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Best Practices and the Continuing Relevance of DSM IV TR in Contemporary Clinical Practice
meet criteria for either. On axis II, she met all the criteria for borderline delusions: that he was a personal friend of the President of the US, that he
personality disorder (BPD). Her revised diagnosis was as follows: had fathered 100 children, and that he was sent by God to Washington, DC
to protect the President. In many previous admissions, various delusions
• axis I: panic disorder without agoraphobia, major depression, recurrent were always the most prominent symptoms and the diagnosis of CPS was
with anxious features; always maintained, but he also had prominent disorganized speech and
• axis II: BPD; behavior. His symptoms started when he was in his early teens. A medical
• axis III: none; student checked the criteria for paranoid schizophrenia and became
• axis IV: chronic mental illness, and inadequate family support; and perplexed because, although Mr Sanchez had various delusions, he did not
• axis V: global assessment of functioning (GAF) at the time of diagnosis meet criteria for the paranoid type, which called for the exclusion of
approximately 45. disorganized speech and behavior. Rather, Mr Sanchez met criteria for the
undifferentiated type. Alerted sufficiently, the attending psychiatrist carried
She was tapered off lithium successfully, but had recurring depression when out a semi-structured interview, and elicited symptoms that were not
lamotrigine was subsequently stopped. Dr Jones titrated her paroxetine up apparent during previous contacts with the same hospital—including faint
to 50mg, and concomitantly referred her to a therapist who began hallucinations, thought insertion, thought broadcasting, and ideas of
treatment with individual therapy based on principles of dialectical reference, all of which provided strong evidence that Mr Sanchez suffered
behavioral therapy. Barbara felt “relieved” about the diagnosis of BPD, from chronic undifferentiated schizophrenia. All of these symptoms had
always been there, but were newly recognized, and were then made targets
for a more aggressive trial of antipsychotic medications.
In psychotic disorders especially,
Of course, a more accurate diagnosis does not immediately translate to a
better treatment regimen for the patient, or even just a re-thinking of it.
greater scrutiny is emerging of the
However, it is difficult to argue that it is not a better situation to have
adequacy of care.
accuracy. In psychotic disorders especially, greater scrutiny is emerging of
the adequacy of care, not only acutely, but also in the long term. There is a
school of thought that early intervention and aggressive multimodal
treatment can affect the course of illness of those patients with early-onset
especially after she carried out her own research on this diagnosis. To her, it psychosis.
7
For those with dual diagnoses, integrated treatment programs
made “perfect sense” given her historical presentation of symptoms and are the emerging treatment of choice with comprehensive and detailed
her assertion that no combination of previous medications was ever assessment as the lynchpin and crucial first step.
8
Clinicians can only benefit
successful by itself without the individual therapy she was now having. She from the discipline of precision in diagnostics with a more frequent use of
also thought that what were historically classified as ‘hypomanic’ episodes the DSM IV TR. The habit can only hone sharpness in formulating a
were really episodes of high anxiety with restlessness. To Dr Jones, the fact
that she felt better on lamotrigine did not necessarily connote the accuracy
of a bipolar disorder diagnosis because the mood fluctuations in BPD may
benefit from lamotrigine. The previous underdosing of paroxetine arose out
of fears that she may switch into rapid cycling while under the impression
Clinicians can only benefit from the
that she had BPD II. The result was the unfortunate perpetuation of her
discipline of precision in diagnostics with
panic disorder. After six months of paroxetine treatment, there has been no
switching to mania.
a more frequent use of the DSM IV TR.
Especially helpful to this case were the higher satisfaction level and the
surprising ready acceptance of this patient of the diagnosis of BPD because
it augured well with her own knowledge of her symptoms. Additionally, the diagnosis and the appropriate treatment plans. Semi-structured interviews
comorbid diagnosis of panic disorder was elicited. She appreciated the can pick up comorbid conditions that are often missed when using a non-
greater effort placed by Dr Jones on performing a semi-structured interview, structured clinical interview alone.
and actually checking with the text of DSM IV TR, in contrast to the purely
clinical unstructured interviews previous mental health professionals had Tracking Progress in Treatment through the Global
given her. Assessment of Functioning
The scale for the GAF coded in axis V has always been designed to assist in
The following case again illustrates better treatment resulting from the use treatment planning and predicting outcome.
1
The usefulness of the GAF is
of DSM IV TR in re-visiting a patient’s diagnosis. especially underscored when patients present at multiple sites during a
course of illness with multiple clinicians evaluating the efficacy of treatment
Mr Sanchez is a 49-year-old Hispanic male who “has always carried” the modalities. This is briefly illustrated in the following case.
diagnosis of chronic paranoid schizophrenia (CPS). He presented again to
the inpatient unit with deterioration in functioning and disorganized Mr Blake is a 44-year-old man with a long history of bipolar mood disorder
behavior. On presentation, the most prominent symptoms were various type I and alcohol dependence in remission. He lives in a group home after
US PSYCHIATRY 2007 47
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