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DSM-5: “A Living Document” Dead on Arrival?

Will mini-updates (DSM-5.1, 5.2, etc.) create chaos?

The new edition of the Diagnostic and Statistical Manual (DSM-5), a compendium of psychiatric diagnoses, will be released this month. DSM-5 has been heralded by its authors and publishers (the American Psychiatric Association, for whom at least 10% of its income is derived from the previous edition, and that percentage will increase dramatically with the new edition). It has been criticized (some might say vilified) by its detractors. (Read Book of Woeby Gary Greenberg for a riveting history of DSM-5.) I don’t want to weigh in on one side or another here, though I have elsewhere.

Instead, I want to address a feature of the new manual—that of it being a “living document,” typified in the change of edition number from Roman numeral (the previous edition was DSM-IV) to Arabic numeral (DSM-5) so that there can be have mini updates (5.1, 5.2, and so on) before DSM-6 comes out. That’s right, just as your software has mini updates (sometimes because it’s a patch, sometimes with a new feature), so too with DSM-5. Here’s what the heads of DSM-5 say about this:

“DSM-5 is a work in progress, and we must await the outcome of several proposed changes before ascertaining their true impact on the field.” (p. 673)

“…one of the new, core features of DSM-5—the ability to exist as a ‘living document’ that can be readily updated to reflect changes in our understanding of neuroscience and pathophysiology in a world of (sometimes) rapid and dramatic neuroscience discovery.” (p. 674)

I want to talk about why this is an absolutely ridiculous idea. First, let’s consider it from a mental health clinician’s point of view. Every time the criteria changes for a disorder, the clinician should (ideally) (a) become aware that the criteria has changed, and (b) learn the new criteria so that his or her diagnoses can be accurate. Otherwise why bother to diagnose? (For most clinicians, the diagnosis is needed for insurance payments.)

In the past, when new editions of DSM were published, mental health clinicians figured out the changes in the new edition on their own, read various published works that helped clinicians figure it out, or they went to one of various training opportunities to learn about the changes. With frequent mini-updates, though, retraining--keeping abreast of the changes--will be an ongoing, perhaps never-ending process. Many clinicians typically want to spend their time and money devoted to continued education on enhancing their skills to help their patients get better, not to keep abreast of changes in a diagnostic manual that that was released too soon and so needs to be revised. Learning the new diagnostic criteria piecemeal with each update will have no substantive gain for their patients. But it would provide the publisher of the DSM—the American Psychiatric Association—additional financial opportunities with revised manuals and lots of training courses as the manual goes from 5.1 to 5.2 to 5.3. For most mental health clinicians not taking part in a research study, the undoubtedly minor revisions will not affect their practice, so why bother?

Second, let’s consider it from patients’ points of view. Any change in criteria means that some people currently diagnosed with a given disorder will be excluded and/or some people not currently diagnosed will be included; which one will depend on the specific nature of the changes in criteria. For people no longer meeting the (new) criteria, they may no longer be eligible for services—not because they got well enough, but because the criteria changed. Such changes will become a political hot potato, with patients and their loved ones fighting to retrain social and education services. Those newly meeting the criteria will become eligible for services, increasing the possible costs for local municipalities and governments. This has already occurred with the changes to Autism and Asperger’s Disorder (Asperger’s is being subsumed under the diagnosis of the newly renamed Autism Spectrum Disorder.) Mini-updates will make this political process more frequent and more confusing for patients and their families, as well as municipalities, thus serving no one well.

Third, what about researchers who study psychopathology? In the past, many researchers have used DSM as a way to sort patients’ and their symptoms, in order to learn more about etiology, course, prevalence, and treatment for a given disorder. If DSM-5 revises the criteria for disorders through mini updates, researchers won’t be able to compare patients across studies, as different researchers will be using different versions (5.1, 5.2) depending on when their study began. Needless to say, this would create a nightmare for researchers and would waste a lot of research dollars. It appears that this nightmare will be avoided, at least for research funded by the National Institute of Mental Health (NIMH). Its director, Tom Insel, announced recently that NIMH would not use DSM-5 classification system for research grants going forward.

No other edition of the DSM has had these mini-updates. Are they necessary? Yes and no. DSM-5 is based on shoddy work, at least in the end stages. The criteria were supposed to be “field tested” (which means that hospitals, clinics, and clinicians in private practice were going to try them out to diagnose their patients and provide feedback). Then, there was supposed to be a second research phase, after the criteria were revised based on the field test feedback, and the wording tightened up. But this second phase was cancelled, in order to get the book out “on time” in May 2013. There isn’t any reason that the book had to be rushed for publication, other than to make an arbitrary deadline that might be financially advantageous to the American Psychiatric Association’s coffers.

The main rationale, to my mind, for DSM-5 being a living document is to “correct” for the shoddy work that is being launched this month. Although I haven’t seen it yet, based on the proposed revisions online and what I have read about the DSM-5 process, it sounds to me as if this living document is pretty much dead on arrival.

(To mental health clinicians: I discovered, thanks to the Book of Woe, that you won’t have to buy DSM-5 in order to obtain the new diagnostic codes when the time comes that you need them for insurance next year. You can get them for free online. The current version of ICD—ICD-9 CM—uses the same codes as DSM-IV; when ICD-10 is introduced next year, those codes will be the same as DSM-5.)

Copyright Robin S. Rosenberg, 2013

Robin S. Rosenberg, Ph.D., ABPP is a clinical psychologist in private practice in San Francisco and Menlo Park, Calif. Rosenberg specializes in treating people with eating disorders, depression and anxiety. She often writes about the psychology of superheroes and has co-authored several psychology textbooks, including Abnormal Psychology and Introducing Psychology: Brain, Person, Group. Her latest book is Superhero Origins: What Makes Superheroes Tick and Why We Care.

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