DSM 5 (2013) AND INFANT – JUVENILE PSYCHOPATHOLOGY

The article presents and discusses the general and specific novelties which DSM V brings to the restructured field of what was formerly called „Disorders first diagnosed during infancy, in childhood or in adolescence” and now called „Neurodevelopmental disorders”.

As it is well known, all classifications and codifications proposed for mental disorders over time had to be reviewed not only to assimilate scientific progress gained along the way. The US tentative started after the Second World War and completed in 1952 under the name “Diagnostic and Statistical Manual” (DSM I) was no exception so that over 61 years there have been seven revisions of which four were completed in only the last 33 years. Among them, DSM III and DSM -V are considered radical revision (Vraşti, 2011).
NEW OPTIONS AND SOLUTIONS PROMOTED BY DSM-V. Some are general, most of them concern relatively precise matters. Among the arguments we keep in mind the following:

• adequacy to reality by eliminating what the practice has not confirmed,
• assimilation of scientific progress attained in the field,
• facilitating the capacity to absorb future discoveries,
• drawing more rigorous borders between various entities and between them and and normality,
• alignment to the nosography promoted by WHO,
• need to facilitate the ability to forecast the evolution of disorders and to assess the severity and the needs of the patient,
• reducing the number of false comorbidities and the excess of cases that were not classified elsewhere, and of course,
• de-stigmatization.

NEW OPTIONS AND SOLUTIONS WITH GENERAL CHARACTER.

Four new general methodological options can be identified in DMS-5, namely:

1. Renunciation to the explicit multiaxial classification system.

It was introduced in1980, with the DSM-III. Five axes were nominated, i.e.: Axis 1 that includes clinical disorders except those of Axis II designed for personality disorders and mental retardation; Axis III targets general medical conditions; Axis IV refers to present psychosocial and environmental problems; Axis V is designed for the overall assessment of functionality.
Certainly, until the current version of the DSM, specialists used to emphasize the advantage that it is an explicit multiaxial classification, which meets the need to discriminate the clinical reality, by the supplement of information provided. However, the fact that, in reality, the exposed diagnosis was only biaxial has been minimalized. It must be said that classical classifications are multiaxial by default because the axes (evolution, causal assumptions, prediction) are directly included in the diagnosis. I consider that, in terms of the clinical significance given by the diagnosis, this is a bonus, even if it is limited and sometimes questionable due to theoretical disputes relating to, for example, aetiopathogenesis. In fact, as we shall see, DSM-5 feels obliged to compensate the renunciation to the explicit multiaxial system by adopting a particular form of multi-axiality, this time an implicit one, because it relies on the practical application of what received the general term of “specifier”.

2. Transition from a categorical classification to one doubled by quantitative criteria.

It is the second new methodological option. It supplements the diagnosis based only on phenomenological elements, respectively on minimal required set of symptoms considered representative, with the quantitative data provided by scales with three or four value levels, which assess the severity of its main components or the extent of the necessary support. It is an important gain because, this time, the severity registers as a default axis, which allows emphasis on what should be treated with priority, the drawing of a minimum level of intensity of manifestations from which they can be taken into account and thus eliminate false positives, as support for progressive and prognostic assessments.

3. Substantial diversification of the types of specifiers.

This is the third methodological option operated by the DSM-5. It means a significant increase in the number of diagnosis parameters and their involvement in the individualization within each category of mental disorders in part of as many well-delineated and accurately demarcated, particularised and nuanced diagnostic entities as possible. Of the large number of specifiers, different from one diagnosis group to another, we will exemplify those regarding the duration in time, the state of primary diagnosis, of partial or total remission, transient character, character of acute, unique or recurrent episode, significant details on age, gender, cultural or environmental circumstances, characteristics of some of the symptoms, etc. In fact, these signifiers, together with the one of severity become internal axes intended to diversify greatly the diagnostic entities, to delineate firmly types, subtypes, particular forms of manifestation and the pathological normal and thus reduce false comorbidities as well as the number of cases previously included in the category diagnoses without further specification.

