Family Diagnosis/DSM-IV

The Diagnostic and Statistical Manual of Mental Disorders (DSM) classification system of the American Psychiatric Association (APA) attempts to unify language about mental disorders. This classification system developed from the need to collect statistical information. Roots of the DSM reach back before the publication of the first DSM in 1952 as a clinical parallel of the International Classification of Diseases (ICD-6) adopted by the World Health Organization (WHO) in 1948. Nineteenth-century census data did not have adequate categories to describe mental illnesses. In 1917, the APA expanded the classification concept to gathering uniform statistics across mental hospitals. After World War II, the Veterans Administration expanded the nomenclature developed by the APA to include more outpatient presentations of servicemen and veterans. This clinical utility focus continued and incorporated more research with each publication: DSM-I in 1952, DSM-II in 1968, DSM-III in 1980, DSM-III-R in 1987, DSM-IV in 1994, and DSM-IVTR in 2000. Unfortunately, the wide acceptance of the DSM as the full and complete picture of mental illness overlooks the value of family therapy theories regarding the underlying diagnosis and treatment of symptomatic behavior.

DSM-IV is designed to facilitate clinical and research shared language. Special efforts have been made to address the impact of culture: where relevant, a special paragraph is devoted to cultural variations within the text describing each diagnosis; the appendix includes a description of culturally related syndromes that have not been included in the DSM classification system; and the appendix includes a brief discussion of steps the clinician can take in determining impact of culture on the diagnosis. The DSM-IV is organized for making diagnoses using the following guidelines:

• Axis I: Clinical disorders and other conditions that may be a focus of clinical attention (including V codes);
• Axis II: Personality disorders and mental retardation;
• Axis III: General medical conditions;
• Axis IV: Psychosocial and environmental problems; and
• Axis V: Global assessment of functioning scale (GAF).

Perhaps because of the DSM's roots in the medical model and its wide acceptance as the standard, current insurance coverage of behavioral health/mental illness as a medical problem, and the relatively new systems theory and research, a true family systems model of understanding mental illness has not yet been included in the DSM classification. Axis IV identifies psychosocial and environmental problems that may affect diagnosis and treatment, but insurance companies will not provide coverage without an Axis I diagnosis. Family problems are identified on Axis IV in the category Problems with Primary Support Group. Family functioning problems can be identified on Axis I with diagnoses under the category Other Conditions That May Be a Focus of Clinical Attention; however, the V codes V61.20 (Parent-Child Relational Problem), V61.1 (Partner Relational Problem), V61.8 (Sibling Relational Problem), V61.21 (Child Abuse), and V61.1 (Adult Abuse) alone are generally not considered to be medical problems covered by insurance. The policies of insurance companies tend to shape the thinking of clinicians and consequently researchers. Thus, a linear medical model of simplistic static answers to complex dynamic problems is reinforced.

In preparation for the DSM-IV, work began among professionals (Group for the Advancement of Psychiatry (GAP) Committee on the Family 1996; Kaslow 1993) to construct new classification schemas for family functioning. Work begun by the 1986 GAP Committee on the Family—later joined by the Coalition on Family Diagnosis (with members from fourteen different organizations)— resulted in the Global Assessment of Relational Functioning (GARF) being included in the DSM-IV appendix under the category Criteria Sets and Axes Provided for Further Study. The two new schemas for family functioning were a rated comprehensive range of functioning (the GARF as a dimensionalized rating parallel to the GAF individual functioning now used on Axis V) and a categorical identification of functioning (Classification of Relational Diagnoses [CORD]) parallel to the discrete descriptive diagnoses of individual disorders now used on Axes I and II). (For more on GARF and these classification schemas, see next section, below.) However, work on the CORD was not completed in time for DSM-IV. Recommendations in the DSM-IV note that the GARF can be included along with the GAF on Axis V. This inclusion was a significant change in attitude of the APA; professionals recognized the need for the development of a systems method for understanding mental illness. However, the challenge has fallen to family therapists to provide the necessary research to verify the concepts in systemic diagnosis/assessment and treatment/intervention before DSM-V is published.