The acronym DSM-IV-TR stands for Diagnostic Statistical Manual, Fourth Edition, Text Revision. The DSM-IV-TR is a comprehensive, revised guide used to translate psychiatric disorder diagnoses and the accompanying claim coding on ICD-9 forms. To assist medical professionals, this manual separates psychiatric disorders into several categories and chapters. There are set criteria for each diagnosis, which this book provides, as well as the diagnosis coding once a diagnosis is determined.
This manual is used mainly by psychiatrists and provides information pertaining to recognized psychiatric disorders. ICD-9 & 10 forms are used for medical records, treatment protocol, and submission to insurance companies. ICD-9 codes are in the format of three digits, a decimal point, and two following digits, i.e. 314.00. After any type of visit to the doctor, claims are processed according to ICD-9 coding, (as well as HCFA coding) which may or may not be illness related. For example, a yearly physical exam has its own code which would be documented. If, in that exam, an allergy is discovered, that code is placed on the form as well, as a secondary diagnosis.
The coding in ICD forms is important for any doctor, regardless of which field, to complete accurately in order for the patient to gain access to the treatment they need, pay the appropriate amount, and keep consistent records. For example, if a doctor codes a diagnosis of acne as primary that is truly a secondary diagnosis, the patient may run into trouble acquiring medications at a pharmacy for the primary diagnosis. If the patient has insurance, the claim will be processed incorrectly, the patient may get overcharged, and the amount of monies may be applied to a deductible, where perhaps, there should be none.
The DSM-IV-TR is a work that has been refined over 50 years. In 1952 the DSM-I was published, which included 60 disorders and later in 1968 the DSM-II was published (Grob, G.N, 1991. Origins of DSM-I: a study in appearance and reality. American Journal of Psychiatry; 148:421-431). Influenced chiefly by the psychodynamic approach, these two manuals were still in their infancy due to the inability to accurately and scientifically pinpoint disorder causation and prognosis.
The psychodynamic approach was first introduced and coined by Dr. Sigmund Freud, an Austrian doctor interested in studying how humans process and conceal society-labeled taboo emotions, such as guilt, and how the attempts to cover those emotions manifests psychologically. Freud was a strong believer in cultural norms and societal influences such as religion, and how these expected conformities stifled psychological growth. Freud used one on one analysis of patients in order to formulate his hypotheses about human conditions and attempted to support his idea that there is a universal theory of human behavior (Ferris, 1997).[i]
In 1980 the DSM-III was published, phasing out the psychodynamic approach and focusing on the experimental/scientific approach to diagnosis criteria and disorder classification (Spitzer, William & Skodol, 1980. DSM-III: the major achievements and an overview. American Journal of Psychiatry; 137:151-164). 1987 marks the date in which the DSM-III-R was distributed and in 1994, the DSM-IV was on the market. The most current copy of the DSM-IV-TR was published in July of 2000. With more than 35 authors credentialed with Ph.D and M.D. doctorates, this extensive revision is highly respected, meticulous, and encompasses psychiatric disorder scientifically.
Page count totals 943 excluding introduction sections. The first sections are titled "Use of the Manual", "DSM-IV-TR Classification", and "Multiaxial Assessment". Briefly, in using this manual, there are specific classifications that the DSM explicitly lists for correct diagnosis coding represented by categories. For example, mental retardation is a classification, and each code that falls into that category is listed. There is an accompanying diagnosis structure based on forms that use "axis" classification. Each axis has a title and each title as a list of appropriate diagnoses that fall under that bracket. There are five axes, which encompass all medical, subjective environmental components, and psychiatric disorders that may accompany an initial diagnosis. The last axis reports a Global Scale of Functioning based on the collected information and these methods. Since the presence of psychiatric illness may be manifested or exacerbated from other factors, the multi-axis approach attempts to include each influence in order to formulate the most accurate scientific method in which to treat patients (American Psychiatric Association, 2000. DSM-IV-TR).
The first category for diagnosis in the DSM-IV-TR is “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence”. This section places importance on when the diagnosis for these disorders is usually observed and reported, not to separate adult disorders from earlier disorders. Mental Retardation and Motor Skills Disorder are included in this section. [ii]
“Delirium, Dementia, and Amnestic and Other Cognitive Disorders” follows. Disorders that represent a deficit in cognition that was not present earlier in life are placed in this group. These disorders must show clinically significant declines in cognition and are labeled as delirium, dementia and amnestic disorders.
The next chapter, “Mental Disorders Due to a General Medical Condition”, is designed to help the clinician distinguish potential causes for impairment that may not be present if it were not for a medical condition. An example is Sexual Dysfunction Due to a General Medical Condition which is distinct from sexual dysfunction that may be present during a phase of clinical depression.
