Diagnostic and Statistical Manual of Mental Health Disorders Essay

Diagnostic and Statistical Manual of Mental Health Disorders Essay

Apply documentation skills to examine family therapy sessions *
Develop diagnoses for clients receiving family psychotherapy *
Analyze legal and ethical implications of counseling clients with psychiatric disorders



* The Assignment related to this Learning Objective is introduced this week and submitted in Week 3.
Select two clients you observed or counseled this week during a family therapy session. Note: The two clients you select must have attended the same family session.Diagnostic and Statistical Manual of Mental Health Disorders Essay

Then, address in your Practicum Journal the following:

Using the Group Therapy Progress Note in this week’s Learning Resources, document the family session.
Describe (without violating HIPAA regulations) each client, and identify any pertinent history or medical information, including prescribed medications.
Using the Diagnostic and Statistical Manual of Mental Health Disorders, Fifth Edition (DSM-5), explain and justify your diagnosis for each client.
Explain any legal and/or ethical implications related to counseling each client.
Support your approach with evidence-based literature.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) has a number of features. First of all, every disorder is identified using a name and a numerical code. In addition, the manual provides the criteria for diagnosing each disorder as well as establishes subtypes of a disorder and examples that would illustrate the disorder. The manual goes further by addressing the typical age of onset, culturally related information, gender-related information, prevalence of a disorder, typical clinical course of a disorder, typical predisposing factors of a disorder and genetic family patterns of a disease (Summers, 2009). The DSM-IV is a tool that is used by mental health practitioners and social service workers. Diagnostic and Statistical Manual of Mental Health Disorders Essay
Personality disorders have a sex prevalence rate and there has been some suggestion that those rates reflect gender bias. The bias concerns derived from the “conceptualization of personality disorders, the wording of diagnostic criteria, the application of diagnostic criteria, thresholds for diagnosis, clinical presentation, researching sampling, the self-awareness and openness of patients and the items included within self-report inventories” (Butcher, 2009, p. 356). Studies have failed to prove that there is significant gender bias in the DSM. However, research has showed there is gender bias within clinical judgments. For example, gender related items would be included within self-report inventories (Butcher, 2009). Clinicians tend to judge female patients as being mentally ill more readily than male patients, even when the symptoms are the same. Moreover, women are more likely to be cast as overly emotional, have a need for mood-altering medication and require ongoing monitoring/treatment (Zur and Nordmarken, 2010). Sexual orientation has also caused considerable bias. Homosexuality was listed in the DSM as a mental disorder up until 1974. Even law had identified homosexual behavior as criminal; for instance, sodomy laws. Although homosexuality is no longer listed in the DSM, therapists still have the option of considering homosexual behavior as a sexual disorder not otherwise specified. The ability to still classify homosexuality as a

The Diagnostic and Statistical Manual of Mental Disorders is the handbook widely used by clinicians and psychiatrists in the United States to diagnose psychiatric illnesses. Published by the American Psychiatric Association (APA), the DSM covers all categories of mental health disorders for both adults and children.

It contains descriptions, symptoms, and other criteria necessary for diagnosing mental health disorders. It also contains statistics concerning which gender is most affected by the illness, the typical age of onset, the effects of treatment, and common treatment approaches.Diagnostic and Statistical Manual of Mental Health Disorders Essay

Just as with other medical conditions, the government and many insurance carriers require a specific diagnosis in order to approve payment for treatment. Therefore, in addition to being used for psychiatric diagnosis and treatment recommendations, mental health professionals also use the DSM to classify patients for billing purposes

