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Superior Health Council DSM (5): the USE AND Superior Health Council DSM (5): THE USE AND STATUS OF DIAGNOSIS AND CLASSIFICATION OF MENTAL HEALTH PROBLEMS JUNE 2019 SHC № 9360 COPYRIGHT Federal Public Service Health, Food Chain Safety and Environment Superior Health Council Place Victor Horta 40 bte 10 B-1060 Bruxelles Tel.: 02/524 97 97 E-mail: [email protected] All rights reserved. Please cite this document as follows: Superior Health Council. DSM (5): The use and status of diagnosis and classification of mental health problems. Brussels: SHC; 2019. Report 9360. Public advisory reports as well as booklets may be consulted in full on the Superior Health Council website: www.css-hgr.be This publication cannot be sold. ADVISORY REPORT OF THE SUPERIOR HEALTH COUNCIL no. 9360 DSM (5): The use and status of diagnosis and classification of mental health problems In this scientific advisory report, which offers guidance to public health policy-makers, the Superior Health Council of Belgium provides recommendations on use of classifications in mental health for professionals, policy makers and researchers. This version was validated by the Board on June - 20191 SUMMARY The SHC notes that the most commonly used tools for diagnosing mental health problems (the Diagnostic and Statistical Manual of Mental Disorders (DSM), or the International Classification of Diseases and Related Health Problems (ICD)) pose several problems and recommends that they be used with caution and that the DSM categories not be at the centre of care planning. From an epistemological point of view, classifications are based on the assumption that mental disorders occur naturally, and that their designations reflect objective distinctions between different problems, which is not the case. The boundaries between people with a disease and those who are free from it are more dimensional than categorical. At an organizational level, the SHC raises the question of the function of diagnostic classifications, which tend to legitimize a structure based on a biomedical model and protect psychiatry from the pressures of change, while mental health care is in a state of flux. On the other hand, this biomedical approach does not, as hoped, reduce stigma and discrimination of patients in mental health care. In Belgium, the authorities give stakeholders and organisations a wide margin of freedom to use these systems, mainly used for registration purposes (MPD). At a clinical level, classifications do not provide a picture of symptoms, management needs and prognosis because they lack validity, reliability and predictive power. On the other hand, they do not respond to new conceptions of health, defined by the ability to adapt, despite bio- psycho-social obstacles. However, it is more useful to understand the combination of factors causing and maintaining symptoms than to identify a category. A recovery-based approach (clinical, personal and social) better contextualizes symptoms and adapts interventions according to patients' values, affinities and goals, working closely with them. 1 The Council reserves the right to make minor typographical amendments to this document at any time. On the other hand, amendments that alter its content are automatically included in an erratum. In this case, a new version of the advisory report is issued. Superior Health Council www.shc-belgium.be − 1 − The SHC therefore recommends the use of clinical case formulation as part of a "multi-layer" diagnostic process. This involves starting with a narrative description of the individual's symptoms, then recontextualizing them, classifying them on the basis of a limited number of general syndromes, and finally discussing these symptoms in terms of a continuum from crisis to recovery, to assess the need for care, the level of crisis and the recovery perspective (considered a contextual phenomenon). This case formulation is a reasoned and still incomplete hypothesis, based on a continuous back and forth between data collection and the use of theoretical knowledge. The person and his relatives are a source of information about his or her mental state and context. The therapeutic relationship is at the heart of the treatment, which requires a reflective method of quality control. Given the limitations of classification systems, and the latitude in their use granted by the different levels of power, the SHC therefore recommends that the use of the DSM or ICD be limited to broader categories of disorders, and that diagnoses remain working hypotheses. Disorders should not be considered as a static characteristic, but rather as interactive. Diagnostic labels should also be used with caution, while taking into account the importance for the person of recognizing their difficulties. Psychological complaints must be