Issue and Debates on Diagnostics and Medication in Mental Health

Introduction

Diagnosis and medication are not the only polarized topics in mental health but also sensitive areas of the practice. Medical practitioners, including psychotherapists, nurses, and counselors need to communicate effectively with members of the mental health fraternity and other staff in any medical environment. Furthermore, the mental health literature uses standardized diagnostic classification criteria as the backbone of empirical and theoretical research. Therefore, it is important for practitioners to use the updated standardized diagnostic classification sets to communicate accurately and understand the literature relevant to the practice to disseminate knowledge.

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There are two standard sets of diagnostic criteria used to classify psychological and behavioural disorders: the International Classification of Diseases (ICD) and the Diagnostic and Statistical Manual for Mental Disorders (DSM). Anxiety disorders are some of the most ubiquitous mental disorders globally. According to NIMH (2014), anxiety disorders affect approximately 40 million American citizens above 18 years of age annually. There is a wide array of anxiety disorders diagnosed by identifying specific or general causes of fear or unease. Typically, such anxiety or fear is considered to be significant clinically when it is persistent and excessive overtime.

Common anxiety disorders include panic disorder, specific phobia, generalized anxiety disorder (GAD), and social phobia (also known as social anxiety disorder). Current paper analyses the use of DSM 5 and ICD 10 in relation to anxiety. Additionally, it explores the strengths and weaknesses of medication intervention for anxiety with recourse to psychopharmacology. In the same context, the abuse potential of the drugs is examined. Lastly, the etiology and treatment of anxiety is explored.

The Use of ICD-10 and DSM-5 in Relation to Anxiety

ICD-10

ICD-10 is a standard diagnostic reference manual created and maintained by the International Classification of Diseases (ICD), a World Health Organization (WHO) division (APA 2009; WHO 2014). The ten (10) added at the end denotes its current revision. According to the WHO (2014), ICD is a standard diagnostic system for health management, epidemiology, and clinical purposes. All WHO members’ states use ICD-10, which is multilingual (43 languages). ICD was endorsed in May 1990 and implemented as of 1994 (WHO 2014). The standard is under a continuing revision process and the ICD-11 is scheduled for 2017 (Friedman 2014).

DSM-5

DSM-5 is a standard diagnostic reference manual compiled and revised by the American Psychiatric Association (APA 2009; Friedman 2014). The fifth revision of the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) was published in May 2013. In comparison to DSM-IV, DSM-5 has several changes in anxiety and phobias (American Psychiatric Association 2013; Friedman 2014; Grohol 2014). Several disorders that were initially grouped together in DSM-IV have been separated.

For example, posttraumatic stress disorder (PSTD), acute stress disorder, and obsessive-compulsive disorder (OCD) are no longer grouped under the chapter on anxiety disorders (Grohol 2014). Instead, the disorders have been moved to their own chapters. Specific phobia, agoraphobia, and social anxiety disorder have been grouped under one chapter. The greatest change for such disorders is that there is no need to present extreme symptoms to receive diagnoses for one of them.

Critical Distinctions between ICD-10 and DSM-5 with Respect to Anxiety Disorder

There is a widespread sentiment that the field of mental health should not have two separate classification standards for mental disorders. Central to such sentiments is the fact that there are critical differences between the two systems. Firstly, DSM-5 is produced by an independent national professional association (APA), while ICD-10 is maintained by a global health agency (WHO). The primary focus of the World Health Organization’s mental and behavioural disorder classification (ICD-10) is to assist member states to minimize the challenges of mental illnesses (WHO 2014).

That is to say, the development of ICD-10 is multidisciplinary, multilingual, and global. Conversely, the primary constituency of the APA’s DSM-5 is the United States psychiatrists. Further, ICD-10 is approved by 193 WHO member states, whereas DSM-5 is approved by the APA’s assembly (APA 2009; American Psychiatric Association 2013; WHO 2014).

While the DSM-5 is mostly used for research purposes in Europe and Asia, European clinicians and psychiatrists are obliged to document ICD-10 codes (WHO 2014). In spite of extensive efforts to minimize the incompatibilities between the two classification standards, discrepancies related to specific operations of various diagnoses still exist in the present versions. The main theoretical difference between DSM-5 and ICD-10 is how they categorize anxiety disorders, as well as how they differentiate the same disorders in childhood and adulthood. ICD-10 distinguishes anxiety disorder in childhood and adulthood, presenting a different diagnostic criterion, whereas for the DSM-5 classification system such separation is canceled (Andrews et al. 2010; American Psychiatric Association 2013; Beesdo, Knappe & Pine 2009).