controversial issues in psychiatry are relevant to
social workers because they provide the majority of mental health services in the United States
(Cohen, 2003; Mechanic, 2008). The controversy over
revisions in the upcoming fifth edition of the Diagnostic
and Statistical Manual of Mental Disorders (DSM-5) has
been widely discussed in newspapers and by the Public
Broadcasting System’s NewsHour. The efficacy of antidepressants has been questioned on 60 Minutes, when
Lesley Stahl (2012) interviewed Irving Kirsch. Recently,
a petition (Open letter to the DSM-5, 2011) launched by
the Society for Humanistic Psychology and several other
American Psychological Association (APA) divisions,
was posted on the Web (http://www.ipetitions.com/petition/dsm5). This essay will begin with some background
on what prompted the petition and why Allen Frances,
co-chair of the fourth edition of the DSM (DSM-IV), has
become a self-professed crusader. The relevance of the
controversies in psychiatry to indigent children and children in foster care will be reviewed here as well. Concerns
about the problematic addition of new diagnoses and the
narrowing of diagnoses elsewhere for the DSM-5 will be
discussed. A brief overview of the controversy regarding
antidepressants will be presented. Finally, some thoughts
regarding how social work can respond will be proffered.
The Petition
The petition (Open letter to the DSM-5, 2011) asks the
DSM-5 Task Force to reconsider its intention to loosen and
expand the criteria for a variety of diagnoses. According to
Frances (2011c), this petition has been signed by more than
5,000 mental health professionals and 17 different mental
health professional organizations. Frances (2011b) earlier
had urged colleagues to sign the petition.Diagnostic and Statistical Manual of Mental Health Disorders Essay
The petition to the committee developing the DSM-5
follows earlier attempts by Frances to prevent the American Psychiatric Association from “falling off a cliff”
(Greenberg, 2010). Frances (2010), concerned about
the proliferation of new diagnostic labels, published an
article in the Los Angeles Times questioning whether
“normality is an endangered species.” Before this, Frances (2009) published an article in Psychiatric Times urging caution in the development of criteria for various
proposed disorders and decrying the unintended consequences of the manner in which the DSM-IV criteria
were stated, which led to the epidemic rise in the diagnoses for attention-deficit/hyperactivity disorder (ADHD),
autism spectrum disorders, and bipolar disorder. In an
interview, Frances explained his activism, “Kids getting
unneeded antipsychotics that would make them gain 12
pounds in 12 weeks hit me in the gut. It was uniquely my
job and my duty to protect them. If not me to correct it,
who? I was stuck without an excuse to convince myself”
(Greenberg, 2010).
The particular issue of children receiving antipsychotic
medications is connected to the rise in the diagnosis of
pediatric bipolar disorder. Although the diagnosis of pediatric bipolar is not in the revised DSM-IV (DSM-IV-R),
no age restriction was placed on the adult diagnosis in the
DSM-IV-R. When Harvard University’s Joseph Biederman and colleagues began publishing articles reporting
that children, many of whom had been previously labeled
as conduct disorder or ADHD, met criteria for bipolar
disorder, the diagnosis of pediatric bipolar took off (Littrell & Lyons, 2010a). Whereas it had been assumed that
bipolar disorder never emerged until late adolescence or
adulthood, by 2004 it was the most frequent diagnosis for
children (Blader & Carlson, 2007). A similar increase in
bipolar spectrum diagnoses was witnessed for adults as
well, according to Moreno et al. (2007).
As more children and adults were labeled bipolar, the
use of atypical antipsychotics escalated. Domino and
Swartz (2008) documented the rise in the use of atypical antipsychotics for both children and adults. Most recently, Comer, Mojtabai, and Olfson (2011) documented
Families in Society | Volume 93, No. 4
an increase in the use of atypical antipsychotics for the
treatment of anxiety disorders. As the addictive liability
of tranquilizers has received attention, an atypical antipsychotic, Seroquel (quetiapine), is now being used for
insomnia (Sinaikin, 2010).
While Comer et al. (2011) documented the rise in the
use of atypical antipsychotics, others have documented
the deleterious impact of the atypicals. In February 2011,
Ho, Andreasen, Ziebell, Pierson, and Magnotta (2011)
published their findings of brain volume reduction given
the use of antipsychotic medications (both older neuroleptics and the new atypicals). While the Ho et al. study
did not use random assignment to conditions, and thus
causality could not be inferred from their data, the researchers cited animal work with the same findings,
where random assignment was observed. After 27 months
of dosages in the therapeutic range for people, there was
an 11.8–15.2% reduction in the parietal lobe and a reduction in total weight of brain volume (Konopaske et al.,
2007, 2008). Brain tissue volume decrement is only the
latest recognition of the devastating impact of the atypical antipsychotics. Atypicals are associated with weight Diagnostic and Statistical Manual of Mental Health Disorders Essay
gain that does not plateau, high levels of blood lipids, and
increased risk of diabetes (Goodwin & Jamison, 2007,
p. 846), as well as osteoporosis (Kawai & Rosen, 2010). Although the atypicals were initially believed to be free of
movement disorder risks, the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study, a large
government-funded study, revealed that the atypicals,
like older neuroleptics, can cause movement disorder
(Casey, 2006). Additionally, the Food and Drug Administration (FDA) has issued a warning regarding Seroquel’s
capacity to induce cardiac arrhythmias and sudden death
(Wilson, 2011).
Relevance to the Child Welfare System
Children covered by Medicare and Medicaid are more
likely to receive prescriptions for antipsychotics than
privately insured children. High proportions of foster
children are being medicated with antipsychotics and
polypharmacy (dosReis, Yoon, Rubin, Riddle, Noll, &
Rothbard, 2011; Littrell & Lyons, 2010b), which is costly
(Leslie & Rosenheck, 2012). This is particularly troublesome given that few medications are FDA-approved for
children. State Medicaid programs allow for more office
visits when there is a severe diagnosis, and Supplemental
Security Income (SSI) eligibility is easier to obtain with a
severe diagnosis, both of which probably contribute to the
increase in severe diagnoses and heavy medications (Littrell & Lyons, 2010b). Recently, push-back on these issues
has occurred. On December 1, 2011, U.S. Senator Tom
Carper held a hearing on the report of the U.S. Government Accountability Office (GAO) investigating medication of foster children. In several states, doses were found
that exceeded the maximum levels approved by the FDA.
Across states, 0.11–1.33% of children were being treated
concurrently with more than five medications. According to the GAO panel, “Our experts also said that no evidence supports the use of five or more psychotropic drugs
in adults or children, and only limited evidence supports
the use of even two drugs concomitantly in children”
(GAO testimony, 2011, p. 14).Diagnostic and Statistical Manual of Mental Health Disorders Essay


