The Diagnostic and Statistical Manual-5 (DSM-5), publishing in late May 2013, represents years of research, debate, and field testing. Called the “Bible of psychiatry,” the DSM-5 includes almost every single possible variation in human behavior, and then some. Although not yet seen by many people, if anyone, outside of the editors, a number of the changes anticipated in DSM-5 have already been previewed.
The changes from DSM-IV-TR, the previous version of the DSM-5 are already being heavily criticized, however, including two recent books on the topic. Psychology Today blogger Allen Frances, a member of the DSM-IV panel, has been perhaps the most outspoken and detailed in his objection to the new system. Activist groups have sprung up, including Boycott DSM-5, and many psychologists have signed onto petitions similarly challenging DSM-5’s publication. The American Psychological Association reports that the Center for Medicare and Medicaid Services (CMS) will require that all healthcare providers covered by HIPAA will be required to use the International Classification of Disease manual, not the DSM, starting in October 2014. NIMH Director Thomas Insel would like to see science driving the diagnoses, not clinical criteria.
My own experience with the DSM-5’s revision was in overhauling my abnormal psychology undergraduate text to reflect the new system. In the process of completing the text, I had the opportunity to delve into the DSM-5 in depth. I read every single diagnosis description, research article, and rationale, all published on the DSM-5 website (though not available anymore). Each new diagnosis was pegged to its old counterpart in the DSM-IV, and the authors of each subsection lavished extensive detail onto the information available to the public. Therefore, it was possible to see what I’ve called “the good, the bad, and the indifferent” which I share with you today. After looking at these, we’ll see what these changes will mean for you.
DSM-5 is eliminating what was a rather cumbersome five "axis” diagnostic system previously in use that required clinicians to rate each client according to criteria other than their main psychological disorder. Apart from the fact that no one truly could define the word “axis” (it was roughly a dimension), the previous DSM’s included a rather strange combination of personality disorders and “mental retardation” into one grouping. All other disorders were placed elsewhere. In addition, a collection of unrelated disorders that “originated in childhood” (but not “mental retardation”) were strung together in one section regardless of what the symptoms were. Eliminated the axes is probably a good thing as it will ease some of this confusion and messiness.
This brings up another good change. “Mental retardation” is no longer being used as a diagnosis but is being replaced by “Intellectual Disability,” which makes DSM-5 consistent with established practices in the field. Several other diagnoses with possibly stigmatizing terminology were also changed, including hypochondriasis (now called “illness anxiety disorder”) and the paraphilias (now called “paraphilic disorders”). The DSM-5 authors felt that these changes were warranted not only for the sake of being politically correct, but because the terms are more accurate. A set of similar changes were made within each of the major disorder categories.
Autistic disorder is now being eliminated as a diagnosis, and is replaced by “autistic spectrum disorder.” In the process of making this change, the DSM-5 authors also decided to eliminate the “Asperger’s Disorder” diagnosis. This has angered some groups, who feel that Asperger’s merits its own diagnosis. However, I’m including this change in the “good” (readers may disagree) because it’s been clear for a number of years that the “spectrum” concept is a useful one for the family of autistic disorders. In fact, many researchers believe that all categories should be eliminated entirely in favor of dimensional ratings, and though this didn’t happen, it might in future DSM’s.
Another good set of changes involves reorganizing and eliminating some disorders that no longer made sense in the new framework. For example, obsessive-compulsive disorder now fits into its own grouping instead of being placed with anxiety disorders. The evidence didn’t support the notion that anxiety is at the root of this disorder. Similarly, PTSD is now part of a new grouping called “Trauma and Stressor-Related Disorders” which, again, highlights the underlying nature of these disorders and groups it with others that bear a substantive relationship.
Guidelines for evaluating suicidality are also being included in DSM-5. This will provide clinicians with greater structure in assessing individuals who may present a risk to themselves.
In the area of schizophrenia, the DSM-5 authors believed that the distinctions among the 5 subtypes (e.g. “disorganized,” “undifferentiated”) were not supported by research evidence, nor could clinicians always reliably distinguish among them. This is particularly good news for the legions of undergraduates who no longer have to memorize these somewhat confusing terms. More importantly, however, other changes made within the schizophrenia diagnosis will allow clinicians to rate the severity of a client’s symptoms in a way that does carry meaning.
Many DSM-5 critics have their own legitimate gripes about the flaws of the new system. For example, the inclusion of “Mild Neurocognitive Impairment” has the very real potential to pathologize the normal age-related changes in cognition that many people experience and lead people with slight memory problems to rush to the conclusion that they have dementia (a term being eliminated, by the way). A “mild” anything seems like an odd term to include in a psychiatric diagnostic system.
