How the DSM Is Used in Clinical Practice

Copyedited by: Hiro Lacang

ORIGINAL ARTICLE

How the DSM Is Used in Clinical Practice AQ1

Michael B. First, MD,* Matthew D. Erlich, MD,* David A. Adler, MD,* Shirley Leong, PhD,† Lisa B. Dixon, MD, MPH,* David W. Oslin, MD,* Beth Goldman, MD, MPH,* Steve Koh, MD, MPH, MBA,* Bruce Levine, MD,* Jeffrey L. Berlant, MD, PhD,* and Samuel G. Siris, MD* METHODS

Abstract: Despite widespread use, how clinicians use the DSM in psychiatric practice is not well understood. Recognizing public and professional attitudes toward the DSM are integral to future DSM development, to address commonly held assumption such as that the DSM is used primarily for coding, and to assess its clinical utility. A convenience sample of Psychiatric Times readers was surveyed to assess the DSM's use in clinical practice. A total of 394 behavioral health care practitioners fully completed the online survey. Results suggest that the DSM, beyond administrative and billing use, is used for communication with health care providers, for teaching diagnoses to trainees, and, importantly, as an educational tool to inform patients and caregivers alike.

Key Words: Diagnostic and Statistical Manual of Mental Disorders, nosology, clinical utility, not otherwise specified, unspecified, health care administration, psychiatric education (J Nerv Ment Dis 2019;00: 00–00)

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ittle information is available as to how clinicians use the DSM in everyday practice (First et al., 2004). A better understanding of its clinical application is important for two crucial reasons (First et al., 2014).

First, the DSM is intended to serve as a universal authority for diagnosis and to accurately and faithfully communicate diagnostic information among clinicians (as well as researchers). Consequently, how clinicians apply the DSM criteria during a diagnostic assessment is of significant interest. Second, understanding current usage is critical to the planning process of future updates to the DSM (First, 2016) and to assess the impact of proposed changes to DSM criteria upon practice patterns.

A commonly held assumption regarding psychiatric classification systems, such as the DSM or ICD, is that they are used by clinicians primarily for administrative purposes rather than for making clinical diagnoses. For example, a 2015 editorial in World Psychiatry (Maj, 2015) posited that European psychiatrists often use ICD criteria administratively, not clinically. Such beliefs are also reflected in the lay press (“Rarely, if ever, [do] I consult the handbook to make a diagnosis.”)

(Reidbord, 2016). Moreover, high utilization rates of the residual not otherwise specified (NOS)/other specified/unspecified categories are assumed to be a manifestation of the DSM's inability to accurately describe a majority of clinical presentations (Clark et al., 1995; Widiger and Samuel, 2005).

To better understand the role of the DSM in psychiatric practice, an Internet-based survey was conducted to clarify how clinicians use the DSM to arrive at diagnoses, to guide treatment, to assess clinical attitudes toward the DSM, and to elucidate the prevalence of the use of NOS category (referred to as “other specified” and “unspecified” in DSM-5).

AQ2 *Psychopathology AQ3

Committee of the Group for the Advancement of Psychiatry; †MIRECC, Corporal Michael J. Crescenz Veteran Affairs Medical Center, Philadelphia, Pennsylvania.

Send reprint requests to Michael B. First, MD, Psychopathology Committee of the Group for Advancement of Psychiatry. E‐mail: mbf2@columbia.edu.

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ISSN: 0022-3018/19/0000–0000 DOI: 10.1097/NMD.0000000000000953

Overview The Psychopathology Committee of the Group for the Advancement of Psychiatry (GAP) developed an Internet-based survey via Survey Monkey as part of a Psychiatric Times article about the DSM and its clinical utility (Kweskin, 2015). Psychiatric Times is a monthly periodical distributed by mail and available online to nearly 40,000 mental health professionals. In addition, Psychiatric Times included the link in several of its e-mail newsletters sent to registered users on the Psychiatric Times Web site. The survey was open to participation from February 1, 2015, through April 15, 2015. The survey took between 10 and 15 minutes to complete. The survey was exempt from institutional review board review as individually identifiable information was not collected. Subjects did not receive reimbursement for completing this survey. The only requirements for participation in this convenience sample included being 18 years of age or older, English-language proficiency, and having direct clinical contact with patients for at least 4 hours a week.