Concerns regarding prepsychosis. In addition to concerns about the rise in atypical antipsychotic medication
use for children, Frances (2011a) also expressed concern
about the inclusion of a prepsychosis diagnosis in the impending DSM-5. Frances reported that attempts to identify those individuals who would later become psychotic
have yielded high levels of false positives (see Thompson,
Nelson, & Yung, 2011). Antipsychotics have failed to
prevent the emergence of psychosis in high-risk groups
(Marshall & Rathbone, 2011; although the salubrious
Omega-3 fatty acids have demonstrated efficacy in preventing the emergence of psychosis in those at high risk—
see Amminger et al., 2010). Frances fears a new diagnosis
of prepsychosis could result in many more individuals
being stigmatized and placed on ineffective medications
with severe adverse effects. Social worker researchers
should endeavor to identify social factors that prevent the
emergence of psychosis in those who are at risk so that
prevention strategies can be developed.
Limiting diagnoses without drug treatments. Ironically, the DSM-5 Committee on Autism Spectrum Disorders has suggested more stringent criteria. Dr. Fred Volkmar, director of the Child Study Center at the Yale School
of Medicine, forecasted that the new criteria would disqualify many of the individuals who are currently being
treated. Consumer advocates have protested the tightening of criteria for autism spectrum disorders, fearing the
loss of insurance coverage of nonpharmaceutical treatments (Carey, 2012). Since social workers provide services
to the developmentally disabled, this change could limit
the ability of social workers to serve their clients.
Controversy about the efficacy of antidepressants.
The questionable use of antipsychotics is only one of the
latest controversies in psychiatry. Speaking more broadly,
Thomas Insel, current director of the National Institute
of Mental Health (NIMH), reflected, “The unfortunate
reality is that current medications help too few people get
better and very few people to get well” (2009, p. 704). In
Anatomy of an Epidemic, Whitaker (2010) examined each
category of psychotropic medication in turn. He contrasted current outcomes of psychiatric disorders with
outcomes for these same disorders prior to the advent of
drugs. Surprisingly, not only are current outcomes not
any better than those prior to drugs, but for major depression and for bipolar disorder, current treatment seems to
contribute to chronicity. Whitaker’s book was reviewed
in New York Review of Books in the summer of 2011 by
Marcia Angell, the former editor of The New England
Littrell & Lacasse | Controversies in Psychiatry and DSM-5: The Relevance for Social Work (Occasional Essay)Diagnostic and Statistical Manual of Mental Health Disorders Essay
Journal of Medicine. Angell pointed out the lack of data
on long-term outcomes with psychiatric medications;
placebo-controlled trials, often sponsored by industry,
evaluate outcomes after only 8 weeks. Moreover, there are
no definitive tests for any of the diagnoses in the DSM.
Angell did not disagree with Whitaker’s conclusions (Angell, 2011a, 2011b, 2011c).
An exchange between Angell and several psychiatrists
(i.e., Oldham, Friedman, Nierenberg, and Carlat) later
was published in the New York Review of Books (2011c).
In response to Angell in the exchange, Oldham argued
that depression is undertreated and that psychiatry, as a
whole, has never argued that “chemical imbalances are
causes of mental disorders or the symptoms of them”
(Angell, 2011c, p. 82). Friedman and Nierenberg, in response to Angell, argued that physicians in other areas
of medicine treat before they understand the conditions
they are treating. Also, in response to Angell, Carlat cited
Turner and Rosenthal’s (2008) defense of antidepressants,
who wrote, “When considering the potential benefits of
treatment with antidepressants, be circumspect but not
dismissive” (p. 51).Diagnostic and Statistical Manual of Mental Health Disorders Essay
The Larger Context
