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What is Your Label: DSM-5 Update for Nutrition Therapy

by April Winslow, 8.19.13

The birth of the 5th version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) on May 18, 2013 in San Francisco, CA at the American Psychiatric Association annual meeting was welcomed with criticism and controversy (1).  The integrity of the DSM-5 task force members has been challenged due to industry ties that are speculated to have influenced the categorization of symptoms.  Additionally, the National Institute of Mental Health (NIMH) has openly criticized the once bible of Psychiatry as a book that lacks scientific validity (2).  Furthermore, the NIMH is developing Research Domain Criteria (RDoC), that will formulate a Psychiatric research infrastructure based upon pathophysiology, clinical neuroscience, and genetics; rather than symptoms (3).  Despite the trauma associated with the introduction of the DSM-5, there are important clinical updates that impact all Dietitians working in the Mental Health arena.   

History of the DSM

The historical evolution of the DSM-IV to the DSM-5 began in 1999 with a research planning committee.  A task force of 27 members, assigned to specific workgroups, evaluated the literature to form consensus statements for grouping symptoms into specific diagnoses.  Interestingly, the transition from Roman Numerals (DSM-IV) to an Alpha Numeric digit (DSM-5) was done in anticipation of future revisions of this manual (i.e., 5.1, 5.2, etc.).  

It is well documented the diagnosis does not determine the course of treatment, but rather serves as a guide to understanding contributing factors and underlying defense mechanisms that contribute to a specific clinical manifestation.  Each diagnosis has a distinct number (e.g., Anorexia Nervosa: 307.1, Schizophrenia: 295.90, Autism Spectrum Disorder: 299.0, etc.).  The severity of the disorder also generates a new diagnosis code (e.g., Major Depressive Disorder, moderate: 296.22 vs. Major Depressive Disorder, with psychotic features: 296.24).   These numbers are called ICD-9 codes and are often what are used to determine insurance coverage for a client.   Thusly, a correct and consistent diagnosis code among the interdisciplinary team is essential for proper care.  ICD-10 codes are currently established, but will not go into clinical practice until October 1, 2014 (1).  

The Coding Process

A general understanding of the coding process is vital to identification of the key nutritional issues of an each diagnosis.  But also serves as platform for rapport building with your client.  Understanding and sympathy for a clients’ struggle is one gift a Dietitian (RD) can offer.  The following is a summary of the DSM-5 changes within the specific areas Behavioral Health Nutrition (1,4).

Mental Illness   
• All subtypes of schizophrenia were deleted; there is one diagnosis code:  295.9
• The clinical specifier “with mixed features” can now be added to bipolar I/II/NED (formerly NOS) and Major Depressive Disorder (MDD).  Anxiety symptoms can also be added, but not required to have the primary diagnosis.
• Anxiety disorders no longer require the individual recognize their fear and anxiety as excessive or unreasonable.
• Body Dysmorphic Disorder (300.7) is an Obsessive-Compulsive Disorder; however, it could also be coded under Eating Disorders (307.5), if appropriate.

Intellectual Developmental Disabilities
• Mental retardation is now called Intellectual Disability (319)
• Communication Disorders (315.39) replace phonological disorder and stuttering
• The Autism Spectrum Disorders (299) incorporate Asperger Disorder, Childhood Disintegrative Disorder, and Pervasive Developmental Disorder (PDD) rather than each condition having separate diagnosis codes.

Eating Disorders
• Binge Eating Disorder (BED) is an official diagnosis; DSM-IV used this label for research purposes only.   Severity of mild, moderate, severe, and extreme are also noted.  Obesity does not automatically qualify as BED.
• Anorexia Nervosa (307.1) no longer requires amenorrhea and a specific numerical value to determine “low body weight.”  Clinical judgment and weight history patterns are taken more strongly into consideration.  The subtypes (i.e., restricting and binge/purge).  Levels of remission can also be added as a qualifier.
• The frequency of the binge with Bulimia Nervosa (307.51) has been decreased to once weekly over the last 3 months.
• Pica (307.52) and Rumination Disorder (307.53) can be used for adults, as well as children
• Avoidant/Restrictive Food Intake Disorder (307.59) has replaced “feeding disorders of infancy or early childhood” that was used in the DSM-IV.   This diagnosis can be closely tied to Post Traumatic Stress Disorder (PTSD) and can often be misdiagnosed.

