-assisted diagnostic interview, the traditional diagnostic assessment produced greater imprecision and longer lengths of stay for hospitalized inpatients.2 In studies comparing unstructured with semi-structured clinical evaluations, there have been high rates of missed diagnosis in the former to the point at which the placement of the unstructured clinical interview as the gold standard has been seriously questioned.3 In studies of specific disorders, there have been questions on the accuracy of initial clinician diagnosis in samples of patients with major depression,4 eating disorder not otherwise specified,5 and attention deficit hyperactivity disorder (ADHD) among pediatric patients.6 Chronic patients customarily present to practitioners already carrying a diagnosis. These diagnoses are often accepted, and re-evaluated only when a difficult situation arises, such as non-response to treatment or a sudden deterioration in that patient’s clinical state. However, a routine re-evaluation of the diagnosis using DSM IV TR as a guide in all intake interviews may be helpful not only to the treating team of professionals, but also to the patient. This point is demonstrated well in the following case study.
Barbara is a 24-year-old single woman, never married, with no comorbid medical problems or substance abuse, who presents to Dr Jones for the firsttime with a chief complaint of worsening anxiety. She has been seeing mental health professionals since she was a teenager and for many years she has ‘carried’ the diagnosis of bipolar mood disorder based on mood instability, impulsivity, and suicidal ideations with gestures. She has impulses to hurt herself when anxious to alleviate the distress and discomfort of the anxiety. These episodes of self-harm had different meanings: often she used them to allay anxieties, while at other times she would scratch or self-lacerate her skin when she was angry with friends.
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