EVALUACIÓN MULTIAXIAL EN DSM-5 Tras la publicación definitiva en castellano, A pesar del amplio uso del sistema multiaxial del DSM-IV, éste no era. From DSM-IV-TR to DSM Analysis of some changes *Correspondencia con el autor: Departamento de Personalidad, Evaluación y Tratamiento Psicológico. Sumario: Clasificación DSM-IV con los códigos CIE — Evaluación multiaxial — Trastorno de inicio en la infancia, la niñez o la adolescencia — Delirium.
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Valdés Miyar, Manuel [WorldCat Identities]
The DSM-IV is a diagnostic and statistical system for the classification of mental disorders that follows a categorical model. It is used in the clinical practice and research in the psychiatry area. The aim of this study was to analyze the use of the DSM-IV in the clinical practice and to report on its advantages and limitations.
A wide bibliographic review was made to show the relevance of the topic. Some probable changes were evauacion out, which will be included in the next editions. A discussion on the diagnostic models, both dimensional and categorical, was carried out as well. The paper was divided into the following sections: DSM-IV, multiaxial system, psychopathology.
In ancient Greece, 5 b. Words such as hysteria, mania and melancholy were used to characterize some of them.
Over the centuries, a number of terms have been incorporated into the medical jargon, as for example: The first system including a comprehensive classification and with real scientific profile arose with the studies by Emil Kraepelinwho gathered different mental disorders under a single denomination – dementia praecox, later termed schizophrenia by Bleuler – together with other psychotic disorders, separating them from the clinical status of manic-depressive psychosis.
New diagnostic categories were created, such as: Many words started to be avoided. The term neurosis, for example, was no longer used, so that etiologic issues were not invoked; the word hysteria was vanished from the text for the same reason, and the expression mental disorder replaced mental illness, etc.
A patient diagnosed as schizophrenic, for example, could not be simultaneously diagnosed as having panic disorder. Schizophrenia, a more severe pathology, was considered superior than the panic disorder.
Such hierarchy followed the well-known practice of medicine that recommends the identification of a single pathology to explain all symptoms of a clinical status. Inwith the publication of the DSM-III-R, such hierarchy was abolished, and the manual started to recommend that two or more diagnoses were made for the same patient.
This allowed for the arousal of the concept of comorbidity in psychiatry, later confirmed by the DSM-IV and widely known in the s and today. In fact, the concept of comorbidity dates back towhen Feinsten employed it for the first time to define “any additional clinical entity that exist or that can occur during the clinical course of a patient.
It was published in the s, considered the “brain decade” by the WHO. The DSM-IV uses a multiaxial approach to diagnoses organized in 16 distinct classes, which are assigned specific number codes and distributed in five major axis: Describes the clinical disorders.
Valdés Miyar, Manuel
Describes general medical conditions. Approaches the psychosocial and environmental problems associated to a mental disorder.
It is a global assessment of functioning AGF scale that is assigned a number. In the clinical practice there is a number of examples. Individuals firstly described as having “hysteria” were mocked in the emergency rooms, because physicians did not understand their suffering. Derogative terms were used to refer to them. The dysthymic disorder could be understood as a clinical disorder that, in spite of its clinical course, is not characterized as a personality trait, as it was firstly considered, but as a pathologic state that can be diagnosed and treated.
The development of research in the mental health area had an extraordinary impulse over the last years. Attention to evaluaciom and communication among different professionals – psychiatrists, psychotherapists multiadial psychologists – established a new partnership between the clinical psychiatry and the behavioral, cognitive-behavioral CBT and interpersonal psychotherapies – that is unique in the history of our specialty.
Such an approach resulted in the development of new therapeutic techniques, thus providing a great improvement of our patients’ life quality.
Some findings have been confirmed in the specialized literature. The obsessive-compulsive disorder, for example, can be effectively managed with antidepressant drugs, which inhibit the Selective Serotonin Reuptake Inhibitors IRSSor with behavioral therapy. Original studies say that functional alterations found through brain imaging before such procedures decrease after treatment. In several cases, both forms of treatment are indicated and one of them may be chosen.
The specific phobia does not improve with medication, but it has very good response to behavioral therapy. Mild and moderate depression episodes have a good response to antidepressants or CBT. Associating both procedures, however, may offer even better and long-lasting results. Similarly, patients with social phobia may be indicated both forms of intervention – antidepressants and CBT, because many of them, after remission of physical symptoms resulting from anxiety with medication, need treatment to change behavior, improve assertiveness and increase the sociability.
The first one concerns to the system itself, which produces an excessive fragmentation of the clinical states of mental disorders. This is the reason why many patients are given many different diagnosis simultaneously, once the symptoms overpass the rigid borders the manual proposes.
Comorbidity within an axis or many of them is almost a rule and not an exception. Eighty percent of individuals with social phobia are given other correlate diagnosis. Besides, the list of symptoms do not comprise all patient’s complaints.
For example, headache, dry mouth, blurred sight and cry outbursts are not described as symptoms of panic attack, although they are frequently present in those episodes.
The second problem concerns the professional that will use the manual. The DSM-IV must not be used as an infallible list that automatically provides psychiatric diagnoses after it is filled.
The results may be a disaster in non-experienced hands. Many symptoms overlap different clinical conditions, and deciding their origin, or the state they belong is an action exclusively derived from clinical judging, which comes from theoretical knowledge from psychology, psychopathology and psychiatry areas, adequate training and experience accumulated with practice.
By listing symptoms, the manual intends to help acknowledge mental disorders, but not to replace the comprehensiveness of the clinical diagnosis, which is overall a result of intuition, perception and feelings that arises from this unique relation between the therapist and the patient.
