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Clinical Implications of DSM V

Promising and Challenging issues for clinical work in the development of DSM-V. 1. Developmental perspectives2. Dimensional rather than Categorical diagnoses3. Utility of a diagnostic system in non-psychiatric settings4. Age-related manifestations and subtypes5. New diagnoses . 1. Developme

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Clinical Implications of DSM V

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    1. Clinical Implications of DSM V Bela Sood, MD and Doug Robbins, MD Co-Chairs – Clinical Committee Society of Professors of Child and Adolescent Psychiatry May 7, 2009 With appreciation to D. Pine, MD

    2. Promising and Challenging issues for clinical work in the development of DSM-V 1. Developmental perspectives 2. Dimensional rather than Categorical diagnoses 3. Utility of a diagnostic system in non-psychiatric settings 4. Age-related manifestations and subtypes 5. New diagnoses

    3. 1. Developmental perspectives Opportunity to consider developmental processes in understanding disorders. Integration of neuroscience and environmental factors. May increase emphasis on teaching “normal” and atypical development May encourage multi-modal, more comprehensive treatment planning More multi-faceted, less automatic relationships between diagnoses and treatment More detailed and comprehensive assessment will conflict with pressures for reimbursement and workforce limitations

    4. 2. Dimensional rather than Categorical diagnoses Emphases continuity with “normal” phenomena More consistent with polygenic modes of heritability More appropriate to the Spectrum concept of disorders Depression Schizophrenia Autism ADHD Axis II

    5. 2. Dimensional rather than Categorical diagnoses - continued Useful approach to Co-Morbidity Different patterns of manifestation of a shared risk (genetic, other), rather than multiple separate disorders E.g. Anxiety disorders and Depression Some comorbidity may be an artifact of DSM-IV’s approach of splitting more than lumping. Can incorporate degrees of severity and impairment Supports recognition of importance of sub-syndromal symptoms. Possible support for more early intervention Will decrease “Check-List” evaluations. Will conflict with reimbursement pressures for clear, present/absent diagnoses

    6. 3. Utility of a diagnostic system in non-psychiatric settings Goal – help with workforce shortage; increase access to care. Usable by pediatricians, nurse practitioners, others Goal – more use of “objective” factors, less reliance on clinical judgement, e.g. Lab testing Psychological testing Rating scales Realistic with our current knowledge? Conflicts with other goals of DSM V which may require more complex, detailed assessment. (developmental, neuroscience, dimensional…)

    7. 4. Age-related manifestations and Age-related subtypes Age-related manifestation – e.g. ADHD – childhood vs adolescent presentation Age-related subtypes – e.g. Conduct Disorder Valuable for treatment planning, anticipating course Can help families understand what appear to be changes in diagnosis May increase emphasis on early identification and early intervention Challenge – limitations of retrospective history regarding age of onset, prior sub-threshold symptoms

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