Addictions
• Substance abuse and dependence are now one category; with 10 separate classifications for specific substances (e.g., alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, etc.)
• Gambling disorder (312.31) and tobacco use disorder (292.9) are new
• Caffeine Intoxication (305.9) and caffeine withdrawal (292.0) are outlined  

The changes noted are bridging the gap for RD’s to have a stronger voice in field of Mental Health treatment.  The connection between the nutritional precursors obtained through food and the manifestation of cognitive dysfunction is unknown.  However, the fundamentals of biochemistry, medical nutrition therapy, and practical life-skills based counseling have tremendous potential.  The stigma attached to these labels serves as one of the primary barriers to treatment.   

Shifting Perceptions

Your role as a RD in mental health can shift this stigma.  The knowledge we hold and disseminate to our clients impacts not only the immediate symptom manifestation, but also those in community with that person.  Glucose stabilization through the inclusion of protein and unsaturated fatty acids has the power to down regulate anxiety.  Proper hydration allows for hydrolysis and subsequent improved digestion, so an individual who is recovering from an Eating Disorder can have less bloating; therefore, decreasing feelings of being fat and unworthy of vital nutrition.  Myelin repair through the enhancement of fatty acid intake can improve self-efficacy through successful communication between neurons.   

The ability of a RD to speak the same language as a Psychiatrist or Therapist adds credibility to our discipline.  The awareness of the differential diagnoses within your chosen specialty can support a swift interdisciplinary referral.  Moreover, using a common language will allow our field to develop research protocols and begin to show scientific data of the efficacy of nutrition therapy in the Psychiatric population.  As the DSM-5 finds its’ place within our professional lives and will continue to change with future revisions, one truth is already validated; RD’s are essential to mental health treatment!   Use your voice and your knowledge to help those who are unable to help themselves find healing.   

Guest blogger April Winslow MS, RDN, is a Registered Dietitian with a passion for food.  Her client-centered approach emphasizes nutritional education and personal empowered to choose foods that promote systemic restoration.  She teaches individuals to investigate the emotional, biochemical, and environmental factors that influence nutritional health.
 
April’s academic and professional training includes a MS in Clinical Nutrition from New York University, BS in Dietetics from Virginia Tech, Dietetic Internship at the John J. Peters Veterans Affairs Medical Center in Bronx, NY, and Pediatric Acute Care training at the University of Virginia Children’s Hospital.  April’s has extensive training in psychiatric Medical Nutrition Therapy that began with developing the nutritional restoration protocols for the Adolescent Eating Disorder program at Alta Bates Summit Medical Center – Herrick Campus in Berkeley, CA. 
 
She has worked clinically at UCSF (Department of Adolescent Medicine), UC Berkeley (Tang Center), and La Ventana Eating Disorder Program in San Jose.  Currently, she has a private practice office in San Jose, guest lectures at San Jose State University and John F. Kennedy University, and donates time as the national public policy liaison for the Behavior Health Nutrition Practice Group of the Academy of Nutrition and Dietetics.

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Arlington, VA: American Psychiatric Association, 2013.

2. Belluck P and Carey B. “Psychiatry’s Guide Is Out of Touch With Science, Experts Say.”  New York Times.  6 May 2013 (Online).  Accessed 6 June 2013.

3. Insel T, Cuthbert B, Garvey M, Heinssen R, Pine DS, Quinn K, Sanislow C, Wang P. Research domain criteria (RDoC): toward a new classification framework for research on mental disorders. Am J Psychiatry. 2010 Jul;167:748-51.

4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text Revision. Arlington, VA: American Psychiatric Association, 2000.

 

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