La biblioteca | Experta en evaluación multiaxial | CATA | Flickr
The manual itself warns the reader about such aspects, in the chapter “A word of caution” from the introduction, and users are advised to read it thoroughly. This shows that the DSM-IV is jv from solving the diagnostic and statistic problems of our specialty. It shows us there is a long way to run, which will be successfully accomplished, provided that issues and prejudices of each area are left aside, and a joint effort is made to multaixial out a collaborative work, gathering scientific findings of psychiatry, which include advances in the field of neuroimaging and neurophysiology on the one hand, and the application, comparison and systematic measurement of psychopharmacologic and psychotherapeutic procedures on the other.
Thus, the diagnostic systems – DSM-IV and ICD – are nosographic and aim at listing and classifying mental disorders, but they do not replace the clinical practice. The model of such systems is named categoricalas opposed to the dimensional model. The scope of the categorical wvaluacion allows for the inclusion of comorbidities.
The concept of comorbidity by Feinsten was extended by Klerman, inas a term that comprises the “occurrence of two or more mental disorders or other medical conditions in the same individual. A and B are influenced by an underlying factor C, predisposing or causal; 4.
A and B are associated because their symptoms overlap. The categorical model distinguishes also the primary disorder, the first in a time sequence, and the secondary disorder. This is the case of depression secondary to panic disorder, as described by Klein et al. Depression, in this case, has different characteristics than those of a typical primary major depression episode, with more favorable progression, and remits with specific treatment for panic disorder, which is considered evaluaciln primary and causal disorder.
They described the mental disease as a unique dysfunction, which is expressed in different ways. The typical symptoms of depression – according to the school by Akiskal et al. Intermediate disorders would be represented by events with mixed symptoms of depression and anxiety. Thus, in the dimensional model, different from the categorical one, depression and evqluacion are considered the expression of the same pathology.
This makes us think of the concept of spectrum, term used as a metaphor of the physic phenomenon of light decomposition, which takes place when it passes through a prism. Similarly, the spectrum of a mental disorder, which the DSM-IV can not cover, includes predictive symptoms that arise during childhood, and prodomal and peripheral symptoms, which occur together with typical symptoms, or which appear with sufficient muliaxial to evaluaacion them. Under the point of view of the dimensional model, the clinical pictures are resulting from alterations in quantitywhich are expressed according to the degree of intensity, different from the categorical model includes the DSM-IV and the ICDde considers mental disorders as something produced by alterations in qualitydifferent for each disorder.
Some groups will be sub-divided into other diagnostic categories, thus widening even more the list of mental disorders. This is what is likely to happen with bipolar mood disorders I and II. The bipolar disorder III is characterized by symptoms of patients who naturally develop only depression episodes and start to have mania or hypomania episodes as well, which are triggered by antidepressant drugs.
The bipolar disorder IV seems to develop in people with hyperthymic temperament who develop episodes of depression, which are in general very severe with high risk of suicide.
The recovery of psychopathologic statuses, neglected by the current classificatory systems, such as hyperthymic alterations, firstly described by Kurt Schneider, is admirable from the scientific point of view.
On the other hand, some disorders should be reorganized, such as the avoidant personality disorder of Axis II, which may be grouped with the selective child mutism within social phobia, as they present the same symptoms, progress and mulitaxial response.
The classic division of schizophrenia into the subtypes paranoia, hebephrenia, edl and simple may be seen in a new way, having as reference the positive symptoms delusions and delirious ideas and the negative ones cognitive deficits. This results from findings of studies performed with last generation imaging techniques. The schizophrenic patients with predominantly negative symptoms have higher frequency of alterations in some brain structures that act in a correlate way as compared to patients with positive symptoms.
The positron emission tomography PET allows for an in vivo evaluation of the brain flow, which shows to be decreased in the prefrontal cortex, cerebellum and thalamus, the information sensorial filter.
The cerebellum coordinates cognition, language and motor skills. The term cognitive dysmetria has been used to characterize such disorder found in schizophrenia. If future studies confirm the cognitive loss of logic associations, they will be considered the main signal for the diagnostic of schizophrenia, confirming Bleuler original description of the start of the 21 st century.
Other authors consider that some personality disorders axis II are in fact part of the spectrum of other mental disorders. Thus, similarly to the dysthymic disorder – firstly acknowledged as a personality disorder and later described as a category from axis I – the borderline personality disorder would not be considered an isolated clinical condition anymore and would be part of the bipolar disorder spectrum; the schizotypal personality disorder, schizoid and paranoid would be included in schizophrenia.
Currently, several clinical research have been conducted with the goal of acknowledging and grouping symptoms that are not typical, but that mix or blur the major symptoms and are not in the DSM-IV list of diagnostic criteria. The objective is to narrow the gap between the categorical and the dimensional models. The partnership between both universities will allow for comparisons among different population. The first results will be published in a partnership, in the near future.
As an example, we will briefly describe the work developed with panic disorder that is currently ongoing. The Spectrum Project comprises the assessment of different anxiety and mood disorders. Two scales of mu,tiaxial evaluation were specifically developed for panic disorder.
The first was designed for the general population and the second for patients diagnosed with panic: Both comprise the following items: Adequately consulting and using the DSM-IV is extremely important for ddm that work with mental health care. Over the last years, the use of the DSM-IV multiaxjal provided significant scientific advances in the clinical practice and epidemiologic study of mental disorders. It also made possible a wide communication between psychiatrists and psychologists through a language that could be understood all over the world.