Other changes drawing widespread criticism (in addition to what I mentioned above about Asperger’s) similarly include a general broadening of the nosological (meaning diagnostic) net or, put into lay terms, making what’s normal seem sick. Broadening the diagnoses of, for example, major depressive disorder, the DSM-5 authors eliminated the so-called “bereavement exclusion” in which a grieving person had a up to 2 months to experience severe symptoms of depression without being diagnosed with a psychiatric disorder. The rationale for eliminating the exclusion is that a person who is vulnerable may have a depressive episode triggered by becoming bereaved but this explanation doesn’t sit well with critics or other researchers. I understand both sides of the argument, but I’m going to rule in favor of the “bad” for this particular change. Similarly "Premenstrual dysphoric disorder" and "Disruptive mood dysregulation disorder" are two new depressive disorders that pathologize PMS and temper tantrums, according to critics.
Not changing the personality disorders was a non-change that also led to considerable outcries, as I reviewed in a previous post. I understand why the changes were not made, but the preponderance of evidence favoring a dimensional instead of a categorization system seemed very compelling to me, as it did to the personality disorders work group members themselves. It’s likely that this decision will be revisited as fortunately the unimplemented changes are presented in a section in the DSM-5 that makes them available for further testing.
As I mentioned earlier, the childhood disorders were virtually all reclassified. However, in the process of doing so, the DSM-5 authors used the term “neurodevelopmental” for the disorders that remained in this category. This includes attention deficit hyperactivity disorder (ADHD). The problem with the relabeling, according to critics, is that it places emphasis on the biological causes of ADHD, minimizing the behavioral contributions. As a result, the critics maintain, people with this diagnosis may turn to pharmacological interventions instead of what many believe are the more effective (and side effect free) behavioral strategies. Furthermore, the criteria for adult ADHD were broadened slightly, meaning that the nosological net will expand to include more people with perhaps mild or borderline symptoms.
You’ve seen already that there are pro’s with the con’s and con’s with the pro’s in DSM-5. Here I’m including several changes in which there’s a bit more of an equal balance (in my opinion). One area concerns the former category of gender identity disorders, now being labeled “gender dysphoria” (meaning extreme sadness). Critics argue, as you can imagine, that people who seek gender reassignment surgery don’t have a psychiatric disorder. Therefore, the DSM-5 shouldn’t even include this category at all. On the other hand, people within the transgendered community who were consulted in the DSM-5’s revision seemed to accept the idea that for those individuals truly dysphoric in the other gender, their symptoms were substantial enough to warrant a diagnosis and without this, they couldn’t receive insurance coverage for their therapy and/or surgery.
A new category called “Binge-Eating Disorder,” which was in the appendix of DSM-IV-TR, is now included with eating disorders based on a comprehensive literature review which showed to the DSM-5 authors that there was sufficient validity to the diagnosis to justify its inclusion. Although critics argue that including this disorder, once again, pathologizes behaviors that were not considered “abnormal,” the proponents cite not only the research evidence but the fact that people with this disorder will now be given the same attention as is given to those with anorexia nervosa.
Alterations throughout the DSM-5 are occurring that are intended to tighten up definitions that were too loose and include some additional rating scales of severity. Some specific disorders were eliminated and grouped together such as learning disorder. In addition, diagnostic criteria were cleaned up and clarified, which are changes that will probably lead to clinicians providing more valid diagnoses.
What it Means for You
This is not a complete listing of all changes, by any means, and please feel free to leave additional comments either here or on my Facebook page, or Twitter account, which you can find below.
In the next few weeks, if not months, you can expect to see a great deal of criticism levied at the DSM-5, if not the entire field of psychiatry. You will also hear that the American Psychiatric Association is giving way to big pharmaceutical companies who see the new manual as helping feather their own quite lavish nests. If you have a psychiatric disorder, know someone who does, or think that you or someone you love might, the bad press you’ll see might discourage you from getting treatment. It’s also possible that you’ll end up being so confused (as indeed many professionals are) that you’ll despair about being able to find the treatment that you, or your loved ones, may need.
Overall, the purpose of having diagnoses is to allow mental health professionals to use a common language when working on behalf of their clients. Also, without diagnoses, researchers would not be able to compare their results from study to study. Research in psychiatry and abnormal psychology consistently specifies the nature of the diagnoses of the people who participate in research, and without these diagnoses they wouldn’t know how to compare their findings. Furthermore, in the world of managed care, not to mention the Affordable Healthcare Act, diagnoses are unavoidable. The authors of the DSM-5 weighed the disadvantages of labeling clients with a diagnosis against the advantages to them of receiving healthcare coverage.
Fortunately, there are many effective treatments available, including psychotherapy, counseling, support groups, and behavioral approaches. While the experts, consumer groups, advocates, and various other pro- and anti-DSM-5 groups continue the debate, you can still benefit from the advances being made in the field both now, and as we move to DSM-5’s successor, whatever that may be.
My advice is that you keep an open mind as you read articles in the press or in the self-help section of the Internet (this blog included). You have the ability to evaluate the evidence relevant to your own concerns. As they say, “talk to your doctor,” but in this case I would add “talk to your psychologist.” We're listening.
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Copyright Susan Krauss Whitbourne, Ph.D. 2013