Changes to the psychiatrists’ bible, DSM: Some reactions

That big fat bible of psychiatric diagnosis — the DSM — is one step closer to its overhaul, a task that has taken more than a decade. On Dec. 1, the board of trustees of the American Psychiatric Assn. voted to approve the fifth edition of the book, which psychiatrists use to diagnose patients. The final edition is due out in May.

Among the changes:

• Asperger’s disorder will no longer be classed as a separate condition but will be folded into an umbrella category called autism spectrum disorder.
• Hoarding disorder is added to the book.
• “Disruptive mood dysregulation disorder” is a new psychiatric category for children and adolescents who exhibit “persistent irritability and frequent episodes of behavior outbursts three or more times a week for more than a year.” Many such kids are today diagnosed with — and then medicated for — bipolar disorder, which is an issue of concern to many who work in mental health.
• Identifying as transgender will no longer be listed as “gender identity disorder.” The term is replaced by “gender dysphoria,” which would refer to “emotional distress over a marked incongruence between one’s experienced/expressed gender and assigned gender.” The distress is the focus, in other words, not the state of being. Many within the transgender community support this de-pathologizing, though some note it might make it harder for people who identify as transgender to receive medical services, as this article discusses.
• People suffering grief had in the past been excluded for a diagnosis of depression during a certain window of time: Grief, after all, is a natural reaction to loss. That “grief exclusion” is out. The change “reflects the recognition that bereavement is a severe psychosocial stressor that can precipitate and major depressive episode beginning soon after the loss of a loved on,” the APA statement explains.
• Hypersexual disorder — what’s popularly termed sex addiction — did not make it into DSM-5, though its inclusion had been debated.

“We developed DSM-5 by utilizing the best experts in the field and extensive reviews of the scientific literature and original research, and we have produced a manual that best represents the current science and will be useful to clinicians and the patients they serve,” said Dr. Dilip Jeste, the psychiatric association’s president, in a release you can read on the DSM-5 website.

Here’s a longer statement from Jeste in which he acknowledges that not everyone is going to be pleased with the final version. He says that the right balance is hard to find. Pull too many people into your net and you’re accused of medicalizing the common rainbow of variation in human behavior -- potentially stigmatizing people and offering up more customers to the drug companies. Exclude problems from the book and you may be cutting suffering people off from receiving services and insurance reimbursements that they need.

The DSM-5 website notes (presumably in response to charges that the DSM gets fatter all the time and that nearly every single one of us could end up under its wings pretty soon) that it contains the same numbers of disorders as the last version, DSM-4, did.

The DSM-5 panel has been accused of overdoing it and underdoing it, and you can get more of a sense of that by scrolling around on the DSM-5 website.

Reaction has been mixed.

Here is a slam on the revisions at the Huffington Post by psychiatrist Allen Frances, professor emeritus of Duke University and chair of the DSM-4 task force, who pretty much finds nothing good to say about the end result. His article begins, “This is the saddest moment in my 45 year career of studying, practicing, and teaching psychiatry” and urges clinicians to “be skeptical and don’t follow DSM-5 blindly down a road likely to lead to massive over-diagnosis and harmful over-medication. Just ignore the 10 changes that make no sense.” (He lists them in his article.)

Over at Slate, here’s a closer look at one of the new categories, disruptive mood dysregulation disorder (DMDD), written by David Dobbs.

Dobbs notes that part of the reason for creating this new category is to avoid over-diagnosis of bipolar disorder in kids, with the attendant stigma and likely result that many will end up taking powerful psychotropic drugs. “At first glance, DMDD seems a decent alternative,” he writes.

But the science doesn’t support the new category, he goes on. Dobbs cites a study in which psychiatrists at different institutions diagnosed DMDD at very different rates in a group of children: This is not meant to happen if a disorder is well-defined, and doesn’t bode well for its use in the field. And he cites work by psychiatrist David Axelson at the University of Pittsburgh (who studies bipolar disorder) that found lots of overlap between DMDD and other diagnoses (conduct disorder and oppositional defiant disorder) and that a diagnosis of DMDD didn’t well predict future problems.

On the Asperger syndrome issue, listen to this podcast interview with Emily Willingham, editor of Thinking Person’s Guide to Autism, whose son has Asperger’s.

Willingham says it makes sense scientifically to make this change because there is so much overlap among what were three separate categories in DSM-4 — autistic disorder, Asperger syndrome and Pervasive Developmental Disorder-Not Otherwise Specified (PDD-NOS).

But, she says, some people with Asperger’s syndrome are not happy with the change because the word has become a term they have embraced with pride. “There is a big identity issue,” she said. And some parents worry that a child may end up being excluded from an autism spectrum disorder diagnosis and thus from receiving services. Willingham notes that the most conservative estimate from studies are that maybe 10% of children who receive a diagnosis via the DSM-4 categories would lose the diagnosis under the single “autism spectrum disorder” category and some studies suggest the number would be higher.

Geraldine Dawson, chief science officer for the advocacy group Autism Speaks, said her group has been following the developments of DSM-5 closely and expressed “cautious optimism” about the revisions. She added that research “suggests that the revisions increase the reliability of diagnosis, while capturing the vast majority of those who would have been diagnosed under the DSM-4. Of the small number of individuals excluded, most received the new diagnosis of “social communication disorder.”

But, she added, it will be important that the real-world results of the diagnostic changes are tracked carefully going forward.

Experts debate removal of the “bereavement exclusion” for depression. Is this medicalizing something normal, as Frances would argue, or helping people who are suffering? For arguments for and against the change, see this editorial by Dr. J. Sloan Manning in Psychiatric Times and Dr. Richard A. Friedman in the New England Journal of Medicine.

Dr. Kenneth S. Kendler, who was member of the mood disorder work group for DSM-5, argues that a bereavement exclusion didn’t make sense unless you were to similarly put it in place for any other “depression that arises in the setting of adversity,” such as a cancer diagnosis, say, or losing one’s job. He would seem to have a point.