4. New terminology and diagnostic options.

It is the fourth change. It consists, on the one hand, in the expansion of a process begun earlier, of marginalization and even elimination from the psychiatric language of some notions, names of classes, groups or diagnoses and even of some established clinical entities and, on the other hand, in the introduction of some new ones.
We know, for example, that, over time, traditional notions such as those of neurosis (DSM III), endogenous, organic mental disorder (DSM IV) have been abandoned, while others have appeared as novelties. This time, concepts of dementia or psychosis go into the background and, as we shall exemplify in the field of child and adolescent mental disorders, names and diagnostic entities, some with tradition, are put aside, and new ones are introduced.

CHANGES AND NEW PRECISE SOLUTIONS PROVIDED BY DSM V.

There are many of them. They can be distributed on four levels: ● the one of the major diagnosis groups; ● the one of their subordinate diagnosis classes; ● of the entities contained in each diagnosis class in part; ● and fourthly, on the level of clinical forms that have been identified and authenticated following the involvement of the new specifiers. They allow for reorganizations, restructurings, removals, re-groupings, disjunctions, renaming, deletions or creation of new terms, names, groups, classes and diagnostic entities. From the beginning, we specify that we will look only at the psychic pathology included in the large diagnosis group now called “Neurodevelopmental disorders”, which in DSM-5 replaced largely the one introduced in 1980 by DSM III and called “Disorders usually diagnosed for the first time in infancy, in childhood or in adolescence” As we shall detail, this group together with its content, is subject to a wide restructuring process. It should be emphasized that this diagnosis group, although it is intended to encompass mental disorders present in children and adolescents, does not cover them all. Furthermore, DSM-5 expands the number of mental disorders encountered in children and adolescents placed alongside those of adults. It is true that some of them (Tab. 1) are clearly delineated by means of a specifier that proves their belonging to infant-juvenile age group.

Table 1 Child and adolescent mental disorders placed together with adult disorders and defined by means a specifier

Changes and new specific solutions regarding the constitution and the content of the diagnostic group called “Neurodevelopmental disorders.”

A- Removal of certain diagnosis classes from the group called “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence” in the DSM-III, DSM-III-R, DSM-IVTM and DSM-IV-TRTM” and their transfer into the category of adult disorders. We mean the following:

• a «Feeding and eating disorders in infancy or early childhood” presented in DSM-IVTM and DSM IV-TRTM;
• b «Elimination disorders” presented in DSM-IVTM and DSM IV-TRTM;
• c «Conduct disorders,” “Oppositional defiant disorder” and “Disruptive behaviour disorder not otherwise specified” are removed from the diagnosis group called “Attention deficit and disruptive behaviour disorder” presented in DSM-IVTM and DSM IV-TRTM;
• d “Separation Anxiety”, “Selective mutism” and “Reactive attachment disorder of infancy and early childhood” are removed from the diagnosis group entitled “Other disorders of infancy, childhood or adolescence” presented in DSM IVTM and DSM IV- TRTM. Thus, two of the previous diagnosis classes were dismantled and removed: ● “Attention deficit and disruptive behaviour disorders” of which only the component that we call ADHD was retained; and ● “Other disorders of infancy, childhood or adolescence” of which only “Motor stereotypes” were retained.

B- Establishment of new diagnosis names, entities and classes:

1. Introduction of specifiers with which, as we shall see, clinical forms may be individualised and transformed into new diagnostic entities.
2. Establishment of a diagnostic group called “Motor disorders”. It was meant to subordinate three previous diagnosis entities, as follows: “Developmental coordination disorder (DCD)”, previously being a distinct entity (in DSM III-R, DSM IVTM, DSM IV-TRTM); “Tic disorders” also a previous distinct entity (DSM IVTM DSM IV-TRTM) and “Stereotypic movement disorder (SMD)”, an entity which was included anteriorly into the group “Other disorders of infancy, childhood or adolescence” (DSM III-R, DSM IVTM, DSM IV-TRTM). At this level, here are the specifiers that determine distinct, newly individualized clinical forms. In the case of motor stereotypes, there are three degrees of severity, (mild, moderate and severe), the presence or absence of self-aggressive behaviour, of some known genetic or neurodevelopmental medical conditions, or of certain environmental factors. And, in the presence of chronic tics, the presence of only vocal tics or of only motor ones.
3. Assigning an independent status to the “Attention-deficit/hyperactivity disorder”. For this purpose, it was removed from the previous diagnosis group called “Attention deficit disorder and disruptive behaviour disorder”. (DSM IVTM, DSM IV-TRTM).
4. Furthermore, within this diagnosis class a new clinic entity is established called “Other specific attention deficit and hyperactivity disorder” for cases that, in spite of their suffering from this diagnosis, do not meet the minimum criteria necessary for it. Moreover, by involving some specifiers, new clinical forms are delineated depending on the degree of severity (mild, moderate and severe) and on their partial remission.
5. Establishment of a new diagnosis entity within the frame of intellectual disabilities called “Global development delay” (CIM 10 -F 88). It is reserved for children under five years of age in whom, for various reasons, the severity of intellectual disability cannot be ascertained. They will have to be re-assessed later on.
6. Establishment a new diagnostic entity within the group “Communication Disorders” entitled “Social (pragmatic) communication disorder” for difficulties in verbal and nonverbal communication of the social content of messages. We consider it an important option because it offers a real obstacle in front of the risk, which is possible today that the respective cases might be confused with those belonging to the autistic spectrum.

C- Change of the name of certain groups, classes and diagnostic entities and/or restructurings of their contents. It is understood that the substituted names are eliminated from practice.

1. The name of “Intellectual disability” replaces the one of “Mental retardation” present in DSM III, DSM III-R, DSM IVTM, DSM IV-TRTM and CIM- 10 F 70-79. In turn, the clinical forms (mild, moderate, severe, profound and with unspecified severity) also become intellectual disabilities. It should be noted that the onset is situated before the age of 18 years. Furthermore, at this level, a further specifier is introduced with three degrees of severity, referring to the level of the adaptive function and of the necessary support and, as mentioned above, a new clinical form called “Global developmental delay”. By this, the number of recognized clinical forms increased from five to sixteen.
2. The name “Autism spectrum disorder” replaces the one of “Pervasive developmental disorders” (DSM III, DSM III-R, DSM IVTM, DSM IV- TRTM). Besides covering the contents of the substituted diagnostic category represented by diagnosis entities hitherto considered distinct (Autistic disorder, Rett syndrome, Childhood disintegrative disorder, Asperger disorder, and Pervasive developmental disorder –not otherwise specified), the new name restructures this category profoundly. It restructures and not just covers the former category because it is the expression of a radical option, which starts from the idea that, apart from Rett syndrome (DSM IVTM DSM IV TRTM) that, it excludes without eliminating from mental disorders, all the other entities actually represent a relatively uniform clinical reality. We start from the belief that, in this case, we are dealing with the same clinical reality whose diversity of expression is determined by the absence or presence of intellectual or language impairment, by the severity of their damage and by that of the other manifestations, by age, environmental factors or associated diseases, and of course by the way these parameters combine among themselves. Consequently, on the one hand, these disorders disappear as diagnoses being transformed into simple clinical variants of a common core of previously well individualized entities such as the “Autistic disorder” (DSM III, DSM III-R DSM IVTM DSM IV TRTM), “Childhood disintegrative disorder”( DSM IVTM, DSM IV TRTM)¸ “Asperger Disorder” (DSM IVTM, DSM IV TRTM) and “Pervasive developmental disorder – not otherwise specified” (DSM III-R, DSM IVTM, DSM IVTRTM). On the other hand, it is possible that those who already know the clinical entities excluded should recognize them among the many forms of manifestation, as expression of the involvement of the mentioned specifiers, but only as a symptomatic group without identity, clearly formulated limits and explicit diagnosis.
3. The name “Specific learning disorders” replaces the one of “Learning disorders” (DSM IVTM, DSM IV-TRTM). This time, without any explanation in the text, the old accentuation of the specific nature of these clinical manifestations reappears (CIM 10, DSM III and DSM III-R). A detail that was dropped out in DSM IVTM and DSM IV-TRTM and one that even in 2012 we regarded as lacking support.
4. The clinical form entitled “Learning disorder not otherwise specified” disappears but, this time, by involving 10 specifiers plus three degrees of severity (mild, moderate and severe) for each one specifier, the number of individualized clinical forms increases from four to thirty
5. Communication Disorders (DSM IVTM DSM IV TRTM) preserve the same name. But, the content is marked by:

– Combination of receptive and mixed receptive-expressive language disorders under the name of “Language disorders”.
– Replacement of the name “Phonological disorder” with “Speech sound disorder”
– And, as noted above, a new clinical form was introduced entitled “Social (pragmatic) communication disorder”.

D- In DSM 5, the entire restructured context of what previously was called “Disorders usually first diagnosed in infancy, childhood, or adolescence” is now called “Neurodevelopmental disorders”. Note that in DSM III-R, a part of it was called “Developmental disorders”, a designation that the revision of the DSM IV gave up only to revert to it and to exploit again explicitly the idea of ​​relating these disorders to the development process.

DISCUSSIONS

1. We believe that the new name of “Neurodevelopmental disorders” meant for child and adolescent mental disorders represents an important gain because it emphasizes that the disease, its carrier and the interaction between the two sides bear the specific imprint of their evolutionary nature and of their dependence on age, a fact, which should be stressed. However, two findings need to be mentioned, and cannot be omitted. The first refers to the fact that the name focuses exclusively on the “neuro” particle although it is a classification of psychic disorders. The second finding regards the fact that this time, as noted above, the area was restricted, being deprived even of clinical entities such as, for example, conduct disorders, reactive attachment disorders, enuresis, encopresis and not only, which in child are completely different from adult.
2. Of the DSM series of six revised editions over time, none was rather like a bible of psychiatry nor did it propose to be one as dangerously and erroneously considered those who did not understand what the mentally ill patient really is. It is a psychiatric book where a diagnosis cannot be separated from causal considerations, pathogenic mechanisms, evolution, prognosis and individual specific.
DSM cannot replace clinical reality and psychiatric manuals, an aspect that was emphasized by the authors of DSM III (1980). This fact is a consequence of the following issues:

• the atheoretical and aetiological characteristic;
• shifting of the focus from the patient to the disorder and from the explanation of the disease to its description;
• simplifying the diagnosis reduced to a frame scheme, a snapshot, a too general abstract, laconic, levelling formula, a simple description and grouping of a minimum of symptoms, and only the visible ones, the only considered to be defining and sufficient for diagnosis;
• the lack of nuances or of opportunities to individualize and represent the patient regarding his/her rights, therapy conduct and its cost, though even for the cost it is habitually used the most – in short, ignoring the Hippocratic principle, there are no diseases but only sick people or, what today is of great actuality, the need to customize the intervention, a requirement to which mental disorders have always been subject to.

The excess of disorders that are not classified in other parts cannot be minimized, either. Making a synthesis of the drawbacks of DSM IV, Lăzărescu (2010) notices the failure to clarify the issues raised by: the abuse of comorbidities and clinical types, the notions of cluster, of subclinical disorder or malady spectrum as well as that episode and disorder. In fact, not only the need to connect to the progress of knowledge in the field but also the many un- accomplishments has required the six revisions of DSM. It should also be stressed in particular that the limitation to the DSM is a source of important risks and negative consequences. We consider placing on a secondary level: ● the causal thinking and clinical practice restricted to collecting and comparing observable data with standard tables ● as well as the primary psycho-prophylaxis based on identifying, assessing and combating psycho-pathogenetic factors. It is right, in DSM 5, a number of causal circumstances are exploited (Table 2) but they are far from their real number.