The subtext of the current controversies refers to corruption in the process of the writing of the DSM-5. The
obvious “elephant in the room” behind the rise in psychiatric diagnoses is the unhealthy relationship between
academic psychiatry and the pharmaceutical industry.
U.S. Senator Charles Grassley’s Finance Committee investigated the degree to which prominent psychiatrists
who set standards for practice are paid by industry, revealing that several had failed to disclose the extent of
their financial ties to drug companies (Harris & Carey,
2008). Others have decried the influence of pharmaceutical houses in medicine (Bremner, 2011; Elliot, 2010;
Sinaikin, 2010). This potential for influence extends to
DSM-5 task force members, many of whom have financial ties to the pharmaceutical industry (Cosgrove &
Krimsky, 2012).
Angell (2005) has published extensively on the broader
issue of the pharmaceutical industry and purveyors of devices influencing students in medical school with biased
information. Most of the clinical trials in this country are
funded by industry, and only positive findings are published (Turner, Matthews, Linardatos, Tell, & Rosenthal,
2008). Given the rampant ghostwriting by industry in
medical journals (Lacasse & Leo, 2010), industry-funded
studies are sometimes best regarded primarily as marketing efforts rather than truth-seeking endeavors. How is
the reader of journal articles to know when these influences are or are not present? The ramifications of this
commercial influence on the interrelated practice of diagnosis and treatment by social workers are difficult to
quantify, but certainly our profession must wrestle with
these issues.
Action Strategies for Social Work Professionals
So how should social workers respond to these developments? The APA has not taken a position on the online
petition to the DSM-5 Task Force, although a special
e-mail was sent to members to alert them to an article
by Rebecca Clay in the February 2012 issue of Monitor.
Clay (2012) pointed out that most psychologists use the
World Health Organization’s International Classification
of Diseases rather than the DSM. Indeed, Frances (2011c)
has suggested that mental health professionals can defect
from using the DSM in rendering diagnoses if efforts toward reform are unheeded. The National Association of
Social Workers (NASW) announced the petition on its
website but has not taken an official position. Given the
social justice orientation of our profession and our history of critical engagement with the issue of diagnosis (e.g.,Diagnostic and Statistical Manual of Mental Health Disorders Essay
Kutchins & Kirk, 1992; Saleebey, 2001), social workers
should read and consider signing the petition. On a macro
level, NASW should consider entering this debate, particularly regarding the diagnosis of foster children and other
vulnerable populations. Practicing social workers should
familiarize themselves with the many controversies related to DSM-5 (only a few of which are addressed here),
so that they can apply critical thinking to the question of
diagnoses relevant to their practice context. In particular,
practitioners should consider whether certain diagnostic
labels drive the prescription of psychiatric medications to
their clients, and whether other explanations or labels for
behavior might instead facilitate the use of effective psychosocial interventions for client problems (e.g., should
major depression be diagnosed and antidepressants used
in the wake of a major loss? See Horowitz & Wakefield,
2007). While DSM clearly serves a valid bureaucratic purpose as a vehicle for reimbursement, these controversies
illustrate the debatable science underlying many of the
DSM categories. Social work researchers should be aware
that NIMH now recognizes the problems with DSM and
that the 21st-century research agenda for studying mental
disorders will change substantially to move beyond such
DSM categories (Insel et al., 2010) Diagnostic and Statistical Manual of Mental Health Disorders Essay

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