FAS in the DSM
Revising The Diagnostic and Statistical Manual of Mental Disorders: Relevance to Alcohol Related Neurodevelopmental Disorders
Michael First, M.D.
New York Psychiatric Institute
American Psychiatric Association
Dr. Michael First is chair of the American Psychiatric Association (APA) committee responsible for revising the Diagnostic and Statistical Manual for Mental Disorders (Fourth Edition) (DSM-IV). FAS is not represented as a specific mental disorder in the current DSM-IV. In order to raise clinical awareness of FAS as well as to facilitate communication among clinicians and among researchers, it might be advantageous for FAS to be included in future editions of the DSM.
Dr. First explained that the first edition of DSM was published in 1952. At that time, DSM was a brief pamphlet and was not very helpful to clinicians. In 1968, the APA published the DSM-II as a larger pamphlet that contained a list of mental disorders and a brief description of each.
DSM-III, published in 1980, was substantially different from previous editions. In addition to the list of disorders and brief descriptions, the volume provided diagnostic criteria for each disorder, based on lists of symptoms (i.e., syndromes) and the number of symptoms from each list that must be displayed by the patient to qualify for the disorder. Therefore, diagnoses were defined by clusters of symptoms rather than etiology. In addition, DSM-III specified patterns and durations of symptoms, provided criteria to distinguish among different disorders, and also listed features that exclude the presence of the disorder.
DSM-III was very successful, and the use of diagnostic criteria was particularly popular. Another well-received feature of DSM-III was its textbook-like information on each disorder. This edition was also successful because it avoided speculative causal inferences concerning the etiology of mental disorders, although it did describe causal factors for specific disorders whose etiology is known. This atheoretical approach was intentional and made DSM-III useful to mental health professionals from all theoretical perspectives.
Since 1980, the APA has revised DSM twice, although the basic characteristics of DSM-III have not altered. With the advent of DSM-III-R in 1987 and DSM-IV in 1994, many professionals believed that the pace of revision was too rapid. Some were particularly concerned about whether the revisions were consistent with the current research. As a result, the APA has decided to delay publication of DSM-V until 2007 or even later. However, some experts were concerned that in the interim, DSM-IVís text might become outdated. The APA will therefore release DSM-TR (text revisions) in June 2000, which will contain updated text but no changes in diagnostic categories.
DSM-IVís categories are intertwined with the diagnostic codes of the
World Health Organizationís International Classification of Diseases (ICD-9),
which is the official international system for all medical diagnoses. (A
clinical modification of ICD-9, called
IDC-9-CM, is the official coding system for use in the United States.) Although the tenth edition of this book is already used throughout the world, the United States still uses ICD-9-CM, but is expected to start using ICD-10 within the next 5 years. While ICD-9-CM includes diagnostic categories for all medical conditions, DSM includes only mental disorders. ICD-9-CM contains a category for "noxious influences affecting the fetus via the placenta or breast milk" (760.7), and FAS is a subcategory (760.71) of this. Other noxious influences in this category include exposure to other drugs and toxins. Dr. First emphasized that ICD-9-CM provides only diagnostic categories, rather than clinical definitions.
Dr. First commented that there is a window of opportunity for new diagnostic criteria to be included in DSM-V. Including a disorder in DSM produces increased attention to it and helps educate professionals in the field about the disorder.
Dr. First listed several ways in which FAS could be incorporated into the current DSM system. The first option is for the APA to add a "behavioral disorders due to prenatal exposure" category to DSM-V. This would mean that FAS would not be a viable psychiatric diagnosis until 2007. Because ICD-9 contains FAS, coordination of a new DSM diagnostic category with ICD-9 would not be difficult.
A second option is to obtain a diagnosis based on existing DSM-IV categories. For individuals with adaptation deficits who have IQs of less than 70, a diagnosis of mental retardation would apply. This category does not refer to the etiology of the mental retardation, although the text for this disorder does mention prenatal exposure as a possible cause. In this diagnostic category, clinicians frequently code etiology on Axis III (physical disorders relevant to the case). Dr. First acknowledged that there are manifestations of FAS other than low IQ. Specific relevant childhood disorders already included in DSM could be noted as the primary diagnosis. For example, reading, mathematics, learning, written expression, or communication disorders could be listed as the main diagnostic disorder with prenatal alcohol exposure noted under Axis III.
A third option is to include FAS under alcohol-induced disorders, which would imply that there is a causal link between the behavior observed in individuals with FAS and the direct physiological consequences of alcohol exposure. Typically, this diagnostic category is used to describe reversible changes in the behavior of adults under the influence of alcohol (with the exception of alcohol persisting dementia and alcohol persisting amnestic disorder). For most disorders under this diagnostic category, DSM-IV implies that the symptoms are resolved once alcohol leaves the body, and the alcohol chapter clearly implies that individuals in this category must have actually consumed alcohol. Although prenatal exposure has not traditionally been included in alcohol-induced disorders, DSM-IV includes toxin exposure as a clear example of a substance-related disorder, so the diagnostic system might have some flexibility to include FAS.
Dr. Betsy Lozoff commented that adding a disorder to DSM can unintentionally affect the type of care that patients receive. For example, pediatricians and neurologists may not be reimbursed for treating children with FAS if the disorder is included in DSM. Dr. First remarked that the APA has traditionally ignored reimbursement issues when revising DSM because reimbursement policies vary among insurers. In some cases, nonpsychiatrists who treat disorders listed in DSM can be reimbursed, and this may be the case for FAS treatment.
Mrs. DeVries commented that, from the familyís perspective, including FAS in DSM is very important and requested that the APA collaborate with the FAS Family Resource Center to include FAS in DSM.
Report from a special session of the meeting for The Early Childhood Neurobehavioral Assessment for the Differential Diagnosis of Fetal Alcohol Syndrome and Alcohol-Related Neurodevelopmental Disorder held in Bethesda, Maryland on March 8, 2000
Related information on DSM-IV and ICD codes for FAS and ARND:
Related article on FAS in the DSM: http://come-over.to/FAS/DSM-IV.htm
FAS Community Resource Center