Survey Instrument The survey was developed using a modified Delphi process by an expert committee comprised of members of the Psychopathology Committee of GAP based on the most recent literature about the DSM (First et al., 2014). Usage of the survey was assessed with five question domains. The first two questions assessed the usage of the DSM in everyday practice both when making initial diagnoses and in the context of ongoing care across the following five scenarios: use of the DSM for administrative/billing purposes; use of DSM criteria to determine if the diagnostic criteria are met; reviewing diagnostic criteria from memory to determine diagnosis; reviewing relevant sections of the DSM text (e.g., differential diagnosis); and assessing how DSM criteria are used with the patient and/or family and caregivers. For each scenario, participants were asked to quantify the frequency of usage using a five-point Likert scale (“never,” “rarely,” “sometimes,” “often,” and “always”).

The third question asked respondents to assess how useful they found the DSM criteria and diagnostic framework to be based on their experience with the DSM in practice over the past year, for the following domains: treatment selection, educating the patient and/or family about the psychiatric diagnosis, determining prognosis, meeting administrative requirements, communicating with colleagues, and teaching trainees or students. For each of the above domains, respondents were asked to rate its degree of usefulness on a different five-point Likert scale (“not at all,” “slightly” “moderately,” “very,” and “extremely”).

The remaining two survey questions focused on usage of NOS categories during the past year, starting with a query about how often respondents use the NOS diagnosis when they record a psychiatric diagnosis. (The NOS designation is used in this article to refer to both the NOS categories in DSM-IV-TR and other specified disorder and unspecified disorder categories in DSM-5.) If respondents reported any NOS usage during the past year, they were presented with six possible reasons for using the NOS diagnosis and were asked, for each

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reason, to rate the frequency with which they used the NOS category on the same five-point scale used to rate the frequency of usage of the DSM components.

The survey concluded with questions about the survey participants, including demographics, mental health specialty, practice setting, version of the DSM (DSM-IV-TR vs. DSM-5) the respondent commonly used at the time of the survey, percent time spent doing various professional activities (e.g., clinical, administrative, research, etc.), and the number of hours per week of direct clinical contact.

Analyses Generalized estimating equations (GEE) models were used to assess the odds of more DSM usage and the odds of more positive attitude with a cumulative logit link function. Outcomes were collapsed into three categories: usage (never/rarely, sometimes, often/always) and attitude about the usefulness (not at all/slightly, moderately, very/extremely). For DSM usage scenario, a binary variable indicating initial evaluation and their interaction were included in the model. For attitudes about usefulness, only usage scenario was included as a predictor. Demographic variables and their interactions with scenario were added into the models. The significance of interaction terms was evaluated based on p-values from type 3 Wald scores.

To investigate the relationship between DSM usage and attitudes about its usefulness, Pearson correlation coefficients were calculated using the survey's original five-point Likert scale.

The odds of more NOS usage were also modeled using GEE models with a cumulative logit link function. NOS usage was collapsed into three categories: never/rarely, sometimes, and often/always. NOS use in the prior year, scenario, and their interaction were included in the model. The significance of interaction terms was evaluated based on p-values from type 3 Wald scores.

RESULTS Description of the Sample A total of 907 individuals participated in the survey, 394 participants completed all survey questions about DSM component usage,

attitudes about utility, and NOS usage and fully completed the demographics section. Excluded from the results were 23 participants as they listed their profession as lawyer or “other” and 74 participants who reported fewer than 4 hours per week of direct patient contact.

In this sample, 254 respondents (65%) were age 50 or older and 235 (60%) were male. Twenty-three (6%) reported less than 1 year since completing training, 63 (16%) were 1 to 5 years, 57 (15%) were 6 to 10 years, 164 (42%) were 11 to 30 years, and 87 (22%) were 31 to 50 years since residency. Two hundred six (52%) reported 30 hours/week or more per of direct clinical contact (354 [90%] reported specializing in adult care and 126 [32%] specializing but not exclusively treating children/adolescents). With respect to specialization, 78 (20%) reported treating addictions, 54 (14%) forensics, 69 (18%) community/public sector treatment, and 53 (14%) consultation-liaison psychiatry. Regarding practice setting, 218 (55%) reported primarily outpatient private practice, 135 (34%) public sector, 96 (24%) academic settings (either inpatient or outpatient), and 54 (14%) nonacademic hospital-based inpatient or outpatient practices.