“Substance-Related Disorders” is separated due to the manifestation of symptoms and behaviors that can mimic other disorders. The professional is able to use this series of characteristics, the presence of a substance or substances, and arrive at a concise diagnosis and method of treatment.
“Schizophrenia and Other Psychotic Disorders” is when an individual predominantly suffers from having hallucinations and/or delusional beliefs. The succeeding section, “Mood Disorders” is established by determining that a disturbance in the patient’s moods is the predominant feature. Take note that the time in which each mood or psychotic episode is experienced, in current episode time as well as a history of episodes, is important for a diagnosis.
“Anxiety Disorders” encompasses many disorders such as Panic Attacks and Obsessive-Compulsive Disorder. The dominant impairment involves anxiety of some sort, due to a specific stimulus or set of stimuli, trauma, or brain chemistry.
“Somatoform Disorders” are remarkable by a reported presence of medical symptoms with no medical basis, but psychological in nature. The term is derived from Greek word “soma” which translates to “body”. These symptoms must cause marked occupational and social impairment for the patient, as well as distress. Such disorders are Hypochondriasis and Body Dysmorphic Disorder.
“Facticious Disorders” are disorders in which an individual intentionally inflicts or pretends to have illness in order to gain the label of being sick. The implied intention is to obtain a status of being sick, but is not, however, to escape responsibilities or duties. People with this disorder may be discovered, (a friend may notice a hypothyroid prescription at the person’s house who is claiming to have an overactive thyroid condition) and when revealed, these people are quick to lie and will seek out further medical help from different medical professionals.
“Dissociative Disorders” encompass perceptual, memory, identity and functions of consciousness in which there is a disruption. For example, in Dissociate Fugue, a person may suddenly wander away from where he/she lives, sometimes for extended periods of time, and when located, is unable to remember his/her identity. The most recognizable disorder from this category is Dissociative Identity Disorder, formerly Multiple Personality Disorder.
“Sexual and Gender Identity Disorders” are diagnosed when there is difficulty with sexual response and desire in which there is clinically significant distress from the patient. Usually interpersonal relationships are affected as well. Exhibitionism, the behavior that involves exposing genitals to a stranger, is illustrative.
“Eating Disorders” have only two diagnostic filters: Bulimia Nervosa and Anorexia Nervosa. Anorexia Nervosa traits include reduction of food to almost no caloric intake due to the fear of becoming “fat” and incessant exercising until body fat and weight become medically dangerous. The Bulimic fears weight gain as well, but habitually binges and purges, while in Anorexia, binges are absent.
“Sleep Disorders” are characterized by interruption in sleep-wake cycles of individuals, sometimes due to biological factors as well as conditioning. Insomnia, the inability to fall or stay asleep over the course of a month, falls under this category.
“Impulse-Control Disorders Not Elsewhere Classified” describes disorders that do not fall under the umbrella of other defined disorders. The behaviors these individuals engage in display an inability to control impulse in a way that is harmful to the self or others. Pyromania, preoccupation with fire, and Kleptomania, the compulsion to steal, are associated with this group.
“Adjustment Disorders” are exhibited as a psychological response to a recognizable stressor that creates behavioral or emotional disturbances that are clinically prominent. These particular stressors may be due to a single event or ongoing. An illustration of this is if a child loses his/her mother in a store briefly, yet after the reunion, the fear remains for months that it will occur again. For months the child is unable to leave his/her mother’s side without outbursts of crying and panicked screams.
“Personality Disorders” are indicated by patterns of behaviors and perceived inner experiences that are uncustomary for the culture in which the individual lives. These traits are usually unwavering, remain over time, and lead to dysfunction and distress. There are 10 personality disorders, all of which have specific characteristics that differentiate one from another. Narcissistic Personality Disorder, loosely defined, is a perception of importance, a need for admiration, and an inability to empathize with others.
The last chapter is “Other Conditions That May Be a Focus of Clinical Attention”. As indicated, this section directs the clinician to consider each factor involved with an individual since environmental, medical, and psychological aspects do not exist in a vacuum. For instance, a person may have Schizophrenia, but due to his/her diabetes, an anti-psychotic that influences blood sugar would not be appropriate to prescribe. Another case is an individual that has an extremely low ability to focus attention, but has recently begun menopause.
The remaining pages include Appendixes (A-K), indexing, and coding structures. A thorough, intricate, and evolved work, the DSM-IV-TR strives to guide the clinician through his/her work and create a unified process for diagnosis in as many countries as possible. In 2010, the next installation will be published and another edition to the “psychiatrist’s bible” will be added, assisting clinician’s world-wide!
[i] Ferris, Paul, 1997. Dr. Freud, A Life. Washington, D.C.; Counterpoint
[ii] This paragraph and each subsequent paragraph’s citation is: The DSM-IV Task Force: American Psychiatric Association, 2000. DSM-IV-TR. Washington, D.C.; APA