WK2 SOCW 6090 Assgn 1 Discussion: Diagnostic Labels as Powerful Communications A diagnosis is powerful in the effect it can have on a person’s life and tre

WK2 SOCW 6090 Assgn 1 Discussion: Diagnostic Labels as Powerful Communications
A diagnosis is powerful in the effect it can have on a person’s life and tre

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WK2 SOCW 6090 Assgn 1 Discussion: Diagnostic Labels as Powerful Communications
A diagnosis is powerful in the effect it can have on a person’s life and treatment protocol. When working with a client, a social worker must make important decisions—not only about the diagnostic label itself but about whom to tell and when. In this Discussion, you evaluate the use and communication of a diagnosis in a case study.
To prepare: Focus on the complex but precise definition of a mental disorder in the DSM-5 and the concept of dimensionality both there and in the Paris (2015) and Lasalvia (2015) readings. Also note that the definition of a mental disorder includes a set of caveats and recommendations to help find the boundary between normal distress and a mental disorder.
Then consider the following case:
Ms. Evans, age 27, was awaiting honorable discharge from her service in Iraq with the U.S. Navy when her colleagues noticed that she looked increasingly fearful and was talking about hearing voices telling her that the world was going to be destroyed in 2020. With Ms. Evans’s permission, the evaluating [social worker] interviewed one of her closest colleagues, who indicated that Ms. Evans has not been taking good care of herself for several months. Ms. Evans said she was depressed.
The [social worker] also learned that Ms. Evans’s performance of her military job duties had declined during this time and that her commanding officer had recommended to Ms. Evans that she be evaluated by a psychiatrist approximately 2 weeks earlier, for possible depression.
On interview, Ms. Evans endorsed believing the world was going to end soon and indicated that several times she has heard an audible voice that repeats this information. She has a maternal uncle with schizophrenia, and her mother has a diagnosis of bipolar I disorder. Ms. Evans’s toxicology screen is positive for tetrahydrocannabinol (THC). The evaluating [social worker] informs Ms. Evans that she is making a tentative diagnosis of schizophrenia.
Source: Roberts, L. W., & Trockel, M. (2015). Case example: Importance of refining a diagnostic hypothesis. In L. W. Roberts & A. K. Louie (Eds.), Study guide to DSM-5 (pp. 6–7). Arlington, VA: American Psychiatric Publishing.
Study Guide to DSM-5(r), by Roberts, M.; Louie, A.; Weiss, L. Copyright 2015 by American Psychiatric Association. Reprinted by permission of American Psychiatric Association via the Copyright Clearance Center.
By Day 3
Post a 300- to 500-word response in which you discuss how a social worker should approach the diagnosis. In your analysis, consider the following questions:

Identify the symptoms or “red flags” in the case study that may be evaluated for a possible mental health disorder.
Should the social worker have shared this suspected diagnosis based on the limited assessment with Ms. Evans at this time?
Explain the potential impact of this diagnosis immediately and over time if the “tentative” diagnosis is a misdiagnosis.
When may it be appropriate to use a provisional diagnosis? 
When would you diagnosis as other specified and unspecified disorders? DSM-5 two years later: facts, myths and some key
open issues

A. Lasalvia, Guest Editor*

In May 2013, the American Psychiatric Association
(APA) published the fifth edition of its Diagnostic and
Statistical Manual of Mental Disorders (DSM-5). The pro-
cess that led to the release of the DSM-5 took nearly
two decades, with working groups of experts asked
to propose revisions based on the most recent research
findings. Originally, the APA hoped to introduce a
‘paradigm shift’, in which psychiatric diagnosis
would be in greater harmony with neuroscience
(Regier et al. 2009). When it became clear the data sup-
porting these changes were too fragmentary for radical
changes, the APA backed off from major revisions
(Paris & Phillips, 2013). In fact, to date, there is no
knowledge on whether most conditions listed in the
manual are true diseases. In the meantime, while wait-
ing for genetics and neuroscience to elucidate the
causes (and guide the treatment) of psychiatric disor-
ders, we should simply acknowledge, ‘our classifica-
tion of mental disorders is no more than a collection
of fallible and limited constructs that seek, but never
find, an elusive truth. Nevertheless, this is our best cur-
rent way of defining and communicating about mental
disorders’ (Frances & Widiger, 2012).