DSM Usage Table 1 presents the frequencies of usage for various DSM usage scenarios, both during the initial evaluation and during ongoing treatment. Using the DSM diagnostic codes for administrative or billing purposes was the most frequent usage scenario during the initial evaluation with 64% reporting using them often or always. An overwhelming number of respondents reported referring to the DSM criteria during the initial diagnostic evaluation to determine whether the diagnostic criteria are met (with 55% often or always reviewing the criteria from memory and 39% often or always referring to the written DSM criteria).

A small number reported that they never or rarely review the diagnostic criteria either from memory (16%) or in written form (29%). Thirty percent reported they often or always reviewed relevant text sections of the DSM during the initial evaluation. Reviewing DSM criteria with the patient and/or the patient's family during the initial evaluation was the least frequent usage scenario, with 20% reporting often or always and 51% reporting never or rarely.

TABLE 1. Frequency of Usage of DSM Components During Initial Diagnosis and Ongoing Treatment (n = 394) “Regarding Your Usage of the DSM in Everyday Practice, Based on Your Experience With Patients Over the Past Year, How Often Do You:”

Never or Rarely

Use the DSM diagnostic codes for administrative/billing purposes (“use” includes referring to the book, using a list on a form or from a drop-down menu, or from memory) Initial diagnosis 98 (25%) Ongoing treatment 122 (31%) Refer to the written DSM criteria (online, hard copy, checklist) to determine if the diagnostic criteria are met Initial diagnosis 116 (29%) Ongoing treatment 168 (43%) Review diagnostic criteria from memory to determine if diagnostic criteria are met Initial diagnosis 61 (16%) Ongoing treatment 107 (27%) Review relevant sections of the DSM text for the disorder (e.g., “diagnostic features,” “associated features,” “differential diagnosis”) Initial diagnosis 136 (35%) Ongoing treatment 172 (44%) Review the DSM criteria with the patient and/or family Initial diagnosis 199 (51%) Ongoing treatment 232 (59%)

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Sometimes

Often or Always

44 (11%) 57 (15%)

252 (64%) 215 (55%)

126 (32%) 146 (37%)

152 (39%) 80 (20%)

117 (30%) 138 (35%)

216 (55%) 149 (38%)

141 (36%) 153 (39%)

117 (30%) 69 (18%)

118 (30%) 108 (27%)

77 (20%) 54 (14%)

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TABLE 2. Clinician Perceptions of the Usefulness of the DSM (n = 394) “Based on Your Experience Using the DSM With Patients Over the Past Year, How Useful Is the DSM Criteria and Diagnostic Framework For:”

Not at All Useful

Slightly or Moderately Useful

Very or Extremely Useful

Selecting a treatment Educating the patient and/or family about his or her diagnosis Determining prognosis Meeting administrative requirements (e.g., determining the diagnostic code and name of diagnosis for an encounter/billing form) Communicating a clinical diagnosis with a colleague or other health care professional Teaching trainees or students about diagnosis and psychopathology

180 (46%) 144 (37%) 199 (51%) 86 (22%)

125 (32%) 149 (38%) 124 (32%) 79 (20%)

89 (23%) 101 (26%) 71 (18%) 229 (58%)

75 (19%)

103 (26%)

216 (55%)

83 (21%)

109 (28%)

202 (51%)

When comparing DSM use in the initial diagnostic phase to ongoing treatment, differences in usage patterns were statistically significant and greater for initial diagnosis compared with ongoing treatment for all five usage scenarios (chi-square = 22.22, df = 4, p = 0.0002).

Attitudes About Usefulness of the DSM T2

Table 2 presents respondents attitudes toward the usefulness of the DSM for various purposes. Odds of more positive attitudes was different between the various types (chi-square = 322.43, df = 5, p < 0.0001).

A majority of clinicians rated the DSM as useful for meeting administrative requirements (78%), communicating a clinical diagnosis with another health care professional (81%), teaching trainees about

psychopathology (51%), selecting a treatment (54%), and educating the patient or family about diagnosis (64%), with only slightly less than half, finding it useful for determining prognosis, “very or extremely” useful for meeting administrative requirements (58%), communicating a clinical diagnosis with another health care professional (55%), and teaching trainees about psychopathology (51%).