dealt with regardless of their seriousness, in a non-medical way, with perspective and meaning at the centre. This requires low-threshold support structures. Keywords and MeSH descriptor terms2 MeSH terms* Keywords Sleutelwoorden Mots clés Schlüsselwörter Diagnostic and DSM DSM DSM DSM Statistical Manual of Mental Disorders International ICD ICD CIM ICD Classification of Diseases Classification Classification Classificatie Classification Klassifizierung Mental Health Mental Health Geestelijke Santé mentale psychische gezondheid Gesundheit Diagnosis Diagnosis Diagnose Diagnostic Diagnose Case reports Case study Gevalstudies Etude de cas Fallstudie Multi layer Meerlagige Approche mehrschichtiger approach aanpak multicouches Ansatz Epistemology Epistemologie Epistémologie Epistemiologie Organizational Organisatieniveau Niveau Organisationsebene Level organisationnel Clinical level Klinisch niveau Niveau clinique klinische Ebene MeSH (Medical Subject Headings) is the NLM (National Library of Medicine) controlled vocabulary thesaurus used for indexing articles for PubMed http://www.ncbi.nlm.nih.gov/mesh. 2 The Council wishes to clarify that the MeSH terms and keywords are used for referencing purposes as well as to provide an easy definition of the scope of the advisory report. For more information, see the section entitled "methodology". Superior Health Council www.shc-belgium.be − 2 − CONTENTS I Introduction AND ISSUE ................................................................................................ 4 II ELABORATION AND ARGUMENTATION ..................................................................... 5 1 Methodology ............................................................................................................... 5 2 Epistemological status of mental disorders ................................................................. 5 3 Organisational aspects in connection with the use of diagnostic classification systems 9 3.1 Sociological perspectives .................................................................................... 9 3.2 The use of psychiatric diagnostics in Belgium ................................................... 13 4 Clinical use of psychiatric diagnosis ......................................................................... 15 4.1 Observations about contemporary psychiatric diagnosis ................................... 15 4.2 Problems with the reliability of psychiatric classification systems ....................... 16 4.3 Problems with the precision of psychiatric classification systems ...................... 17 4.4 Problems with the validity of psychiatric classification systems .......................... 18 4.5 Changing conceptualizations of mental health and mental health problems. ..... 18 4.6 Recovery: a new paradigm in psychiatry ........................................................... 20 4.7 The alternative: multi-layered diagnosis ............................................................ 22 4.8 Diagnosis by means of clinical case formulations .............................................. 24 III CONCLUSION and RECOMMENDATIONS ............................................................... 25 IV REFERENCES ............................................................................................................ 28 V COMPOSITION OF THE WORKING GROUP ............................................................. 33 List of abbreviations used ADHD Attention deficit hyperactivity disorder AViQ Agence pour une Vie de Qualité BeWo Initiatieven beschut wonen DSM Diagnostic and Statistical Manual of Mental Disorders ICD International Classification of Diseases and Related Health Problems MHC Mental Health Care MPD Minimum Psychiatric Data ONE Office de la Naissance et de l’Enfance PVT Psychiatrische verzorgingstehuizen Superior Health Council www.shc-belgium.be − 3 − I INTRODUCTION AND ISSUE Worldwide mental health problems are usually diagnosed in terms of the mental disorder categories such as described in the Diagnostic and Statistical Manual of Mental Disorders (DSM) by the American Psychiatric Association, or in the International Classification of Diseases and Related Health Problems (ICD) by the World Health Organisation, which has a chapter on mental and behavioural disorders. A first edition of the DSM was published in 1952, and currently the fifth edition is in use (DSM-5), which was published in 2013. A first precursor of the ICD, in its turn, was presented in 18933, and currently the tenth edition is in use (ICD- 10; published in 1999). A new edition was published in 2018 (ICD-11). Both the DSM and the ICD are diagnostic classification systems, containing lists of disorders (e.g. ‘major depressive disorder’, ‘schizophrenia’…) that are grouped in overarching clusters
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