The main and most consistent criticism of the
DSM-5 (actually it was criticised both before and
after it was formally published) is that it included a
number of new and untested psychiatric disorders
without sufficient data on prevalence, reliability, valid-
ity, treatment response and risk/benefit ratio (Frances,
2010, 2013). According to critics, all of the proposed
new diagnoses, together with lowered thresholds for
some existing diagnostic categories, would expand
psychiatric diagnosis at its fuzzy and hard-to-define
border with normality, leading to overdiagnosis, i.e.,
attributing diagnostic labels to responses to life situa-
tions that should be considered to be within normal
variation. This is both a major clinical and an ethical
issue (Wakefield, 2010, 2013a). Such overdiagnosis
could discredit psychiatry by claiming that there is
no essential difference between mental disorder and
normality, and by forcing clinicians to treat normally

functioning people with medications that they do not
necessarily need (Paris & Phillips, 2013). Psychiatry
has long been criticised for medicalising and patholo-
gising normal variations and overdiagnosis means
overtreatment, with all the existing side effects of psy-
chopharmacological interventions.

However, as critics themselves acknowledge, ‘des-
pite all its epistemological, scientific and even clinical
failings, the DSM incorporates a great deal of practical
knowledge in a convenient and useful format; it does
its job reasonably well when it is applied properly
and when its limitations are understood. One must
strike a proper balance’ (Frances & Widiger, 2012).
At its core, the DSM-5 should be simply regarded ‘as
a guidebook to help clinicians describe and diagnose
behaviours and symptoms of their patients; it provides
clinicians with a common language to deliver the best
patient care possible’ and aims to encourage future
directions in research (Kupfer, 2013).

Two years after its publication, it is time to carefully
weigh the pros and cons of the new diagnostic system
and to explore the facts and the myths surrounding the
DSM-5. For this purpose, we invited to comment in the
‘Editorial in this Issue’ of Epidemiology and Psychiatric
Sciences, two eminent scholars who have leading
roles in the DSM-5 debate taking place in the scientific
literature, Jerome Wakefield (see e.g., Wakefield, 2010,
2013a, b) and Mario Maj (see e.g., Maj, 2012, 2013,
2014).

Wakefield (2015) highlights a number of critical
issues with the DSM-5, considering this new diagnos-
tic system flawed in process, goals and outcome. The
revision process itself suffered from lack of adequate
public record of the rationale for the changes, thus mis-
leading the future scholarship. In fact, for scholars try-
ing to understand and evaluate the validity of the
DSM-5 task force’s decisions, the most important prob-
lem with the revision process was its secrecy and lack
of adequate documentation. Moreover, the declared
goals of the revision process, such as dimensionalising
diagnosis, incorporating biomarkers and separating
impairment from diagnosis (Regier et al. 2009), were
ill-considered and were eventually mostly abandoned.
In Wakefield’s view, the major drawback of the DSM-5
is the worsening of the false-positive problem. This is a
major problem: the DSM-5 has missed the opportunity

* Address for correspondence: Dr A. Lasalvia, Department of
Psychiatry, Azienda Ospedaliera Universitaria Integrata di Verona,
Policlinico “G.B. Rossi”, Piazzale L.A. Scuro, 37134 – Verona, Italy.

(Email: antonio.lasalvia@univr.it)

Epidemiology and Psychiatric Sciences (2015), 24, 185–187. © Cambridge University Press 2015
doi:10.1017/S2045796015000256