Relationship Between DSM Usage and Attitudes About Usefulness Table 3 shows the correlation between the different DSM usage scenarios during the initial evaluation and corresponding attitudes

TABLE 3. Correlations Between DSM Usage During the Initial Evaluation and Attitudes About the Usefulness of the DSM “Based on Your Experience Using the DSM With Patients Over the Past Year, How Useful Is the DSM Criteria and Diagnostic Framework for:” Educating the Communicating a Patient and/or Clinical Diagnosis Teaching Trainees Family About Meeting With a Colleague or or Students About Selecting a His or Her Determining Administrative Other Health Care Diagnosis and Treatment Diagnosis Prognosis Requirements Professional Psychopathology “Regarding your Use the DSM usage of the DSM diagnostic codes in everyday for administrative/ practice, based billing purposes on your experience with patients over the past year, how often do you:” Refer to the written DSM criteria (online, hard copy, checklist) to determine if the diagnostic criteria are met Review diagnostic criteria from memory to determine if diagnostic criteria are met Review relevant sections of the DSM text for the disorder Review the DSM criteria with the patient and/or family

0.234

0.202

0.171

0.637

0.210

0.170

0.427

0.422

0.419

0.262

0.479

0.377

0.442

0.425

0.368

0.262

0.433

0.434

0.401

0.408

0.372

0.133

0.405

0.356

0.324

0.555

0.266

0.204

0.326

0.239

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TABLE 4. Usage of DSM NOS Categories

In the past year, how often do you use the NOS category (n = 394) Based on your experiences using the DSM with patients over the past year, in those circumstances where you use the NOS category, please indicate how often each of the following reasons for using NOS apply: To indicate that the patient's presentation does not conform to any of the specific categories (n = 370) To indicate there is insufficient information to make a more specific diagnosis (n = 370) To prevent more specific diagnostic information from being entered into the patient's record for privacy reasons or to avoid stigma (n = 370) To indicate that the criteria are met for more than one diagnosis in a grouping rather than listing comorbid diagnoses (e.g., using Anxiety NOS instead of listing multiple anxiety disorders) (n = 370) To indicate that it cannot be determined whether the symptoms are due to a primary condition (e.g., schizophrenia) or are secondary to a substance (e.g., substance-induced psychosis) or a medical condition (e.g., brain tumor) (n = 370) Because making a more specific DSM-IV diagnosis, like major depressive disorder (as opposed to depressive disorder NOS) is not useful for patient care (n = 370)

about the DSM's clinical utility in practice. Strong correlations (Cohen, 1988) were found between attitudes about the usefulness of the DSM for administrative requirements, such as using the DSM for administrative or billing purposes (r = 0.637, p < 0.0001), and attitudes about how the DSM's utility for educating the patient and/or family about diagnoses, and its usage for reviewing DSM criteria with the patient and family (r = 0.555, p < 0.0001). In addition, moderate correlations were found for using the DSM (memory, written, and relevant text sections) for treatment selection, prognosis, patient, family, and student education, as well as a means of communicating with others.

Relationship Between DSM Usage/Attitudes and Demographic Information There was no difference with respect to clinical experience when using the DSM for administrative or billing purposes (odds ratio [OR], 0.97; 95% confidence interval [CI], 0.90–1.04). There was a significant interaction between the various other usage scenarios and the respondents' age (chi-square = 13.2, df = 4, p = 0.01) and the number of years since completing training (chi-square = 16.0, df = 4, p = 0.003, data not shown). Every 5 years of experience beyond training indicated lower odds of finding the DSM useful by 10% to 19% for all other scenarios. Clinicians who are 50 years or older were less likely to refer to the DSM criteria from memory as compared with those less than 50 years (OR, 0.66; 95% CI, 0.46–0.94). There was no difference in age groups when assessing DSM usage for any other scenario. More experienced clinicians were less likely to refer to or review the DSM. For every 5 years posttraining, the odds of using the DSM decreased by a factor of 7% to 13%, either to assess whether criteria were met or to review the DSM criteria with patient and/or their family. Age and years since training were related to attitudes about the DSM's utility. Respondents aged 50 years or older were less likely to find the DSM useful for communicating a clinical diagnosis with a colleague or other health care professional (OR, 0.51; 95% CI, 0.34–0.78).