The classification of mental disorders in ICD-10 and DSM-5 is, to some extent, similar to the surface. However, discrepancies and concordances exist and are manifested in aspects of the diagnostic criteria: inclusion criteria, identifying criteria, exclusion criteria, and typology. For instance, DSM-5 constantly classifies more children than ICD-10 in relation to anxiety disorders, such as GAD, social phobia, and specific phobia (American Psychiatric Association 2013; Grohol 2014). There was very minimal participation in the revision of DSM-IV; as a result, DSM-5 and ICD-10 (the versions in effect at the time of writing) were different.

However, the descriptive phenomenological approach to diagnose mental illness has become almost similar, moderately due to joint initiatives between APA and WHO. DSM-5 was published followed by enormous controversy and debate. ICD-10 is based on similar principles of alternative classification standards. In 2006, professionals in obsessive-compulsive disorder (OCD) and obsessive compulsive-related disorders (OCRDs) suggested the separation of OCD from anxiety disorders in the DSM-5 (Hollander, Braun & Simeon 2008).

The proposal was consistent with the ICD-10 classification of obsessive-compulsive disorder as an independent category from anxiety disorders. Despite the fact that ICD-10 bundles both OCD and other anxiety disorders under a wider grouping of “neurotic, stress-related, and somatoform disorders,” the two are independent categories, distinct from one another (Hollander, Braun & Simeon 2008).

The Strengths and Weaknesses of Chemical Intervention in Anxiety Disorders

As of present writing, there were a number of anxiety medications available. Psychiatric medication or chemical interventions are divided into six main categories: stimulants, depressants, antidepressants, mood stabilizers, antipsychotics, and anxiolytics (Jacofsky et al. 2014). Anxiety disorders are often treated with anxiolytics and antidepressants. Such medications have general benefits for suppressing anxiety symptoms, especially for severe anxiety. However, just like any other mental disorder, medications are the last resort because benefits from the chemical intervention are least effective as compared to mindfulness-based interventions. It is so due to the fact that anxiety management requires mindfulness-based therapy (Davis & Kurzban 2012; Sipe & Eisendrath 2012).

When medicine is used to relieve anxiety symptoms, the client becomes dependent on them. It implies that in the absence of the medication, anxiety recurs. Additionally, chemical interventions tend to alter the user’s personality and his energy levels in a manner that makes his life problematic. Therefore, it is important to consider the strengths and weaknesses of anxiety medication before taking them. Chemical interventions or medications require little effort to prescribe or administer.

Additionally, they can complement therapy (van der Watt, Laugharne & Janca 2008). Anxiety medication can also be used in scenarios where therapy strategies are ineffective. Furthermore, anxiety medication may catalyze recovery in individuals with severe anxiety. In spite of the perception that chemical intervention seems to be a quick solution to anxiety disorder, such medications also have potential disadvantages.

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Central to the weaknesses of the anxiety medications is that they cause extreme dependence and withdrawal complications (van der Watt, Laugharne & Janca 2008). Some clients’ anxiety symptoms limit their ability to participate, attend, or practice mindfulness-based therapy (Davis & Kurzban 2012). With time the body may develop tolerance and eventually resist them. It makes the medications lose effectiveness. Besides causing extreme fatigue, anxiety medications are known to alter personality. Jacofsky et al. (2014), argued that chemical interventions are weak because they hinder the introduction of natural management strategies. Anxiety medications also have a considerable potential of inducing gastrointestinal side effects (Kaplan & DuPont 2005; van der Watt, Laugharne & Janca 2008).

Such observations imply that chemical intervention is necessarily bad. However, it shows that medicine is not the best intervention for anxiety. Anxiety is a complex mental disorder, thus, people respond to anti-anxiety medications in different ways (B?gels et al. 2010; Encyclopedia of Mental Disorder 2014). That is to say, there is no ideal anti-anxiety medication because most of them result in dependency or potential abuse, especially when they become short-term symptom relievers.

In the same context, most of the anti-anxiety medications create side effects. Most people consider medication, but therapeutic studies contend that chemical intervention can have undesired effects on the recovery and long-term management therapy for anxiety (ADAA 2014; Davis & Kurzban 2012; Finucane & Mercer 2006). Medication should be the last choice when considering treatment options for anxiety. All that is needed is commitment and the right therapy interventions.

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Abuse Potential of Anxiety-Based Drugs

The efficacy of medication depends on proper usage, but some can be dangerous or addictive when abused. Anxiolytics or anti-anxiety drugs are strong central nervous system depressants with the capability to slow normal brain functionality. As cited in the Encyclopaedia of Mental Disorder (2014), anti-anxiety drugs are often prescribed to lessen tension or the feelings of anxiety. Additionally, they can be prescribed to cause sleep. In spite of their intended medicinal value, they are among some of the most abused drugs obtained either legally through prescription or illegally.