EDITORIALS IN THIS ISSUE,
JUNE 2015

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to increase the conceptual validity of psychiatric diag-
nosis by aggressively addressing false-positive issues;
in squandering this opportunity, the DSM-5 placed
the hard-won integrity of psychiatry as a medical dis-
cipline at risk. According to Wakefield (2015), the wor-
sening of the false positive problem specifically applies
to: (1) substance use disorder (increasing the symptom
options while decreasing the diagnostic threshold will
pathologise mild conditions), (2) major depression (the
elimination of the bereavement exclusion implies that
bereaved individuals who manifest five general dis-
tress symptoms for 2 weeks after a loss will now be
classified as having a Major Depressive Disorder), (3)
intermittent explosive disorder (allowing verbal argu-
ments among diagnostic criteria will artificially inflate
its prevalence rate) and (4) attention deficit hyperactiv-
ity disorder (expanding diagnosis to adults before
addressing its manifest false positive problems in chil-
dren will perpetuate the same high false positive rate
by encompassing normal variations within the
umbrella of the disorder). On the other hand,
Wakefield (2015) also acknowledges that the DSM-5
has made some progress in addressing the false posi-
tive problem, such as the addition of a more stringent
criterion for insomnia disorder, the exclusion of defiant
behaviour directed only at a sibling for the diagnosis of
oppositional defiant disorder, and the exclusion criter-
ion of severe relationship distress for diagnosing sex-
ual dysfunction. Moreover, the DSM-5 changes are
likely to prevent some false positives, e.g., excluding
‘irritable mood’ from manic episode criteria (only
‘abnormally and persistently increased activity or
energy’ is now required) will probably reduce mis-
diagnoses of bipolar disorders.

Maj (2015) challenges some recurring critical com-
ments in the media that have preceded and followed
the publication of the DSM-5. These include statements
such as (1) the DSM is ‘the bible of psychiatry’ (e.g.,
Horgan, 2013), (2) the DSM pathologises conditions
that are in the range of normality (e.g., Cassels,
2013), (3) the unavailability of biological tests invali-
dates psychiatric diagnoses (e.g., Insel, 2013), and (4)
the Research Domain Criteria (RDoC) project recently
launched by the NIMH in the USA (Cuthbert, 2014)
is going to transform psychiatric diagnosis by
replacing descriptive psychopathology with behav-
ioural and neurobiological measures (e.g., Insel,
2013). Maj challenges these statements by applying
rigorous reasoning and providing compelling evidence
drawn from the scientific literature. Regarding the first
issue, literature shows that only a minority of psychia-
trists around the world use formal diagnostic systems
in their ordinary practice and, when a diagnostics sys-
tem is used, only one tenth of clinicians use the DSM. It
therefore seems that the wide gap exists between

current diagnostic systems and ordinary diagnostic
practice; the scientific community keeps revising diag-
nostic systems, but the impact of these revisions on
clinical practice is much lower than expected. With
regard to the second statement, after having acknowl-
edged that some conditions included in the DSM-5
may not qualify as psychiatric disorders and that the
threshold for the diagnosis of some conditions that
do qualify may be too low. Maj argues that a pragmat-
ic set of inclusion and exclusion criteria needs to be
developed in order to apply them explicitly and con-
sistently when the introduction of a new condition in
the diagnostic system is proposed (and if a balance
between possible benefits of the inclusion and possible
risks is involved in the decision, this should be made
explicit). Moreover, non-validated thresholds should
not be used in the name of reliability or to avoid chan-
ging current assessment instruments; alternative
thresholds should be formally studied, especially
with respect to their clinical utility. As far as the
third issue is concerned, Maj points out that the crucial
element is not whether the threshold for the diagnosis
of a disorder is based on a biological test or a set of
clinical variables, but rather whether the threshold
has sufficient predictive validity (therefore, in the
absence of biological tests, an active search for clinical
thresholds that are predictively valid should be per-
formed). Finally, the notion that the RDoC approach
will transform psychiatric diagnosis in the foreseeable
future is also challenged; based on the current avail-
able research evidence, the RDoC project is more likely
to develop neurobiological measures that may help in
subtyping rather than replacing current diagnostic cat-
egories, with the aim of improving the predictions of
outcomes and treatment responses.

In summary, a number of problems do exist in our
current diagnostic systems (and the DSM-5 has
probably even worsened the situation), and many lim-
itations still affect the diagnostic process in psychiatry.
However, trashing current diagnostic practices may be
harmful for psychiatry’s image and, more importantly,
for our patients. Throwing out the baby with the
bathwater, so to speak, is always dangerous.

