New DSM-5 Receives Praise And Criticism
In May 2013, the new edition of the Diagnostics and Statistical Manual of Mental Disorders (DSM) — commonly referred to as the “psychiatrist’s Bible,” because of its importance to mental health professionals — was released. DSM-5 is the most recent version of the original manual and the first revision since 2000. Many changes have been made since the release of the decade-old DSM-IV-TR, and these changes are indicative of the advances in psychiatric research. Yet not all have received the new DSM-5 with open arms. In fact, there have been many criticisms of five major changes the DSM-5 has made from the DSM-IV-TR.
The DSM, which is published by the American Psychiatric Association, sets standards for the diagnosis and classification of mental disorders. Clinicians, researchers and others in the mental health profession — including social workers — use the DSM widely.
Critics have been pointing to different changes and their reception, namely the elimination of the separate diagnoses of autism and Asperger’s disorder and the addition of 15 new mental illnesses, including premenstrual dysphoric disorder and caffeine withdrawal.
The DSM-5 omits some of its predecessors’ disorders, including autism, Asperger’s syndrome, childhood disintegrative disorder and pervasive development disorder, and has combined these autism spectrum disorders into a single category. Because disorders will be diagnosed according to a spectrum, there is a concern that certain disorders — particularly the ones that have already been diagnosed like Asperger’s — will be excluded. Previously, autism and Asperger’s syndrome belonged to a set called pervasive developmental disorders. Now, according to the DSM-5, people will be diagnosed according to the spectrum and not with one of the four pervasive developmental disorders.
According to Dr. Alexander Kolevzon, an associate professor of psychiatry and pediatrics at Mount Sinai Hospital in New York City, the concern is particularly high for those with pervasive development disorder “not otherwise specified” (PDD-NOS). Those previously diagnosed with Asperger’s will most likely still be on the spectrum of autism, but those with PDD-NOS may not “meet the criteria” to remain on the spectrum. He does, however, concede that the spectrum model allows for a patient-specific approach as opposed to a general diagnosis.
Among the critics of the 15 disorders added to the DSM-5 is Dr. Allen Frances, the chair of DSM-IV task force, who believes that the DSM-5 “will lead to high false-positive rates and unnecessary treatment.” According to Dr. Frances, “drug companies take marketing advantage of the loose DSM definitions by promoting the misleading idea that everyday life problems are actually undiagnosed psychiatric illness caused by a chemical imbalance and requiring a solution in pill form.
“This results in misallocation of resources, with excessive diagnosis and treatment for essentially healthy persons (who may be harmed by it) and relative neglect of those with clear psychiatric illness (whose access to care has been sharply reduced by slashed state mental health budgets.)” He contends that incidence of disorders like autism and ADD increased significantly, though only two diagnoses were added to the DSM-IV. His concern is that the addition of 15 new disorders will lead to the unnecessary diagnoses and treatment of even more people.
Others, however, disagree with Dr. Frances and believe that the additional disorders will allow people, especially parents of young children, to receive the help that they need.
Other new additions to the DSM-5 are social communication disorder, hoarding disorder, cannabis withdrawl, caffeine withdrawl, and disruptive mood dysregulation disorder.
Disruptive mood dysregulation disorder, limited to children under 18, differentiates explosive rage and behavioral dyscontrol from mere temper tantrums. David Kupfer, the chairman of the DSM-5 task force, claims that children will no longer have to “fall through the cracks” and remain untreated for a disorder that was previously misunderstood as tantrums.
The reason for the addition of disruptive mood dysregulation disorder, however, is to combat the trend of the misdiagnosis of children with pediatric bipolar disorder, which has been eliminated from the DSM-5. Pediatric bipolar disorder had led to a “false epidemic” in the 1990s. Still, critiques of this addition revolve around the possibility of misdiagnosis. Dr. Max Wiznitzer, a pediatric neurologist in Cleveland, Ohio, calls for doctors to be “rigorous in application” to ensure the proper diagnosis of children.
Not only has pediatric bipolar disorder been eliminated from the DSM-5, but bipolar disorder has also undergone a significant change: The DSM-IV’s criterion for “mixed episode” has been replaced by a new specifier called “with mixed features,” a term used to describe episodes of mania or hypomania and episodes of depression. This invariably creates confusion for clinicians who are prescribing treatment, and Dr. Gin Malhi, a psychiatry professor at the University of Sydney, argues that this new definition will lead to “improper treatment.”
While Dr. Wiznitzer concedes that the DSM has undergone many changes since its first edition (which diagnosed autism as child schizophrenia), and will continue to change in subsequent editions, the DSM-5 has been passionately resisted by the National Institute of Mental Health (NIMH). NIMH says that “patients deserve better,” and a group of doctors have even petitioned against the new manual.
A Huffington Post article, which discusses the debate between the APA and NIMH, says that the controversy behind the new DSM-5 is all about evidence. Jordan Smoller writes: “Of course, all fields of medicine have relied on clinical observation until biology gave up its secrets and allowed us to move from classification based on symptoms to one based on causes. For psychiatry, this transition has been particularly difficult because the organ of interest — the brain — is more complex and inaccessible than most.”
Despite their conflicting opinions on the changes in the DSM-5, the ultimate goal of both the APA and the NIMH remains the same: to provide help to those who are suffering with mental disorders.