Anti-anxiety medications are also known as sedatives. High-potency benzodiazepines manage anxiety but have several effects besides drowsiness (Kaplan & DuPont 2005; NIMH 2014). Benzodiazepines are relatively safe, and when used continually they can be addictive. Since most patients become addicted to benzodiazepines and may need large doses to achieve the same calming effect, thee drugs are normally prescribed for short periods (Longo & Johnson 2000; National Institute on Drug Abuse 2011).

Anti-anxiety drugs also find uses in the prevention and treatment of non-psychiatric conditions, such as seizures, anesthetics, and muscle relaxants. The National Institute of Drug Abuse outlines stimulants, depressants, and opioids as prescription drugs with the potential of abuse. According to the National Institute of Drug Abuse (2011), 16 million Americans reported abusing prescription drugs in 2010. Second to marijuana, prescription accounts for most of the abused drugs. Benzodiazepines and barbiturates prescribed for sleep deficiency or anxiety have a high abuse potential among the central nervous system (CNS) depressants. Benzodiazepines and barbiturates and anti-anxiety drugs administered through swallowing. The intoxication effects include:

  • reduced anxiety;
  • dizziness;
  • poor concentration;
  • lowered inhibitions;
  • impaired coordination (ADAA 2014; National Institute on Drug Abuse 2011).

The potential health consequences include withdrawal, slowed breathing, addition, and tolerance. When combined with alcohol or other substances, they increase the risk of respiratory complications or even death. For barbiturates, there is a possibility of unusual excitement and euphoria occurrence.

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Causes and Symptoms of Prescription Drug Abuse

There is a risk of being addicted to anti-anxiety drugs even when an individual in under legal prescription. Anti-anxiety medications are often taken orally to cause calm or sleep. The abuse of such drugs can develop with prolonged usage or rapid growth of tolerance. To produce the initial effect, an increased amount of medication is needed. The trigger factor of anti-anxiety medication abuse is the intake of such drugs alongside with other drugs and substances, such as cocaine and alcohol. Even when the drugs are prescribed for medical use, individuals taking them often feel drowsy during the initial days of treatment.

Such feelings usually disappear as the body adapts to its effects. If the usage is prolonged, tolerance develops and an increased dose is needed to produce the same effect. Withdrawal from anti-anxiety drugs can be disastrous if not approached under professional medical advice. One of the established safest approaches to withdrawal entails a steady reduction in dosage. It should be noted that sudden withdrawal from such central nervous system depressants can result in seizures that are subject to spikes in brain activity.

In spite of the fact that benzodiazepines are effective anti-anxiety drugs, caution must be exercised with their prescription and usage, especially when they are prescribed to individuals with an active history of substance addiction or abuse (Longo & Johnson 2000). According to Longo and Johnson (2000), drugs that work within a short time tend to be addictive. Benzodiazepines have a shorter onset of action compared to antidepressants. Similarly, antipsychotics and anticonvulsants have an intermediate onset action. As of consequence, they are not suitable for long-term treatment of anxiety disorders.

The Etiology and Treatment of Anxiety Disorders

According to the National Institute of Mental Health (2014), anxiety disorders affect approximately 40 million people above 18 years of age annually. Women are 60% more vulnerable than men. African-Americans are 20 % less vulnerable, while Hispanics are 30% vulnerable than whites to experience anxiety in their lifetime. According to the Anxiety and Depression Association of America (ADAA), generalized anxiety disorder affects 6.8 million adults in the United States annually (ADAA 2014).

Women are two times open to anxiety. The National Institute of Mental Health (NIMH) highlighted anxiety as a response to stress, which can actually be beneficial in some scenarios (NIMH 2014). For example, when a person suffering from anxiety has difficulty managing it, it may affect his or her life negatively. There are six major types of anxiety, including generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), social anxiety disorder, and panic disorder. Jointly, they are some of the most common mental disorders affecting Americans.

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Causes of Anxiety Disorders

Presently, scientists contend that anxiety is probably caused by a combination of genetic, psychological, environmental, and developmental factors due to its complexity (NIMH 2014). For example, NIMH suggested that genetics is at the centre of factors contributing to anxiety and disorders like PSTD activated by trauma. In the same line, scientists have shown that some parts of the brain (hippocampus and amygdala) play a critical role in most types of anxiety disorders. The amygdala serves as the hub of communication between parts of the brain that process sensory signal and parts that interpret the signals.

Therefore, it alerts the brain about any looming threat activating fear or other symptoms of anxiety. The hippocampus encodes threatening events into memory (central part of amygdale). The ongoing studies at the National Institute of Mental Health address how behavioural therapies and medication work in prevention and treatment disorders like OCD and PSTD. Further, there are studies about the efficacy of medication for children with comorbid anxiety disorders.