Table 2
Psychiatric disorders aetiologically defined in DSM-5

There are mentions of the kind: Associated with … or, more directly, With….- for example a medical condition…- which cannot be equated with the statement: Determined by …..
3- DSM – a valuable and necessary tool of administrative psychiatry. As I have already said (Milea 2009), administrative psychiatry is a highly necessary reality, completely different from clinical psychiatry. Given its complementary role, it is not a substitute for clinical psychiatry but it serves its own, necessary purposes, based on diagnosis and classification systems of mental suffering for which it found a major tool in the regularly revised offers of the DSM. Its value stems from the following facts:

• enables the identification, designation, systematization and classification of mental disorders;
• facilitates scientific research and studies on morbidity and communication between specialists;
• provides a common language and truths based on the average of statistically significant data;
• minimizes conflicting disputes arising from doctrinal guidelines;
• puts semiotics in its rights and obliges researchers to know it;
• is based on evidence;
• reduces subjectivity (Lăzărescu -2010);
• enables the creation of standardized tools for diagnosis and treatment;
• protects the psychiatrist from false accusations of malpractice.

These are all arguments supporting its acceptance and recognition. However, two very important issues should be kept in mind namely:
a- At consultation, when we are obliged to apply the standardized diagnostic instruments and especially those for treatment based on statistically significant truths, nothing tells us whether in front of us there is a case that belongs to the exceptions, which, when summed up, could sometimes reach about 49 percent of what reality can offer, and
b- Not infrequently, at surface, the clinic has offered appearances, respectively misleading evidence, therefore we are obliged to learn to seek and identify the true reality. It should be recognized, however, that neither administrative psychiatry, nor DSM helps us in this regard. We give the examples with the hyperkinetic disorder that was substituted for decades to the current ADHD diagnosis and that this is considered attention deficit and not what we think it actually is, an involuntary hyperprosexia (Milea 2010). Similarly, many clinical entities have been certified over the years by the various versions of the DSM, only to be dropped out later on.
4- Without doubt, in the intention to solve some of the shortcomings, DSM 5 has taken important steps, it remains to be seen whether they are sufficient or valid enough.

References:

1. American Psyichiatric Association: Diagnostic andStatistical Manual ofMental Disorders. ThirdEdition. DSM III (1980)Washington, DC
2. American Psyichiatric Association: Diagnostic andStatistical Manual ofMental Disorders. ThirdEdition, Revised. DSM III-R (1987) Washington, DC
3. American Psyichiatric Association: Diagnostic andstatistical manual ofmental disorders. FourthEdition DSM-IVTM (1994)Washington, DC
4. American Psyichiatric Association: Diagnostic andstatistical manual ofmental disorders. FourthEdition Text Revision. DSM-IVTRTM (2000) Washington, DC
5. Lăzărescu M (2010). Noile frontiere ale nosologiei. Psihiatru ro. Anul VI. Nr. 23. 4:24-27
6. Milea St. (2010)Attention Deficit/HyperactivityDisorder (AD/HD) o formulare diagnostică imprecisă cu consecinţe care nu pot fi minimalizate. Revista SNPCARVol 13. Nr 1 pg: 9-16
7. Milea Şt (2012) Tulburări Specifice de Dezvoltare- o clasă diagnostică depăşită. Revista SNPCAR nr. 1 pg.: 7-14
8. Milea Şt. (2009) Psihiatrie clinică şi/sau administrativă. Orientări şi perspective în gândirea psihiatrică românească actuală. Vol III Sub redacţia: G Cornuţiu, D Marinescu. Pg: 78-98
9. Vraşti R (2011) DSM-5, riscurile unei sarcini suprapurtate (depăşite) sau o sinteză rapidă asupra dezvoltării lui.Psihiatru ro. Anul VII. Nr. 24. 1: 42-49