References

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persists. Medscape Multispecialty, May 18.

Cuthbert BN (2014). The RDoC framework: facilitating
transition from ICD/DSM to dimensional approaches that
integrate neuroscience and psychopathology. World
Psychiatry 13, 28–35.

Frances A (2010). The first draft of DSM-V if accepted will fan
the flames of false positive diagnoses. BMJ 340, 492.

186 A. Lasalvia

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the Medicalization of Ordinary Life. William Morrow & Co.:
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Frances AJ, Widiger T (2012). Psychiatric diagnosis: lessons
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Annual Review of Clinical Psychology 8, 109–130.

Horgan J (2013). Psychiatry in crisis! Mental health director
rejects psychiatric “bible” and replaces with. . . nothing.
Scientific American, May 4.

Insel T (2013). Director’s blog: Transforming diagnosis
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about/director/2013/transforming-diagnosis.shtml.

Kupfer D (2013). Statement by David Kupfer. Chair of DSM-5
Task Force Discusses Future of Mental Health Research.
American Psychiatric Association: Arlington, VA; May 3,
2013 http://www.psych.org/FileLibrary/
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13-33-Statement-from-DSM-Chair-David-Kupfer–MD.pdf.

Maj M (2012). Bereavement-related depression in the DSM-5
and ICD-11. World Psychiatry 11, 1–2.

Maj M (2013). The DSM-5 approach to psychotic disorders: is
it possible to overcome the ‘inherent conservative bias’?
Schizophrenia Research 150, 38–39.

Maj M (2014). DSM-5, ICD-11 and ‘pathologization of normal
conditions’. Australian and New Zealand Journal of Psychiatry
48, 193–194.

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commentsandlessonsforthefutureofdiagnosisinpsychiatric
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implications for human freedom. Theoretical Medicine and
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DSM-5 two years later: facts, myths and some key open issues 187

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http://www.psych.org/FileLibrary/AdvocacyandNewsroom/PressReleases/2013Releases/13-33-Statement-from-DSM-Chair-David-Kupfer–MD.pdf

http://www.psych.org/FileLibrary/AdvocacyandNewsroom/PressReleases/2013Releases/13-33-Statement-from-DSM-Chair-David-Kupfer–MD.pdf

http://www.psych.org/FileLibrary/AdvocacyandNewsroom/PressReleases/2013Releases/13-33-Statement-from-DSM-Chair-David-Kupfer–MD.pdf

http://www.psych.org/FileLibrary/AdvocacyandNewsroom/PressReleases/2013Releases/13-33-Statement-from-DSM-Chair-David-Kupfer–MD.pdf

http://www.psych.org/FileLibrary/AdvocacyandNewsroom/PressReleases/2013Releases/13-33-Statement-from-DSM-Chair-David-Kupfer–MD.pdf

http://www.psych.org/FileLibrary/AdvocacyandNewsroom/PressReleases/2013Releases/13-33-Statement-from-DSM-Chair-David-Kupfer–MD.pdf

http://www.psych.org/FileLibrary/AdvocacyandNewsroom/PressReleases/2013Releases/13-33-Statement-from-DSM-Chair-David-Kupfer–MD.pdf

http://www.psych.org/FileLibrary/AdvocacyandNewsroom/PressReleases/2013Releases/13-33-Statement-from-DSM-Chair-David-Kupfer–MD.pdf

http://www.psych.org/FileLibrary/AdvocacyandNewsroom/PressReleases/2013Releases/13-33-Statement-from-DSM-Chair-David-Kupfer–MD.pdf

http://www.psych.org/FileLibrary/AdvocacyandNewsroom/PressReleases/2013Releases/13-33-Statement-from-DSM-Chair-David-Kupfer–MD.pdf

http://www.psych.org/FileLibrary/AdvocacyandNewsroom/PressReleases/2013Releases/13-33-Statement-from-DSM-Chair-David-Kupfer–MD.pdf

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DSM-5 two years later: facts, myths and some key open issues
References

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