Moreover, respondents 50 years or older were less likely to use the DSM for teaching trainees or students about diagnosis and psychopathology (OR, 0.61; 95% CI, 0.41–0.91).

Usage of NOS Categories T4

The frequency of NOS category use in the prior year as well as the frequency of NOS usage for specific reasons for those respondents who reported using NOS is shown in Table 4. There was a fairly even 4

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Never or Rarely

Sometimes

Often or Always

113 (29%)

161 (41%)

120 (30%)

33 (9%)

122 (33%)

215 (58%)

54 (15%)

127 (33%)

189 (52%)

227 (61%)

94 (26%)

49 (13%)

188 (50%)

106 (29%)

76 (21%)

133 (36%)

141 (38%)

96 (26%)

247 (67%)

57 (15%)

66 (18%)

split among those who reported that they often or always (30%), sometimes (41%), and never or rarely (29%) used the NOS category. The three most common reasons for using the NOS category were not meeting criteria for a specific category (91%), insufficient information to make a more specific diagnosis (67%), and inability to discern whether the diagnosis was primary, substance-induced, or due to a general medical condition (64%). These results are consistent with guidelines included in the DSM-IV-TR “Use of the Manual” section describing appropriate circumstances for the use of the NOS category (American Psychiatric Association, 2000, p 4),” which only includes these three reasons. The other surveyed reasons (i.e., using NOS to avoid entering a specific diagnosis in the patient's medical record, using NOS to indicate that criteria are met for more than one diagnosis in a diagnostic class, and having an NOS diagnosis because it is not clinically useful to make a more specific DSM diagnosis) are not considered to be valid reasons for using the NOS category and were also less commonly endorsed as reasons for using NOS in the survey results.

DISCUSSION The survey results confirmed some commonly held expectations about DSM usage. The most frequently used component of the DSM in clinical practice is its diagnostic codes, which might be expected given the requirement to use such codes for administrative and/or billing purposes. Second, a majority of clinicians review the DSM criteria either from memory in written form to determine whether diagnostic criteria are met during the initial assessment. The survey also confirmed conventional wisdom that DSM components are most likely to be used during the initial evaluation. The lower frequency of use during ongoing treatment may be due to the fact that once the initial diagnosis is made, clinicians are likely to maintain the same diagnosis in subsequent clinical encounters. Third, the survey supports the DSM's usefulness for teaching trainees or students about diagnosis and psychopathology.

Although only a minority of clinicians use it to educate patients and their families about their psychiatric diagnoses (Duckworth, 2015), when they do, they consider it to be useful.

Clinicians' attitudes about the usefulness of the DSM largely mirror identified strengths and weaknesses of the DSM in the literature (First, 2010). Recognized strengths of the DSM include administrative utility and facilitation of clinician-to-clinician communication regarding patients' psychopathology (Hyman, 2007; Krueger, 1999).

Identified weaknesses of the DSM in the literature include the © 2019 Wolters Kluwer Health, Inc. All rights reserved.

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diagnostic heterogeneity of individuals with the same DSM diagnosis and the lack of alignment between DSM diagnoses and applicable treatments, each of which compromise the DSM's utility for treatment selection and determining prognosis (Clark et al., 1995; Regier et al., 2009; Widiger and Samuel, 2005). Accordingly, the survey respondents found the DSM much less useful for treatment selection and determining prognoses.

Despite a limited sample size, age did have an impact on usage.

Younger and less experienced clinicians were more likely to use the DSM criteria as compared with older, more experienced clinicians. It is unclear how accumulated clinical experience impacts clinical perceptions and use of the diagnostic manual.

Not surprisingly, there is a relationship between the clinician's attitudes about the usefulness of the DSM for various purposes and the frequency of use of various components of the DSM. There was a strong correlation between clinicians' feeling that the DSM is useful for meeting administrative requirements and usage of the DSM for administrative and billing purposes. There was a strong correlation between finding the DSM useful for educating patients and families and reviewing the DSM criteria with the patient or family. Finally, there were moderate correlations between attitudes about the usefulness of the DSM for various clinical purposes (treatment selection, determining prognosis, communicating with other clinicians) and educational purposes (educating patients and families about diagnosis and teaching trainees) and usage scenarios involving the diagnostic content of the DSM (reviewing diagnosis criteria from memory or in written form to determine if diagnostic criteria are met, reviewing relevant sections of the DSM text).