Signs and Symptoms of Anxiety Disorders

Anxiety disorders are known to be severe and last for more than six months. Each anxiety disorder has specific symptoms, but all the symptoms are tacked around extreme dread or irrational fear. Typically, anxiety disorders occur besides other mental disorders and physical conditions, including depression and alcohol or substance abuse. The comorbidity often masks anxiety symptoms or worsen them. Besides medication, effective therapies for anxiety disorders exist.

The research continues to uncover new treatments that can help anxiety patients lead fulfilling and productive lives. In general, the obsessive-compulsive disorder occurs when unwanted or negative thoughts prevail; generalized anxiety disorder (GAD) occurs when worry cannot be controlled, and panic disorder occurs when fear overwhelms. Common signs and symptoms of anxiety disorders include insomnia, trouble concentration, headaches, and muscle tension, feeling restless, shortness of breath or racing heart, excessive tension, nausea, dizziness, trembling, and irritability.

 

Diagnosis and Treatment of Anxiety Disorders

A cautious diagnostic evaluation is conducted to establish whether the presented symptoms meet the criteria of anxiety disorder and not coexisting conditions. If an anxiety disorder is diagnosed, the specific type or comorbidity is determined (ADAA 2014). Sometimes, depression and alcoholism override anxiety symptoms. In some scenarios, mental health illnesses can appear due to comorbidity or co-occurrence of conditions. For instance, some clients with anxiety disorder symptoms also abuse drugs or alcohol (ADAA 2014; NIMH 2014).

In such a context, it would be right to highlight both disorders when providing a diagnosis. For example, the practitioner can denote generalized anxiety disorder (GAD) and alcohol abuse. In some scenarios, mental disorders can worsen each other. An apt example of it could be an individual who presents the symptoms of anxiety, but his or her symptoms only surface, while withdrawing from alcohol. In such a case it is appropriate that the client is diagnosed with a substance-induced mood disorder. At times, physical symptoms caused by a medical illness may be similar to one or more mental disorders. For example, some of the symptoms of anxiety include insomnia, restlessness, fatigue, irritability, and difficulty concentrating. Interestingly, all of the stated symptoms are also attributed to depression and hypothyroidism (Finucane & Mercer 2006).

Therefore, besides assessing clients for mental conditions, it is also imperative for them to be diagnosed with potential medical conditions. One way of approaching it is to collect specific details about when the patient began experiencing his or her symptoms (NIMH 2014). Such details will be essential in the determination of whether symptoms emerged while a medical condition was present and whether there is a possibility that the concurring medical condition caused the mental disorder. For example, if a client meets all the criteria of anxiety disorder, but it is evident that he or she was a drug addict, the diagnosis should factor in withdrawal symptoms and note that the disorder was activated by the existing medical condition.

Psychotherapy encompasses talking with mental health professionals, including psychiatrists, social workers, and psychologists to establish the factors that caused the diagnosed anxiety disorder and to understand how it should be treated. Cognitive behavioural therapy (CBT) has a proven track record of being effective in the psychotherapy or treatment of concurring alcoholism and anxiety (Finucane & Mercer 2006; NIMH 2014). Numerous empirical studies on the efficacy of Mindfulness-Based Cognitive Therapy (MBCT) have substantiated that mindfulness-based interventions, including home-based sitting meditation, yoga, and controlled breathing, are effective approaches in preventing and treating mental illnesses, such as anxiety and depression (Davis & Kurzban 2012; Finucane & Mercer 2006; King et al. 2013; Sipe & Eisendrath 2012).

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Conclusion

The International Classification of Diseases (ICD-10) and the Diagnostic and Statistical Manual for Mental Disorders (DSM-5) by APA are diagnostic standards for mental disorders. ICD-10 is maintained by the World Health Organization and it is widely used in Europe and all WHO Member States. On the other hand, DSM-5 maintained by the American Psychological Association and it is popular in the United States. They are both used by physicians, nurses, psychiatrists, other providers, policy-makers, health information managers, insurers, and coders to classify diseases and other health issues documented on various typed health records.

Further, they enable mental health practitioners to communicate accurately and understand the literature relevant to the practice. Individuals with anxiety symptoms or anxiety disorders are advised to discuss their medication with the appropriate healthcare professionals, including neurologists, psychopharmacologists, and psychiatrists. Such discussions enable clients to make informed decisions regarding the strengths and weaknesses of medication. As highlighted, some therapies may be less effective when chemical interventions are used.

Overall, the combination of cognitive behavioural therapy and medication complement each other. The two approaches have proven to be effective in reducing anxiety symptoms, hence improving the quality of patients’ daily lives. Based on the reviewed therapeutic studies, anti-anxiety drugs should be the last resort when treatment for anxiety disorder is considered. There is a potential of anti-anxiety drug abuse even when an individual is under genuine prescription. Potential abuse or addiction is caused by prolonged use or a rapid increase in tolerance. Withdrawal from anti-anxiety medication should be done under the advice and supervision of a professional health practitioner to avoid disasters.

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