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Silver Linings of the New DSM Playbook

The arrival of DSM-V: 11 reasons the new manual may prove beneficial
Allen Frances, M.D.
This post is a response to Mislabeling Medical Illness As Mental Disorder by Allen J. Frances, M.D.

Silver Linings of the New DSM Playbook

DSM-V
Like it or not, the long-awaited DSM-V arrived today.  Although there has been much criticism and controversy[1] surrounding its changes, I’d like to point out some of the potential benefits. 

Why do we need the DSM anyway?  Three main reasons: to communicate information, to bill insurance, and to provide standardized criteria for research purposes.  So when looking at each change, we might consider the following questions:  Is this particular change going to help me diagnose someone properly? Pick up something I might otherwise miss? Avoid a wrong diagnosis that might lead to unnecessary or the wrong type of medication? Provide better or more appropriate services? Communicate or advocate with insurance companies? Provide more accurate information for research trials? Promote research needed for environmental influences on mental health?

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I’ve read the criticisms of the DSM-V and agree with some of the concerns.  Additionally, as I’ve written previously, I believe the newly added Disruptive Mood Dysregulation Disorder is actually dysregulation due to overstimulation and hyperarousal from electronic screen devices.   Aside from that, however, I was curious to review the summary of changes and was surprised by how helpful I thought they might actually be.    This is not an overview of that summary (which you can read here), but instead is a list of what I—as a clinician—thought might be prove beneficial. 

  1. Sleep-Wake Disorders category.   Sleep is of the utmost importance to mental health, as many disorders (mood, anxiety, thought disorders, learning disorders, ADHD, etc) are associated with abnormal sleep architecture, are worsened by poor quality sleep, and/or are improved by improving sleep.   In fact, some “disorders” are actually resolved simply by addressing this issue.  Thus, it’s of the utmost importance to increase awareness of sleep science in general, and more specifically here to the following two sleep-wake disorders, which are common. 
    1. Breathing-related sleep disorder.  This is usually obstructive, and can be due to enlarged tonsils/adenoids, blocked sinuses, or being overweight—i.e. things that are treatable!   Clinicians should be screening for this with every patient.   Treating this issue gives a high yield; for example some cases of suspected ADHD or learning issues in children are resolved when this is addressed. 
    2. Circadian rhythm sleep-wake disorder.  This is divided into advanced sleep phase syndrome, irregular sleep-wake type, and non 24-hour sleep-wake type.    I’m not sure into which of these overstimulation from electronics would fall (irregular type?), but at least it’s there.  Interactive screen-time, especially after sundown, suppresses the sleep hormone melatonin and desynchronizes circadian rhythms, which in turn causes dysregulation of other hormones.   (See also  Wired and Tired.)
    3. Hoarding.  This was previously subsumed under obsessive-compulsive personality.  Hoarding can cause severe impairment/disability and has “unique neurobiological correlates.”  Furthermore, it may respond to proper treatment or interventions and deserves further research. 
    4. Inclusion of Computer Gaming Addiction in Section III.  This section is for topics that were being considered but need further research before they’re included as formal diagnoses. I’m not sure what more evidence the committee needed to prove gaming or internet use can be an addiction and/or problematic, but at least it’s included in Section III.  Other countries already recognize this disorder and treat accordingly.  Treatment centers are cropping up around the world and in the US as well, but of course treatment will not be covered at this point.   Although I always stress to patients and parents that one doesn’t need to be addicted per se to suffer adverse effects of screen-time, I think the medical community and mental health clinicians would agree that there are certainly individuals who are addicted, psychologically and/or physically, and that addiction can cause a high level of impairment (academically/work-related, socially, and physically).   
    5.  (Disruptive Mood Dysregulation Disorder).   I add this one parenthetically since I don’t support its inclusion, but do support the rationale:  to prevent overdiagnosis of bipolar disorder in children, which can have serious consequences—e .g. a child receiving major psychotropic medications unnecessarily.  (Incidentally, the diagnostic code for DMDD will be the same as Mood Disorder NOS.  Why couldn’t they just add descriptive terminology under a subcategory of Mood Disorder NOS rather than add a new diagnosis?) 
    6. Removal of Global Assessment of Functioning (GAF).  In my experience no one uses this anyway other than to make sure it’s low enough to keep necessary services going.   Most clinicians feel it’s useless, as do I.  Instead there will be separate measures of symptom severity and disability.  Not sure how useful that will be either, but this area of assessment is moving in a direction toward alignment with the World Health Organization’s Disability Assessment Schedule. 
    7. Intellectual disability to replace mental retardation.   This is an outdated term and many consider it offensive.  Enough said.
    8. Developmentally sensitive criteria.  For example, PTSD will now have separate criteria for children six and under.  Since children present in different ways than adults for many mental health disorders, this is progress. 
    9. Gender dysphoria.  Replaces gender identity disorder, and more accurately (and sensitively) describes gender identity issues and distress thereof. 
    10. Incorporation of An Integrative Approach.   Basically, some disorders will now be considered on a spectrum, most notably the Autistic Spectrum Disorders (ASD) and substance abuse disorders.   Regarding categorizing Asperger’s  under ASD, I feel it will be helpful.  Currently, there are children and young adults with Asperger’s with significant impairment who don’t qualify for services, when in fact services might greatly improve their level of functioning. 
    11. A plan to incorporate revisions more readily.  This is necessary to incorporate updated research findings more readily than in the past.   (My hope is that they recognize DMDD for what it really is, and remove it!) 

For more information visit www.psychiatry.org/dsm5 or www.dsm5.org .

 

 

[1] For a summary of legitimate DSM concerns, see Dr. Allen Frances’ blog here: DSM-V in Distress  

Victoria L. Dunckley, M.D., is a board-certified child and adolescent psychiatrist specializing in treating children with complex diagnoses and/or treatment-resistant conditions.

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