Recognizing that the DSM may not provide a specific diagnosis for every clinical presentation, each subsequent DSM edition and revision includes residual categories to address clinical presentations, which do not conform to any of the diagnostic definitions. For example, DSM-IV-TR included a NOS category for each diagnostic class, whereas DSM-5 included two residual categories (“other specified” and “unspecified”). A long-standing criticism of the DSM system, especially among those that favor a dimensional approach to psychiatric diagnosis, is that reported high rates of the NOS categories (Rajakannan et al., 2016) indicate that the DSM fails to cover a majority of clinical presentations (Clark et al., 1995; Widiger and Samuel, 2005). Survey results demonstrating that clinicians often use the NOS diagnosis for reasons other than the patient's presentation not fitting into any discernible DSM categories (i.e., having insufficient information to make a more specific diagnosis) indicate that it is misleading to characterize high reported rates of NOS as de facto evidence of the inadequacy of the DSM categorical approach.

There are several limitations. Soliciting participants from a convenience sample raises generalizability concerns. Problems of generalizability are inherent to all surveys, even those that randomly select participants, because traditionally low response rates as occurred in this sample mean that those who agree to participate are those most interested in the topic covered by the survey. As the link to the survey was embedded in an article about how clinicians use the DSM, those that participated may have had an interest in the DSM and psychiatric diagnosis, and thus, survey participants may have been more inclined to use the DSM rather than the average clinician. In addition, some of the survey questions, particularly those about usage, may have been subject to a social desirability bias, as clinicians might have wanted to present their diagnostic practice in the best possible light.

Regier D, Narrow W, Kuhl E, Kupfer D (2009) The conceptual development of DSM-V. Am J Psychiatry. 166:645–650.

CONCLUSIONS

Reidbord S (2016) Is the DSM clinically useful? Psychology Today. Available at: https://www.psychologytoday.com/us/blog/sacramento-street-psychiatry/201608/ is-the-dsm-clinically-useful. Accessed October 19, 2018.

The results of this study challenge the notions that the DSM is almost exclusively used for looking up diagnostic codes for billing purposes and charting requirements. Most clinician respondents reported

Widiger TA, Samuel DB (2005) Diagnostic categories or dimensions? A question for the Diagnostic and Statistical Manual of Mental Disorders—Fifth Edition.

J Abnorm Psychol. 114:494–504.

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reviewing the diagnostic criteria in either written form or from memory to determine if diagnostic criteria are met during the initial evaluation.

Moreover, the DSM was often used as an educational tool to train the next generation of mental health practitioners. Less positive attitudes were apparent when using the DSM for treatment selection and determination of prognosis, suggesting that the value of the DSM for these two pillars of clinical utility is problematic. Feedback such as from this survey may contribute to future improvements to the DSM to render it more useful for the core aspects of clinical management.

DISCLOSURE Dr. First receives royalties from APPI press. Dr. Adler is co-owner of Health and Productivity Sciences.

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Duckworth K (2015) Understanding mental disorders: Your guide to DSM-5. Am J Psychiatry. 172:916.

First MB (2010) Clinical utility in the revision of the diagnostic and statistical manual of mental disorders (DSM). Prof Psychol Res Pract. 41:465–473.

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AQ5

AUTHOR QUERIES AUTHOR PLEASE ANSWER ALL QUERIES AQ1 = Please check if authors name are correctly captured for given names (in red) and surnames (in blue) for indexing after publication.

AQ2 = Please check and provide location (city, state, country) for the affiliation "Psychopathology Committee of the Group for the Advancement of Psychiatry".

AQ3 = Please provide the complete address for correspondence, including street name, postal code, etc.

AQ4 = Please provide the reference citation for Batstra and Frances (2012). As a rule, all references given in the list of references should be cited in the main body text.

AQ5 = Please provide the reference citation for First (2015).

END OF AUTHOR QUERIES

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